Oh dear, I couldn't wait till any longer. The moment I stepped home, I been recalling what Prof B has told us in class just now. Having class with her is always inspiring. In fact I wonder why is it so quality professors like her are not teaching us during our junior semester? They are the people who guide us on the right track. Perhaps many of us would have perform much much better if given the chance to have teaching sessions from them starting early in the course.
Anyways....I can't do much to change the system. So I'd just share what Prof has taught me today. Hope you benefit from it in any way.
What are the components of a good history?
1. The chief complaint (always the symptoms + duration)
2. History of present illness (note it is not presenting illness!!!) which includes:
a. chronology
b. description of the symptoms
c. relevant positive & negative symptoms
d. systemic review
The trick is, let the informant (be it the mother or the father or whoever the care taker you are taking history from) tell you the story. Ask open questions! History = his story. Get the sequence right and be clear of the progression of the present illness. Starting from the point when the child was still perfectly well. When you have get the clear picture, you move on to details of each symptoms. Get as much as possible regarding the symptoms. If it is vomitting, you may wanna know about the frequency, the amount, the content, the position while the patient vomitted, etc. Then ask about symptoms that you think is relevant to your differential diagnosis both positive and negative. Finally review systemic condition. Another point to remember is, document everything you get from history taking and physical examination and best is to make a timeline so when you look at it you know what happen from beginning to the point when you clerk.
Physical examination of a child is oppoturnistic. But your documentation must be systematical. PE comprises of general examination, nutrition status, hydration status, and systemic examination. Well I shall not go into details. Go look up from the textbooks what are the signs you look for in each component.
Well, after finish clerking first round, organise and work out the history you have taken. Does it give you clue as to which exactly is the system you are dealing with? Be very specific. Say you concluded it is the upper airway that is involved here because there is stridoer, further asking to decide the exact location whether it is the larynx in which case patient will have hoarseness of voice.
Next, work out the underlying pathology. Fever tells you patient has inflammation which may be due to infection or autoimmun disease so on. Then determine the most likely etiology such as viral infection which is most common in URTI. Lastly decide whether there are symptoms or signs suggestive of complication eg. vomitting complicated by aspiration pneumonia.
Okay, here is a simple guide for you to make diagnosis based on your history and physical findings:
1. site of the disease eg respiratory system: nose - bronchioles
2. pathology eg. inflammation - infection / autoimmune
3. etiology eg. viral / bacterial / fungal / protozoan
4. complication eg. sepsis
So an example of a complete diagnosis that should be written down in the case file is:
Acute gastroenteritis secondary to Rotavirus infection with 5% dehydration
Prof B mentioned, Do not give up!!! She meant when you still cannot determine the diagnosis after finish clerking the first round, go back the list again and look into each of them and see what other information you may need to obtain to help you to formulate the diagnosis. Always check the evidence for your diagnosis at the end of the day and try to explain the symptoms by the underlying pathophysiology. Diagnosis which is complete and specific is essential because it guides you for good management! So DO NOT ever diagnose just for the sake of diagnosing! Diagnose because you want to help the patient in the best way you can. Understood?
For those who do not know, Prof B is a neonatologist. Respect to Prof! I think it's the toughest job to diagnose disease in neonates who do not speak our language yet. I still find being a paediatrician is a 'cool' thing. Mainly because it's more challenging to me. =)
