Doctor Patient- how to develop clinical skills

Doctor-Patient – how to develop clinical skills
 How to overcome the common mistakes in case taking – based on real examples from IPD and OPD

Dr Mansoor Ali KR
Professor, Govt Homoeopathy Medical College. Calicut

The art of case taking can be learned only by interacting with the maximum number of patients of different age groups and diseases during student life.

The patient should feel that the doctor is someone who cares. where he can trust and to him, he can reveal anything.

History taking and clinical examination are crucial initial steps even in the middle of sophisticated investigations. Clinical skill is acquired only by study and experience, always something to learn from each case, that too needs tremendous skill.

Difference
Symptoms are obtained from history taking
A sign is elicited Clinical examination findings
Eg: Abdominal pain, fever and vomiting: Symptoms
Guarding and tenderness in Rt iliac fossa : Sign
Diagnosis: Acute appendicitis
Provisional diagnosis: Diagnosis before clinical investigations

Diagnosis will be obtained from symptom/ history: in more than 80% cases

Examples
Chronic smoker, Pain leg > rest – Arterial Insufficiency – Buerger’s disease
Shop keeper, Pain > lying down, elevating limb- Venous incompetence – Varicose vein

History is more important than the investigation
An infertility case in OPD – All investigation normal
Later only patient told about the history of TB – Tubercular salpingitis is a common cause of infertility in India

A patient presenting with an acute exacerbation of COPD may have a history of the respiratory problem going back many years. So take the history ‘along timeline’ gives a better picture – how they developed and how it now interacts with the quality of life and work.

The part of history taking is probably the most dependant on the skill of the doctor. The process of history taking for different patients will never be identical.

Note down the complaint in the language of the patient with adequate space in between them. After completing the history part each symptom should be qualified by sensation, location, modality, extension, duration, prodrome, onset, sequence etc.

Communication Skill
A doctor who is gentle & confident during case taking will get more patients than a doctor with perfect knowledge
Eg: Knowledge & Clinical skill are like Biriyani rice and Chicken
Communication skill is Spices and masalas
So a proper combination of Spices and rice will give nutritious and tasty biriyani

Check before case taking

1. How do you look – First impression will create a lasting impression
2. Proper time and place – avoid taking the case in IPD during early morning hours and lunchtime
3. Sit on the chair – never at the bed of the patient
4. Accompanying person – only one or two accompanying persons, ask gently others to leave
5. Avoid checking documents in the beginning
6. Avoid questions with obvious answers – Never ask the religion of a lady with Sindhoor, or a Muslim with cap
7. Volume of speech – moderate and not audible to patients in neighbouring beds
8. Listen actively – avoid using a mobile phone during case taking and rounds, avoid thinking about home or children during case taking – the physician should be constantly alert.

Never expect a quick and precise answer for every question from your patients

Before looking at the patient ,look at yourself
No patient will show a serious interest in talking to a young medical student with dirty clothes and apron.

Introduce your self, explain the purpose – the patient should feel that this conversation has benefited – so he will cooperate

The patient is always in stress – The only time when a person visits happily to a hospital is the birth of a child or newcomer.

Reassure the patient that the extra length of time you take to complete your examination is for the benefit of the patient.

Give a short summary of each section after completing it and give an introduction to the next session

Note-taking
When making notes, it is important to keep eye contact with the patient. Note down once the patient finished a complaint. We are not document writers.

Investigation
Prescribe investigation – only after history taking and clinical examinations

Two patients from the same family with similar complaints – investigation may be different based on history
History + Exam

1. Appendicitis
2. Intestinal Obstruction

Next investigation?

1. In the first case is USG
2. In the second case is X-ray

So take proper history and examinations before prescribing an investigation

A 50-year-old c/c smoker – abdominal pain & occasional vomiting
Ordered directly USG without examination – Stones in GB- removed – the pain still persist
Actually, that is a peptic ulcer – Gall stone was asymptomatic and incidentally detected in USG

Unnecessary investigation without proper indication adds a negative reputation to the doctor.

Never go for a high-end investigation at the beginning itself – the patient may ask for CT, MRI etc. after referring to internet sources, but do the basic investigation first. Otherwise, other doctors and lab people may suspect the doctor for giving costly investigations for trivial complaints.

After case taking says thanks and wish a speedy recovery. Contact your patient regularly till the discharge – that give assurance and satisfaction

Why age is important
BHP is a common cause of straining micturition in the elderly – but if the same symptom in the younger group, what may the diagnosis?
Answer : Urethral Stricture

Renal lump and hematuria may be a renal cell carcinoma in 35-year-old individual, same symptom in a 3 year old?
Answer : Wilms’ tumor

Breast lump in adolescent female probably a fibroadenoma, but in middle aged or elderly?
Answer : Carcinoma

A elderly female didn’t remember her age, but she knows that menopause attained 5 year back. So what may be her age?
Answer : 50

Parents not sure about exact age of a child. But he is studying in 3 standard. her age maybe?
Answer : 8

How to utilise Age for a rubric selection and prescription

Remember: Medicines will be different for the same complaint in different age groups.

Rubrics related to New born complaints

Murphy’s Repertory

• Bladder – PAIN, bladder – urine, retention, of, painful – new born infants
• Bladder – RETENTION, of urine – infants, in new born
• Breathing – ASPHYXIA – new-born, infant
• Children – URINE, retention, in – infants, in new born
• Clinical – asphyxia – new-born, infant
• Clinical – death, general – apparent, death – new-born, infant
• Mind – DEATH, general – apparent – new-born infant
• Nose – SNUFFLES, general – infants, in new-born

Synthesis Repertory

• MIND – DELUSIONS – born into the world; he was newly
• MIND – DELUSIONS – cats – he is a cat – kitten; he is a newly born
• SKIN – DISCOLORATION – yellow – children, new born

Rubrics related to Babies

• Abdomen – CRAMPING, pain – babies, in
• Abdomen – PROTRUSION, abdomen – umbilicus – babies, in, with flatulence
• Bladder – RETENTION, of urine – babies, in
• Brain – STROKE, apoplexy – babies, in
• Clinical – aphthous, ulcers – children, in – babies, in
• Clinical – stroke, apoplexy – babies, in
• Mind – JEALOUSY, general – children, between – when a new baby takes the attention of the family away
• Mouth – THRUSH, mouth – babies, in
• Rectum – REDNESS, anus, congestion – rash, fiery red in babies
• Skin – DRY, skin – babies, in
• Toxicity – FOOD, poisoning – artificial, food, agg. – baby, food agg.
• Urine – RETENTION, of urine – babies, in
• STOMACH – APPETITE – ravenous – anemic babies
• ABDOMEN – PAIN – babies, colic
• RECTUM – CONSTIPATION – babies
• GENERALS – CHILDREN; complaints in – delicate, puny, sickly – artificial baby foods; from

Rubrics related to Infants

• Abdomen, Inflammation, umbilicus, infants
• Children, Respiratory affections, infants in
• Eye& inflammation, infants
• Mind, Crying, children, in babies
• Nose, Obstruction, children, nursing infants
• Rectum, Constipation, children, in,infants
• Rectum, Diarrhea, children in, infants
• Rectum, Diarrhea, nursing, after, infants
• Skin, lntertrigo, infants in
• Rectum, Fissure, infants
• Nerves, Convulsions, children, in, infants
• Fever, Children, in, infants
• Lungs, Pneumonia, infants
• Abdomen, Hernia. umbilicus
• Generals, Nursing children, ailments in

Adolescence: Bladder Urination invol night adolescence

Puberty : Gen puberty ailments in

           Ext throat.gioter puberty

Young people: Head Hair baldness young people

Menopause : Female Menopause
Gen.Heat flushes menopause

Old people : Resp.Asthmatic old people

•  Mind. Memory weakness of facts,recent facts for old people
•  Female.metrrohagia old women in
•  Eye.Catract senile
•  Prostate gland Enlargement senile

SEX :

• Boys : Bladder.urination invol night boys in
• Girls : Head pain school girls
• Female : Eye.catract women in

Same complaint in different sex – medicine will be different

Occupation
A policeman or bus conductor complains about pain in leg – Vericose vein

Carcinoma……..is common in rubber, textiles and petrochemical industry – Bladder.

Pulmonary diseases – Silicosis of minors, asbestosis in asbestos workers, coal workers pneumoconiosis, byssinosis in textile workers

Hepatitis B – blood-related workers – Doctors, nurses

Radiological technicians – leukemia, thyroid cancer

A person with HA and blurring vision – he was an employee in garment showroom, major part of his day in front of computer screen

A 29-year-old employee in the multinational company presented with during pain in the epigastric region since one month. He was non-smoker, non-alcoholic and consumed non spicy food. Diagnosed as a peptic ulcer on the basis of stressful life – long working hours, inadequate sleep, regular sleep, irregular meals, pressure of achieving targets etc.

In case of unemployed – ask about the type of work he used in earlier days.

Along with occupation, it is important to know the lifestyle of the patient during his work.

Occupation related rubrics are available both the Mind and General Chapters of repertories

PRESENTING COMPLAINT
They usually give main complaints only

A 40 year old individual complaint only about dull pain in left loin. On asked about any other complaint, he had some episodes of hematuria and painless swelling in his left scrotum. Diagnosis is Renal cell carcinoma

Other examples
Fever is the main symptom
But if it is associated with

• Cough and expectoration – respiratory infection
• Burning micturition – UTI
• Diarrhoea – GIT infection
• Jaundice – hepatobiliary disease
• Tender swelling – Cellulitis/abscess
• Altered sensorium – CNS infection like meningitis, malaria etc.

The diagnosis given by the patient may be wrong 

• All Scrotal swelling he may say as hernia
• All Bleeding per rectum – Hemorrhoids – but may be fissure, Cancer, fistulae
• Any abdominal pain – appendicitis
• All respiratory – pneumonia to the common man
• Symptoms like anger, restlessness, HA – attributed to BP by patients
• Weakness and fatigue – Low BP is the main reason sited by public

Duration
Severe sudden pain in lower limb for few hours – embolism – but few weeks or months – Burger’s disease

Cough and fever since few days – acute bronchitis – since few weeks can be tuberculosis or chronic respiratory complaints

In inflammatory swelling – pain appears before swelling- but in neoplastic disease, swelling noticed much before pain.

History of presenting complaints
A young male with severe pain in rt testicle since few hours. He revealed a history of sudden lifting heavyweight in gymnasium. – Testicular torsion

A child with high-grade fever and tender swelling in buttocks. On asking parents revealed that – an injection by the local doctor yesterday – post-injection abscess

Coincidental
An old man informed about a painless swelling in left inguinal region since two months, notice after taking medicine from local doctor fro diarrhoea and vomiting. This may be inguinal hernia or lymphadenopathy – that has no relation with medicine. So coincidental happenings.

Diagnosis possible from major symptoms 

• Renal colic – dull aching pain
• Ureteric stone – colicky pain
• A child with neck swelling and high-grade fever – acute bacterial lymphadenitis
• Swelling with a low-grade fever may be – tuberculosis
• Abdominal pain < by meals but > empty stomach – Gastric ulcer
• Pain < empty stomach > meals – Duodenal ulcer
• Non-bilious vomiting is mainly due to non-obstructive cause like – gastritis, meningitis, migraine
• Bilious vomiting indicates obstruction of bowel beyond the opening of common bile duct
• Hematuria before micturition – urethral polyp or hemangioma
• Hematuria after micturition – Urinary bladder calculi

HPC – Especially deals with the aetiology behind the onset of disease. How the disease progressed along with the appearance of the symptoms in sequential order.

RUBRICS RELATED to the history of presenting complaint :

 1.Etiology
Gen.Measles after
Male. Swelling testes mumps from

2. Diagnosis Gen.Paralysis apoplectic

3. Nature of the disease – acute, chronic or recurrent

• Rectum. Constipation chronic
• Throat Inflammation tonsils recurrent
• Eye. Inflammation acute

4. Onset and progress of the disease – sudden or gradual

• Vertigo. Sudden
• Gen.Paralysis Gradual

5. Extension and alternation

• Gen.Paralysis ext upwards downwards etc
• Gen Side symptoms on one,Rt then Lt etc
• Nose. Obstruction alt sides
• Resp.Asthmatic alt with eruption

PAST HISTORY – History of past illness

The student must inform the patient – that now he/she is moving from present to past

It includes 

• History of any significant disease
• History of any surgery
• History of hospitalisation
• History of similar complaints in the past
• Any other significant event
• Include cured disease in the past and chronic disease still suffering

If nothing significant in the past – write as
“ There is no history of any significant acute or chronic illness in the past history of the patient. Besides, there is no history of hospitalisation and any major or minor surgery in the past”.

If you are asking about TB -because of social stigma, they will hide – many patients will not understand- but ask

Have you ever suffered from chronic cough in the past ?

Have you received some prolonged treatment in the past for 6 or 9 months?

A 10-year child presented with a swelling in epigastric region of the abdomen. Revealed a blunt abdominal injury while playing in school, few weeks back. This information led to a strong suspicion of a pseudo pancreatic cyst.

A 45year old male presented with a winless slowly growing swelling at the tip of his right finger for a few days. He was able to recall the history of pain prick injury at same site a few month back. – diagnosis is implantation dermoid cyst.

A 5 month old girl was brought to a surgeon with a non-tender swelling on this left thigh. On enquiring about any significant even in past, informed about DPT vaccination. So this may be – abscess after vaccination

Fever and malaise in a case of rheumatic heart disease patient. History of tooth extraction ew days ago. – Probably infective endocarditis

A 30 year old Kerala male presented with a swelling of left leg for one month. He revealed a history of a visit to Bihar. – Probably filariasis

A patient with a swelling in the floor of the mouth. He revealed a similar small swelling in the same site a few years back. – probably Ranula

A girl with severe pain in Rt iliac fossa, with similar episodes a few months back – Ureteric stone

Ask for the previous illness from childhood down to the present, chronologically, which ages at which attack appeared, with its nature, symptom, duration, severity and sequence.

Disease processes that gradually progress may start off by being asymptomatic and the patient may only notice symptoms when they start to interfere with his lifestyle and activities

Past history is 

• Very important in finding the miasmatic background of the patient.
• Ask for the history of any pronged illness in the past,r/c attacks etc.
• Birth history – It include prematurity, post maturity, truma, congenital defect etc.
• H/O of developmental milestones, normal / abnormal.
• H/O of vaccination with or without any outward reaction.
• H/O of any surgical interference, exposure to radiation etc.
• Details of domestic circumstances, negligence, the attitude of the parents, over protection, relationship between father and mother.
• Details of the accident, mechanical injuries / mental shock..

Rubrics related to Past history 

1. Aetiology
Resp.Asthmatic eruption after suppressed

2. Diagnosis
Cardiac complaints and joint affections in a patient with a history of recurrent tonsillitis
Chest. Inflammation heart endocardium rheumatic

3. Development of the disease
Surgically or mechanically corrected disease in the past history could be considered as presenting complaint in the concept that they would have been present there if a surgical intervention has not been made. Examples are surgically treated Hernia,fibroids.haemerrhoids,catract,deformities,fistulae,tumors etc..

4.Miasm

• Gen.Sycosis
• Gen.Syphilis

In Synthesis repertory, General chapter, there is a good rubric History with god number of useful sub rubrics

In complete repertory also few rubrics related to History is given

PERSONAL HISTORY  

For the personal identity of the patient.

• Ask about the occupation, habit, diet, regimen, exercise…
• The habit of smoking, alcoholism, extramarital relations..
• Born and brought up, job, study, status of children, mode of living… Marital status, no.of children.
• Antenatal and postnatal development.
• Economic circumstances.

Increased sleep and decreased appetite are common – Hypothyroidism
Increased appetite – common in Duodenal ulcer , DM, Duodenal ulcer
Appetite decreased – Depression, hypothyroid, TB, malignancy, appendicitis, old age, less physical activity
Sleeplessness – common in Anxiety, mania, schizophrenia , hyperthyroidism, BHP, change of sleeping place
Hypersomnia – common in hypothyroidism, uraemia, depression
Sleep in supine < : CCF, Burger’s disease,

Addiction
The patient usually will not reveal – confirm from friends and relatives

A 45 year old male with the severe paining epigastric region, refused any type of addiction, but physician reconfirmed from the wife about alcoholism since last few years. Arrived at a provisional diagnosis of acute pancreatitis.

A 30 year old male patient with infertility due to azoospermia. He has a painless scrotal swelling since long duration. Varicocele causes azoospermia.

Related rubrics are :
Delayed mile stones :

• Mind.Talk slow learning to
• Extr.Walk late learning to

Nature or conditions of the dwellings :

• Chill.Exposure to tropical countries
• Resp.Difficult mountains in

Nature of occupation :

• Gen.stone cutters
• Resp.Asthmatic miners asthma from cold dust
• Rectum.Constipation sedentary habits from

 Rubrics related to habits :

• Resp.Asthmatic drunkards
• Head.Pain tobacco smoking from
• Gen.Food alcohol <
• Gen.tobacco <
• Gen.Narcotics <

Rubrics related to marriage :

• Mind. Marriage idea of marriage seems unendurable
• Genit.F Sexual desire increased in widows

FAMILY HISTORY
Extreme care should be taken while eliciting the family history 

A 25-year-old female with a painless nodule in the left breast. Usually benign. But with a positive family history of cancer – probably malignant

A 18 year old male with a non-healing ulcer and not diabetic. Positive family history of diabetes mellitus. The physician checked the sugar level and found diabetic.

A 35year old female with a lump in breast informed that her mother-in-law had suffered from Ca breast a few years back. Based on the family history doctor arrived at a provisional diagnosis. – ?? Mother in law not genetically related to her

A 5 year old female presented with increased appetite and thirst. When asked about heath status of the family, nothing relevant in husband, inlays, parents. But missed inform about her younger brother living at parent’s home – was a known case of DM.

A 3-year-old child was admitted with complaints of fever and convulsions. Parents gave a history of tuberculosis to his grandfather who had died 5 years back. – This information has no significance as the child had never been in contact with grandfather.

Family history helps us 

• In deciding the miasmatic background.
• Helps in tracing consanguinity
• Ask about any miasmatic disease in the family including parents, grandparents, siblings with paternal and maternal relations. Eg : T.b,Schizophrenia,Eczema…..
• H/O disease, cause of disease, cause of death etc
• Pre disposition and tendency to disease.
• Individual peculiarities of all the relatives.
• This will create a feeling in the patient that “doctor knows all about them” that he is not only interested in them and their families, personally and professionally, but that he takes pains to learn and keep in touch with all their individual peculiarities.In Synthesis repertory General Chapter rubrics with sub rubrics – Family history available

MENSTRUAL AND OBSTETRIC HISTORY
A 16 year old unmarried girl with severe pain Rt iliac fossa. Thought of appendicitis. But when asked about LMP, in the absence of parents, she informed that she missed one period. Who enquired further, she gave a history of unprotected sex with her boyfriend. USG abdomen revealed ectopic pregnancy.

Always think about the possibility of pregnancy before sending a patient of childbearing age for a radiological investigation like X-ray, CT etc. A negligent prescription may lead to congenital abnormalities and miscarriage. The first half of the menstrual cycle is comparatively safer for investigations.

TREATMENT HISTORY
A young woman presented with complaints of restlessness, involuntary movements and uncontrolled speech. This is an extrapyramidal side effect of metoclopramide which she has taken for control of her hiccoughs.

In treatment history – confirm whether they are taking medicines regularly.

Must ascertain the treatment already undergone by the patient for the chronic disease, must understand what medicine has been administered and what effect they produced. The original picture of the disease must be ascertained in order to understand the progress of the disease from its original state.

Treatment history helps the physician to avoid the administration of medicine used earlier improperly.

Related rubrics :

• Gen Irritability When too much medicines have produced…
• Fever. Changing paroxysm after Homoeopathic potencies
• Chest .Inflammation lungs abuse of aconite after

Medicine, Remedies and Convalescence are important rubrics listed in General Chapter of Synthesis repertory which gives many useful sub-rubrics and medicine

In Murphy’s repertory a full chapter Toxicity – represent a good number of useful rubrics and sub rubrics

PAEDIATRIC CASE TAKING
Stranger anxiety is common in pediatric age group – some parents threaten the child for taking food by saying the name of some doctors.

Do not ignore the child. He will become more uncomfortable if the doctor always talking with parents. Simply have a smile, ask his name, school etc.

Above 4 years ask him directly about his problem. But avoid frequent and prolonged eye contact with the child – they are very sensitive to eye contact of strangers.

Do not give false reassurances as this will result in a loss of trust which will hinder the examination. The consulting room must have a range of toys suitable for all ages, and the child should be allowed to play with whatever takes his fancy.

For the experienced clinician, much of the information needed to reach a diagnosis for a child is gleaned from careful observation. While talking to the parent, watch and listen to the child.

Always take notice of what the parent is saying, and listen to their concerns. But Remember that the print is giving their version of the problem, not the child’s many time.

Older children will usually cooperate sufficiently to be examined lying down, and routine physical examination is similar to an adult examination. A younger child should be examined sitting on his carer’s lap, as any attempt to get him to lie down will result in instant distress.

Order of examination in children (Hutchison’s clinical methods)

• Starts in Feet
• Hands and pulse
• Face
• Head
• Neck
• Abdomen
• Chest
• Neurological
• Eyes and funduscopy
• Genitalia, groins, anus
• Ear, nose and throat
• Routine measurements and simple clinical test

The worst part of the examination in a child is the examination of nose, ear, mouth and throat.

How to handle a crying infant
Make sure that his cry is not because of hunger
Give some toys or key chain to pacify
In an extreme case, ask any relative to take him out for some time, after finishing the history, call him back.

The history you obtain in the child’s presence may be less accurate and more limited terms than when you interview the parent(s) alone.

Address the infant or child by name rather than by “him,” “her,” or “the baby.”

Babies are best-examined parent’s lap

Observation Eye is important in Paediatric
Observe the child for 

• Hyper-activity: Mind, Body
• Discontent, Anger, Tantrums
• Constitution: obese, frail, puny, skin and nails.
• Character of: Perspiration, stool, urine etc.
• Quietness, Passivity, Sluggishness
• Nutritional status
• Developmental landmarks
• School performance

Presence of both parents is recommended during the interview.

Parents need practitioners who are supportive rather than adjudging or critical. Hence it is better to avoid criticizing the parents.

Try to put the parents/grandparents at ease by making them sit down first in cases of acutely sick / emergency case.

Adolescent
A good way to begin the interview with adolescents is to chat in an informal manner about their friends, school, hobbies, games, sports and family.

It is better to speak to the adolescent alone after obtaining past medical and social history from parents

A teenager may not accept abo any kind of addiction in front of parents.

Menstrual history of adolescent girl should be enquired cautiously, never ask in a loud voice, preferably ask mother about menarche.

ELDERLY PATIENTS
Behavioural changes are common
Accept it as a natural phenomenon
Loud volume and slow speed speech is preferred or accepted

Interviewing the elderly 

• Respect the aged person not in terms of consolation, but in terms of his personality.
• Pay extra attention to them.
• Ageing patients have longer histories and may tell them slowly. Don’t be impatient.
• Do not try to accomplish everything in one visit.
• Learn how they have handled crises in the past. This will help you in planning the old patients and also in the selection of a constitutional remedy.
• Don’t be idle in physical examination. Also, do investigations frequently / as and when necessary.

Older people are considered in three distinct chronological groups: the young old (65-74), the old (75-84) and the very old (85+).

If the patient is confined to bed, observe his positions in bed, his manner of moving,

mental state, turning, skin, color, odor, the appearance of excretions, temperature, sensorium,

covering, ventilation etc.

Reticent OR Timid patient
Presence of some specific relatives may be the cause of silence of the patient
Some may too apprehensive while talking to a doctor
Silence may be an indication of lack of interest
But do not interpret the nature of any patient instantly, as the talk progress, they may become more comfortable

Irritated patients
Many patients are irritated because they are not satisfied with the treatment
Some irritated by nature
Do not respond instantly in the same way – an irritated patient cannot settle down by your anger.
In OPD or IPD if you are a student or junior doctor – tell him about the purpose and benefits of your case taking, if completed successfully

Emergency patient
If there is a huge crowd accompanying the patient – allow only the minimum number in the chamber
If relative constantly interfering the conversation, gently request him not to interfere and allow the patient to explain
Do not ignore the relatives while talking to your patient
The presence of relatives should not be ignored while asking about addiction, menstrual history or sexual history.

Garrulous patients
They will give a huge amount without really revealing the information that goes towards a useful medical history

Angry patients
For some patients, anger may be part of the symptomatology or expressed as a reaction to the diagnosis or treatment. This will be particularly true in patients with a non-organic diagnosis who insist that there is ‘something wrong’ and that the doctor must do something.

It is always worth apologizing on behalf of the unit or institution

Google patient
Nowadays it is not unusual for a patient to come into the first consultation with a new doctor armed with printouts from various websites that he feels are relevant. The doctor must go through the information with the patient and help them by showing what is relevant and what is not.

Too many accompanying persons
There is always a reason why people come accompanied, but if there appear to be too many people present, or it seems to be not suitable for case taking, it is appropriate to consider asking the others to leave politely. Beware of a situation in which the accompanying people answer all the questions, even if there is not a language difficulty.

Communicating with loquacious patients

• The physician has limited time and there is a need to “get totality”
• Try to focus on important issues.
• Show interest and ask questions in those areas.
• Interrupt if the need arises, but courteously.
• Do not display your impatience.
• If you have used up the allotted time or, more likely, go over it, explain that to the patient.

Dear Students

• Interaction with every new patient brings some new experience to the student
• Try to interact with the maximum number of patients with different types of disease
• During UG – Concentrate on how to take the history of a patient, how to examine the petting etc.
• Repeated case presentations will build up your confidence
• Before visiting the IP patient, read about the case taking and practice of medicine part of his disease.
• Do not visit any patient in a big group
• Do not check the documents of your patient, arrive at a diagnosis of your own.
• During presentation – never address your patient by diagnosis. Eg. Never say – I am going to present a case of carcinoma breast – but a lump in the breast.

Common mistakes 

1. Incomplete the name of the patient
2. Detailed address of the rural patient
3. Incomplete occupation details
4. The irregular arrangement of history of presenting complaint and past History
5. Repetition of details
6. Deep description of unrelated complaints – constipation in the elderly patient with a small wart on the neck.
7. Excessive use of the abbreviation

Communication skill during internship and PG 

1. The internship is an opportunity to observe and learn the practical implementation of his theoretical knowledge
2. Learn important procedures like catheterisation, IV etc.
3. Communication with the patient should not be affected by the work pressure
4. An intern should maintain a proper balance between his routine work and studies
5. Interns and postgraduate students are of the same age – but different designation and responsibilities
6. A postgraduate student is in the classroom throughout a day
7. No doubt the PG period is the most hectic phase of any doctor’s life
8. Avoid prolonged phone conversation in from of the patient
9. Some patients intentionally blame the previous doctor to get some sympathy from the current physician – avoid making any comments based on his arguments.
10. Whenever possible, the disease should eye explained with suitable diagrams. Show the photographs of previous good results. That will add confidence to the patient.
11. Investigation of choice should of physician’s choice and not of the patient’s choice. Do not read only the final interpretation written on the bottom.
12. Explain the outcome, but explain the major complication only
13. Never give false assurance
14. Never hesitate to accept if you cannot treat a condition or patient
15. If you are taking a photograph – explain the purpose. Show the photograph immediately to the patient. Mask the face for presentation or publication.
16. Bad news should be informed only to selected relatives.
17. Take care of your voice and facial expressions while discussing mistakes in any language. Don’t forget to appreciate the student’s ad staffs.

Examination
Start the examination on the right of the bed/couch with the patient semirecumbent (approximately 45°). From the right-hand side of the patient, it is easier to examine the jugular veins, apex beat and abdominal viscera, although left-handed students will take longer to master this approach.

SOME RANDOM THOUGHTS

• All the events and effects should be recorded without any interpolation or deletions.
• Don’t get influenced by the symptoms of drugs recorded in the Materia medica.
• The intensity of the symptoms should be given due consideration while recording.
• Each symptom should be valued properly with the marks against them.
• Should not hurry a patient in his narrative.
• Do not put leading questions which suggest an answer.
• Do not ask in a haphazard manner.
• Do not use complicated technical terms.
• Do not hide anything from the patient.
• Do not rely on patients statement entirely.
• Avoid questions along the line of remedy.
• Never ask alternating questions.
• Never skip from one symptom to another at random
• Never examine a lady in the absence of her relatives or a female nurse. Take minimum symptoms of maximum importance.
• Give attention to bystanders – ask something, never ignore

Avoid questions along the line of remedy
It is very dangerous to think about medicines during case taking.

For example, if a patient narrates about ineffectual urging and straining, we will immediately think about Nux. Vomica and ask a few more questions in order to make or confirm the case as Nux. Vom patient. This is not good but surely bad.

Take the rubric Rectum –Constipation- Ineffectual urging and straining in Synthesis Repertory. There is 252 medicine with 23 first grade remedies. But we know only one remedy Nux.Vom……so we will make the case as Nux. V by some leading questions.

Similarly, Abdomen – Pain Pressure amel, 55 medicines are there. But we used to prescribe Colocynth in all cases of pain ameliorated by pressure.

Once a patient attempted suicide because the cruelty of husband, we will prescribe Aur.met throughout her life whatever may be the complaint. See Mind Suicidal disposition. 196 medicines with Aur.met, Aur.Muriaticum,Nat.s and Psorinum as the three mark remedies.

Remember 

1. Our aim is an open, empathic and non-judgemental approach and maintain non-threatening eye contact as much as possible.
2. Taking history from a patient in pain is more complex than recording symptoms and making a diagnosis.
3. Always confirm the symptoms from friends & relatives – especially mental symptoms – they will give an only positive side or one side information
4. Observe the expression on the face of the person accompanying the patient, while the patient is narrating his symptoms.
5. Never accept what the patient says at face value. Symptoms provided by the patient should be accepted with interest but without judgment.
6. Look at the hidden expression behind the symptoms.
7. The symptoms expressed with spontaneity, clarity and intensity is of the highest value.
8. Try to confirm the essential parameters of the patient in diverse situations of his life.
9. Avoid asking the patient directly about his nature – Avoid questions like – Are you angry easily? Consolation > etc.
10. Try to lead him through other questions to express it without being conscious of doing so.
11. Many patient bring out the best symptom if you give a pause after the answer. Once interrupted, the patient rarely completes what he was intending to say.
12. The expression of characteristics can often be provoked. Eg .By making the patient wait beyond his time of appointment ie, inpatient, mild or rigid.
13. If you come to a dead-end in case taking and just don’t know how to make the patient talk, just ask him to describe one typical day, his routine from morning to night.
14. Leave space between the symptoms .Questions are then put in a manner as to complete each symptoms as location, sensation, modality and concomitance.
15. The examiner should be constantly on the alert and observing while making an oral examination. Avoid phone calls, chats, and using social media during consultation hours. The physical examination will be made thoroughly and systematically and the findings added to the record.
16. Look for peculiar, uncommon, characteristics, individual peculiarities from causal expressions of the patient, attitude or gait.
17. Note the patient’s name, age, sex, vocation, the record of the family (Age of the parents, general health, cause of death etc.) We often get a good picture of the hereditary tendencies in this way.
18. If you are dealing with an acute condition, limit yourself to dealing with the acute state alone, and do not at the same time attempt to dip in to what has been a chronic state. In an acute explosion, the chronic picture will retreat completely.
19. Before leaving the case, go over again the family history, the personal history, the mental and physical symptoms, temperament, personality etc. Verify if you have skipped anything.
20. Remember that the nature and sensation of symptoms, concomitants, the time of day, the position and circumstances under which the symptoms appear etc. are the most important modifiers of any given case.

Retaking the history
Sometime the patient may not get decided improvement, so we have to re-take the case. The logical conclusion of this is that no two histories taken from the same patient about the same set of symptoms will be identical, even if the same doctor repeats the process. Repeated histories, taken at different times, by different people and in different ways may provide just as much extra information

Particular gestures useful in analysing specific pain symptoms  (Hutchison’s clinical methods)

• A squeezing gesture to describe cardiac pain
• Hand position to describe renal colic
• Rubbing the sternum to describe heartburn
• Rubbing the buttock and thigh to describe sciatica
• Arms clenched around the abdomen to describe mid-gut colic

Judging the severity of symptoms
A tiny alteration in the neurological function of the hands and fingers will make a huge impression on a professional musician, whereas most others might hardly notice the same dysfunction. A mild skin complaint might be devastating for a professional model but cause little worry in others.

Case taking should be perfect
 “If you neglect to make a careful case taking. The patient will be the 1st sufferer, then you yourself will suffer from it .. and ultimately Homeopathy also”

The patient still complaining – don’t feel bad
It is very common for the doctor to be pleased that one condition has been solved, but the patient still complains of the remaining symptom that he originally came with. Some patients will keep on changing doctors. Give good quality treatment and never expect courtesy from the patients.

Outcome
Successful case taking supplies the physician all the evidence that is necessary for proper diagnosis, treatment, and prognosis.

Conclusion
History taking is the cornerstone of medical practice. It combines considerable interpersonal skill and diversity with the need for logical thought based on a wealth of medical knowledge and represents the beginning of treating and caring for patients in the widest sense. Ending the interview properly is important as how it begins.

References 

• Hutchison : Clinical methods 23 edn.
• Hahanemann – Lesser writing of Hahnemann edited by RE Dudgeon
• The Skills of History Taking (2nd edition) – Dr. Rahul Tanwani
• The clinical approach – RD Lele
• Dhawle.M.L : Principles and practice of Homoeopathy.
• Robert.H.A : Principles and art of cure by Homoeopathy.
• Close S : The Genius of Homoeopathy.
• Schmidt.P : The art of case taking.
• Rajan sankaran : The spirit of Homoeopathy.
• Vithoulkas : The science of Homoeopathy
• Munir Ahamed : Introduction to Repertorisation.
• Tiwari : Essentials of repertorisation
  

(c)Dr Mansoor Ali
Professor, Govt Homoeopathy Medical College. Calicut
similima@yahoo.com

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