art in taking history

Assalamualaikum n hellllooooooo~

hey, today im so free to write. yeah im home and im feeling so great! XD

here im gonna write a lil pieces of my stories in HTAR (klang hospital)

all of us hve been divided into groups of postings..

Medicine, Surgery, Paeds, OnG and PCM.

since im now in medicine posting, kinda broad things to learn but

for beginners like us, History Taking n Physical Examination are the main points.

it was all about basic skills that all medical students have to practise, and practise, and practise. eventhou u're already a doct or even a specialist.

They always say, taking history is an art.. that u must practise and be creative with it! so that u can come into diagnosis very easily and be a great doctor! =D

i remembered my paed's consultant (almost all actually) taught tat history and physical exam will lead to the correct diagnosis 90% most of the time.

Basically, these are the things that we have to find out from the patient we clerk.

His/Her chief complaint (of what makes them come to hospital)..

History of presenting Illness

Past medical history

Past surgical history

Family history

Social history

Sexual history

Review of systems (just to make sure we arent missing sumthing)

It's kinda hard for first time doing it. i mean, taking history of my first patient.

I remembered how awkward was i when i first came to ward.. to find a patient as a task for next day's presentation.

n ive no idea why i went there alone. probably just to get the 'feel' first.. lol

yeah the patient came with shortness of breath which its abb is just SOB or in medical term, it's dyspnea.

''ok.. SOB... SOB.. SOB, gosh, wut else to ask!''

actually it was hard when u or even me had fixed things like SOCRATES format in ur head because tat's mainly for pain.

can we ask about SITE for SOB? or radiation? no rite.

but others like Onset, Aggravating factor, Relieving factor can be asked in this case.

so that means, ive to be creative enough in modifying questions.

It's okay to keep socrates in mind but be able to correlate with the presenting complaint. and so that we wont MESS UP!

n doctors always remind us to start with open-ended questions. such asss...

“Tell me more about your chest pain.”

“What did your stool look like?”

“What is your pain like?”

 n avoid  this way

“Was your stool black?”

“Did you have a crushing pain in your chest?”

btw, why im like giving a lecture pulak? gosh~ haha

im just excited to share jee..

n of course im still brushing up my skill. lol

things getting better in Klang.

i enjoy clerking and talking to patients even sumtimes u get pissed off by certain people (i wont mention who. =P)

n of course, it always be US that being our own 'enemy' when u feel so a lazyass..

urmmmm..

''Miscommunication often occurs not because you didn't ask the right question but by HOW your asked it''

oh ya. other thing about Klang..

it's like a dead city (well said Zhafir) with a bunch of crows.. not just one.. it's a lot of bunches or supposedly flocks kann? ahhh.. easy said, it's like they own Klang. =P

so many of them n they simply poop everywhere.

the poops look like paintball stains to me.

n really annoying when they shoot their toxic and acidic wastes onto ur car.. -.-

other than that,

the hostel itself is like a castle of coachroaches (do i spell it right? =P)

i think im gonna make friends with these creatures later lahh.. really good friends. hmmmmm

lol, i think not only patients experience this.. =P 

me n eddy pernah macam in a spelling class when we wanted to figure out what's written by the HO. haha

ok that's all.. a lot of things to say but it's 3 a.m already~

need to sleep.

tomorrow gonna be a long day for me.

btw, i bought these..

taddaaaa~

they're from a new bakery shop near to my house.

i like it! but the goods there are quite pricy.. huhu

for just boxes, all together cost around rm12. which i think it wud be around 6-7 if i buy at Bagus Bakery shop in Shah Alam. =.=

but, never mind then.

ok papai uolss~

thanks for reading.

have a great day n

Assalamualaikum! =)

''Laughter reduces pain, increases job performance, connects people emotionally, and improves the flow of oxygen to the heart and brain.''