I shall quote a few examples of Arab patients seen in my clinic, where the main diagnosis was missed elsewhere because of reliability on machines!

1. A few Bahrainis (non-English speaking) in whom "Angina Pectoris" was missed because the resting electrocardiogram was normal which as we all know is the case in over sixty percent of such patients. Stress test was not asked for, because history was not elicited properly.
2. Bronchial Asthma and allergic bronchitis were missed because X-ray chest was normal.
3. Kidney stone, seen on plain X-ray of Abdomen was being treated when patients' symptoms were due to "Peptic ulcer syndrome".
4. Gall stones were blamed when the symptoms were due to straight-forward, severe irritable bowel syndrome.
5. Symptoms of peptic ulcer were diagnosed to be due to chronic hepatitis, because the auto-analyser report showed a few abnormal liver function tests and the liver scan showed a patchy uptake of the isotope.
6. Patient has been diagnosed as having
   1. Peptic ulcer (reported on a routine barium meal examination) and
   2. Kidney stones (seen on routine X-ray K.U.B. and l.V.P. Examination) and
   3. Giardiasis (reported on routine stool examination) and
   4. Diabetes (which was in fact a slight glucose intolerance) and
   5. Umbilical hernia (detected on clinical examination)

All this when in fact his main aim of coming abroad was for treatment of his sexual weakness.

I can go on enumerating a number of examples—all of them to show that in a clinic, the time spent on history taking is the most important part of the examination.

And next comes the situation where the history is elicited through the interpreter. However well trained the interpreter is in his language, he is more fit for colloquial, non-medical speech. For taking medical history, he is no good.

The interpreter is usually looking at his watch and is always in a hurry for his next appointment. In case the interpreter is a relative or a friend, then, as is the usual habit of all the people, after hearing the patient, he twists the whole story according to his own taste, wisdom, prejudice, common sense and style of presentation. If at all an interpreter is used, he should be forced to translate patient-doctor dialogue line by line and even word by word.

It is always worth knowing, from which part of the Arab world the patient comes. Thus conditions like "Functional Arab Syndrome" described elsewhere, become a "spot" diagnosis by asking leading questions. Also the age of every patient should be asked. Do not guess. You could go wrong. The beautiful artificial dentures (golden teeth included), artificial eyes and use of hair dyes even on beard and moustache can be misguiding!

A word about all the Arab patients, specially Yemenis. They use the anatomical words of the organs while giving the history. It is so common to hear them saying, "I have pain ("Wajaa") in my heart ("Gulb")—my kidneys ("Kiliyaa") are painful ("Awar")—I have pain in my stomach ("Maidaa") or liver ("Kibid")".

While taking history, this tendency of using the names of the organs should be discouraged. If he says "I have high blood pressure" ("Dhakht"), it is probably giddiness. Often he would say "I have an ulcer ("Garhaa") of the stomach". Tell him to explain his symptoms and it turns out that he is suffering from colicky pains ("Ikfahas") due to irritable bowel syndrome. Still many would use the word "Fooaat", which has multiple meanings in different subcommunities in Arabs.

Present Illness

Another habit of an Arab patient is that he starts with the details of past illness first, and by the time he comes to his present complaints, the doctor is already bored, biased and confused. To avoid this situation, always ask him "What is your present ("Alhain") complaint ("Aish Takleef")?"

Past Illness

The Arab population, however, illiterate, knows the 'names" of so many diseases which other patients hardly ever know. If the past history of following illnesses is asked for, often the answer is 'yes'.

1. Bilharziasis with urinary or bowel complaints (often in Yemenis)—pronounced as "Bilhaarzia".
2. Giardiasis—(pronounced as G for goat—"Giardia")
3. Amoebiasis or dysentery (pronounced as "Aamoeba or Dysentaaria")
4. Worms in stools ("Dood fil KHaruj" or "Albraaz")
5. Respiratory allergy ("Hassassiya")
6. Tonsil operation ("Liwaaz Amaliya")
7. D.N.S. Operation ("Khusham Amaliya")
8. Piles operation ("Bawasoor" or "Bawaaseer")
9. Appendix operation ("Dood Zaidaa")
10. Kidney stone operation ("Kiliya", "Hajar" or "Hassa").

In Bahrainis, Saudis and Qataris, do not forget to ask for family history ("Fee Aeelitik") or past history of high blood pressure ("Dakht") and diabetes ("Boal Sukkar"). I n Yemenis, it is worthwhile asking for a past history of Kochs ("Sil").

Personal History

must be elicited in detail.

HABITS

Smoking ("Sigaraa")

Smoking cigarettes is universal in Arabic countries. Arabs who can afford to spend for "filter cigarettes" or "long tip cigarettes" easily fall prey to the advertisements. Many Arabs specially young, become heavy smokers thinking that they are protected by "filter". Some elderly women in Bahrain, Qatar and Saudi smoke Hooka known as "Sheesha" in their countries. In a female patient with chronic cough this should be kept in mind, though as mentioned elsewhere, it is not so common.

Drinking Tea ("Shaye") and Arabic coffee ("Qahwah")

Most of the Arabs would consume 2 to 6 or more cups of tea per day. But when it comes to "Qahwah", it is often 10, 20 or 30 times a day! Although they would insist that the quantity they drink at a time is very small (which is a fact), it is a concentrated drink.

Alcohol ("Khamar-Sharaab")

Details about consumption of whisky ("Wisky") or beer ("Bir") should be found out. In Bahrainis the answer is usually "yes". You have then to enquire, "how often and how much". Unless asked in such details, many would not talk about 2 to 4 cans of beer which they consume in the afternoon—especially the young population. However, most of them are social drinkers.

In countries like Kuwait and Saudi Arabia, it is nearly impossible to obtain alcoholic drinks. In Oman and U.A.E., it may be possible to procure them. In Yemen, alcoholic drinks are easily available.

Qat

Use of "Qat" (or "Gat"), Hashish and other intoxicants including tablets mentioned in the preface, should be elicited. Hard addicts of Hashish or barbiturates rarely come for treatment. The use of "Qat" needs special mention. Nearly the whole Yemen population—men, women and grown-up children too—has tasted, heard of or used it regularly. In North Yemen, it is still sold freely. In Democratic Yemen, the Government has restricted the sale to twice a week. yet there are many people who use it daiIy or a couple of times per day. An average Yemeni reminds me of an underweight Maharashtrian policeman seen in Bombay who will be seen stuffing "Tobacco leaves" in his oral cavity in between the buccal mucous membrane and the gums. The secretion which is swallowed constantly peps him up with energy—which lasts for a couple of hours. Then he needs a "refill". Yemenis use "Qat" in the same manner. Many Yemenis serving in Saudi Arabia miss "Qat".

There are different types of "Qat" available—costly, moderate or cheap, for sex stimulation or intoxication. Most of the times "Qat" is used for experiencing euphoria and hyperactivity, especially when groups of friends (men or women) meet on week ends (Thursdays and Fridays). Many people in service, use this stuff daily to increase their work output or may be, to relieve themselves of tension ! "Qat" is not available in or used by Gulf or Saudi population. Some symptoms e.g. severe constipation, dryness of the mouth may be due to atropine—like action of "Qat".

Other points in personal history regarding urine, stool, sleep and sex should be recorded.

Urine

If an Arab patient is asked a leading question, "Do you sometimes or off and on ("Aao Kaat") experience burning ("Harara" or "Horga") of urine—his answer is usually "yes" and if he is a Yemeni, it is invariably "yes".

Stools

Most of the Arab population is constipated. Many of them have bowel movement once in 2, 3 or 4 days—especially females. But in Yemenis, it is common to have history of weekly evacuation if not every 8 to 10 days! Also the faeces are often very hard ("Yeboosaa")

Sleep

In many Arab patients, specially Yemenis, the sleep is not satisfactory. Dreams ("Halaam") are so common (though often not frightful) that they leave the patient exhausted ("Taihbaan") and weak ("Daaeef") in the morning when they wake up.

Sex

Sex must be inquired into detail even if the patient is 80 to 90 years old. "Jahaaz" or "Juma" is a decent word for all. But for young Arabs, the colloquial word is "Zib Mazboot", which literally means, is your penis strong?