Medical Histories for the MRCP and Final MB

Iqbal Khan, Zafar Iqbal

• Publisher: CRC Press
• Year: 2018
• Print ISBN:
  9781138446298
• eBook ISBN:
  9781315358024
• Topic: Medicine
• Subtopic: Medical Education

Taking a patient's medical history is a vital skill often overlooked by junior doctors and medical students, leading to a worryingly high failure rate in the PACES and OSCE exams. Don't be caught out! This book has been specifically designed to give you invaluable guidance and practice for taking medical histories. It features 50 complete case studies, including referral letters, medical histories, suggested data gathering methods, points to consider, warning signs, management of uncomfortable topics and differential diagnosis. With a focus on the importance and benefits of role-play in revision, this concise and easy to read format provides the study aid for Membership of the Royal College of Physicians (MRCP) candidates sitting their Objective Structured Clinical Examination (OSCE) and Practical Assessment of Clinical Examination Skills (PACES) examinations. It is also of great benefit to undergraduates approaching their final year examinations.

PART 1

Taking a Medical History

THE OBJECTIVES

The key objectives of a medical history include:

•  establishing a rapport with the patient

•  clarifying the nature of the patient’s ailment and their perception of the illness

•  identifying possible organs or systems involved and to then focus the clinical examination

•  comprehending the social context of the illness. Namely what impact the illness has on the patient’s life and the impact of ‘life’ on the patient’s symptoms

•  identifying the patients expectations.

To achieve these objectives the doctor needs to be able to take a detailed and effective medical history within a limited amount of time. It is essential to realise the significance of time and its importance in determining whether or not you will pass or fail the exam. Any competent layperson should be able to take a comprehensive medical history if given enough time and a performa outlining the questions to ask. However, during busy clinics and acute medical takes, the skilful doctor should be able to carry out the same task over a few minutes and formulate a plan of action. This skill is developed by practising and fine tuning your technique so that irrespective of the case you are presented with at the exam, you can take a detailed medical history, outline an action plan and present it to the examiners – all in the space of about 20 minutes.

Inspection of the MRCP PACES mark sheet (readily accessible on the MRCP (UK) website at http://www.mrcpuk.org/Examiners/Documents/Station_2.pdf) for the history taking station shows that the candidates will essentially be examined in three areas:

1  data gathering in the interview

2  identification and use of the information gathered

3  discussion related to the case.

These will now be discussed in greater detail. Final MB examiners will use similar mark sheets and hence medical students may also choose to use these sheets while practising their skills.

1.  DATA GATHERING IN THE INTERVIEW

The examiners will expect you to perform the following tasks.

•  Elicit the presenting complaint and document all associated symptoms logically and systematically. Find out about any relevant psychosocial factors. For instance, it is very relevant if a patient presents with headaches and you find out that these symptoms started shortly after she found out that her husband was having an affair!

•  Take a detailed past medical, drug, social and family history.

•  Display appropriate verbal and non-verbal communication with a good balance of open and closed questions and behave in an appropriate manner.

It is essential to note that the history needs to be taken in a logical and systematic manner. Over the course of your training most of you will have developed a system for taking a medical history. And if you are happy with the format, please stick with it as long as you incorporate the above tasks. For those of you that are not happy with your history taking skills or are in the process of developing your skills, I present a possible scheme here:

Taking a Medical History

Presenting complaint (PC)

State the problem that has prompted the medical referral, e.g. shortness of breath, chest pain, double vision etc.

History of the presenting complaint (HPC)

Elaborate on the presenting complaint. This is the most important part of the history and should yield the most relevant information and hence appropriately more time should be allotted to this portion of the history. The doctor has to encourage the patient to start talking about their medical problems by asking open questions or statements such as ‘Your doctor has referred you here because of your medical problems, tell me more’, ‘What is your medical problem?’ A common error is to ask too many questions and thus afford the patient little opportunity to give the history. So, let the patient talk. However, time is precious so it is important that the patient doesn’t waste time by talking about issues that are not relevant to the presenting complaint. Patients have to be ‘kept on track’ with suitable interjections. In any case the occasional remark such as ‘Tell me more’ and ‘Go on’ will aid in eliciting a history, particularly when the patient is reticent. As the consultation continues, more specific and closed questioning will become necessary to elicit a more detailed history: ‘Does the pain go down your arms or up into your neck?’, ‘What caused you to develop the breathing difficulties?’, ‘Was the pain sharp or dull in nature?’ An important point to bear in mind is that questions should not be leading.

Past medical history (PMH)

Enquire about other illnesses that the patient is suffering with or has suffered with in the past. Also enquire about any previous operations that the patient may have had. You can develop a ‘sieve’ of common conditions that can be specifically enquired about; for instance, hypertension, asthma, epilepsy, diabetes, angina, peptic ulcer disease etc. Try not to rush through a list as you will leave the patient confused and the examiners will not be too impressed. Remember also that much of this ground will be covered in the systems enquiry below.

Drug history (DH)

Although many people will suggest that you proceed to a systemic/systems enquiry at this stage, I feel that it is more logical instead to ask about the patient’s current medications, including the dosing. Also ask about any known drug allergies and use this opportunity to enquire about allergies to other substances. It is also essential that you remember to ask about over-the-counter medicines.

Social and personal history (SH)

This is an opportunity to really get to know the patient. Ensure that you have enquired about the patient’s occupation and, if appropriate, any bearing it may have on their illness. For instance, if someone has presented with abnormal liver biochemistry and it transpires that they work as a pub landlord, it would perhaps be logical to ask whether this results in them consuming excessive amounts of alcohol. Generally, in any patient it is important that you specifically ask about cigarette smoking and alcohol consumption. It is also worth enquiring into the patient’s social set up, i.e. who they live with and in what sort of house. In the UK, there is a major problem with delayed discharge of elderly patients for social reasons once they are deemed medically fit for discharge. Hence, it is particularly important to take a detailed social history in elderly patients. Examiners will be very impressed if you do. Particularly ask about their activities of daily living (ADL) such as cooking, washing and shopping, whether they do this themselves or receive help from family/friends or social services. In some instances (for example, where sexually transmitted diseases or blood borne viral illness is suspected) it may be appropriate to take a sexual history and ask about illicit drug use. But it should not be part of the routine history. It is important to tease out the relevant information without appearing to be prying. This is particularly true if a sexual history, such as the number of partners, episodes of unprotected sex and sexual orientation, needs to be taken. With certain conditions, particularly infectious diseases, a travel history should also be elicited.

Family history (FH)

It is important to ask about illnesses that run in the family. For example a young patient may present with a diarrhoeal illness and it is crucial that you ask about other family members suffering with inflammatory bowel disease. It is worth asking about the circumstances of the deaths of first-degree relatives such as parents and siblings. Where an inherited illness is suspected, consider constructing a genetic tree illustrating the involvement of various family members.

Systems enquiry/review (SE)

Now you can ask about each system in turn, and ensure that there is no important information that has been omitted.

•  Cardiovascular: chest pain, palpitations, pedal oedema, nocturnal dyspnoea?

•  Respiratory: shortness of breath, haemoptysis, cough, sputum?

•  Gastrointestinal: appetite, weight loss, abdominal pain, altered bowel habit?

•  Neurology: headaches, speech, visual or gait problems?

•  Genito-urinary: dysuria, nocturia, frequency, discharge, menstrual problems?

Communication skills

The interview should be entirely purposeful. The questions should not be simply conversational or leading, but should be probing and relevant. It is important that you listen to the patient and at least seem to be very attentive. Rapport is better and patients are more forthcoming with information if they feel that the doctor is listening. Good listening aids empathy (putting yourself in the patient’s shoes). Active listening is demonstrated by the use of eye contact, posturing (e.g. head nodding) and responding or asking, directly after the patient’s last response.

For the interview to be purposeful, it is important that you encourage the patient to remain relevant to the purpose of the interview and redirect them if they go off at a tangent. If there is any doubt about a response it is OK to ask the patient for clarification. Sometimes, patients find it difficult to articulate their true problems and concerns, and both verbal and nonverbal cues help to shed more light on the underlying problem. An example of a verbal cue may be a patient who has presented with heartburn and during the course of the consultation may say, ‘My mother suffered with heartburn and turned out to have stomach cancer.’ This patient may not be particularly bothered about the heartburn and instead be seeking reassurance that he does not have cancer. The good doctor can glean much information from a patient’s gait, posture and general body language – so-called nonverbal cues. For example, excessive eye contact may suggest anger and aggression, whereas lack of eye contact can imply embarrassment and depression.

Appropriate touch (handshake, putting arm around a distressed person) is also a powerful means of communication, building rapport and showing empathy. No doubt some people find it easier to use touch than others. As a general rule, avoid excessive touching, particularly if you are someone who is not comfortable with touching other people.

2.  IDENTIFICATION AND USE OF INFORMATION GATHERED

Normally after the medical history is taken you start to examine the patient. However, in this artificial set up of the PACES exam or an OSCE, you have to conclude proceedings at this juncture. If there is any uncertainty, check that the information is correct with the patient and proceed to summarise the history and produce a list of likely differential diagnoses; formulate a management plan and any investigations that may be necessary. It is always nice to ask the patient if they have any questions. The examiners will be particularly keen to see that you have produced a list of the main problems and your ability to correctly interpret the history.

3.  DISCUSSION RELATED TO THE CASE

In a nutshell, the examiners will be assessing your ability to discuss the implications of the patient’s problems and your strategy for solving these problems.

PART 2

Practice Cases

CASE 1: SUDDEN BLINDNESS

Candidate information

You are reviewing patients in the medical outpatient clinic. Your next patient has been refe...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• About the author
• Abbreviations
• How to use this book
• PART 1 TAKING A MEDICAL HISTORY
• PART 2 PRACTICE CASES
• Useful web pages
• Index