the Examiner in the FCPS 2 Exam in Medicine.
It is time for you to be assessed in the knowledge and skills that you have acquired in the last four years of your training. Some of you underwent the training earlier maybe several years ago and have settled into a routine you use daily with your patients but shortcuts have slipped in and methods not academically acceptable are being used by you. These may appear to work but may actually be delaying the diagnosis or needing to be supplemented by a lot of tests which may be unnecessary. Unconfirmed diagnoses are being treated with shotgun therapy. So candidates who have been practicing on their own need to go back to basics so that they may be successful in the exam.
What are the components of a patients history?
Students are no longer taught to ask patients for a presenting complaint, they are told to ask the patient why they have come to the hospital or ER today or now. this is called “Reason for admission”. Try to write or relate one or two complaints which need admission or write down the procedure for which the patient has come.”
Writing down a list of complaints in chronological order is obsolete. It leads to confusion and does not indicate what immediate action should be taken. I give an example.
- epigastric pain postprandial 8 months.
- heartburn on lying down or bending 7 months.
- bloating and belching 7 months.
- flatulence 6 months.
- loss of appetite 5 months.
- vomiting of fresh blood 2 hours ago.
When this patient is admitted out of working hours and you ring up the consultant to give him/her the list of complaints it is natural to think of a chronic gastric/esophageal/duodenal problem. The consultant will schedule this patient for a routine assessment within 24 or 48 hours and forget him.
If you write: Reason for admission; a fresh GI bleed with loss of a cupful of fresh and clotted blood.
The response from the senior doctor will be: “send a sample for crossmatch and arrange 2 pints of blood, check his Hb and PCV, alert the gastroenterologist, surgeon and anesthetist, start an IV life line, shift the patient to the ICU. I will be there as soon as I can reach the hospital.” Where does the rest of the information go? Into the history of current illness.
So we now have two components of the history:
When you are presenting the history do not use any headings like “this is the history of present illness;” just give the information as it becomes relevant to the diagnosis of the disease.
- Reason for current admission. This may be a procedure like a biopsy. or bronchoscopy or for observation for fits etc.
- History of current illness. What does this include? The other complaints that you had written in the original list with some details added in, treatment taken during the 8 months of the illness, any significant tests done including their results. Ask the patient if he has the test results. Any improvement or worsening of the symptoms. Any procedures undertaken like and upper GI endoscopy or gastric biopsy. If a tentative diagnosis was given to the patient please mention this. Add any co-morbid conditions. Most illnesses even if they appear unrelated are mentioned here as well as long term medications. A neoplastic disease treated even several years ago needs to be mentioned here. Infections that have effects years later like Hep C, Hep B, HIV/AIDS acquired at any time need to be mentioned. Any disease or condition being treated by a clinician needs to be mentioned. The priority that you use in mentioning these are your own.
- There is no such thing as a past history or rarely so. Possible one might be something like fell from the roof of his hut 12 years ago and broke his tibia. Has no disability from that. Was treated for tuberculosis when he was a teenager. The disease has been inactive since then.
- Personal history. Geographical area where the patient lives permanently as different diseases are prevalent in different countries and areas. You should be aware what they are. Current residence may have a similar effect so mention this. Remember that in the subcontinent we have a mobile population and some people may move with the seasons. If the area has a special feature like the climate is very hot or freezing cold, or a desert area, dusty, with lots of fog or smoke or pollen then mention this. Mention the kind of house they have and access to electricity and water if you consider it relevant. Are they educated enough to communicate in writing, texting or telephone? Can they afford the treatment? What is the occupation and does it affect their health? Where you mention this depends on how significant the information is and can be mentioned in the current illness. Ask about their normal diet and dietary preferences but do not waste too much time on it. The objective is to detect a deficiency.
- Family history. Please mention if parents are alive and if not what they died of and at what age; mention siblings, whether older or younger, if they have any disease or if any have died. If it is a strongly inherited disease like diabetes or polycystic kidneys mention any aunts, uncles, grandparents or cousins who had the disease.
Remember that you are presenting the history after you have examined the patient. Because of the examination you have picked up the diagnosis. Use this information when presenting the current illness.
A candidate was presenting the case of a 38 ear old woman who had swelling of her body for 21/2 months. The candidate kept insisting that her face was swollen first and that the swelling then involved the lower part of the body. This usually happens in glomerulonephritis for some reason but not always. He/she insisted there was no breathlessness or orthopnea. They then proceeded to to do systemic survey of the liver, kidney and heart which took a few minutes. The examiner asked whether the patient knew what was wrong with her. The answer was yes. Well tell me. She has a valve lesion. Which one? She does not know. The candidate continued with the history.
“In the past history 11 years ago she had become very breathless and had a PMVC.” “What is that?”
“A percutaneous mitral valve commissurotomy.”
“What caused the severe breathlessness 11 years ago?” the examiner answered himself “Probably pregnancy and atrial fibrillation. Am I right?” Yes said the candidate. “What medication was she put on?” “Shall I tell you the names?” “Yes of course if she knows them” ” Lasoride, Tenormin, and an intramuscular injection every month for 5 years”.
Here is the story of a patient who had tight mitral stenosis 11 years ago. It was not calcified so a commissurotomy was done and penicillin prophylaxis was given for 5 years. She had two more pregnancies during this period and both were uneventful but no one seems to have given her contraceptive advice. By now the re-stenosis seems to have occurred along with AF and calcification of the valve. She now needs valve replacement, treatment for AF, anticoagulants and sound contraceptive advice. The candidate was not mentioning the events that took place 11 years ago as they thought it was “past history”. It is not past history but very much part of the current illness as the valve continued to be damaged over the years. When the candidate knew about the mitral commissurotomy and had examined the patient and heard the murmur of mitral stenosis the involvement of the mitral valve should have been mentioned at once.
Please do not “hide’ information with the idea that this has to be mentioned in the past history or family history. It is fatal to say to the examiner “I will tell you later”. This is not a guessing game, it is about making a diagnosis as quickly as you can and as accurately as you can. When you tell the examiner later you will not get any marks for the information. If the patient has a strong family history of Adult Polycystic Kidney Disease then mention this early in the current illness and do not wait until you come to the family history. This is essential history which will change the course of your investigation and treatment.
Try and get hold of a history from a patient who has travelled from a Western country. He will have a well written history with all the relevant information given in order of medical priority without any headings like “present illness” “past illness” family history” etc.
Please remember there is no “formula” which must be followed. Rely on clinical common sense. One common cliché to remember is that common things are common. A runny nose is most likely caused by a common cold and least likely by CSF rhinorrhea! Anemia is most likely caused by either a dietary deficiency or a bleed somewhere rather than an HLTV causing a rare leukemia. Ask about the diet. The daughter of a domestic cleaner is very unlikely to eat meat, chicken and eggs daily. Ask her what the menu is on a typical day in her home. That is why a personal history becomes important in history taking. If the patient appears well fed then skip the diet.
Another simple rule to impress the examiner is to talk to the patient politely and in a socially acceptable manner. Don’t shout or bark questions at them. Many trainees who come from a hospital OPD and its noisy environment tend to shout loudly. Being asked “Do you have heavy periods?” or “Do you have problems during sex since you started taking this medicine?” are not questions the patient wants the whole hall to hear.
You do not have to ask detailed questions about every symptom that either you or the patient has mentioned. If the patient mentions fever ask if he or a doctor or nurse ever used a thermometer to document it but if the patient only feels feverish please do not spend time in the usual litany
of “Is it in the morning or evening; is it high or low; is it with a rigor; etc.” Remember your clinical acumen is being assessed as well as your ability to evaluate the significance of the patient’s symptoms.
The patient may not tell you immediately about the essential symptom because either they are afraid or do not understand the importance themselves; weight loss and poor appetite, somnolence are some that are missed unless you ask about them. Understand the relevance of the questions you ask. You may be asked why you wanted some particular information. Please refrain from asking questions just to show that you know about a disease especially if the patient does not have the disease. It may backfire.
Remember the guidelines commonly used for either the diagnosis
or for assessing the severity of an illness and also remember who has set the guidelines and when. You may be quoting outdated guidelines. For example there are guidelines for assessing the severity of esophageal varices and there are differences in the treatment of each grade; kidney diseases are divided into stages dependent on creatinine clearance; the severity of heart failure has its own guidelines so does COPD. There are many others. The real test is how you present the information you have gathered. You will need to edit the information that the patient has given you into a form that makes clinical sense, The trick is not to miss out an important detail. If you understand why you asked certain questions and if you understood the answers not just the language; the relationship of the question to the diagnosis and how the answer clarifies the clinical problem, then your presentation will be good. Here is where you think about why, what and how: why am I asking this question?
- Be polite but not obsequious i.e. excessively polite.
- Remember the answer to your questions so that you do not have to repeat everything.
- Write down an important point but do not write down the answer to all your questions.
- Evaluate the information you are getting from the patient and divide it in your mind into
- essential information or the reason that the patient is seeking help. If you get this wrong you are going to get your whole diagnosis wrong.
- information that will help in making clinical decisions like is the patient a diabetic or has renal failure or is allergic to a drug or make the diagnosis clear.
- incidental information which may or may not influence the diagnosis and treatment.
- When you present the history do it in the above order.
- Why did the character of the pain or symptoms change? What difference does the answer make?
- What is the duration of the symptoms? Is it chronic or acute? Longstanding or recent?
- What weight-age should I give the answer?
- How did the disease progress? Is it getting worse or is a new complication developing? Remember most patients come to us with complex diseases or more than one disease.
- If the disease is infective pay attention to the epidemiology; where did the patient get it? Has the patient passed it on to someone else? Does the patient need to be treated in isolation? Do you or your staff need to be shielded from the disease?
- Why did the patient take so long to come to a hospital or consult a doctor? The reason may be financial or lack of access to medical care for geographical reasons, lack of awareness or treatment by practitioners of alternate treatment or by a doctor who had got the diagnosis wrong. I once came across a 12 year boy drugged to the gills for the last 1 year, with antiepileptic drugs, so drowsy that he had stopped going to school. His episodes of hypoglycemia were giving him the fits and eventually the insulinoma was removed and he no longer had epilepsy.
- What treatment has the patient already taken? How has this treatment modified the symptoms or the signs?
- How am I going to present the case? Which symptom or symptom complex should I talk about first?
When you are presenting the case and want to make a good impression change the the emphasis from the written history. In the written case file, you are required to write the patient’s bio data first e.g. name, age, marital status, occupation, home address, telephone, next of kin, person to call in an emergency. Do not recite all this when you are presenting the case.
During the presentation it is sufficient to give the name, age, occupation briefly and what the patient was doing at the time of onset of the symptoms if this was sudden or related to exercise and duration. Start with the most significant symptom or symptom complex. Talk about the co morbid conditions or lack of them; talk about the medication the patient is already taking. You can give the personal information after you have given the clinical information.
Try to give the information in your presentation so that you are leading up to a probable diagnosis. Even if your initial diagnosis is not accurate it does not matter. You can make up for it when you are presenting the clinical findings. Just randomly presenting symptoms without leading towards any diagnosis leaves a poor impression.
For example “This patient vomited blood two days ago. He has had no malena i.e. black tarry stool so it appears to have stopped. He has not had jaundice in the past, is not an alcohol drinker and has not been tested for Hep B or C.” This case may turn out to be a malignant peptic ulcer or even a bleeding disorder but you have shown clinical acumen by talking about liver disease and have scored good marks on presentation.
Or another example: “This 56 year old-lady, who is a school teacher, has come in with swelling of her feet for the past 5 days. She is not breathless and has no cough. She is diabetic but has never had her urine tested for proteins. Her blood pressure is also high so her major risk is either from diabetic nephropathy or hypertensive nephrosclerosis. After assessing her renal functions she may need a renal biopsy to clarify the diagnosis”. by saying this you have pre-empted a lot of questions and have exhibited your knowledge. The examiner then has time to ask you questions about management, recent advances, research and give you a better score.
Some phrases and modes of information you should avoid.
- Avoid lists of negative symptoms or signs. Do not say “there is no any (this is incorrect English grammar) breathlessness, there is no any cough; there is no any expectoration; there is no any cyanosis; there is no any clubbing, there is no any orthopnea.
- “The patient is a known case of hypertension/anemia/jaundice etc.” How do you know? It is better to say that the hypertension was detected when the patient went for a physical examination for an insurance policy 3 years ago. He has been on antihypertensive therapy with captopril but has not been investigated for the cause of the hypertension. This lady was found to be hypertensive during her second pregnancy and has been hypertensive since then. Her urine was checked for proteins and she says that she had no proteinuria and her feet have never been swollen, She needs her renal function checked. Another case may be “this patient has come in with the third episode of swelling of the abdomen. He was found to be Hep B positive at his first admission. He received interferon injections for 6 months but could not afford them any more. Appears to have gone into cirrhosis of the liver” Do not say that this patient is a known case of cirrhosis of the liver.
Have fun preparing. Lots of confidence is what is needed. The examiner is not out to kill you only to help you pass.