The questions experts ask when taking a medical history

When treating a patient, information gathered by any means can crucially guide a doctor to a diagnosis and direct care. The first step of a medical consult is almost always taking a medical history.

A complete history includes an in-depth inquiry into the patient’s medical issues, which includes the following aspects:

• the patient’s medical history,
• past surgical history,
• family medical history,
• social history,
• allergies, and
• medications the patient is taking or may have recently stopped taking.

The main goal of obtaining this information is to relate the history to a diagnosis. Additionally, gathering information is necessary to avoid iatrogenic injury: injury that is (unintentionally) caused by the treatment itself. An example of this is an unnecessary (invasive) diagnostic procedure.

Taking the history of the present illness is dependent on a case-by-case basis. For example: asking females age-appropriate questions about their last menstrual period or pregnancy status can be important, but is not applicable to the male. In the case of our patient, the history of the present illness is most important.

As the experts of the head and neck region, our top three questions when taking the history of the present illness are:

• How long did you have these complaints?
• Do you have pain?
• What are your other complaints?

We ask this because the answers will differentiate between complaints due to serious illness requiring quick work-up and less serious illnesses, which are not acute.

Length of complaints

The length of complaints is a simple question which differentiates the likelihood of malignant, benign or infectious (acute or chronic) disease. A swelling in the neck which was noticed less than two weeks ago is very likely to have an infectious cause. If the swelling has been there for several weeks, malignancy should be considered. A swelling which has been there for months, without any growth or very slow growing is likely to be benign.

Pain

When the patient is experiencing pain in the swelling, it is likely to have an inflammatory origin. This can be helpful in differentiating between benign or malignant disease. Besides pain, local erythema of the skin around the swelling may indicate infectious disease.

Other complaints

Other complaints such as hoarseness, dysphagia, otalgia or bad hearing may have a malignant origin. A growing tumor in the head and neck area can affect the delicate anatomy. Malignant disease growing in these regions can cause these complaints.

It is also important to assess whether the patient belongs to the high-risk population. For example, patients above 50 with a history of smoking and excessive alcohol intake have a higher risk of developing head and neck cancer and consequent neck metastasis. To complete the history of the present illness, you should therefore ask for specific risk factors of malignant disease:

• Tobacco use
• Alcohol
• Earlier head and neck tumors
• Premalignant lesions
• Viral exposure HPV/EBV