That lament was heard from patients many times every day. Every day someone would come to my office saying they didn’t feel good. They couldn’t put their finger on what it was, but they knew their state of health was not what it should be or was normally. They might have some symptoms that would point me in a certain direction, but more often than not they didn’t. Thus began the difficult investigation into what was causing them to not feel good.
Indeed, this complaint was one of those things that challenged my ability to think. Along with the symptoms of fatigue, weakness, dizziness, and “the blahs,” not feeling good posed a difficult diagnostic dilemma. Because this complaint is so vague and so uncertain, the possible causes were infinite. Just about any illness or disease can make us not feel good, and when you read medical textbooks, fatigue, malaise, weakness, and lethargy are symptoms of just about everything. These synonyms used to describe vague feelings patients express can be a real nemesis to physicians.
Unfortunately, I don’t recall any chapter, or even a paragraph, in my medical textbooks discussing the diagnosis “I just don’t feel good.” It wasn’t there. But, instead, the entire textbook was the “I don’t feel good” section.
Some patients have trouble putting their symptoms into words. They have a difficult time explaining the timeline or progression of their illness. Physicians call them “poor historians.” They find it hard to organize their thoughts in a logical manner, to verbalize those thoughts, and to convey them in a manner a listener, the doctor, can understand and make sense of. They start in the middle of a story, or forget details of the illness, or don’t mention something because they think it’s unimportant. They just can’t describe how they feel. It often seems like they expect the doctor to read their minds, which, of course, is impossible. “You’re the doctor; you tell me!”
So what does a doctor do when a patient comes in and says “I just don’t feel good?”
The first thing I did was take a deep breath, calm down, and do my best to elicit additional symptoms that pointed me in a direction I could pursue. A good “historian” makes the doctor’s job easy. When a patient expresses his or her symptoms clearly and is able to logically present the history, the diagnosis can almost be made without an examination.
From this point on, it feels like you and the patient are playing “20 Questions.” It’s important to obtain as much information as possible so doctors use a specific process to give themselves something to go on. The “history taking” process learned in Med school has four steps. They are:
Determining the Chief Complaint
Obtaining a History of the Present Illness
Recording Past Medical History
Doing a complete Review of Symptoms
The CHIEF COMPLAINT (what is bothering the patient most) in this case is “I just don’t feel good.”
The HISTORY OF PRESENT ILLNESS (the timeline of symptoms) in this case “I don’t know what’s wrong.” It is at this point the doctor attempts to elicit other pertinent symptoms and get things in chronological order by asking specific questions.
The PAST MEDICAL HISTORY records the patient’s previously diagnosed illnesses, surgeries, and hospitalizations, as well as health habits (smoking, alcohol consumption) and family history. This information may give an important clue.
The REVIEW OF SYSTEMS is the final step in the process. In this step, abbreviated “ROS,” each body system is reviewed and questions pertaining to the system are asked. The order I used in the ROS, along with sample queries, was as follows:
Head—headaches, dizziness
Eyes—blurred or double vision
Ears, Nose, Throat—ringing in the ears, bleeding, trouble swallowing, hoarseness
Lungs—cough, shortness of breath
Heart—chest pain, palpitations
Abdomen—pain, nausea, vomiting
Bowels—constipation, diarrhea, blood
Bladder—trouble voiding, leaking, burning
Extremities—Pain, swelling, numbness, tingling
Nervous—trouble walking, talking, using arms
Listed above are just some of the questions asked to extract information that would lead me to some explanation for why the patient didn’t “feel good.“ A positive response would lead to further questions to pursue that possibility. Based on what I learned from history taking, and after thoroughly examining the patient, appropriate lab tests were done to get more precise information, and hopefully get to the bottom of why the patient felt bad.
This scenario was a daily occurrence that presented a real diagnostic challenge. The age of the patient had a lot to do with the possible cause of symptoms—older people tended to have more serious diseases while younger people were more often suffering from a viral illness. This determination was sometimes not made right away, and days or weeks might pass before a diagnosis could be determined. But persistent observation and patient cooperation usually led to an answer that would have a good outcome.
I always knew patients who came in with vague, non-specific symptoms like “I just don’t feel good!” were going to be a challenge, but following a systematic procedure, being patient and inquisitive, and not expecting to make a diagnosis immediately, usually led to the answer.
