When I was teaching in Monash, I always tell my students that taking a GOOD history and physical examination is the key to making a good diagnosis. Some students felt that my history taking is too deep/detailed and not worth doing it. I had proven them wrong at many instances during bedside teaching and they will always look surprised and shocked when I come to a diagnosis just from the history without even looking at the patient!
Yesterday, I had an interesting patient who came to see me. This 47-year-old Engineer was seen in the A&E department of a very famous general hospital a day earlier. He was discharged as another case of “giddiness” and was asked to go to the general Outpatient Department the next day. I attach the referral letter here:
The first thing that striked me when I saw this young patient is when he was wheeled into my room on a wheel chair! Why a young 47-year-old need to use a wheel chair ? When I took the history from the patient, I notice something is not right. He stopped working as an engineer in Singapore 2 years ago and since then, has been doing some small time business in town. Last 2 -4 months, he has stopped working all together, so much so, that he has gone bankrupt, he had to sell his house and currently staying in a low-budget hotel with his wife!!. He has no children. When I asked him why he stopped working, his answer was ” feel tired/weak and no mood?” The family members who accompanied him said that over the last few months, he was seen to be very quiet, keeps to himself and mentally very slow.
In fact, the family came in requesting for a scan!!. On examination, I noticed that he’s unable to walk properly, his gait was unsteady. He could not even climb up the couch by himself. Power of the lower limb was reduced to about 3-4/5. Mentally he was slow in response. He did look depressed as well.
Surprisingly, in the letter of referral to OPD , it is stated that ” no neurological deficit” . Any one would have noticed that this guy is NOT well. If not an organic disease, atleast he has major depression. Even if they have referred to a psychiatry clinic, it is still excusable.
I proceeded to do an MRI of the Brain:
What’s the DIAGNOSIS????
A huge Mass over the upper part of Midbrain causing Obstructive Bilateral Hydrocephalus………………………….
As I said, a good history taking and asking yourself “WHY” is the best way to solve a problem.
Ironically, I had to refer this patient to the same hospital again for neurosurgical intervention.
If this had happened in NZ (where I work), it would be all over the papers and the person who wrote ‘no neurological deficit’ would be placed under review. This is no joke because of the delay in diagnosing the patient’s tumour. Imagine if this was one of your loved ones – the problem is there is no accountability!
Giddiness….. Interesting….. Is not even a diagnosis that is taught in my medical training overseas….. Dear doc., is there any good news about the health care in Malaysia…. I am worry reading about all the -ve news.
There is nothing new happening in Malaysia. The situation will only get worst, soory to say. Too much politics!
Dear Dr.Pagalavan,
Thank you for bringing up this issue.I am a young GP,practising in Kuchai Lama,KL.
I also noticed that we are from the same Alma Mater,St.Paul Institution.
I fully agreed with you that a good history and physical examination is important as taught back in medical school.However,the attitude of majority of new doctors may have gotten them elsewhere.
Best of regards,
Dr.Soo TK
Majority of new doctors are not fir to become a doctor!
sorry, FIT
Daddy,
thank you for the sharing this case to us. It is pity for the patient because he have been suffering this illness since 2 years ago. However to be honest, the referring doctor did excellent job by refered this case to you although he made some ‘spelling mistake’ in his letter. I am sure this patient has been shopping for a doctor since last 2 years. When the symptoms are progressing, he might choose to come to A&E. So the blame shouldn’t be transferred into a referring doctor who attempted to write a letter at 4 AM early in the morning, wasn’t he?
I don’t agree with your statement with ‘majority new doctor not fit enough to be a doctor’..what do you mean by ‘fit’. Have you run a study to prove they are not ‘fit’ ? On what criteria or classification have been referred to label majority are not fit? They have been tested in 5 years medical school with at least 3 times professional exam and are reviewed by external examiner.
If you said majority, how many percent?
Santa Claus
Dear Santa Claus,
I think you got it all wrong. The referral letter is NOT directed to me. I am a Consultant in a private hospital. This referral letter was written by the A&E MO to the General Outpatient Clinic. The patient just showed me the letter when he came to see me. Have you worked in a genral outpatient clinic before? If this patient were to go to the general OPD, his waiting time to get a CT brain will be around 2-3 months, if at all the doctors orders one. I am not sure what ” spelling mistake” are you talking about?
An A&E Mo works on a shift basis and thus there is no excuse that he failed to pick up the sign just because it is 4am in the morning. Furthermore, you should ask a question of why this patient came to A&E at odd hours ofhe morning. Something is not right, that’s why the patient came at that time.
You can ask all senior consultants in all government hospitals nowadays, and they will tell you exactly what I have said about ” not being fit to become a doctor”. If you want to do a study, well by all means go ahead, I can assure you that you will be shocked. As for me, I don’t need to do a study, a simple observation is good enough. Being a doctor is not about passing exams and completing 5 years education. It is more than that. You need to have passion, caringness, empathy and certain level of intelligency. Any person can become a doctor nowadays with minimum qualifications. Exams are just gimmicks. Please do a survey and find out what is the failure rate of all the medical schools in the country. Almost 0%!!!!
All private colleges just passes all their students because it is a money making business. Already the entry qualification is so low and then all of them are passed and the problem is passed to MOH. In Australia, despite having a strict entry qualifications (you need to be the top 10% of students in the country), followed by a structured interview the failure rate is still about 3-5% annually.
Malaysia boleh mah……………….
yes..i was been told to take a complete history and perform good examination,
BUT how to take a good history when there are 50 patients waiting and there are other emergency cases
That’s why I said, the power of observation is important. By just lookig at the patient and asking your self “why” is good enough to tell you that something is not right about the patient. I have worked in general outpatient clinic before and have seen even up to 100 patients a day. But you should be able to pick up subtle warning signs as for this patient. If not what is the difference between us and an MA/nurse?
Daddy,
I agree with you that the referral doctor made mistake (very serious mistake). thank you for the explanations.
however, i don’t agree with you when you mentioned;
….”Any person can become a doctor nowadays with minimum qualifications. Exams are just gimmicks. Please do a survey and find out what is the failure rate of all the medical schools in the country. Almost 0%!!!!…”
you have made very very serious mistake with this statement. You should aware how many failure rates per year and how many student have been rejected by medical school.
i think one individual mistake by a junior doctor mustn’t be blamed to the whole educational system, it was personal mistake.
thank you for the whole story, as you put in title, an interesting case for us..
I think you are talking about public universities. I agree that public universities have limited space and thus many students are rejected and only the top students get a place. BUT don’t forget that there are 32 medical schools in the country!!The highest percapita population in the world. More than half are private.
Pls go and check for yourself the passing rate and the entrance qualification for these universities including the one from Russia and Indonesians. You will be shocked!!
dear santa claus,
agree with u in some part where some students been rejected by medical school, but this only happen in public uni… and actually i am happy to hear that cause they will have a better future compare to dr that will end up jobless very very soon… …
in fact, failure rate in private is almost 0 but not for public (i mean certain public uni…) mine uni is very famous in falling students especially for OnG and medicine… almost 25%…
dear dr pagalavan,
nice blog!!! amazing!!! this is the true that people should know!!!
I am TOTALLY agree with history to come out with diagnosis! it just like a jigsaw puzzle where u complete it piece by piece to come out with a pic… as what my prof said … “is like orgasm if u can get the correct diagnosis through history!!! ” … 🙂
as a medical students now, there are too many of us till we need to fight for case write up… currently, we are roughly 10 students/dr … even dr were so surprise of the big no of us… and not to mention to present case during ward round… students fight with HO… … a HO even said “i am a HO, i will present the case… ”
so… the quantity is there but not the quality… 😦
a question for u dr… what is ur view for undergrad to do their housemanship in singapore???
thanks and have a nice day… 🙂
regards.
Thanks for your comment. That’s exactly what I was saying about ” quality of doctors nowadays” but some people don’t get what I am trying to say. Housemanship is Singapore is similar to Malaysia but you would not be able to do many procedures as most of it is done by registra and above.
i’m not surprised..
that doctor must be junior doctor..or maybe a houseman..
this things happens because of lack of specialist/senior doctor to guide and counter check as most of them leaving MOH joining Columbia Hospital
Ha ha . People leave government service mainly not because of money but frustration! The hard working ones and the lazy ones get simlar promotion and same salary and thus the hard working ones will get frustrated and leave! Most head of departments do not do any clinical work but gets the highest salary! They are known as ” World Travellers” because they attend almost all conferences in the world , fully sponsored by pharma companies. Thus you are left with mediocre ones in the government service, sorry to say.
TQ for sharing. Poor guy.
I too have a tale to tell. A relative who was 21yo then was mistakenly diagnosed as having Lymphoma after biopsy done at a private hospital*. She was severely depressed & threw TANTRUMS after being persuaded to undergo the gold standard Chemo treatment quickly. The poor girl’s dad then sought 2/3 opinion at different hospitals and the result was the same until a young specialist at another private hospital did more history taking & round of biopsy before concluding that it was harmless.. Kikuchi disease: A disorder that typically causes “swollen glands” in the neck ( cervical lymphadenopathy). Imaginei if the girl was the compliant type, she would probably have undergone unnecessary treatment.
And 2yrs ago, I had to lose my reproductive organs to CANCER after two “older” specialists (one a gynae oncologist) at the same hospital (READ same hosp*) brushed away my 1year old abnormal bleeding HISTORY as peri-menopausal symptoms. My current oncologist says I’m too young to be diagnosed with this type of ca !
Yes? No? Doctors are not to blame..they are not God. We are just patients who lived to tell a tale.
The problem with govt clinics and hospitals are there are too many patients thus the system is severely under starined
The ” World Travellers ” gets to go anywhere but not doing clinical work. Compare to the ” non-world traveller ” , they are the one running the clinics , ward and on-call.
But the HOD gets a higher post and pay plus a govt car.
Compare the poor non-traveller , he drives a old car and on a lower pay scale.
So who to blame if Dr Pagal decides to leave to private sector ? I dont blame him. In fact i am deciding where and when to leave public sector.