If the patient complains of dyspnea—difficult, rapid breathing, "short breath" as we say—we shall ask about œdema or swelling of any part, especially of the legs.
In every patient who has a cough we are concerned primarily with the diagnosis of one disease, that is, tuberculosis, its presence or absence. Hence every patient who coughs should be questioned about the other symptoms of tuberculosis and especially about emaciation. A man with a chronic bronchitis or emphysema does not lose much flesh; he does not become emaciated. A person does not become thin from throat trouble. Hence emaciation, especially recent, is a helpful guide to the doctor in making up his mind. Fever we investigate for the same reason. The only disease that often causes cough and fever during a long period is tuberculosis. Unfortunately the patient's statement about fever is usually unreliable. We can believe most of what he says on the rest of these points. But he does not know whether he has fever or not.
In women we must ask also about the monthly sickness, because it is suppressed in cases of moderately advanced tuberculosis. Nephritis, anemia, heart trouble and emotional disturbances may have that same effect. It is a measure of the degree of disease, not its type.
For the purpose of dispensary consultations I do not think we should take any family histories except when we suspect tuberculosis. But when the history leads us to think that the person may have tuberculosis, the social worker can help the doctor by asking the patient questions about the possibility of the same disease in mother, father, or others who are in contact with the patient—grandfather, grandmother, or other relatives or friends living in the same house. We believe less and less in the heredity of tuberculosis, more and more in infection by contact. If separated from a tuberculous father or mother in early infancy we believe that the child does not acquire tuberculosis. But the main mode of infection is by association in the same house, over a prolonged period, with people who have tuberculosis. Often the patients do not know or will not confess that anybody in the family now has tuberculosis or has died of it. But if we can establish the fact that one of the patient's family has died after having a cough for many years, that he grew very weak, and spit blood, we have established the diagnosis without the name. Not the degree of relationship to a tuberculous patient, but the amount of time spent in the same house with a tuberculous individual—what we call the degree of "exposure" to tuberculosis—is the important thing.
Past history
After getting the patient's present symptoms, one should ask, "Were you ever sick previous to this illness? If so, what troubles have you had?" That is of use in clearing up the limits or boundaries of the present illness. The sicknesses which the patient says he has had are not of very much use to us in diagnosis because we cannot get true answers. The patient's diagnoses or his doctor's are apt to be vague or meaningless. But the questions about the patient's past history tend to make him more clear as to the date when his present illness began. Hence his answers on these points should be written down very briefly, a word or two only about each, and usually in the words used by the patient.
In our written histories in hospitals we usually take a considerable body of notes about the patient's habits. I do not advise this for social workers. But there are certain routine questions which should be asked of all patients concerning their appetite, bowels, sleep, weight, and work. The answers should be recorded in a separate paragraph, at the end of the history.
What is printed here is meant to give a sample, not a full account, of medical-history-taking. Competence in this field takes long practice. Nevertheless the intelligent social worker can learn in a few weeks to be of great assistance to the doctor by taking either in the dispensary or in the home such histories as I have sketched.
In social-history-taking there is no single order or schedule of questions agreed upon by all social workers. But there should be some order and system determined partly by the personality of the worker and partly by the nature of the trouble. If poverty or destitution is the presenting symptom, one must find out the items in the family budget, the figures of income and outgo, paying especial attention as in medical histories to the question, "How long?" How long have you paid that rent, earned that wage, been without a job, taken boarders, been in debt?