history taking

[real chick]

---

Members don't see this ad.

hi
im a 4th year student.
i would like to ask if anyone could help me & tell me if there are any sites or books that would help a student on how to present the history.

 

[Dral]

check out:

Clinical Examination: A Systematic Guide to Physical Diagnosis.

 

[RySerr21]

you never covered this in the first three years?

 

[geogil]

hi
im a 4th year student.
i would like to ask if anyone could help me & tell me if there are any sites or books that would help a student on how to present the history.

What exactly did you do as an MS3 for 50 weeks then?

CC: "my tummy hurts"
HPI:
-who is the patient : age, gender, race, occupation (if pertinent)
-with Hx of ____________ chronic disease (HTN, CAD, etc)
-why are they presenting (cough, bloody urine, etc)
-How long has this been going on? when did it start? why, how?
-what makes it better/worse
what do they think it is?
How has it influenced their life/behavior/well-being

-Other history that is RELEVANT:
family Hx, Birth Hx, Immunization, previous illnesses, Social Hx: drugs, etoh, tobacco, psych history if relevant

-ROS

-The rest of the history that wasn't relevant to the HPI, but should be included in the H&P

PE
Labs
Imaging

DDX
Plan

This is just a basic outline and you should tweak the details, but these are the things you should include, at a minimum. I don't believe you are an MS4 and don't know this though. Do you attend a US school or a 6 year program?

basically you should present the history in a way that tells your audience in a logical way who the patient is, and why they are seeing you, and what has been going on with them. You should order it chronologically. If you are really stuck, try writing it out in paragraph form to see if what you know makes sense in the order you would say it in. Obviously this technique is not going to work when you're pre-rounding. Listen to the way your residents and interns do it, fake it til you make it.

 

[monback5555]

My question is about the review of systems. Surely you're not going to do a complete neurological review for someone with a tummy ache, right? So what do you guys usually do for review? Just heart, lungs, eyes, ears? That's about all my FM doc does anyways.

 

[Dral]

Ideally, you cover most of your ROS during your history taking. You cover the other relevant ones later on in the interview if they remain unanswered. This is difficult for Medical students since we don't have enough experience/knowledge to be able to integrate ROS into the history as well. For instance, if a pt has a certain lesion on their shins bilaterally, you might think of Crohn's (erythema nodosum), so as you are taking your history, you would at least briefly explore this by asking about GI sx's. If they have sx's, you explore avenue further, if not, you at least have a ROS point covered. Suddenly, you are dictating "ROS, blah blah blah, otherwise negative" in no time flat.

 

[geogil]

My question is about the review of systems. Surely you're not going to do a complete neurological review for someone with a tummy ache, right? So what do you guys usually do for review? Just heart, lungs, eyes, ears? That's about all my FM doc does anyways.

I usually do a quick couple of questions just to check, because patients will often not reveal things unless asked, or they might forget unless they are questioned directly. I usually ask about syncope, TIA s/s, numbness and tingling, and weakness.

 

[Knicks]

you never covered this in the first three years?

What exactly did you do as an MS3 for 50 weeks then?

...... I don't believe you are an MS4 and don't know this though. Do you attend a US school or a 6 year program? .......

I had the same questions as you two.

Hopefully the OP will respond, as I'm genuinely curious for some reason.

 

[physics junkie]

She asked how to present a history, not how to take one.

Although I would assume you would know how to do both by now.

 

[geogil]

My question is about the review of systems. Surely you're not going to do a complete neurological review for someone with a tummy ache, right? So what do you guys usually do for review? Just heart, lungs, eyes, ears? That's about all my FM doc does anyways.

I usually do a quick couple of questions just to check, because patients will often not reveal things unless asked, or they might forget unless they are questioned directly. I usually ask about syncope, TIA s/s, numbness and tingling, and weakness.

 

[geogil]

She asked how to present a history, not how to take one.

Although I would assume you would know how to do both by now.

How would the information you present differ from the format I suggested?

 

[treva]

How would the information you present differ from the format I suggested?

When presenting a patient you wouldn't just list off the points of the history in the order you wrote them. You want to put the important stuff at the top and hightlight stuff only relevant to the P/C (i.e. a GI attending wouldn't really give a crap about the patients sore knee unless it was related to GI pathology).

A mock presentation could be as follows:

Mrs. HM is a xx year old woman who presents with a xx day history of intermittent burning epigastric abdo. pain following meals. She has a significant previous medical history of (insert relevant GI history) and is on (list GI relevent meds - ie NSAIDS). Associated with the pain is / are (list relevent GI symptoms, i.e. nausea, hematemsis, etc), but no (list relevant negative). Important risk factors include (list) Relevant physical examination findings were (list), but (list important negatives) were not seen.

If needed you could further suggest DDx, investigations, management plan, etc.

To the TS, I think the best way to get better at presenting patients is to just do it. Think about what is important and what the doctor would want to know, and then present the patient to the resident / attending. Ask for their feedback (usually they'll just tell you anyway). Everyone sucks at first, but practice and you'll get better.