The history of the presenting complaint used to be one of the biggest enigmas in all times for me. It still is, mind you. But unlike in the bygone days of utter ignorance, I'm kinda confident that i can at least steer not completely blind. Maybe not along the chartered mapped and established course in the smoothest manner.... but i can be pretty sure that i would somehow or other end up where I'm supposed to do.
The world is full of misleading advices. Most directions given by reputed books were more confusing rather than very informative. For example some doctors kept saying that all the symptoms should be documented in the chronological order as the patient describes it. No place for fancy words like dyspnea.... just simple terms, 'difficulty to breathe'. Still other books and consultants would mock you until you wish either you or him would annihilate just then if you use simple language that everyone can understand.
Still others would recommend that you proceed not in the chronological order, but in the order of importance of symptoms. Now this, although may suit the grizzled veterans of medicine,may be quite impossible for a total minion like me, because i just can't decide which symptom is more important. For example, a 55 year old lady may present with a ulcer on her foot following minor trauma, but in the cause of conversation she might mention passing very frothy urine since about one week. It ain't causing her discomfort, so she doesn't consider it a big deal. But we know the implications.
Life is complicated. So the best method is obviously personalized. You tell it the way you like and make sense to you.
So how do 'i' do it??
I usually go with a big smile and start gossiping. Well i mean literally. I try to sound as much as possible like some concerned and slightly curious person than some nerd who go scavenging for"exam cases".
I ask the patient what happened and let them talk a bit. Now the first few minutes will decide whether you are in for a bad day or not. Some patients are excellent storytellers. They begin from the beginning and go on just like a well told story ought to go. They quench your curiosity with just the right answers and do Sheherzad proud.
Others, well the least that you can do is to resist the terrible urge to write a psychiatry referral for the others. They begin from the end and refer to obscure event in the past, and when you ask about it look at you as if you are the biggest idiot not to know about it. These type of patients are unfortunately the more common.
So what i do is to listen and somehow or other get the whole history in order they happene. For example, in a patient comming with a pelvic pain, i would inquire and dig up her previous year diagnosis of a right sided polycystic ovary. My history would begin with that. " ... Sir, a 17 year old female, previously diagnosed with a right sided polycystic ovary presenting with a RIF pain of three days duration..."
Then i would go on and relate the events that led up to her current hospital admission.
Now remember, a history is unique. You only get one history once ever. No two histories are alike.
Before proceeding to the next level of history presenting i tried to master this art. The most difficult art of relating things in the way they happened in the order they happened.
So for my 17 year old patient that would be,
"....Sir, a 17 year old female, previously diagnosed with a right sided polycystic ovary presenting with a RIF pain of three days duration.. She had initially undergone USS of abdomen which hadn't revealed any significant abnormalities."
This is what she told me. And if i repeat the same thing,
1) The consultant,the registrar and all the buggers would openly laugh at me. Or there's an equal possibility of them descending on me like a pack of dragons and scaring me speechless.
2) The story so meticulously planned would be a senseless idiocy. It won't make sense to anyone.
3) Princess scherazad would be ashamed of me.
4) The story won't help to form any diagnosis.

So like someone who is a diciple of Sherlock Holmes should do, i make some very specific inquiries and form my own story based on the patient's experience.
That of course will be the content of my next post.
And a big thank you to all of you guys reading me. I would so like to hear what you have to say!

When i started this blog i never intended to make it a clinical blog. I just wanted to write.. But now i find myself relating almost entirely my clinical experience. After all that is what my life revolves around. That is the reason i spend most of the nights sleepless.... the cause I've had no real holiday in eons...
Anyway back to history.
As i was saying the other day, the gog and magog of a history is the presenting complaint and the history of presenting complaint.
* The presenting complaint is the opening.. The beginning.. And a bad beginning would inevitably lead way to a series of unfortunate events. ;P So it must be perfect. Like a woman's clothing, it should reveal just sufficient to give you an overall idea of the patient.
Essentially it should contain the patient's details in summary and his main complaint.
The text books say, it should contain the reason for hospital admission.
It would be quite a piece of cake in a senario like, " 75, year old mr. Nandadasa, presenting with acute abdominal pain of 6 hours duration.."
But yesterday i met a patient who told his story this way..
me: so, mr. G, what is you problem?
mr. G: Ahh, I had abdominal pain for the past 6 months.
me: Do you have abdominal pain still. Where does it hurt?
Mr. G: It doesn't exactly hurt now.. Well now after the fall of course my back hurts.
me: A fall? So did you get admitted because you fell?
Mr. G: No it was a near thing.. But still, ain't it?

And all the while the patient had gotten admitted for something completely different most likely.
After you somehow get why the patient got admitted, your whole life centers around that. The history of presenting complaint should elaborate the complaint like a story... But a most logical and systematic story it should be..
I would so like to go on about the history of presenting complaint too now, but after a busy casualty day and night I'm afraid I'm just too tired... A whole day...listening to patients, taking histories painstakingly, only to be laughed at by the registrar upwards is a very rewarding and morally satisfying passtime i guess..
Right now I'm in dire need of a room of requirements of which i could shut the door and sleep till i wake a natural waking... But alas.... sleep my dear friends is a luxury which is not for us in purgatory...

I frankly believe that I've never been this busy in my whole life. ;) But for the first time in my life i feel smart. I'm not sure whether it is justified or not. But I feel more in control when taking a history .
I guess i can try to put down my formula to several specific points.
1) When taking a history, do not try to medicalize the whole thing. Chat with the patient. Sick people don't like to give histories, but they do like to talk about their illness to anyone who would listen. And that is something which can't be read and learnt.. Chatting and harmless gossiping are priceless skills for a med student. ( i'm very good at that)
2) Don't ever take off the smile you wear. It's part of the uniform.
3) Try to be genuinely good natured. Those if you who are inherently unpleasant, may at least try acting.
........ The technical aspects come next.

4) History is not taking down a huge yarn. It is a story. The actual tale is based on a drama in real life. But you are the narrator even though you are not the hero. So the whole plot is in your control. You have the final say in determining the climax. Don't betray that right of yours to the patient. He already enjoys the honour of being the hero.
5) The gog and magog of the whole history are the presenting complaint and the history of presenting complaint. You absolutely got to get them right.
### From my next post onwards i'd like to share my perception and what little experience I have about each component of the history. Especially the two giants.... Gog and magog. :)

Welcome to the arabian nights..... where suspense is the thread by which her life hung. But unlike princess Scheherazade
I have very little confidence.
To think that it took me three years to understand that this is what it is all about!!!! Storytelling.. Every patient is a character in some drama in real life and we are the narrators.
The all interesting adventure is his complaint, and like every good story, his also has the many complicating twists and turns and dead ends. Every time i listen to an account of abdominal pain, interspersed with worries about an unmarried daughter, and complaints about an irritating boss, and reminiscences of a college love affair, i am reading a story....
To narrate the story doing justice to the original storyteller, and in the time honoured flow, so that not all but only the necessary is disclosed to my audience is my job.
I am a storyteller... and the clinicals are just the storytelling sessions.
And after this discovery i can't even describe in writing how ashamed i am!!! And THAT is supposed to explain a great deal.
I the dreamer, the artist of pen and ink and letters, and the STORYTELLER, can't tell a proper story to impress some unimaginative muggle who doesn't know the first thing about dreams. Pathetic!
A good story with a lot of suspense.... :) Now THAT is my element...
Something tells me that from today onwards, ( tomorrow sounds kind of too distant, I mean with a whole night in between it doesn't feel safe to send important dreams to tomorrow without personal supervision) everything is going to be different..... for the better.

useless, worthless and hopeless...
I wonder why they don't adopt these time honoured phrase as the motto of our faculty. These three words must be the most frequently heard words of "encouragement" by any medical student, from our faculty at least.. ( other med facs must be the same most probably, but we have this natural tendency to consider that the neighboring pastures are the greenest.)
Anyway, what's the point? I mean there is a limit. A limit to how much we can do without any guidance or supervision. From the very first clinical appointment, we got to know the bitter truth. We are not taught. Never taught.. Expected to know everything, and severely reprimanded when we do not know.
And worse, we are not listened to or believed. I mean who believed or cared that 6 weeks of our first medical appointment was wasted doing nothing? Who asked us wether the "lectures" we got in our first surgery appointment were useful, relevant or worthwhile?
In the beginning of the fourth year very few of us know how to get a good history or examination..
And nobody would ever know, nobody would ever care.
Maybe one day i will be a consultant.. Just as i still remember all about being a child, then also i will hopefully remember all about being a medical student. I will remember about having to wear hevy white coats in damn hot weather, about staying up most of the night studying and still being 21, about having to worry about the modules, wards and the real world which does seem to exist on and off.... I would doubtless remember with "nostalgia" the ethics lectures from the behavioral department which seems to be the only place where medical ethics exist... And i most certainly will remember the hopelessness and fraustrated anger that i felt when the consultants treated me like furniture... i swear, i will definitely teach all the students whom i'll come across, and make a great job of it....
That will be my kind of revenge. :)

....another day's end. So muchh is happening. I mean can we even fathom the things that has happened around the world in the past 24 hours? The world besides can we even make sense of all the stuff that has happened in our own lives during the day?? Sooo complicated...
The patient i was assigned today had undergone a below knee amputation. 52 year old man.... Unmarried.... And no place to go... no one to look after him.. But he won't admit it. A simple "insufficient social support" would suffice for my notes.., and my case file would have an "interesting case".. But what would happen to him ?
Long Long ago,when we started clinicals, I would worry the hell about things like that. But now i know that i can't play the god. All that we can do is to be normal towards him i guess.
Not sympathetic, not pitying, just normal. Anyway i know that i hate being pitied, so do unto others as thee would do to thyself.

the one good thing about dawn, is that it is a new beginning.. No matter how bad a day you are having, you can always look forward to a new dawn...a new beginning when all will be alright once again. The thought is especially welcome after one hectic day with the community research project , and a dead ending argument with two research mates. Well, maybe i'm being a shade too grumpy, but life is not easy for fourth year medical students.
But, despite everything, life is lovely., The nearly missed romance in the centuries old hospital buildings, the unsuitably colourful vascular theater building, the quaint wooden stairs in the merchants ' ward.... old plaques, and tablets.... and right in the midst, signs of dawning modernization... That is the unlikely place with which i'v most remarkably fallen in love with. My hospital. God knows what hillariously flimsy right i have to call it my hospital.. But somehow i do feel more at my element there, than out among the crowds...
Next week we will begin our second surgery appointment...and with that,once again will i be required to bear witness to the reality... Life and it's tears. But then, i know despite everything,i won't be beaten in my game of being happy....