A. Approach to the Patient

physician with notepad Communication skills lie at the heart of the physician-patient relationship.

Introduction

Patients go to see their doctors for a variety of reasons, only one of which is to seek relief from disturbing signs and symptoms of medical disease. As every primary care physician knows, a large number of patients who visit doctors do not have detectable, much less serious, underlying disease. Indeed, the most common single diagnosis in general medical practice is “no disease.” One explanation for the lack of correlation between the presence of complaints and visits to physicians lies in the important distinction between disease (the biologic abnormality) and illness (the person’s unique experience of whatever disease he or she has and the behavior resulting from it). Thus, some patients have little or no disease but manifest severe illness, and conversely, some patients have severe disease but display little or no illness. When patients are first seen, however, their physicians do not know the cause of their complaints and are obliged to look for whatever sickness that may be responsible. This Section, then, provides some guidelines on how to approach the patient, especially during the all-important first encounter. Although the emphasis is placed on patients who have pulmonary disease, the general approach applies to other disorders as well.

Communication

Communication skills lie at the heart of the physician-patient relationship. Doctors must know how to communicate effectively with patients and their families, including how to deal with the psychosocial, preventive, and rehabilitative aspects of illnesses. Most physicians, though, are better at obtaining a medical history and assessing compliance than in learning about patients’ understanding of their illnesses, and in ascertaining the patients’ emotional response to their disease. Doctors find it easier and are more comfortable with communications related to the medical aspects of a particular disease than with the psychosocial complications associated with the same condition. Communication is more than words; it is an interaction of intellectual and medical give and take that creates an atmosphere whose quality has enormous impact on the subsequent behavior of the patient. Effective communication requires calm surroundings, a relaxed environment, and plenty of time, prerequisites that are not always easy to provide in a busy practitioner’s office.

Medical History

There is much more to the medical history than asking questions and recording answers, especially by questionnaire; the expanded concept is reflected in the alternative term, the face-to-face medical interview, with its verbal and nonverbal nuances. From this interaction, especially the first one, physicians and patients learn a lot about each other, and this knowledge has considerable influence on subsequent trust, understanding, concern, and compliance. Even in the contemporary era of high technology and reliance on laboratory studies, more diagnoses are made on the basis of a medical history than by any other method. Of equal importance is the fact that the differential diagnosis derived from the initial medical history determines which laboratory tests will be ordered.

Present Illness: The three cardinal symptoms of lung disease are dyspnea, cough, and chest pain; other common manifestations are hemoptysis and wheezing. All are discussed in subsequent Sections. Regardless of which complaint the patient comes in with, each must be explored in detail. When did the symptom begin and under what circumstances; when does the symptom occur now, at night, on awakening, or during exercise? What brought the symptom on to begin with; moreover, what makes it worse or relieves it now? The time-course after onset provides important clues to etiology; is the complaint intermittent, progressive, or evanescent? Also crucial is how the symptom is affecting the patient’s life style; are daily activities unrestricted, or are there limitations to going to work, attending school, or shopping and other household tasks? The intensity of pain needs to be documented; is it bearable or does it force the sufferer to stop what he or she is doing? Similarly, the severity of breathlessness should be quantified; how many stairs are manageable or how much exercise is tolerable? Finally, the consequences of cough should be ascertained; is it productive, and if so, what is produced; does it wake the patient up at night?

It is equally important to ask questions about associated systemic features, such as fever, sweats, weight loss, weakness, and fatigue, which are important corollaries of chronic disease, especially infection and malignancy. No evaluation of pulmonary symptoms is complete without a detailed history of smoking habits. If the patient says “no” when asked “do you smoke?” the next question must be “did you ever smoke?” Exposure to cigarettes is customarily quantified as the number of “pack-years,” which is calculated by multiplying the average number of packages of cigarettes smoked daily by the number of years they were consumed.

Family and Social Histories: Household contact with a family member known to have tuberculosis or some other respiratory infection may account for similar disease in another family member. A positive family history provides important clues to the presence of both common (e.g., asthma) and rare (e.g., hereditary hemorrhagic telangiectasia) pulmonary diseases. Knowledge of the site(s) of residence helps to diagnose endemic fungal diseases, and a history of travel suggests possible diseases that may have been encountered in other countries. It is important to determine if there are risk factors for infection with human immunodeficiency virus; questions concerning homosexual activity among men and use of drugs by injection should be asked.

Occupational History: Though often included as part of the social history, the occupational history is such a key part of the medical history of patients with lung disease that it should be considered separately. The relationship between the patient’s complaints and work should be queried. Has there been exposure to dusts, chemicals, or fumes? Are other workers similarly afflicted? For completeness, the physician should be concerned about the patient’s entire environmental exposure, not just at work. Careful sleuthing about hobbies, recreational activities, and contact with pets and other animals may furnish solutions to mysterious medical diseases.

Past History: Many pulmonary diseases tend to recur, especially infections like tuberculosis and many malignancies. Thus, questions should be asked about previous illnesses, operations, and trauma involving the chest and/or lungs. One of the most useful aids in evaluating patients who present with pulmonary symptoms and an abnormal chest x-ray is a previous chest x-ray. Thus, all patients should be asked about past x-ray examinations, and every effort should be made to obtain the actual films, not just the reports. Finally, a history of current and past medications should be obtained with specific identification of any allergies.

Physical Examination

A key element in the initial evaluation of every patient is a complete physical examination. Subsequent examinations may be more abbreviated as the situation warrants. This Section emphasizes the detection of signs indicative of pulmonary disease, but finding abnormalities of other organs is equally important in evaluating patients with different complaints.

Pulmonary Findings: Examination of the lungs still incorporates the basic techniques of inspection, palpation, percussion, and auscultation. The results of these modalities are complementary and, as shown in Table 1, allow the examiner to infer the presence and type of many common pulmonary disorders. “Crackles” is the new generic term for the discontinuous sounds that used to be called “rales.” Moreover, all former descriptors of rales, such as “fine,” “dry,” and “wet,” have been discarded. The continuous sounds, wheezes and rhonchi, have also been lumped together in current terminology, but retain some pathogenic utility: a wheeze is an uninterrupted musical sound that generally originates from narrowing of medium or small airways, whereas, a rhonchus has a gurgling quality that usually indicates secretions rattling around within large airways. Other useful signs are a pleural friction rub, a leathery creaky sound, which is often localized and intensified by pressure with the stethoscope, and a mediastinal crunch, which sounds like pulmonary crackles (rales), but which are synchronous with the heart beat and can be heard during breath-holding. A variety of other sounds may occasionally be heard that originate within the chest wall, such as the rubbing of hairs underneath the stethoscope, the crackling of subcutaneous emphysema, and the popping of fractured ribs. It should be emphasized that the absence of physical signs does not exclude the presence of significant lung disease. A complete evaluation requires a chest x-ray, and sometimes specialized examinations (e.g., pulmonary function tests or computed tomography) are needed.

Extrapulmonary Findings: Clubbing of the digits occurs in many different disorders, including chronic pulmonary infiltrative and suppurative diseases, and most importantly in bronchogenic carcinoma. Cutaneous lesions are less specific, but may also indicate certain underlying lung diseases. The examiner should listen to the heart carefully, palpate the abdomen for enlarged organs or masses, and search the extremities for edema or other findings. Any abnor-mality on physical examination may be of great help in deciphering the cause of the patient’s complaints.

Diagnosis

The diagnosis of “no disease” can often be confidently made from the medical history alone. Moreover, when significant disease of the lungs or neighboring structures is present, the medical history provides important clues as to its origin and what types of studies should be obtained to confirm its presence or absence. The results of the physical examination supplement those from the history in deciding which diagnostic tests to order. For suspected respiratory disease, the first diagnostic test is usually a chest x-ray. For suspected cardiac disease, the first test is usually an electrocardiogram. From then on, the workup proceeds or referral is indicated as discussed later in this monograph and in other medical textbooks.

Treatment

Making a diagnosis alone seldom satisfies a sick person. Patients want relief of the complaint they went to see the physician for in the first place, and that means treatment. Here again, the distinction between disease and illness must be remembered. The doctor must treat the underlying disease, for example antibiotics for community-acquired bacterial pneumonia, but must also attend to the accompanying illness, which might manifest intolerable pleurisy, nausea and vomiting, or intractable cough. Treatment options should be discussed thoroughly, and in certain instances, such as before carrying out invasive procedures or administering toxic drugs, signed consent must be obtained. Because successful treatment, particularly as an outpatient, requires the patient’s active cooperation, education and explanation concerning exactly what must be done is vital; enlisting the support and collaboration of a family member or friend is helpful.

Medicolegal Concerns

As emphasized in all our previous monographs for primary care physicians, efforts should constantly be directed toward preventing medical litigation. Patients must be kept informed about what tests are being ordered and why, what treatment is being recommended, what the alternatives are, and what plans are being made for follow-up. Perhaps the most frequent cause of medicolegal awards, ones that concern all patients, not just those with respiratory disorders, is failure to document adequately in the medical record all contact with, the advice given to, and the rationale for the approach to a patient and his/her particular problem. Another common mistake is neglecting to inform the patient, in writing, how to contact the doctor should the need arise.

Summary

The onset of symptoms, especially those arising in the chest, is one of the chief reasons patients seek help from their physicians. Evaluation of presenting complaints begins with a medical interview and is followed by a thorough physical examination. From these fundamental maneuvers, physicians formulate a clinical impression about what and where the abnormality is, and if necessary, test this hypothesis by ordering laboratory tests, radiographic examinations, or other diagnostic procedures. Subsequent evolution of the condition can also be assessed simply and inexpensively through the medical history and physical examination, and, when needed, by selected confirmatory tests.

References

Fletcher SW. Approach to the patients. In Bennett JC, Plum F (eds). Cecil Textbook of Medicine. 20th ed, WB Saunders, Philadelphia, 1996, 75-77. Brief but elegant advice on this all-important subject.

Murray JF. History and physical examination. In Murray JF, Nadel JA (eds). Textbook of Respiratory Medicine. 2nd ed, WB Saunders, Philadelphia, 1994, 563-584. Comprehensive review of all the elements of history taking and performing a physical examination of the chest.

Noel GL, Herbers JE, Caplow MP, et al. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West Med J 1992;156:163-165. A careful study that showed—once again —that a careful medical history is the best way of making a diagnosis.

Pryor DB, Shaw L, McCants CB, et al. Value of history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med 1993;118:81-90. A nice clinical study that documents the value of the initial history and physical examinations as a means of identifying patients likely to benefit from further testing.

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