“The most beloved actions to Allah are those performed consistently even if they are few”- Prophet Mohamed (SAW)
To be consistent is the closest you can get to accuracy. Practice makes perfect. Watch one, do one, teach one. All of us are familiar with these old adages, as they’ve been repeated constantly to us over the years. From learning how to ride a bike, to mastering algebraic equations, the idea of consistency has been strongly enforced as part of our learning process. When we started our clinical rotations, these overused expressions were once again reinforced. Although we sighed and grumbled why we were expected to listen to the same instructions of how to conduct a history and physical exam, it really proved to be true. Once you get into the habit of performing the same physical maneuvers in the same order each time, it’ll become second nature for you.
Starting from when we first began seeing standardized patients (actors) last year, we were introduced to the concept of NLDOCAT. Basically, it’s a mnemonic for figuring out the history of the present illness. Nature, location, duration, onset, causation, aggravating factors, and treatment. After listening to it for a few hundred times, it kinda just rolls off your tongue, which is how it should be when you see a patient. When we first stated those workshops in second year, I made it a habit to write it on my scrap paper before I introduced myself to the patient. Now when I see a patient, I just automatically ask them to describe the pain, use 1 finger to point at the location, how long has it been occurring, when did it start, recall any event or trauma that may have caused it, what makes it worse or better, and any attempted treatment.
As any well-trained physician will tell you, if you got a good history then you’ve got the diagnosis. Once you have gathered as much info about the HPI as you can, you should automatically start thinking of differential diagnoses. This is something else that comes with practice. At my first couple tries at this, I could only think of the most obvious diagnosis. My mind drew a blank for others, and I didn’t think it made a difference since I “knew the answer”. However, in real life situations, there are rarely textbook patients. You should always have 3 differentials and be able to support them with your HPI and physical exam info. Every good lawyer has evidence to back up his client, and every good doctor should have evidence to back up his diagnosis.
Next stop is the past medical, surgical, social, family history, medications, and allergies. These are extremely important to aiding you in your diagnosis, and can lead you onto the track for an additional differential diagnosis in case you’re stuck. Just as an aside, even if you are seeing an established patient, you should always ask these questions. No, its not because they could be miraculously cured from diabetes since their last appointment six months ago, but because there are sometimes mistakes in the charting. I’ve had several incidents in the clinic where I’ve noticed discrepancies in the chart when verifying it with the patient. An extra minute could save you a whole lot of time down the road.
Right before you get to the physical exam, remember to ask the review of systems, which consist of yes or no answers for any headaches, fever, chills, shakes, nausea, vomiting, urination, rashes or blisters, and muscle pain. Again, its one of those things that you just memorize and can eventually say it in your sleep.
All that’s left is the VOND, vascular, orthopedic, neurological and dermatological exam. Find a system that works for you. I mentally recite VOND to myself each time, then start by taking pulses, capillary refill time, notice the absence or presence of digital hair, and look for any redness or swelling. Then I check for any calluses, ulcers, lesions, and how the nails look. After that I test for manual muscle testing and joint range of movement, before I check for peripheral nerve sensation with a monofilament.
The other day, we all had the afternoon off from clinic to review a case study in preparation for our clinical boards this summer inshaAllah. After the case was read to us, we all discussed the case while going through all I mentioned above. Although when we first started seeing patients seven months ago we stammered and referred to our notes, forgetting things and going back to it at the oddest moments, eventually we got it down and were able to recite it effortlessly alhamdulillah. It sounds like a lot, but in reality, this becomes imprinted in your mind after doing it over and over again. If you are persistent you will get it, but if you are consistent you will keep it 🙂