Clinical Communication and Anamnesis Techniques for Medical Students

• "What can I do for you today?"
• "Tell me, what is going on?"
• "How are you feeling right now?"

Once the patient has spoken, use summarization to ensure accuracy. This prevents errors and shows the patient you have understood them. Use phrases like, "So, if I understand you correctly, you have... Is that right?" or "Let me list everything to make sure I haven't missed anything".

Anamnesis Structure and the "Tractus"

Anamnesis (medical history taking) should follow a logical flow to ensure no critical information is missed.

The Six-Step Structure

1. Open Inquiry: Let the patient speak extensively about their complaints.
2. Summarization: Verify the story with the patient.
3. Lifestyle Inquiry: Ask about alcohol, smoking, diet, and exercise.
4. Physical Examination: Inform the patient of the upcoming exam or the tests required.
5. Results and Hypothesis: Share findings (e.g., blood pressure) and discuss potential causes and solutions.
6. Closing: Check for understanding and ask if the patient has further questions.

The "Tractus Anamnese" (Systemic Review)

To ensure a comprehensive history, medical students use a "tractus" approach, systematically reviewing organ systems:

• General: Weight changes, fatigue, sleep, appetite, and fever.
• Circulatory: Palpitations, shortness of breath (especially when lying flat), edema (swollen ankles), and chest pain.
• Respiratory: Cough (with or without mucus), wheezing, and breathing difficulties.
• Digestive: Swallowing difficulties, heartburn, nausea, vomiting, and changes in bowel habits (color, consistency, blood).
• Urological/Genital: Urinary frequency, pain, color, or incontinence; for women, menstrual history and pregnancy; for men, erectile function.
• Neurological: Headaches, dizziness, vision/hearing changes, coordination, and numbness.
• Endocrine: Diabetes symptoms (thirst, frequent urination), thyroid symptoms (heat/cold intolerance, tremors).
• Musculoskeletal: Joint pain, swelling, or limited movement.
• Intoxications & History: Medications, alcohol, smoking, drugs, allergies, past surgeries, and family history.

Clinical Documentation: The SOEP Method

Once the consultation is complete, you must document your findings. The SOEP method is the standard for clinical documentation, providing a clear, concise, and professional record.

Note for Students: While students often write long, narrative paragraphs for each section, professional medical documentation (the "Doctor's version") is much more concise and uses medical abbreviations.

Referral Letters

When a patient requires specialist care, you must write a referral letter. This document should only contain information relevant to the specialist to ensure efficient care.

Essential Elements of a Referral

A professional letter should include:

1. Patient Data: Name, DOB, address, and insurance details.
2. Reason for Referral: A clear description of the main complaint and the specific question you want the specialist to answer.
3. Anamnesis: Relevant findings, including the onset, duration, and previous treatments.
4. Physical Examination: Key positive and negative findings.
5. Current Treatment: Any medication currently being taken.

A well-structured letter, as seen in the provided template, ensures a seamless transition of care from the GP to the specialist.

Giving Instructions and Advice

The final stage of a consultation often involves giving instructions. Using the "friendly imperative" (e.g., "Please lie on your back") helps guide the patient through examinations without sounding overly commanding.

When giving medical advice, use "could" or "should" to remain professional yet suggestive. For example:

• "You could make an appointment with a dietitian".
• "You should move more frequently".

When instructing on medication, clarity is paramount to ensure patient safety:

• "Take these tablets three times a day with plenty of water".
• "Do not take this medicine more than three times a day".