Adventures in Medical School

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Secret tips and hot pointers
by fiona

Yesterday Patty and I met with Tom, a pathology resident who was an internist in his former life. The purpose of the meeting: to learn secret pointers and hot tips on how to do a good job as a third year medical student. Basically, how to avoid looking like a moron when interacting with residents and attendings. He went over, in painstaking detail, how he takes a clinical history, what he looks for in a case presentation, and what things to focus on in a physical exam.

The history, he said, is one of the most difficult things in medicine. You will never master the history. "The history will master you," I helpfully chimed in.

The clinical history is something that I have learned about many times, but am not good at actually taking. For example, the last time I volunteered at the Wallace clinic, I saw someone with a cough and forgot to ask if they smoked. Kind of an important question, but i didn't remember to do it because the history is not in my blood yet. It has not yet seeped into my soul and flooded my dreams. That is what next year is for.

The history is divided into several parts that must be addressed in a very specific order. When you present a patient's history to another medical professional, it must be in the exact same format, every time, so that the relevant information can be quickly and effectively communicated. If I may make a poor and inappropriate analogy to music: Its like when you are reading sheet music, and all the things have to be in the customary place - the time signature, the staff, the other stuff - otherwise it would be very difficult to play it with your bassoon.

Here is the order.
- ID - age and sex of the patient, and any relevant identifiers
- Chief Complaint: Why did they come in? (Tom: this should be in the patients own words. It is ok to put "I feel like shit" as a chief complaint. I, of course, immediately imagined reading off a list on graphic obscenities to an attending - i have a feeling some amount of censure is required).
- Reason for Admission - this applies to "in-house" patients only
- History of Present Illness (HPI) - when did the pain start? What kind of pain is it? Leading open ended questions: "Tell me about your diarrhea." Etc etc.
- Past Medical History - any hospitalizations/ medical problems/ major surgeries. Or minor ones, for that matter.
- Medications
- Drug Allergies/ Intolerances
- Family history - have all their primary relatives died of lung cancer at the age of 30? This might be relevant
- Social History - What is that person's life like? Are they a iv drug user that lives on the street? Do they live in a nursing home and get no physical exercise? Are they a marathon runner with a binge drinking problem? Do they have a rare species of python as a pet? Do they sleep every night with their rare python pet curled around their head? These are things that may be important. Figuring out how and why they are important is another issue. For now, that issue is not mine.
- Review of Symptoms (ROS)- This is the part where you quickly try to ask the patient about every single thing that is going on with their body, starting with the general, then skin, and then moving from head to toe. This too has a very specific order that I have a hard time remembering. And the trick is knowing which aspects of the ROS are relevant to and should be included under the HPI.

And then you move on to the physical exam, which has a whole other order and way of presenting it that revolves around a series of unintelligible acronyms. For example: HEENT (head eyes ear nose throat) PERRLA (pupils equally round and reactive to light and accomodation), EOMI (extra-ocular motions intact), RRR (regular rate and rhythm). And on and on. And on.

The moral is, I will need approximately four and a half hours to actually see a patient. Which doesn't account for the roughly 7 hours that I will be need at home to write up that patient before presenting them the following day during rounds. I kind of don't understand how anyone can actually do this. But the gauntlet has been thrown, and, good sir, I ACCEPT THE CHALLANGE!

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