Reflective Writing on History Taking

The first lecture on history taking that I had attended was conducted by Dr Yambao. It was an introductory lecture in understanding the basis of taking history from the patients and the effective skills on how to come out with a complete history of patients in order to identify one’s disease. It was an interesting lecture to me but far more interesting when I entered the clinical skill learning session (CSL). In CSL classes, I had acquired the idea and illustrations on how history taking is done with the help of Dr Min Zaw Aung, my facilitator for CSL Module.

After few classes on CSL, including history taking on presenting illness, past medical, surgical, family and social history as well as history taking in paediatrics and women, I had better acknowledged myself in the process and techniques. However, it wasn’t that easy as I thought to carry out the history taking myself. Dr Min Zaw Aung had taught me very well in doing the history taking.

Me and my CSL group members was given cases and practiced on history taking among ourselves with Dr Min Zaw Aung’s guidance. Then, comes the session where I had to do the real history taking, with the real patient at the Kepala Batas Hospital near the campus.

I was excited at the beginning as I would be able to see real patients and talk to them. At the hospital, I was assigned a task on history taking in the women’s ward together with my team-mates.

Later that day, I became very nervous as I thought that I wasn’t prepared to do the history taking with them. Dr Min Zaw Aung had divided the group in pairs and each pair had to take the history from one of the patient in the ward.

The patient that I got was a Malay woman aged 43 years old with diabetes and a wound on her right toe. She was so friendly and she had given a good cooperation so that I and my friend can conduct the history taking very well. At first, I was worried that I will disturb the patient when she is having her rest but then, I know, I had to do this as this is important in my process of learning in becoming a good doctor in the future.

At first, we had applied the skills that were taught by our facilitator. To begin, we put the patient at ease and comfort. My friend and I did the history taking and noted everything that we have to know about her illness so that, we can better diagnose her. All the questions pertaining to patients’ symptoms and chief complaint were being asked; including history of presenting illness, history of past medical and surgical history as well as medication, dietary history, family history and social history. During the processes, I realized that we had to be careful in phrasing our questions, give good verbal and non-verbal cues, differentiate closed and open ended questions and ask relevant questions systemically. This is to ensure that the patient wouldn’t feel disturbed or angry and more pleased to give information.

It turned out that, the patient I had met was actually a type 1 diabetic patient since she was 31 years old and she inherited the disease from both her parent. Her injured right toe was swollen and worsens after her first meeting with the doctor. The wound is healing very slowly and it caused bacterial infections which consequently made her feverish. So, she was diagnosed with infection on right toe associated with fever which worsens by her diabetes.

After the history taking was done, we had to present the case to our facilitator, Dr Min Zaw Aung. We did the presentation well but still, there were some mistakes that we had made. Dr Min Zaw Aung had helped us in correcting our mistakes and came out with the right diagnosis. He also gave us information regarding our case and explained further about it so that I and my friend understand it better and learn from our mistakes.

So, I had finished the CSL session for this semester. I had learned so many things in the classes and sessions with the lecturer especially on history taking. The experiences that I gained are an exposure to me of the medical world before I am able to be in it. All of it is so important in pursuing my medical years as training in becoming a good doctor to thousands and in fact millions of patient s that I will attend and help in the future.