History Taking

There are 2 opinions in history taking session, some think it is not difficult to score, some especially those whose English is not their mother tongue might think that it is difficult. My friends and I practiced history taking a lot before our exam. One of my friend taught me a technique to tackle this question and I found that it is very useful.

First of all, read the scenario carefully and take note of the important points, it could be the history itself, from physical examination or investigations. Subsequently, generate a list of differential diagnoses (pen and paper will be provided). When you are with the surrogate, you should be able to ask history according to the differential diagnoses in order to exclude them one by one. In between, if you realized there are still other differentials that you have missed, just add it in your list. With this method, you should be able to narrow down your list. If you are still uncertain of the diagnosis, continue with a full systemic review from head to toe. Of course, for an examination like this, knowing the social history and sometimes sexual history is important as well. Some candidates find it difficult to ask about sexual history. You can try opening sentence like this “ I know it could be a little uneasy for you, but there are a few personal question that I have to ask in order to know what is wrong with you, is it ok?” Find out whether the surrogate has a partner, and whether the partner is male or female (particularly important if you sit for exam in UK), whether there is recreational drug usage, smoking and alcohol.

Before you end the session, give the surrogate a summary of what he or she had told you. You may try asking “ Is there anything that I missed?” or “ Is there anything else that you would like to tell me?”. However, sometimes you might not get an answer as the surrogate might be taught to ask you back “Like what?” Then you should ask if he or she has any particular worries and answer to the worried. Lastly, inform the surrogate about what you think could be the diagnosis and advice on further investigations.

The examiner usually would ask for the diagnosis and whether there are other differentials, then the approach to confirm the diagnosis as well as treatment.

Here I have a scenario that my consultant rheumatologist gave me while she took me for a history taking session. Let’s see how we can approach it.

HISTORY TAKING
You are the SHO in the rheumatology clinic, about to see the patient below. Please read the letter from the patient’s general practioner.

Dear doctor,

Re: Mr Mohan, aged 40, lecturer

Mr Mohan has two weeks history of joint pain of right wrist and left knee. He is unable to walk because of the pain. On examination, his right wrist and left knee are swollen , erythematous and tender. X-ray of the right wrist and left knee showed no significant abnormality. His FBC is normal and ESR is 100.

Please give us your expert opinion and advice on the management of this patient.

Yours truly,
Dr G. Practioner.