The Why and How of Case Histories. 2

Hello young doctors.

I  recently attended a prep class for candidates for the FCPS 2 examination in internal medicine. I realised that many candidates did not know what is the purpose of having two examiners sitting and listening to them when they are taking the history in front of the examiners.

let me talk to the candidates now. You are being assessed as to your clinical maturity and your ability to take what is a focused history. This focused history is not the one that is taught to the undergrad med students. The med students are given a list of areas into which they must make an inquiry. this is done so that they do not forget to take any information. They do not know what is relevant so they are expected to follow a list. A post graduate registrar is not expected to follow a list. He/She is expected to ask relevant questions in any order so that a comprehensive and relevant history is obtained. This is called focused history taking. He /She is expected to show empathy and respect for the patient and treat the patient as a person not just piece of information to be entered in a file.

Remember that you are taking a FOCUSED HISTORY. This enables an experienced doctor to reach a diagnosis quick and to start relevant management i.e. treatment and investigations quickly. No consultant ever asks an unnecessary question. They will only ask about a marital history if it is relevant to the diagnosis or prognosis of the disease. You will not be penalised for not asking if it is not relevant. In a focused history ask yourself  “Why am I asking this question? What difference will it make to my diagnosis or management?” Be prepared to answer the question “Why did you ask this question?”

First greet the patient, ask their name and then ask  “How are you feeling and what made you come to the hospital?”Ask “Have you been attended by a doctor and are you feeling better with your treatment?”, next. Then ask the patient to tell you the symptoms that are bothering them. The mistake the candidates make is that they ask the question then they do not listen to the answer. Please listen to the patient!!! Note down the answer if necessary.

Let me give an example. In a practical demonstration a candidate for the FCPS 2 exam was taking a history. The patient was a 60- ish woman with gross ascites; she had massive edema; her muscles were emaciated; she could barely walk from her chair set a few feet from the examination couch in the demonstration room. She asked if she could sit because lying down made her uncomfortable. As she started giving her history the candidate asked asked if she had any other disease to which she replied “yes six months ago I went to a doctor who said I had high blood pressure.” The candidate then said “I will ask you about this later”. When the tutor conducting the exam asked why he was putting it off for later he said that this is part of the past history. No it is not. Any and every ongoing illness is part of the current illness especially if it needs to be monitored and treated.

You can ask the information that you need for a file like age, occupation, place of permanent residence, current address etc later. Also ask for the next of kin but not at the start of the patient interview or the patient may think they are going to die soon.

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I am a Professor of Medicine and a Nephrologist. Having served in the Army Medical College, Pakistan Army for 27 years I eventually became the Dean and Principal of the Bahria University Medical and Dental College Karachi from where I retired in 2016. My passion is teaching and mentoring young doctors. I am associated with the College of Physicians and Surgeons Pakistan as a Fellow and an examiner. I find that many young doctors make mistakes because they do not understand how they should answer questions; basically they do not understand why a question is being asked. My aim is to help them process the information they acquire as part of their education to answer questions, pass examinations and to best take care of patients without supervision of a consultant. Read my blog, interact and ask questions so that I can help you more.

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