Student Consultation 1

This is a consultation between a 4th year UiTM medical student in a primary care setting with a 60 years old Indian lady who came for her routine appointment for HPT. (Pt's answer is red in colour)

• Good evening, I am fourth year uitm medical student
• Can you introduce yourself
• (My name is Mary)
• May I know why you come to clinic today
• (Follow-up HPT)
• For how long
• (Long time)
• Before this how about the reading
• (Few months been having chesty colds and they say lungs got water, yesterday suppose to go for scope for lung but my letter missing so they ask to come and get a new letter from here)
• So how about now, how is your chest
• (I think I'm having arthritis also)
• For how many years
• (many years)
• How do you know you have this problem arthritis
• (The orthopaedics told me)
• Why did you go and see the orthopaedics
• (I had knee pain)
• Do you have any stiffness of your joints
• (Stiffness? what do you mean)
• When the dr diagnose the arthritis
• (3 yrs)
• Where did the dr told you had arthritis, in the hospital or clinic
• (no answer from patient)
• So currently doing physiotherapy
• (yes, it all started with the right eye giving problem)
• Can you explain more about the eye problem
• What eye problem do you have, blurred vision or what
• How long been having the problem
• (Had laser done)
• Then after the laser..
• Is it improve
• (They said I had fungus in my eyes)
• Do you recieve any treatment for the fungus
• How about your vision now
• (OK)
• You mention about your glucose just now
• (Huh?)
• Your sugar
• (So far so good, just now they took my sugar, what was the result?)
• Hmm, its OK
• May I know what medication are you taking for high BP
• (I don't know how to pronounce the name)
• How many times a day
• Have you ever missed the medications
• (Sometimes)
• Do you have any chest pain
• (Yes, not always)
• When is it?
• Since when
• (Long time already)
• Then, have dr done anything about your chest pain
• (ECG all normal)
• When was the last ECG
• (Long time)
• Then how about your high BP, do you check it
• (I go to clinic every time OK)
• Everytime visit how about your blood pressure reading
• (it is OK)

At this point the Primary Care Lecturer took over the consultation. Please comment on your collegue's history taking. How can your collegue improve his/ her consultation?