Nov 28, 2014

History Taking (Video Recording Session)

Assalamualaikum warahmatullahi wabarakatuh.

Yeayyy done with my video recording session!
What's 'video recording'?
Video recording is actually another type on how we learn during the clinical skills session.
We will have to interview a simulated patient (history taking) according to the case that we get.
The duration for the interview is 5 minutes and another 1 minute is for the simulated patients (SP) to give feedback.
What we do will be recorded and on the following week we'll get feedback from our peers.

I was quite excited and a bit nervous.
Excited because this is the time to know where am I (at which level) and nervous because this is my very first time!
We were divided into few groups and guess what?
I was in group 1!
Each of us got a room and a case.
I was assigned to be in the room 29C.
My case for today's video recording was a patient with sore throat.

I just waited in the room until the patient came in.
Okay now I'm going to tell on what I supposed to do.
Then I will tell what I forgot to do haha.

The patient came in.

Hello and good morning. (Greet)
My name is Nurul Ardilla Noorezan, first year medical student from IMU. (Introduction and role)
Please, have a seat.
May I know your full name please? (Patient's full name)
Can I address you as Ms _____?
Okay Ms ____, I'm here on behalf of my consultant to gather some information from you.
Is that okay with you? (Ask for consent)
I will make sure that all informations will be kept confidential between me, you and my consultant. (Confidentiality)
So, can we proceed?

Ms _____, what seems to be the problem? (General open-ended question)
(She told me she was having sore throat).
Oh I can see it's hard for you to talk.
Do you need some water?
Do you feel comfortable?
Can you tell me more about your sore throat? (Open-ended question)
Is swallowing food painful?

(I tried to use SOCRATES in this case. Later I will explain what is it).
Do you have any idea on how you get this sore throat?
When did you get it?
How's the progress? Is it becoming better or worser?
How the sore throat feels like? Is it like sharp pain or burning?
Is there any other things (aka symptoms. I tried to minimise medical jargon as many as I could) that come along with this sore throat?
Does the sore throat follows any pattern? Is it constant or on off?
Did you take any medications or do anything to relieve the sore throat?
If I give you a scale from 1-10, what is the level of the pain that you feel?

Okay now I'm going to ask few questions about your current health. (Signposting)
Is that okay with you? (Consent)
Do you lose your weight?
Is your appetite okay?
Do you drink alcohol? Do you smoke?
Do your sleep cycle change?
Is your bowel motion okay?
Has there been any changes in the character of your bowel movement?
Is there any changes in colour or consistency of your stools?
Did you have any bleeding?

Now I'm going to ask about your family. Is that okay with you? (Signposting & consent)
Is there any of your family members who is affected too?
Do any of them has any diseases?

Ms _____, do you have any other medical problems?
Have you had any surgery in the past?
Do you take any medications?
What is the dosage?
How often do you take it?
Do you have any allergies to drugs and medications?

Okay Ms ______, now I would summarise a bit everything. (Summary)
(Use ICE)
Ideas, Concerns, Expectations (Patient's expectations).

Alright Ms ______.
Don't worry, you have come to the right place.
I will pass everything to my consultant and he will decide on what we should do.
Hopefully you will have a very speedy recovery.
Thank you Ms ______.

So the feedback that I got from the SP were;
I was neat. I maintained eye-contact.
Body posture and gestures were good.
My voice and tone were good.
Bla bla bla.
But.. (jeng jeng jeng)
I didn't show enough empathy wuaaaaa.
She told me that I looked too calm.
I just asked her if she wanted some water which was not really enough.
Sokay, I will improve myself next time InshaaAllah!

Oh and I'm not really sure is it right if I use SOCRATES in this case.
SOCRATES is usually used if the patient has pain (knee pain, arm pain etc).
SOCRATES stands for Site, Onset, Character, Radiation, Association, Time course, Exacerbating/Relieving factors and Severity.
You can google it if you wanna know more details.

As I mentioned we had to interview the SP for 5 minutes.
I had asked all questions 1 minute before the bell rang so I simply asked few more questions regarding urination and travel history, which I think were not necessary haha.
Travel history is usually taken from patient who's having fever.

This is just the basic thing that I learned.
I'm so sorry if there's any mistake.
And I know the flow may be quite bercelaru bcs we haven't learned the systems yet so we don't know what are the real questions that we should ask.
If there's anything that you want to correct me, just tell me okay.

With that, I thank you.
Assalamualaikum and good night! :)