Study Finds Medical History Key to Correct Diagnosis

Doctor with Patient Reviewing Medical HistoryA new study published in the Archives of Internal Medicine, a journal of the American Medical Association, found that patients’ medical history “emerged as the key element in formulating correct diagnosis” of medical conditions.

This obviously has important implications both for patients and for family caregivers. It suggests that patients will be well advised to become knowledgeable about the details of their own medical history, and that caregivers should know and be able to advise the doctor about the medical history of the person they are caring for.

The U.S. Surgeon General recommends creating a written individual and family health history, and provides an interactive online tool, My Family Health Portrait, to help you do so. The Surgeon General recommends printing out your “family health portrait” to share with your doctors. When visiting a doctor or being admitted to a hospital or emergency room yourself or when accompanying your loved one as a family caregiver, it would be wise to carry a written summary of the patient’s medical history with you. The US Department of Health & Human Services also recommends carrying a wallet card, listing the patient’s medications.

The new study conducted by Liza Paley MD, Ami Schattner MD and colleagues at the Department of Medicine A, Kaplan Medical Center, Rehovot and the Hebrew University Hadassah Medical School in Israel, is reported in the August issue of the Archives of Internal Medicine.

In a comment on their study, the researchers said, “Research continues to support the enduring value of the history and physical examination in diagnosis and in deciphering problems with multiple diagnostic alternatives.” “However,” they stated, “our study was the first to our knowledge to examine prospectively the value of the basic clinical methods for the diagnosis of the whole heterogeneous population of patients requiring an emergency admission to a general department of medicine.”

The Study Methodology

The researchers studied 442 patients admitted from the Emergency Department to a hospital affiliated with an academic department of medicine over 53 days. Each of the patients was examined within 24 hours of admission by a Senior Resident with four years of training. The examination included taking a full medical history, a physical examination, review of results of tests taken in the Emergency Department upon admission (including basic hematology and chemistry tests, urinalysis, electrocardiography [ECG], and chest radiography, and any additional tests performed), and a review of medical charts from previous admissions, all medications, and vital signs. The Senior Resident then recorded her diagnosis, and identified which of the factors above (medical history, test results, physical examination, medical charts, medications, etc) were most helpful in making the diagnosis.

A Hospital Physician with more than 20 years experience then repeated the process, and made his diagnosis based on all of the same factors, without seeing or having any knowledge of the Senior Resident’s diagnosis.

Within an average of two to seven months after discharge, the patient’s final diagnosis was verified by checking discharge summaries and records of any further hospital visits and calls to the patient’s primary physician.

The initial diagnoses of the Senior Resident and the Hospital Physician were then compared with the final diagnosis, to determine accuracy of the initial diagnoses, and to determine “the value of different elements (history, physical examination, and basic tests) for the diagnosis.” An experienced statistician analyzed the results.

Findings

As reported by the study’s authors, “The patient’s history emerged as the key element in formulating diagnosis either alone (approximately 20% of all diagnoses), in combination with the patient’s examination (another 40%, approximately), or in addition to the basic tests with or without the physical examination (33%).”

Based on these factors the Senior Resident made correct diagnoses in 80.1% of the cases, and the Hospital physician made correct diagnoses in 84.4% of the cases. They made correct identical diagnoses in 73.9% of the cases.

As to the importance of the factors other than the medical history, the study authors reported:

“The examination or basic tests alone were very seldom helpful. Used in conjunction, the physical examination doubled the diagnostic power of the history (19.5% to 39.0%; Table). The basic tests added a further 33%. Imaging was infrequently used in the ED (mainly head computed tomography) and had added little to determining diagnoses, being considered valuable in approximately 1 in 3 patients who had computed tomography performed.”

Conclusions & Implications

“We found that more than 80% of newly admitted internal medicine patients could be correctly diagnosed on admission and that basic clinical skills remain a powerful tool, sufficient for achieving an accurate diagnosis in most cases,” the study authors stated.

“Notwithstanding the great clinical diversity, 90% of all correct diagnoses were accomplished on presentation through a combination of the history, physical examination, and basic tests (excluding imaging studies),” they concluded.

“[Medical] History was the most potent single tool identified,” the researchers wrote.

The medical history plus the physical examination alone were the basis of the diagnosis in 60% of the cases, they found. Adding basic test results to these two factors “further increased the diagnostic yield,” they said. Basic test results they said were “implicated in a third of all diagnoses.” However, even though “a relatively small number of patients had ancillary investigations beyond ECG and CXR,” this “had no adverse effects on the clinicians’ performance.”

“In conclusion,” the authors stated, “4 of 5 of internal medicine inpatients could be accurately diagnosed close to their admission on the basis of little other than the traditional clinical information [medical history, physical examination, and basic tests].” “Physicians may count more on their clinical faculties when making decisions about patients,” the researchers concluded.

The important role that medical history plays in correct diagnosis, as found by this study, underscores for patients and caregivers the importance of making sure that you provide your doctors with an accurate, complete, and detailed medical history, as well as a complete list of all medications being taken.

More Information

The complete study report, Utility of Clinical Examination in the Diagnosis of Emergency Department Patients Admitted to the Department of Medicine of an Academic Hospital, is available in the August issue of the Archives of Internal Medicine, a journal of the American Medical Association.

See also Commentary on The Value of History Taking in Diagnosis, by Rita F. Redberg, MD, MSc, published in the same August issue of the Archives of Internal Medicine.

To create a written summary of your own and your family’s medical history, use the online interactive tool provided by the U.S. Surgeon General at its My Family Health Portrait website.

See also, New Tool Issued by HHS to Help Reduce Medication Errors, including a wallet card on which to list your medications.

And see, generally, the HelpingYouCare™ resource pages on:

Practical Tips, Skills, Checklists, and Tools for Caregiving

Medical Conditions Commonly Faced by Seniors, each condition, with a separate sub-section on Symptoms & Diagnosis.

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Copyright © 2011 Care-Help LLC, publisher of HelpingYouCare™.

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