Stories of Histrory Taking

1) I was posted to MAU-medical assessment unit one day and i was asked to clerk a new patient that was just admitted to MAU. So i went with my clinical partner and we saw a lady on the bed and a young man besides her. We started off by introducing ourselves and asked why the patient was there. And the young man told us that his mum had stroke and she couldnt speak. (OMG, tak kan want to clerk her by using sign language/ non verbal method?) Then her son started to tell us stories that she has weakness on the right side. (OMGx2, she couldnt even do sign language coz one side of her arm was paralysed!!!) I stared at my clinical partner and seeking for help. And we decided to ask the young man for her details then. He was telling us that he found her collapsed in the morning.... But he didnt know about other details, eg: past medical, drug, allergic, smoking and drinking history coz he didnt stay with her and his mum just came over from spain to visit him... (Arghhh... what a difficlut case) We tried to ask closed question directed to the patient, eg: Do you smoke? And she nodded. We asked again to confirmed and she didnt respond. ( i think she's confused) As a result, we didnt obtain much of her medical history but we still presented her case to a SHO and he sorted out the documentation...

From the medical studnet point of view, i feel sorry for the patient, but it's really hard to obtain history from someone who couldnt express themselves even if we are willing to help... It's even harder to obtain history from them if their family dont know they are not close to their family.
The moral of the story is update ur family or friends with ur daily life so that they would be able to provide information to the doctors if you KO one day (touch wood!!)

2) I was asked to clerk this gentleman who has very interesting cardiac history in a GP clinic. (OK, cardiac history, set in my mind, probably he has ischaemic heart disease. Ah, boring! Chest pain again...). I walked in and started with my opening question: What are you here today? ( i always feel that this is a good question to start with for history taking but i found out i was wrong until i met this chap) And he said that he's coming back for his prescription. (Em... Sweat!!! I cant make this a chief complaint and i cant derive any questions from there for history of presenting illness) So, i moved on to asking about what medications he was on ( i regret starting off with drug history coz it was weird to do the history taking in a reverse order) He told me he's on warfarin(first thing came into my mind was DVT-deep vein thrombosis), simvastatin (this is an expected drug if he has IHD), ramipril (OK, he might have hypertension) and two other drugs that i couldnt remember. (there's no GTN, asprin, and beta blocker. it's so strange?! maybe he's not an IHD case) Ok from the drug histroy, i moved backwards to ask what medical problems ha has to make him on those drugs. (Deng deng deng deng!!! this is the interesting part) He said he had cardioversion 3 weeks ago and they put him on warfarin. (OK, next think backward, why was he cardioverted, must be something wrong with his heart rhythm) He said he had palpitation for 18months. (See, i was right!!!) And then i was stucked, palpitation ah, not chest pain ah, and i was trying to apply to SOCRATES. Coz i never clerk a history of palpitation before... After that, i asked about his family history, smoking and drinking history and the GP came in to review my history. I didnt even ask about the regular/ non regular and fast/slow when he had palpitation. ( what a simple mistake) And after that 10min history taking, i really learnt a lot!!!

From the medical student point of view, not all clerking in CVS is chest pain or shortness of breath. Not all diagnosis would be angina, myocardial infraction, and heart failure. Do not forget about arryhthmia, especially atrial fibrillation!!!
The moral of the story is do not make any assumption or have any expectation coz life is so unpredictable!!!

3) I was in ICU-intensive care unit and i was asked to clerk Mr Big (that's not his real name, the staffs called him Mr big because he was very obese) I appreciate this clerking coz it's the only case i could clerk in ICU as most of the patients in ICU were in sleep, intubated, on a ventilator and not suitable for clerking. Mr Big was fit enough to talk as they are going to discharge him from ICU to medical ward. Of course, i started with the same question again, "Why are you here today?" ( i clerked him before the second case, so i was still very used to my method, i think i am going to change soon, coz it's no longer very useful.) And he gave me a weird answer saying that he was there because the staff couldnt find the equipment to move him away. (See, it not a very good question as the reply wasnt what i want) So i rephrase my question, "why do you come to the hospital?" and he answered me that he came to the hospital for some breathing test. (OK, i asked the wrong question again) I repharse it the third time and make sure that he would fully understand, "Why do you come to this ward and why were you admitted to the hospital?" (and this time i was fairly sure that i could get the answer i wanted, mana tau...) He said: I dont know... I dont remember how did i come in and i dont remember who brought me in. I just remember that my GP came to see me and asked me to come to the hospital for a breathing test and next thing i could remember after that was i was alreday in this ward. (So Strange... How am i going to write this in my history? Cheif Complaint: patient dont know what happen to himself) I guess he was collapsed and he didnt even remember whether he collapsed or not (Yau mo gau cho ah??? Makes my life so difficult) And luckily his wife and his mum came to visit him at that time. I could obtain history from them and they told me that he always felt asleep and he wouldnt remember what's going on when he was in sleep. And i went to read his notes after that and the diagnosis for Mr Big was Sleep Apnoea. He collapsed( or felt asleep?) in the hospital and the anaesthetist was called to go see him as he stopped breathing at that time. That was how he admitted to ICU.

From the medical student point of view, ask the correct question to get the correct answer!!!
The moral of the story is also ask the correct question to get the correct answer!!!