Chapter 9 : Can I be a good clinician ( 1 )

9.1 How do I clerk a case well?

The golden rule is to establish a good rapport with the patient. This can be  achieved by having good communication skill. Thee are two main parts to clerking a case i.e. history taking and doing physical examination. Agood history will provide eighty percent of the clues in making a diagnosis. Agood framework is illustrated on the next page.

Problem of students :

* Inability of utilise and apply knowledge acquired to the clinical problem

* Study with the aim to pass only

* Not knowing the significance / relevance of the subjects being taught

History

Questions are asked according to the chief complaint of the patient. A good framework would be CDC (Cause, diagnose, complications). History is taken to find out the cause, to help in making the duagnosis and to elicit for complications.

Case illustrations :

* History to be taken for someone who complained of haemoptysis.

* Leading questions need to be asked to find out the CAUSE of the haemoptysis. Two important causes to be ruled out are tuberculosis (TB)  and cancer of the lung. Hence symptoms suggestive of TB such as contact with PTB patients, night sweat, and symptoms suggestive of both TB and cancer of the lung such as weight loss, loss of appetite and chronic cough will have to be elicited.

Physical examination

This is done to look for the cause, to help in diagnosis and to look for complication. Clues to look for the CAUSE would be those suggestive of TB such as lymphadenopathy, those suggestive of cancer of the lung such as clubbing of the fingers, chest finding such as pleural effusion which can be due to both TB and cancer of the lung.

Investigation

This is done to look for the CAUSE to confirm the DIAGNOSIS and to assess for COMPLICATIONS. In the above said patient, investigations to look for the CAUSE would be a chest x-ray which will show the changes typical of TB or cancer of the lung. It would also confirm COMPLICATIONS of pleural effusion if any.

The chest x-ray will assist in the management of the pleural effusion by confirming the level of the pleural effusion and help in the removal of the pleural fluid.

Management

To complete the management. It is crucial that the CAUSE, the DIAGNOSIS and the COMPLICATIONS are treated.

It is very important that the history taking includes three very important aspects of symptoms, i.e.onset, duration, progression.

Classification of aetiology of disease based on onset and duration of symptoms.

* The onset will give a clue as to the CAUSE

* Symptom that has a very acute onset within minutes is vascular in origin such

   as Central retinal artery occlusion or cerebrovascular accident.

            * Symptoms that occur within days may mean acute inflammation which can be

infective or non infective in origin. The younger and the older age group make

infection more likely. This include things like a swelling on the skin due to a boil.

* Symptoms that occur for a duration of a few months tend to be due to chronic

inflammation such as TB and malignancy such as cancer of the lung.

* Symptoms that occur for a duration of a few years tend to be due to be being

tumour or degenerative disease.

# The progression of disease is important especially the relationship to food intake in gastrointestinal symptoms or the response to medications of certain ischaemic heart disease.

 (How to become a good & successful medical student; Muhaya Hj Mohamad)