In the real world, my job does not exist. Many, many years ago, when schools, universities and what we have come to know as the 'conventional' education system, did not yet exist. So anyone who desired to study medicine or aspired to become a doctor, (a medical doctor by default, since PhD's did not yet exist), would basically search for one and then apply for an intern position. Or something like that. As an apprentice, the student learns the trade directly, through what we now call experiential learning. There are no formative or summative assessments. Imagine that, no exams. WOW. The student shadows the teacher for the needed number of years to master the art, or science, of medicine. After the student 'graduates', the new doctor is now licensed to practice medicine in his or her own capacity.
When I was a medical student, we did the two years of pre-clinical mostly lectures and practicals, followed by three years of clinical rotations, where we were attached to different specialities both in hospitals and also in the community. In each clinical rotation, we would follow the activities of the relevant team. Ward rounds, clinics, CME activities, grand rounds, on-call, accompanying the patient for investigations and so on. It was a reasonably exciting time and for the most part, I realised how little I knew and how much studying I needed to do, which never seemed enough.
At present time, part of my job description is to teach medical students how to take a history and perform a physical examination. This may seem deceptively simple. If I were to write a simple ten point "how to take a history and perform a physical examination", it could be done, but would simply not do justice to the topic.
The setting is important. History taking and physical examination is different for different specialities, and is different for the in patient versus the out patient setting.
Regardless of the setting, the medical student must remember that the purpose of taking a history and doing a relevant physical examination is to come up with a diagnosis, or list of differential diagnosis. Sometimes, a working diagnosis is most appropriate.
While there are differences between specialities, for example, there are different subheadings for a paediatric and obstetrics patient compared to a medical patient, in general, the lay out should be roughly the same.
Most people will start with an opening statement that includes some demographic details, for example...Mr X is a fifty year old Malay man from Wangsa Maju...We must always mention the age and gender of the patient, the race if relevant, and hometown if it is important. Wangsa Maju was mentioned as an area which currently has an outbreak of typhoid fever.
The opening sentence must also convey the presenting complaint, which is the main problem that caused the patient to seek medical help. Mr X is a fifty year old Malay gentleman from Wangsa Maju, who presented to the emergency department last night with abdominal pain, vomiting and diarrhoea for two days. For in patients, it is also important to note how the patient was admitted, patients who present to the emergency department tend to have more acute conditions that require immediate or urgent treatment prior and during the early stages of admission. Another factor which helps differentiate the different conditions that can cause the symptoms is the duration of symptoms. This must also be stated very clearly in the opening statement.
The next part is the history of the presenting illness. In this subheading, the student explores the different symptoms and establishes a timeline of how the symptoms progressed or the nature of each symptom that would aid in the establishment of a diagnosis. Pain is a very common complaint that would cause a patient seek medical help. Chest pain and abdominal pain are extremely common complaints and have a variety of causes which each can be discerned by asking specific questions. The good news is, the causes are not entirely exhaustive. Two months in a general medical ward would allow sufficient exposure for the student to see a variety of common and uncommon medical illnesses.
Most medical students are very good at asking about characteristics of chest pain, for example, exact location, severity, radiation, nature, relieving and exacerbating factors. These tend to help distinguish whether the chest pain is cardiac or non-cardiac in nature, as the consequences of a cardiac cause of chest pain carries much cause of
To be continued...
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