I had written two posts on how to take a history in the long case. Nobody bothered to read them. After all you know how to take a history. The problem is that in the exam situation (FCPS 2) in Pakistan the candidate is trying to throw themselves back to their third year days. The two examiners facing them are trying to assess that the candidate is now fit to practice as an unsupervised consultant. Remember there is no CME in Pakistan so that progress in learning and the acquisition of new clinical skills and knowledge is not assessed after the exit exam. It is perhaps equal parts luck and competition in private practice that ensures that doctors keep themselves updated in knowledge though we do have lots of examples where the doctors don’t do this.
The two examiner’s who are listening and watching and rapidly losing their esteem for the candidate’s history taking skills which goes something like this:
- What is your name?
- How old are you?
- What work do you do?
- Are you married?
- How many children do you have?
- How educated are you?
- What is your family income?
- Where do you live?
- Is your house airy or crowded?
- What food do you eat?
All very well when you are a third year student trying to establish personal information about the type of patient you are dealing with but very unlikely to get you to gain empathy or a working diagnosis. The patient is either going to be annoyed or embarrassed nor will these questions help you make decisions about what tests to do or what immediate treatment to start while you confirm your diagnosis.
A good way to help you empathise with the patient is to introduce yourself before asking for a name and a title and using the title to ask more questions. Remember that on the subcontinent people specially older ones do not like to be called by their first name alone. For more professional or educated people use ” Mrs, Mr, Sir, Madam, Miss or mohtarma, bibi, or sahib, aunty or uncle. For more conservative people apaji, Baji, Bibi, Bhai, Baray bhai, Sahib etc and for younger ones beta will do.
Ask how they are feeling, whether someone has taken care of their immediate problem and whether you can get them something i.e. water, a pain killer, an extra pillow, a sheet or blanket etc. When the patient gives you a list of complains or problems ask which one he/she would like help with first or which bothers them most. Watch their face and body language when they tell you about symptoms. It may help you decide which is more of a problem. Ask if they have been to a doctor before and what the doctor told them about their illness.
Remember these are the four things you want to do when you take the history initially: try to make a diagnosis, empathise with your patient, start planning tests in a logical sequence of tests in order of usefulness and relieve distress by starting medication which will relieve pain or breathlessness or swelling or vomiting etc. Personal history comes after you have made up your mind what is likely to be wrong with the patient,
A better way is to introduce yourself by giving your name and asking for the patient’s name. Say that you are sorry for any inconvenience but you have been asked to talk to the patient and examine them. Ask if they need anything before you start like water or some pain medication or oxygen. Would they like to be examined lying down or sitting in a chair and would they like a sheet or blanket. Then start by asking how they are feeling and what their major complaint or symptom is. Note whether there is a wheel chair, crutch, an IV cannula, CVP line and oxygen cylinder, nebuliser equipment in the cubicle or if the patient has a urinary catheter. They will be relevant to the patient’s symptoms. Then take a focused history.
A focused history means you ask for symptoms which are likely to arise from the main symptom or be linked to it. This means that you are trained to follow groups of symptoms or group recognition or pattern recognition. Most candidates can be seen to be trying to recollect these group symptoms sometimes even on their fingers! Certainly shows lack of training which is fatal.
Headache —nausea—vomiting—-visual scintillating—neck stiffness—loss of consciousness—fits—–repetition of symptoms over a period of time—- aura—-trigger–response to treatment–progression to other neurological symptoms or signs.
Fainting attacks or syncope–emotional event– physical event (standing still on parade)–environmental event like smoke, pollen–associated symptoms like palpitation or hyperventilation–recovery on lying down– vomiting–fits– headache–frequency of repetition–use of a medication which will make syncope likely.
Epigastric pain–heartburn– precipitated by bending—lying down flat after a heavy meal–sets off an attack of asthma (aspiration into the lungs)–postprandial epigastric pain–bloating, and belching and flatulence–recurrent urge to empty the bowel–pain at night–disturbance of sleep.
Weight loss– accompanied with a good appetite– think of thyrotoxicosis or type 1 diabetes– poor appetite — think of an inflammatory condition like TB, rheumatoid arthritis, SLE–think of a malignancy specially lymphoma, GI malignancy specially pancreas–duration.
Abdominal cramps and diarrhoea–ask for details of the stool– frequency–consistency– a fresh GI bleed accompanying the stool–black tarry stools–loss of appetite–fever–ask about fecal soiling of clothes may give a clue to anal fistulae.
Insomnia–is there a physical symptom which keeps them awake like pain or frequent micturition, breathlessness or polyneuropathy–do they have a proper place to sleep which is quiet and comfortable and dark–do they feel sleepy early and then wake up in the early hours of the morning–do they have a problem going to sleep and then sleep very late into the daylight hours–do they feel tired and feel like having a nap frequently during the day– do they feel tired all day long–is it affecting their work or usual life routine–do they snore very loudly? Explore sleep apnoea.
These are some examples. Make sure that you have made lists of group symptoms you encounter often. Anticipate the kinds of cases that are often presented in the examination and have your focused history present. It is not obligatory to ask questions which are altogether irrelevant to your case. If somebody has ischemic heart disease you do not have to ask about hair loss or a rash for example.
When starting with your physical examination again use focused examination if possible. Note if the patient is uncomfortable, orthopneic, dyspnoeic or in pain. Ask the examiner for appropriate help to relieve. Start with the height (ask the patient, they often know and it saves time) weight, if it is relevant work out the BMI (or do it at the end of the physical examination) next do the vital signs. These are very important. If the patient has fever or hypertension or hypotension or an irregular pulse or rapid or irregular breathing or wheezing then in each case your examination will be a little different. Note if the patient is visibly overweight or obese, has signs of recent weight loss like loose skin on the arms, face or abdomen. If you can obviously see cyanosis, jaundice, a sallow skin (more and more patients with CRF are turning up in the exams), anemia then mention them at once as also for edema, an ulcer, gangrenous toes or fingers. Tremors and abnormal movements must be mentioned at once. You can then proceed with your own routine for examining a patient.
If the BP is high or the patient has diabetes or evidence of an SOL then do the funduscopy now not at the end of the time you have been given when you will probably have to do it in a rush or not be able to do it at all. Be attentive with the pulse and look at the neck veins if needed. Look at the patient’s colour and note anemia, cyanosis, jaundice. Examine the peripheral pulses, note loss of hair on the body and scalp, note a rash or eruption. Examine the lymph nodes and thyroid. Look at the nails and do not waste too much time on looking for clubbing unless relevant from the history. Examine the nails and look for tremors. Mention anything else like an ulcer or a wound that appears to be relevant for example if there is a bandage ask if you are allowed to undo it, if so you must have the material including gloves to rebandage it. Mention an IV canula or urinary catheter or a scar specially if it is recent. Do not mention esoteric signs like Janeway lesions and Roth spots unless really relevant.
Which system to examine next? The one that is most involved in the complaints presented to you in the history. Do not go for the policy of checking out the system you find most difficult to examine if it is irrelevant. It does not look very intelligent if you examine the tendon reflexes in a patient who cannot breath from pneumonia!
Please practice the examination of the nervous system repeatedly. Remember you have to examine the higher mental functions, the cranial nerves, the cerebellar system, the motor system, the sensory system and some part of the autonomic nervous system too. You should be able to do this in 8–10 minutes not more. Practice, practice, practice.
If you have not been able to elicit from the history which system is involved like in a case of pyrexia of unknown origin, then say that I am going to elicit signs from the lymphatic system because I suspect a lymphoproliferative disorder, re-examine all the peripheral lymph nodes carefully if you left out any look, look for petechial hemorrhages or bleeding from anywhere, also look for the liver and spleen, any irregular lumps in the abdomen and complete the examination of the abdomen looking specially for the presence of ascites and enlarged kidneys. Then the respiratory system should be targeted. If there was an irregular pulse or symptoms of heart failure then examine the heart next specially looking for valvular lesions. Take clues from what you find in order to perform the next action.
For joints first just look at the natural posture that the patient is keeping the involved joint in. There is usually an angle of maximum comfort like flexion at the wrist, flexion and abduction at the knee, abduction at the hip or the patient likes to flex the hip and turn over on to that side, fingers are kept flexed. If there is a physical injury then the angle of comfort will change and help you recognize what is happening. Look for the degree of swelling, any cysts, look for limitation of movement. Join a surgical team to help you learn a proper examination of the knees, hips, spine, shoulders and elbows! Note the number of joints involved. If the hands are involved note the grip strength. When you are discussing the joint mention whether the joint is functional and if it is capable of bearing weight.
Dementia. Often begins with aggressive behavior; quarrelsome behavior, lack of anger management; confusion about major events in the family; confusion about routine events in the day like “Have I had my breakfast/dinner/bath/walk?”. They are likely to become aggressive about this. Confusion about where they sleep or live causes the tendency to wander off and get lost. Forget where the toilet is and urinate inappropriately. Insomnia with evening or night time aggression. Behavioral disturbances commonly peak in the late afternoon or evening, a phenomenon often referred to as “sundowning.” Sundowning affects up to two-thirds of patients with dementia and is closely related to disturbed circadian rhythms. Ask the patient and the caregiver what the major problem is. They tend to forget words so the vocabulary becomes limited hence conversation becomes repetitive and limited. They stop watching the TV news and plays as the words no longer make sense. Stop reading for the same reason. Need help with personal toilet and clothes. May see objects and people that are not there i.e. hallucinations and delusions. Also check with the caregiver what medications they are on and be aware of the side effects of these drugs. You will need to ask questions about all the above symptoms.
When symptoms and signs tend to involve several systems or do not clearly involve one system dominantly don’t panic. Think of diabetes, thyroid, adrenals i.e. endocrinopathies: think of connective tissue disorders: tuberculosis and other infections that can affect many systems: HIV/AIDS: lymphoproliferative and myeloproliferative disorder: diseases modified by treatment like immunosuppression. Keep asking, you will get the answer. Co back over your history; have you missed a symptom or mistaken a symptom for something else? Is the patient recovering from an illness hence the symptoms have gone away? Dig a little deeper.
At the end if you still have not come up with a diagnosis say “I am not sure what the patient has. I have several differential diagnoses. I will do the following tests and imaging processes and re-assess the patient again.” Please do not say “I will do routine tests.” Give reasons for each test that you want to do. Have some idea of false positives and false negatives and how useful each test is going to be.