Pocket Tutor Clinical Examination Peter Cartledge, Catherine Cartledge, Andrew Lockey, Caleb Van Essen
INDEX
Note: Page numbers in bold or italic refer to tables or figures respectively.
A
Abbreviated Mental Test 207, 207, 278, 326
ABC approach 300, 304
ABCDE approach 3316
Abdomen
anatomy 109, 110, 111
auscultation 122
cardiovascular disease 66
common scars 121
critically ill patients 337
elderly patients 325
gastrointestinal disease 117, 11819, 1209
genitourinary organs see Genitourinary system
imaging investigations 132
inspection 12021, 164
neonates 313
pain 11213, 115, 123, 124
palpation 1227, 1645
percussion 127
pregnant women 1656
respiratory disease 93
Abdominal aorta 75, 127
Abdominal aortic aneurysm 115, 127
Abducens nerve (CN VI) 172, 17981
Accessory nerve (CN XI) 173, 189
Active listening 2
Activities of daily living 11, 11
Addison's disease 286
Adolescents 299, 304
see also Paediatrics
Advanced life support algorithm 340, 341
AEIOU TIPS mnemonic 340
Affect 276
Air hunger 32
Alcohol use 13
Allergies 10
Alopecia 55
Ambulatory blood pressure monitoring 35
Amenorrhoea 156
Amniotic fluid volume 167
AMT see Abbreviated Mental Test
Anal canal 111, 130
Ankle
musculoskeletal examination 246, 2589
thyroid examination 290
Ankle–brachial pressure index 812
Anxiety 268
Aorta, palpation 75, 127
Aortic valves 59, 60, 68, 77, 79
Apex, palpation 99
Apex beat 72, 74
APGAR score 310, 311
Apnoea 33
Appendicitis 115, 124
Appendix 110
Arm see Upper limb
Arterial bruits 82, 122
Ascites 118, 128
Asterixis 47, 47, 210
Asthma 103
Atrioventricular valves
anatomy 59
apex beat 72
cardiac cycle 60
cardiac pattern and diagnoses 68
heart sounds/murmurs 78, 79
surface markings 77
Auditory function 184, 187
Auditory hallucinations 277
Auroscopy 51, 52, 305
Auscultation 389
see also specific systems
Autonomy 24, 26
AVPU scale 305, 337
B
Babinski's sign 221
Balanitis 141
Barium studies 132
Basic activities of daily living 11
Beneficence 25
Biliary colic 115
Bimanual pelvic examination 162
Bladder see Urinary bladder
Blood
abnormal bleeding in women 156
coughed up 92
in stools 116
in urine 137
vomiting 114
Blood oxygen saturation see Oxygen saturation
Blood pressure 61, 65
ankle–brachial pressure index 812
elderly patients 322
measurement 345, 36, 81
National Early Warning Score 338
paediatric patients 322
Blood tests
cardiovascular disease 83
dementia 326
endocrine disease 292
musculoskeletal disease 262
psychiatric assessment 279
respiratory disease 104
sexually transmitted infections 145
Blumberg's sign 124
Body mass index 41
Body surface area 41, 296
Bones 241
Borborygmi 111, 122
Bouchard's nodes 245, 247
Boutonnière's deformity 245, 247
Bowel sounds 111, 122
Bradycardia 66
Bragard's test 255, 261
Brain
anatomy 1958
visual fields 174
see also Neurological system
Breast 147, 148, 14955, 168, 287, 328
examination 1524, 168
Breast tissue 118, 286
Breath smells 120
Breath sounds, reduced 94
Breathing
ABC approach 300, 304
ABCDE approach 3316
advanced life support 341
bronchial sounds 94
cardiac pathology 62
paediatric patients 296, 300, 301, 304, 31
patterns 323, 39
physiology 88
Breathlessness 32, 62, 92
Bronchial tree 87
Bronchoscopy 104
Brudzinski's test 230
Bruising 120
Bruits, arterial 82, 122
BSA see Body surface area
C
CAGE 13
Candida albicans 156
Capacity 25
Capillary refill time 36, 305
Carbon dioxide 89
Cardiogenic shock 43
Cardiopulmonary resuscitation 26, 340, 341
Cardiovascular system 5986
ABC approach 300, 304
ABCDE approach 332, 334
anatomy 59
auscultation 756, 306
cardiac patterns 68
causes of fever 33
critically ill patients 331, 3334, 336, 341
elderly patients 323, 324
examination 6771, 86
general inspection 67
history taking 17, 63
investigations 83
jugular venous pressure 51, 68, 97
paediatric patients 300, 301, 304, 306
palpation 72, 812, 83
percussion 75, 306
physiology 6062
pulse assessment 72, 81
signs of dehydration/shock 42
signs of disease 44, 46, 66
symptoms of disease 625
Carotid arterial pressure 71
Carotid ultrasonography 84
Carpal tunnel assessment 2556
Central nervous system 19598
Cerebellum 198, 225
Cerebrospinal fluid analysis 232
Cervix 148
colposcopy 169
smear and swabs 160
Chest
cardiovascular examination 66, 68, 756
critically ill patients 337
elderly patients 327
gastrointestinal disease 117
inspection 97
musculoskeletal disease 241
neonates 312
pain 623, 64
percussion 38, 945, 99, 101
radiographs 84, 102
respiratory disease 94
respiratory examination 98
surface anatomy 88
Chest radiograph interpretation 1057
Cheyne–Stokes respiration 32
Child abuse 314
Chlamydia infection 158
Cholangiopancreatography 132
Cholecystitis 124
Circulation
ABC approach 300
ABCDE approach 332, 334
see also Cardiovascular system
Claudication 65
Clock drawing 2056
Clonus 211
Clubbing 45, 46, 46, 288
CNs see Cranial nerves
Cochlear function 173, 184, 185
Cognitive function 2056, 321, 3201, 326
Collateral ligament stability 259, 263
Colonoscopy 132
Colour
APGAR score 311see also Cyanosis; Jaundice
Colposcopy 169
Compulsions 268
Computed tomography 231
Confidentiality 25
Congestive heart failure 61
Consciousness
ABCDE approach 334
AVPU scale 306
delirium 269
Glasgow Coma Scale 335National Early Warning Score 338
paediatric patients 305, 335
sudden loss of 199
Consent 26, 30
Consolidation, lung 103
Constipation 116, 324
Consultations 1
active listening 2
adolescents 300
clinical examination see Clinical examination
documenting 20
elderly patients 31819
environment for 4
history taking 1, 3, 318
psychiatric 269
question techniques 12, 8, 17
Coronary angiography 84
Corrigan's sign 68
Cough 90
Crackles 67, 79, 3234
Cranial nerves
anatomy 1713
examination 17689
eye movements 171, 1778
Cremasteric reflex 143
Crepitations see Crackles
Critically ill patients 33141
advanced life support 340, 341
early warning score 336, 338
examination 33141
primary survey 33136
secondary survey 336
Cruciate ligaments 25960, 264
Cyanosis 40, 97
D
Deafness 184, 187
Deep tendon reflexes see Reflexes
Deep vein thrombosis 81
Dehydration 42, 42, 302
Delirium 207, 207, 207, 269, 320
DELIRIUM mnemonic 269
Dementia 207, 207, 207, 320
Depression 267
Dermatomes 196, 197, 222
Development assessment 30710
Diabetes 284, 29092, 292
Diarrhoea 116
Differential diagnosis 1819
Digital rectal examination 12931, 325
Disability, ABCDE approach 332, 3345
Distributive shock 43
DNA SORAN mnemonic 1, 3
Doctor–patient relationship 1, 2
Documentation 20
Draw test 259
Dropped finger 245, 247
Drug history 3, 4, 89
breast disease 151
cardiovascular disease 63
elderly patients 318
endocrine disease 285
gastrointestinal disease 113
gynaecological disease 155
musculoskeletal disease 238
neurological disease 199
paediatric patients 296, 297
pregnant women 163
respiratory disease 90
Drug use, illicit 14
Dual-energy X-ray absorptiometry 266
Dupuytren's contracture 44
Durkan's compression 256
Durosier's sign 68
DVT see Deep vein thrombosis
Dysarthria 202
Dysdiadochokinesia 226
Dysfluency 206
Dyspareunia 156
Dysphagia 11316
Dysphasia 206
Dysphonia 206
Dyspnoea see Breathlessness
Dysuria 137
E
Ear
CN VIII function 1847, 188
elderly patients 319
general inspection 512
paediatric patients 305
Early warning score 336, 338
EBM see Evidence-based medicine
Echocardiography 85
ECG interpretation 85
Ectopic pregnancy 115
Elbow examination 245, 252
Elderly patients 31528
examination 32128
functional age 315
history taking 31718
multidisciplinary teams 3289
physiological changes 31516
symptoms 31720
Electrocardiography 83
Electroencephalography 2312
Electromyography 231
Emotional state 39, 276
Endocrine system 28193
anatomy 281, 282
diabetes 284, 2901, 292
history taking 284, 285
investigations 292
physiology 2812, 283
signs of disease 44, 2867
symptoms of disease 2846
thyroid examination 28790
Endoscopy, gastrointestinal 132
Epididymis 141, 142, 143
Epispadias 142
Erectile dysfunction 138
Erythema, palmar 445
Ethicolegal considerations 246
Evidence-based medicine 214
Exposure
ABCDE approach 332, 3356
for examination 31, 119
Eye
anatomy 175
cardiovascular disease 66, 81
colour vision 177
dehydration 42
elderly patients 323, 327
endocrine disease 287, 288
examination 18991
gastrointestinal disease 117, 11920
general inspection 39
innervation 1723, 171, 174
investigations 19192
movements 172, 173, 175, 17980
musculoskeletal disease 241
neonates 313
neurological disease 202
ophthalmoscopy 177, 17980
pupil 96, 172, 175, 1801
respiratory disease 96
visual acuity 176, 189, 317
visual fields 174, 1768, 189, 192, 286
visual symptoms 1736
F
Face
cardiovascular disease 66
cutaneous innervation 172, 185
elderly patients 323, 327
endocrine disease 287, 288
facial nerve examination 172, 183, 184
gastrointestinal disease 117
general inspection 40, 50
musculoskeletal disease 241
neurological disease 202
respiratory disease 93
veins of 70
Facial nerve (CN VII) 172, 185
Fainting 64
Faith history 12
Fallopian tubes, palpation 162
Falls, elderly patients 319
Family history 3, 4, 10
breast disease 151
cardiovascular disease 63
endocrine disease 285
gastrointestinal disease 113
gynaecological disease 155
musculoskeletal disease 238
neurological disease 199
paediatric patients 297
pregnant women 163
psychiatric assessment 274
respiratory disease 90
Family trees 11
Female reproductive system 14769
anatomy 135, 1479
breast 147, 148, 14954, 168
examination summary 168
gynaecology 149, 150, 15456, 168
history taking 14951, 150
investigations 167
obstetric examination 1647, 168
physiology 149
Femoral hernias 141, 144, 145
Femoral nerve stretch test 255
Fetor hepaticus 53, 120
Fetuses, obstetrics 165
Fever 334
elderly patients 321
paediatric patients 3013
FH see Family history
Fibrosis, lung 99
Finger nails see Nails
Finger rub test, hearing 184
Fits 199200, 286
Flap 47
see also Tremor
Fluid thrills 128
Fluorescein, topical 192
Fluorescein angiography 192
Foot 40, 53, 21821, 246
Fundus fluorescein angiography 192
G
Gait 2302
elderly patients 325
GALS assessment 2423, 306
Gallbladder 109, 110, 124
Gas exchange, lungs 8
Gastrointestinal system 10933
anatomy 109, 111, 11011
auscultation 122, 306
causes of chest pain 64
causes of fever 33
digital rectal examination 12931, 324
elderly patients 316, 324
examination 11932, 133
history taking 15, 113
inspection 11922, 306
investigations 132
paediatric patients 301, 306
palpation 12227, 306
percussion 1279, 306
physiology 111
proctoscopy 131
prostate examination 130, 135
signs of disease 44, 46, 11618, 117
symptoms of disease 11216
Genetic disorders 310
family trees 11
see also Family history
Genitourinary system
anatomy 135, 136, 1479
cardiovascular disease 66, 75
causes of fever 33
endocrine disease 285
examination summary 144, 168
female 1479, 15467, 155
gastrointestinal disease 117
history taking 15, 137, 13940, 153, 155
investigations 144, 167
male 13544
Get-up-and-go test 325
Glasgow Coma Scale 333
Glossopharyngeal nerve (CN IX) 173, 1889
Glucose test, ABCDE approach 335
Glycaemic control 282, 284
Goitre 287, 286
Goniometers 253
Gonioscopy 192
Graphaesthesia 225
Graves’ disease 288
Groin lumps 141
Growth, paediatric patients 307
Gunstock deformity 247
Gynaecology 149, 150, 153, 15457, 168
examination 15762, 168
Gynaecomastia 118, 287
H
Haematemesis 116
Haematuria 137
Haemoptysis 93
Hair 55, 285, 288
Hallpike's manoeuvre 187
Hallucinations 277
Hand
cardiovascular disease 43, 44, 66
deformities 247
endocrine disease 43, 266, 287, 268
gastrointestinal disease 44, 46, 117, 120
general inspection 40, 437, 57
hand hygiene 30
movement coordination tests 226
musculoskeletal disease 44, 241, 242
musculoskeletal examination 239, 241, 247, 248, 2534
neonates 313
osteoarthritis 230
respiratory disease 44, 46, 93
rheumatoid arthritis 240
Head
critically ill patients 337
elderly patients 323, 327
neonates 313
Headache 1989
Hearing 173, 184, 187
development 308, 30910
elderly patients 319, 323
Heart
advanced life support algorithm 341
anatomy 59
auscultation 7580, 80
cardiac cycle 60, 61
cardiac output 61
cardiac patterns and diagnoses 68
chest wall percussion 75
elderly patients 322, 323
failure 61, 65, 68
fetal 167
investigations 83
jugular venous pressure 69, 6970
murmurs 68, 77, 789, 79, 28199
National Early Warning Score 338
paediatric patients 300, 301
palpation 612
signs of disease 645
sounds 59, 68, 69, 75, 78
symptoms of disease 625
Heaves 73, 74
Heberden's nodes 247
Height, children 307, 308
Hepatojugular reflex 71
Hepatomegaly 124, 126
Hernias 141, 142, 143, 144
Hip examination 246, 247, 2578
History 3, 4, 67
psychiatric assessment 270, 271
History taking 1, 3, 317
allergies 89
drug history 3, 879
family history 3, 10
history of presenting complaint 3, 67
immunisation history 10
past medical history 3, 8, 8
past surgical history 3, 8
pitfalls 17
presenting complaint 6
social history 2, 1014
see also specific systems
HIV/AIDS 43
Horner's syndrome 96, 182
Hydration 42, 42, 302
Hydrocele 142
Hyperbilirubinaemia 117
Hyperglycaemia 286, 335
Hyperkyphosis 247
Hyperpyrexia 34
Hypertension 35, 65
Hyperthyroidism 288, 290
Hypertonia 203
Hypoglossal nerve (CN XII) 173, 189, 193
Hypoglycaemia 286,
Hypomania 267
Hypospadias 142
Hypotension 35, 65, 305, 322
Hypothalamopituitary axis 281, 283
Hypothermia 33, 34
Hypothyroidism 288, 290
Hypovolaemic shock 43
I
Iatrogenic problems 320
Ileus 122
Illusions 277
Immobility 319
Immunisation history 10
Incontinence 156, 324
Inguinal region
anatomy 135, 136
hernias 141, 145
inspection 141
Inherited disease 30810
family trees 10
see also Family history
Insight 277
Instability 31920
Instrumental activities of daily living 11, 11
Interferon gamma release assay 104
Intermenstrual bleeding 156
Investigations 19
see also specific systems
Ischaemic heart disease 62
J
Janeway's lesions 44
Jaundice 117
Jaw jerk 181
Joints
active movement 245, 246, 250, 25162
effusions 239, 2589
GALS assessment 242, 243
inspection 244, 2456
investigations 265
loss of function 237
osteoarthritis 236, 240
pain 235, 239, 2378, 250
palpation 2489
passive movement 245, 246, 250, 255
position sense 222, 223
range of movement 2504, 25162
rheumatoid arthritis 236, 240
special tests 245, 246, 25460, 2614
stability 250
stiffness 235
swelling 2378
types 233
Jugular venous pressure 60, 68, 6971, 97
K
Kayser–Fleischer rings 11920
Kernig's sign 230
Ketosis 120
Kidney, palpation 126, 127
Knee examination 246, 2589, 265
Koilonychia 46, 57
Korotkoff's sounds 35
Kussmaul's respiration 323
Kwashiorkor 307, 308
Kyphosis 244, 245, 247, 342
L
Labour 167, 299300
Lachman's test 259, 264
Language abnormalities 202, 205, 206
Language development 30910
Large intestine 109, 167
Laseque's test 261
Leg see Lower limb
Legal concepts 247
Leuconychia 46, 57
Libido 138
Listening 2
Lithotomy position 157, 158
Liver
anatomy 109, 111
investigations 132
palpation 75, 123, 126
percussion 38
Lobectomy, lung 103
Lordosis 243, 245, 247
Lower limb
GALS assessment 242, 306
general inspection 39, 53
meningism tests 228
muscle tone 212
musculoskeletal examination 246, 250
neonates 313
peripheral vascular system 5960
power 213, 214
reflexes 21821
respiratory disease 93
Lumps
breast 1537
groin 141
lymph node 49, 141
scrotal 141, 142
Lung
anatomy 87, 88
bronchoscopy 104
CT pulmonary angiography 104
elderly patients 327
function tests 104
gas exchange 89
main pathologies 103
signs of disease 936
symptoms of disease 96
vocal resonance 101
Lymph nodes 4950, 50, 99
M
Magnetic resonance imaging 191, 231, 266
Mallet finger 245, 247
Malnutrition 41, 307, 308
Mania 267
Marasmus 307, 307
Mastalgia 151
McBurney's point 124
McMurray's test 264
Median nerve compression 2556
Medical history see Past medical history
Medical notes 20
Medication history see Drug history
Melaena 116
Memory 207, 320, 326
Meningism 230
Meniscal tears 260
Menstruation
abnormal bleeding 156
menstrual cycle 149, 150
menstrual history 153
Mental state assessment 401, 2078, 208, 2758, 326
Mental State Examination 2758
Micturition 1378
Mini-mental state examination 2078, 208, 326
Mistreated children 314
Mitral valve see Atrioventricular valves
Mood 276
Motor development 30710
Motor functions, CNs 172, 181, 183, 188
Motor pathways 1956
Motor power 203, 213, 218, 219
Mouth
cardiovascular disease 66
elderly patients 3234, 327
gastrointestinal disease 117, 120
general inspection 40, 51
neonates 313
see also Throat
Movement abnormalities 210, 213
CN XII 189
eye 17980
joint examination 24962
see also Tremor
Multidisciplinary teams 3289
Murphy's sign 124
Muscle power 203, 21318, 219
Muscle tone 203, 203, 211, 311
Musculoskeletal system 23366
anatomy 233
causes of chest pain 64
elderly patients 316, 325, 327
examination 24062, 265
GALS assessment 2423, 306
history taking 15, 233, 238, 242
investigations 2626
joint examination 24462, 265
paediatric patients 301, 306
red flags 236
signs of disease 44, 2378, 240
symptoms of disease 2357
N
Nails
general inspection 457, 57, 57
thyroid disease 288
National EWS system 336, 338
Nausea 114
Neck
cardiovascular disease 66
critically ill patients 337
deformities 247
elderly patients 327
gastrointestinal disease 117
general inspection 40, 4851, 50
goitre 286, 287, 289
meningism 22830
musculoskeletal disease 241
musculoskeletal examination 245, 247, 250, 259
neonates 313
respiratory disease 93
veins of 70
Neonates 295, 31013
Nerve conduction studies 231, 266
Neurological system 195232
abbreviated assessment 205, 207
ABCDE approach 3356
anatomy 1958
causes of fever 33
cerebellar function 210
critically ill patients 337
dehydration/shock 42
elderly patients 316, 325, 327
examination equipment 204
examination 2039, 232
gait 230, 325
general inspection 208, 306
higher mental function 20510, 326
history taking 15, 198201
investigations 2078
meningism tests 22830
paediatric patients 301, 306, 311, 335
physiology 198
positioning the patient 205
power 203, 21318, 219
reflexes 198, 202, 203, 21821
sensation 202, 2215
signs of disease 44, 2023
symptoms of disease 198201
tone 203, 203,s 211, 311
see also Cranial nerves; Ophthalmology; Psychiatric assessment
NEWS system 336, 338
Nipples 1512, 153
Nocturia 138
Nocturnal dyspnoea 32, 63
Non-maleficence 25
Nose 53, 54, 313
Note making 20
Nutrition
clinical assessment 412
elderly patients 322
history taking 1415, 297
paediatric patients 297, 307, 308
Nystagmus 179
O
Observations see Vital signs
Obsessions 268
Obstetric examination 1647, 168
Obstructive sleep apnoea 31
Oculomotor nerve (CN III) 172, 179
Odynophagia 113
Oedema 67, 75
Olfactory nerve (CN I) 172
OPERATES+ mnemonic 3, 270
Ophthalmology
cardiovascular examination 81
cranial nerve examinations 1769
eye anatomy 176
eye innervation 172, 173
investigations 1912
visual symptoms 1734
visual system examination 1767, 18991
Ophthalmoscopy 204, 17980
Optic disc 177
Optic nerve (CN II) 172, 176
Optic tract 171
Optical coherence tomography 191
Orchitis 141
Orthopnoea 62
Orthostatic hypotension 35, 321
Osler's nodes 44
Osteoarthritis 236
Otoscopes 52, 53
Ovaries 164
Oxygen
advanced life support 341
central cyanosis 97
delivery devices 97
partial pressure 36
respiration 89
supplemental 96, 333
Oxygen saturation 36
elderly patients 321
National Early Warning Score 338
paediatric patients 304
P
Paediatrics 295314
age definitions 295
anatomy 29596
child mistreatment 314
clinical environment 295
development assessment 30710
examining children 314
examining neonates 31013
history taking 299300
key symptoms 301
physiology 296
red flags 300
Paediatric consultation 296
Paget's disease 153
Pain history 3, 6, 7
Pain sensation 2234
Palms 4445
Palpation 37
lymph nodes 4950, 99
see also specific systems
Palpitations 64
Pancreas
abdominal pain 115
anatomy 109, 110
glycaemic control 282
investigations 132
Parotid glands 51
Paroxysmal nocturnal dyspnoea 32
Past medical history 2, 4, 89
breast disease 151
cardiovascular disease 63
elderly patients 318
endocrine disease 285
gastrointestinal disease 113
genitourinary disease 137, 153, 155
musculoskeletal disease 238
neurological disease 199
paediatric patients 297
pregnant women 163
psychiatric assessment 271
respiratory disease 90
Past surgical history 3, 8
cardiovascular disease 63
elderly patients 318
gastrointestinal disease 113
musculoskeletal disease 238
neurological disease 199
pregnant women 163
psychiatric assessment 271
respiratory disease 90
Patent ductus arteriosus 302
Pelvic examination 1578, 16062
Pelvic pain 156
Pelvis, fetal engagement 16667
Penis 141, 142
Peptic ulcers 115
Perceptions, abnormal 277
Percussion 38
see also specific systems
Peripheral oedema 61, 67, 75
Peripheral vascular system 5960
auscultation 82
elderly patients 324
inspection 81
mid-calf diameter 83
palpation 813
signs of disease 66, 67
symptoms of disease 65
Peristalsis 111
Peritoneum 109, 115, 124
Personal history 272, 273
Phalen's test 255
Phimosis 141, 142
Phobias 268
Pituitary tumours 286
Plantar reflex 221
Pleural effusion 103
Pneumonectomy 103
Pneumothorax 103
Polydipsia 284, 286
Polyuria 284, 286
Position sense 208, 222
Positioning of patients 30, 119, 152, 157, 205
paediatric 305
Postcoital bleeding 156
Postural hypotension 35, 322
Power 204, 21318, 219
Prayer signs 242, 255
Pregnancy
Ectopic 115
obstetrics 1647, 168
paediatric history taking 299
Presenting complaint 3, 4
breast disease 151
cardiovascular 63
elderly patients 318
endocrine 285
gastrointestinal 113
genitourinary 137, 153, 155
history of 3, 4, 6
musculoskeletal 238
neurological 199
obstetric 163
paediatric patients 297
psychiatric assessment 271
respiratory disease 90
Privacy 30
Probity 26
Pronator drift 213
Proprioception 196
Prostate
abdominal pain 115
anatomy 135
examination 131
investigations 144
micturition problems 138
Proximal myopathy 2889
Pruritus 120
Pseudohallucinations 277
Psychiatric assessment 26779
elderly patients 326
higher mental function 278
history taking 26970
investigations 27980
Mental State Examination 2758
physical examination 2789
summary 280
symptoms 2679
Psychotic symptoms 268
Pulmonary oedema 61, 67
Pulmonary valve 76, 79
Pulse oximetry see Oxygen saturation
Pulse(s)
assessment 72
cardiovascular disease 66
elderly patients 321
endocrine disease 288
paediatric patients 304
Pupil, 172, 179
Pyrexia 33
Pyrogens 34
Q
Quincke's sign 68
R
Radiography 84, 102, 132, 265
Record keeping 2021
Rectum
anatomy 109, 110, 111
bleeding 116
digital examination 12930
proctoscopy 131
Reduced conscious 340
Reflex irritability, neonates 31112
Reflexes 177, 198
Relative afferent pupillary defect 181
Religion, faith history 1011
Renal colic 115
Resistance testing 213, 214
Respiration
ABC approach 300, 304
ABCDE approach 332, 333
advanced life support 341
breathlessness 32, 62, 92
cardiac pathology 62
National Early Warning Score 338
paediatric patients 296
patterns of 32
physiology 88
Respiratory failure 89
Respiratory rate 32
elderly patients 298
National Early Warning Score 338
paediatric patients 304
Respiratory system 87107
anatomy 87
auscultation 1004
cardiovascular disease 59, 66
causes of fever 32
chest percussion 38, 94
critically ill patients 331, 3334, 341
elderly patients 3215, 327
examination 96106
history taking 17, 8990
inspection 96, 306
investigations 104
main lung pathologies 103
paediatric patients 299, 304
palpation 989
physiology 88
signs of disease 43, 936
symptoms of disease 903
upper respiratory tract see Mouth; Nose
Resuscitation 26, 336
Retching 114
Reticular activating system 198
Rheumatoid arthritis 236, 240
Rigidity 203
Rigor 34
Rinne's test 1845, 187
Risk assessment, psychiatric 277
Romberg's test 208
Rovsing's sign 124
Rubs 95
S
SAD PERSONS mnemonic 278
Scapula 247
Schizophrenia 268
Schober's test 254
Sciatic nerve stretch test 255, 261
Scoliosis 244, 245, 247
Scratch marks 120
Scrotum 136, 141, 142, 144
Seizures 199200, 286
Sensory examination 202, 2215
Sensory functions, CNs 1889, 202, 209
Sensory pathways 196, 197, 222
Sepsis evaluation, 3368
Sexual function 138
Sexual history 13940
Sexual intercourse 156
Sexually transmitted infections 140, 140, 160, 299
Shock 43
Shortness of breath see Breathlessness
Shoulder examination 245, 247, 251
Skeletal system 233
see also Musculoskeletal system
Skin
breast tumours 153
critically ill patients 337
elderly patients 322, 327
endocrine disease 285, 287, 287, 288
gastrointestinal disease 117
general assessment, 39, 40, 534
graphaesthesia 225
lesion types 56
musculoskeletal disease 241
pregnancy changes 164
Sleep apnoea 33
Small intestine 109, 110, 1323
Smell
of breath 120
sense of 1723
Smoking 12
Social development 308, 30910
Social history 3, 4, 1015
breast disease 151
cardiovascular disease 63
elderly patients 318
endocrine disease 285
gastrointestinal disease 113
genitourinary disease 137, 138, 155
musculoskeletal disease 238
neurological disease 199
paediatric patients 297
pregnant women 163
psychiatric assessment 274
respiratory disease 90
SOCRATES mnemonic 3, 7, 7
Spasticity 203
Speculum examinations 15961, 164, 167
Speech 202, 205, 206, 276
Spider naevi 120
Spinal cord 196, 222
Spinal tap 232
Spine
deformities 247
elderly patients 324
GALS assessment 2423, 306
musculoskeletal disease 224
musculoskeletal examination, 24062, 241, 247
Spiritual history 12
Spleen 110, 1245, 125, 126, 127
Splenomegaly 1256
Splinter haemorrhages 46, 57
Sputum 92, 104
Squint 190
SSS CCC FFF TTT mnemonic 49, 49
Starling's law 62
Stenosing tenosynovitis see Trigger finger
Stereognosis 224
Stethoscopes 39, 100, 101
STIs see Sexually transmitted infections
Stomach 109, 110
Stools 116, 132
Strabismus 1901
Straight leg raise 255, 261
Stretch reflexes see Reflexes
Stridor 95
Suicidal assessment 278
Surgical history see Past surgical history
Swallowing, problems with 113
Swan-neck deformity 240, 245
Symphyseal–fundal height 1645, 165
Syncope 65, 199
Systemic vascular resistance 61
T
Tachycardia 65
Tactile vocal fremitus 99
Taste sense 173
Teeth 51
Temperature 334, 37
elderly patients 321
National Early Warning Score 338
paediatric patients 300, 304, 313
Temperature sensation 2234
Tendon reflexes see Reflexes
Testicles
anatomy 136
carcinoma 141, 150
cremasteric reflex 143
pain 139, 141
palpation 142, 143
signs of disease 141
torsion 139, 141
ultrasound 145
Thirst, polydipsia 284, 286
Thomas's test 257
Thoughts 276
Thrills 73, 74, 128, 302
Throat 512, 53 55, 303, 305
Thudicum speculum 54
Thyroid
anatomy 281, 282
auscultation 20
examination 40, 28790, 293
goitre 286, 287, 288
investigations 292
palpation 28990
regulation 281, 283
Thyroid acropachy 288
Tinel's sign 2
Toe movements 258
Toe nails see Nails
Tone (muscle) 203, 209, 211, 227, 311
Tongue
general inspection 51, 97
innervation 172, 173, 185, 185,
Tonometry 192
Tophi 47
Torticollis 245, 247
Touch sensation 222, 224, 225
Trachea 87, 88, 98
Tremor 47, 47, 202, 210, 288
Trendelenburg's test (hip) 257
Trendelenburg's test (veins) 83
Trichomonas vaginalis 156
Tricuspid valve see Atrioventricular valves
Trigeminal nerve (CN V) 172, 181
Trigger finger 245, 247
Trochlear nerve (CN IV) 172, 179
Tympanic membrane 52, 52, 305
U
Ulcers
genital 141
peptic 115
Ultrasound 42, 132, 141, 191, 292
Undernutrition 42, 307, 308
Upper limb
active movements 250
deformities 247
endocrine disease 287
GALS assessment 2412, 305
joint examination 245, 247, 251, 258
muscle tone 211
neonates 313
power 214, 213
reflexes 218, 220
see also Hand
Uraemic fetor 120
Urethra (female) 135, 148
Urethra (male) 135, 138, 142
Urinary bladder
palpation 126
Urinary tract, anatomy 135
Urine
blood in 137
incontinence of 156, 320
investigations 132, 144
micturition problems 137
polyuria 284, 286
Urine tests
endocrine disease 292
genitourinary assessment 1679
musculoskeletal disease 263
psychiatric assessment 279
Uterus 1479, 162, 1645, 167
V
Vagina 1479, 156, 15962, 167
Vaginosis, bacterial 156
Vagus nerve (CN X) 173, 18889
Valgus deformities 248
Values, patient 22
Varicocele 141, 143
Varicose veins 82
Varus deformities 247, 248
Vestibular function 172, 187, 188
Vestibulocochlear nerve (CN VIII) 173, 1847, 188
Vibration sensation 223, 224
Virus serology 104
Vision development 308, 30910
Visual acuity 176, 189, 317
Visual fields 174, 177, 189, 192, 286
Visual symptoms 17376
Visual system examination 18991
Visual tract 171, 174
Vital signs 3136
cardiovascular disease 66, 66, 82
dehydration/shock 42
elderly patients 3212
musculoskeletal disease 241
National Early Warning Score 338
paediatric patients 301, 304, 308, 313
respiratory disease 93
VITAMIN CDE mnemonic 18
Vocal fremitus 101, 102
Vocal resonance 1012
Vomiting 114
W
Weakness 201, 21318, 219
Weber's test 184, 187
Weight, children 2956, 307, 308
Weight change 116, 285, 288
Wernicke's area 206
Wheeze 95
Whisper test, hearing 184
Whispering pectoriloquy 101
Wrist deformities 247
Wrist examination 245, 247, 248, 2558
X
Xanthomas 47
xanthelasma 120
×
Chapter Notes

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First principlesChapter 1

 
1.1 The consultation
Most consultations between a clinician and a patient follow a very structured pattern: an introduction is followed by a thorough history, which explores the patient's ideas, concerns and expectations (ICE). The patient is examined and a differential diagnosis formulated. Investigations are then organised, when necessary, and a treatment plan is put in place. Over 80% of diagnoses in general medical clinics are based on the medical history, so it is of paramount importance to focus time and energy on becoming a good history taker.
 
At the beginning
Taking a history is not only the key to clinical diagnosis but also the start of the ‘doctor–patient’ relationship. Every consultation should start the same way:
  • Wash your hands
  • Always come to the door to greet the patient. Never greet a patient sitting down, unless you are unable to stand
  • Introduce yourself, your role and designation (in lay terms)
  • Find out who the patient is (biographical details): the mnemonic DNA SORAN (Table 1.1) can be used. These elements don't all have to be taken immediately (name and age are a minimum), but it is appropriate to take them during the social history. You may ask the patient how he or she wishes to be addressed
 
Open and closed questions
Doctors generally interrupt their patients after 18 seconds. This may be necessary in order to guide the consultation, but 2usually it is out of impatience and can significantly reduce the chances of identifying the correct diagnosis. This is difficult because, if allowed to, some patients continue talking for excessive periods with too much detail. You will soon learn key phrases to try to bring them back to the task in hand, e.g. ‘Coming back to your chest pain, have you noticed…’
Questions can be classified as either open or closed:
  • An open question is non-directive and allows the patient to give information freely, e.g. ‘Why don't you tell me what's been going on?’. Patients can report information that is most important to them and also give their own version of events, in their own words. Open questions work only if you are ready to take the time to listen. Use active listening (see below) to encourage the patient to keep speaking
  • A closed question elicits an answer such as ‘yes’, ‘no’ or something else factual, e.g. ‘Does the pain move from your chest into your neck?’.
Use a funnelled approach to your consultation, starting with open questions and leading into closed questions.
 
Active listening
Active listening is a way to show patients that you are taking a genuine interest in what they are saying. This not only makes them feel valued, and improve the doctor–patient relationship, but also encourages them to be honest and forthcoming. Here are a few key ways of listening actively:
  • Lean forward
  • Make eye contact
  • Nod
  • Say ‘mmm’ or ‘okay’ to acknowledge what they have said3
 
1.2 General principles of history taking
Over time you will develop your own style for taking a history. There are, however, key areas that must be covered, these include (Table 1.1):
Table 1.1   History taking: a summary
General:
DNA
SORAN
D – date
N – name
A – age
S – sex
O – occupation
R – religion
A – address
N – next of kin
Presenting complaint
List each presenting problem
History of presenting complaint
Use the OPERATES+ mnemonic for each presenting problem (Table 1.2)
Use the SOCRATES mnemonic for pain history (Table 1.3)
Past medical history
Past surgical history
Previous illnesses or surgery
Important medical problems, e.g. diabetes, heart disease, high blood pressure, epilepsy
Obstetric and menstrual history in women
Drug history
Current medications and effectiveness
Immunisation status (in children or when clinically relevant)
Social history
Smoking (or other tobacco use) – quantify in pack–years
Alcohol consumption (type, amount, frequency, duration) and any symptoms of dependency
Illicit drug use
Exercise
Housing and conditions
Faith or spiritual history
Family history
Red flags: tuberculosis, human immunodeficiency virus (HIV/AIDS), cancers, anaemia, diabetes, heart disease, myocardial infarction, hypertension, chronic obstructive pulmonary disease, asthma, stroke, renal disease, bleeding diseases, allergies, arthritis, alcohol abuse, mental illness
Review of systems
  • 4Presenting complaint (PC)
  • History of presenting complaint (HPC)
  • Past medical and surgical history (PMH/PSH)
  • Drug history (DH)
  • Family history (FH)
  • Social history (SH)
  • The patient's knowledge, feelings, ideas, concerns and effects or expectations
  • Review of systems
Taking a history is an inexact process. Two histories from the same patient on two different occasions will not necessarily be the same. For example, after a history has been taken, a patient may report new or completely different symptoms when a colleague joins the consultation.
 
Environment
Most consultations occur in outpatient or family medicine clinics. Wherever they occur, the environment should be made comfortable and secure.
On a ward, curtains offer little confidentiality and this should be taken into consideration when taking the patient's history, because he or she will be unlikely to disclose embarrassing or intimate information.
Position yourself in an open and non-threatening position. Standing over a patient can be intimidating. Try not to position desks or beds between you and the patient. Use space in a way that makes the patient the centre of your attention. If consulting a threatening patient, never position yourself so the patient is between you and the exit.
 
Cultural differences
People from different cultures have different ideas surrounding healthcare and different ways of explaining their illness. For example, a patient without anatomical or health literacy may say, ‘I have all-over body pain’ but in reality mean that they have a dull pain and stiffness in their joints. These are not classic symptoms described in textbooks and as a result can be confusing, frustrating and time consuming for the clinician. An 5in-depth exploration may clarify these misunderstandings; use narrow ended questions and ask the patient to show you what they mean or give you specific examples.
A patient's ideas surrounding healthcare influences their understanding of the cause of their illness, and what treatments they believe will work (see Ideas, concerns and expectations, page 16). If the patient does not agree with or understand your model of healthcare delivery, they may not accept the investigations or treatments you recommend. In order to overcome these challenges it is helpful to show understanding of the patient's beliefs, educate them on alternative diagnoses and treatment plans, and be flexible in one's own idea of treatment plans.
 
Using an interpreter
It is your responsibility to determine whether an interpreter is needed. An interpreter may be needed if English is the patient's second language; the patient relies on family members for interpretation; or if the patient gives inappropriate response to questions. It is ideal if the interpreter is present in the clinic, however alternative telephone or video interpreter devices can be used.
  • Take time to prepare; it may help to give the interpreter a brief explanation about the patient's medical condition prior to the patient's visit
  • Ensure that the interpreter and patient do not know each other (this is common in small communities with unusual languages) and that the patient is comfortable with their interpreter (for example, a woman may not be happy having a man interpret for her in a gynaecology consultation)
  • Speak directly to the patient (i.e. ‘how long have you had a cough?’) rather than the interpreter (‘ask the patient how long they have had a cough’)
  • Look at the patient when you are speaking to them, not the interpreter
  • Use short, simple sentences and avoid jargon and acronyms
  • Pause for interpretation. Even if you are busy, don't speak over the interpreter because they cannot listen and speak at the same time
  • Be alert and sensitive to issues of culture and religion6
 
Presenting complaint
The PC is the problem – or set of problems – that caused the patient to seek help from a doctor. Patients often have more than one problem and each of these should be listed one by one. A good opening question might be ‘What seems to be the main problem today?’.
Table 1.2   OPERATES+: mnemonic for asking about presenting complaints
Mnemonic
Example questions
O
Onset of complaint
When did the problem start?
P
Progress of complaint
Has it always been the same?
E
Exacerbating factors
Is there anything that makes it worse?
R
Relieving factors
Is there anything that makes it better?
A
Associated symptoms
When you get this problem, do you notice any other symptoms?
T
Timing
Is there any time of day that you notice this problem more? How long does each episode last?
E
Episodes of recovery/ever before
Have you had this problem before? How often do you feel like this?
S
Severity
How bad is it?
+
Function
Does it prevent you from doing particular activities?
 
History of the presenting complaint
Take your time to elicit details on each of the presenting problems. As you take more histories you will become skilled at directing the consultation based on the information the patient gives you. Initially it may be worth memorising a useful mnemonic such as OPERATES+ to ensure that key points are 7not missed (Table 1.2). Obtain details for each of the presenting problems. As you progress through the history, further problems may be identified that the patient did not initially report or identify as problematic. When a patient has several problems, it can be helpful to say that you will go through each problem in turn. That way each issue can be explored systematically and thoroughly without missing anything. A useful mnemonic for taking a pain history is SOCRATES (Table 1.3); this identifies all areas related to pain, but miss key features in alternative presentations.
Table 1.3   SOCRATES: mnemonic for taking a pain history
Mnemonic
Example questions
S
Site
Where is the pain?
O
Onset
When did the pain start?
C
Character
Describe the pain to me, e.g. is it aching, shooting, stabbing or dull?
R
Radiation
Does the pain move to anywhere else in your body?
A
Associated symptoms
Have you had any symptoms other than the pain?
T
Timing
Pattern of pain (including time of day, frequency)
Duration of pain
Is it constant or does it come and go?
E
Exacerbating or relieving factors
Have you noticed anything that makes the pain better or worse?
S
Severity
Does the pain interfere with what you are doing?
Does it keep you awake?
If 0–10 is a scale of pain, with 0 as no pain and 10 as the worse pain that you can imagine, what score would you give this pain?8
 
Past medical history and past surgical history
Some clinicians prefer to take the PMH before the HPC. This enables them to develop a clear sense of what are current and what are past problems. If you choose to do so, explain to the patient: ‘Before we discuss why you came today, I wanted to ask you some background questions. Would that be okay?’.
Start by asking an open question such as ‘Have you had any serious illness in the past?’. Patients often omit or forget important information. This is often because of the way in which a question is posed. Use several different questions to ensure that the patient understands. Similarly, use several different questions to elicit the past surgical history, e.g. ‘Have you ever seen a surgeon?’, ‘Have you had any operations?’ and/or ‘Have you ever had an anaesthetic?’.
 
Specific past medical history
To finish, it is worthwhile asking a series of closed questions to identify any common or significant problems. A useful mnemonic is JADE CAT MARCH (Table 1.4).9
Table 1.4   JADE CAT MARCH: mnemonic for important past medical history
General (JADE)
Respiratory (CAT)
Cardiovascular (MARCH)
J – jaundice
C – COPD
M – MI
A – anaemia
A – asthma
A – angina
D – diabetes
T – tuberculosis
R – rheumatic fever
E – epilepsy
C – CVA (stroke/TIA)
H – hypertension
COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident; TIA, transient ischaemia attack.
 
Drug history, allergies and immunisations
 
Drug history
It can be useful to start this section with the questions ‘Do you have your medications with you’ or ‘Do you have a copy of your prescription?’. Patients often find it difficult to remember the medications they are taking or have taken in the past. Taking a drug history can therefore be one of the most difficult parts of the history.
It is essential to know:
  • Which medication(s) they are currently taking
  • Which medication(s) they have previously taken
  • Why each medication was started
  • At what dose it/they have been prescribed
  • In what preparation(s) it is given
  • The effect that the medication(s) has had
In addition, identify use of:
  • Inhaler, cream, patch or suppository
  • Over-the-counter medications
  • Herbal and complementary medications
  • Medications prescribed for somebody else but taken by the patient
  • Contraception – including implants and injections (patients don't often think of these as medications)
Use this opportunity to check for compliance by asking patients if they take their medications as prescribed, e.g. ‘How often do you forget to take your medicines?’. This is important for medications that may have been stopped by the patient because they have had ‘no effect’. This can become evident for the first time in a patient who is admitted to a ward and has supervised medication administration, e.g. an elderly patient who becomes hypotensive because he is given the high-dose beta-blocker that he had not been taking at home.
Patients may be taking several different medications, each with its own side-effect profile. This can add to the symptoms that they have and also cloud your differential diagnosis.10
 
Allergies
Reactions to drugs can range from life-threatening anaphylaxis through to mild side effects that have been misinterpreted by the patient. Ask the patient several questions to clarify this part of the history:
  • ‘Do you have any allergies?’
  • ‘Have you ever had a reaction to a medicine that you have taken?’
  • ‘What happens to you when you take this medicine?’
 
Immunisations
An immunisation history should be taken if it is relevant to the case. This is particularly important in children. For an elderly patient or anyone with chronic disease, ask if he or she has had the influenza (flu) immunisation. The World Health Organization recommends a minimum schedule of immunisations in all countries, with extended schedules for country-specific diseases.
 
Family history
Ask questions such as: ‘Are there any illnesses that run in your family?’ or ‘Has anyone in your family had a similar problem?’. Taking a family history can also help identify any concerns that the patient may have.
 
How to draw a family tree
If necessary, draw a family tree (Figure 1.1) to help map the possible inheritance of the disease.
 
Social history
Determine:
  • Employment (past and present)
  • Housing type and with whom the patient lives
  • Social support
  • Restrictive or unusual diets
  • Stresses at home and/or work
  • Restrictions on activities
You may wish to ask about the patient's faith, finances and hobbies if relevant.11
zoom view
Figure 1.1: Symbols used for constructing a family tree.
Table 1.5   Basic activities of daily living (BADLs)
Basic activities of daily living
Instrumental activities of daily living
Bathing, personal hygiene and grooming
Dressing and undressing
Toileting
Transferring and mobility
Continence
Feeding
Shopping for groceries
Driving or using public transport
Using a telephone
Undertaking housework
Completing home repair
Preparing meals
Laundry
Taking medications
Handling finances
A good understanding of the patient's background helps to form a diagnosis and an appropriate management plan.
 
Basic activities of daily living and instrumental activities of daily living
Basic activities of daily living (BADLs) (Table 1.5) are used to describe a patient's functionality in self-care tasks. Instrumental activities of daily living (IADLs) describe the ability to maintain an independent household. If a patient is unable to perform any of these tasks, identify what factors are limiting their ability to do so. These assessments are not only good 12measures of how a disease is impacting on a patient, but also of the support he or she needs in order to return home independently.
 
Faith or spiritual history
Taking a faith history requires permission, sensitivity and respect. Not only does it help us to know more about our patients, but it also guides decision-making during the practice of evidence-based medicine (e.g. a Muslim may wish to be offered low-molecular-weight heparin that is non-porcine in origin).
How to take a faith or spiritual history Here are some examples of appropriate questions to ask patients about their spiritual ‘health’:
  1. ‘It would help me to treat your medical problem better if I knew more about you.’
  2. ‘Do you have a personal faith that helps you (in a time like this)? How does it affect your life?’
  3. ‘Do you belong to a faith community? Some people find it helpful to meet with someone. Would you like us to arrange this for you?’
 
Smoking, alcohol and illicit substance use
 
Smoking – what is a pack-year?
Quantify smoking in terms of pack-years: 20 cigarettes per day for 1 year equates to 1 pack-year (e.g. 15 cigarettes per day for 4 years is equivalent to 3 pack-years). Also ask about other tobacco products.13
 
Alcohol
The effects of alcohol on health are enormous, including acute intoxication and chronic disease (e.g. liver disease and psychiatric problems such as addiction and depression). Alcohol also leads to social problems such as reduced productivity, violent crimes and antisocial behaviour. Many patients who are alcohol dependent will enter a stage of withdrawal in hospital if this area is not appropriately investigated. Ask questions such as:
  1. ‘How much do you drink each week?’
  2. ‘Have you ever been a heavy drinker?’
  3. ‘What is the most that you drink in one go?
When documenting the history, report alcohol use in units per week and state if evidence of bingeing is present. One unit of alcohol is equivalent to 10 mL of pure alcohol, so:
Units = alcohol by volume (%) × volume of alcohol (mL) ÷ 1000
Therefore 125 mL glass of 14% white wine is equivalent to 1.75 units alcohol. Be sure to clarify how much a patient means; for example when a patient says ‘a whisky a night’, is this a standard 25 mL measure or a larger shot poured by the patient? A simple and non-judgmental way of asking this is ‘How quickly do you finish a 75 cL sized bottle of whisky?’.
There are several quick and easy scoring systems for assessing possible alcohol dependence:
  • The Alcohol Use Disorders Identification Test (AUDIT) developed by the World Health Organization and comprising 10 simple questions, each scored on a 0- to 4-point scale
  • The Fast Alcohol Screening Test (FAST), developed from AUDIT and having four questions scored according to how often a prespecified alcohol-related event occurs (e.g. memory loss about the previous night)
  • CAGE, developed at the North Caroline Memorial Hospital in the USA and containing just four questions, mainly covering the patient's emotions in relation to drinking, requiring yes or no answers
CAGE and FAST are much quicker to administer than AUDIT and are simpler tests.14
Binge drinking (heavy episodic drinking) is drinking heavily in a short space of time in order to get drunk or feel the effects of alcohol. UK researchers commonly define binge drinking as consuming more than 6 units of alcohol in a single session for men and women.
 
Illicit drugs
Reassure patients that any information they give you is confidential. Asking direct questions often leads to an immediate denial, so indirect questioning can be useful e.g. ‘What drugs have your friends tried?’, ‘… and you?’. Once you have gained the patient's confidence, establish:
  • Which illicit drugs have been used
  • When and for how long
  • How much and how often
  • How they were taken (i.e. orally, smoked, injected venously, injected subcutaneously)
  • What the impact has been on his or her health and life
 
Nutrition
There is a clear association between nutrition and health. A nutrition history may be necessary if a patient is undernourished or overweight. A good nutrition history is important for giving lifestyle advice as part of preventive medicine.
 
Nutrition history
  1. How many meals and snacks do you eat each day?
  2. How many times a week do you eat away from home? What do you eat?
  3. On average, how many pieces of fruit or glasses of juice do you eat or drink each day?
  4. On average, how many servings of vegetables do you eat each day?
  5. How much fibre do you eat?
  6. How many times a week do you eat red meat, chicken and/or fish?15
  7. How many hours of television do you watch each day? Do you snack during viewing?
  8. How many times a week do you eat desserts and/or sweets?
  9. What types of beverages do you drink, how much and how often?
  10. How much alcohol do you drink?
Table 1.6   Systems review (adult patients)
General
generally well or unwell
Weight loss or gain
Appetite loss or gain
Fevers, sweats or rigors
Level of activity
Fatigue
Change in mood
Rashes or bruising
‘Lumps or bumps’
Respiratory
Cough
Shortness of breath
Wheeze
Sputum
Haemoptysis
Frequent chest infections
Genitourinary
Urinary symptoms: dysuria, frequency, urgency, nocturia
Ease of passage of urine
Haematuria
Urethral discharge
Sexual function
Menstrual cycle
Cardiovascular
Chest pain
Shortness of breath
Orthopnoea
Nocturnal dyspnoea
Oedema
Palpitations
Claudication
Collapse
Exercise tolerance
Nervous system
Headaches
Fits, faints or funny turns
Weakness (or unsteadiness)
Dizziness or loss of balance
Changes or loss in vision, hearing or taste
Transient loss of function (e.g. vision, speech or sight)
Paraesthesiae
Muscle wasting
Involuntary movements
Urinary incontinence
Gastrointestinal
Nausea and vomiting
Haematemesis
Dyspepsia
Dysphagia
Odynophagia
Abdominal pain, mass or swelling
Bowel pattern
Diarrhoea or constipation
Rectal bleeding
Jaundice or itchy skin
Musculoskeletal
Weakness
Change in mobility
Stiffness
Joint pain or swelling or erythema16
 
Review of systems
Start with a statement such as: ‘I am now going to ask you some specific questions’. A comprehensive list of symptoms is given in Table 1.6. It would be almost impossible to go through the entire list with all patients. As you start learning to take histories try to be as comprehensive as possible. With time your ability to focus your review of systems, dependent upon the HPC, will improve. Use lay terms when questioning the patient.
 
Ideas, concerns and expectations (ICE)
Explore the patient's ICEs. Although this is part of the history, some clinicians ask about ICEs at the end of the consultation, once they have examined the patient and before discussing the management. This is a matter of discretion.
 
Ideas
  • ‘Do you have any thoughts about what could be causing your symptoms?’
 
Concerns
  • ‘Is there anything in particular that you had in mind when you came to the clinic today?’
  • ‘Is there anything in particular that is worrying you about your symptoms?’
 
Expectations
  • ‘Was there anything that you were hoping we might be able to do for you today?’
  • ‘Did you have any particular tests or treatments in mind that you were expecting us to organise?’17
 
Common pitfalls in history taking
There are many pitfalls that can reduce your chances of obtaining an accurate history. There are three common pitfalls made by clinicians when taking a history.
 
1. Anchoring
This is a mistaken latching on to an early piece of information. For example, if the nurse says ‘Can you see the patient with asthma in room 4’, there is a danger of focusing on the history around this early suspicion of asthma. Closed questions may confirm early suspicion of asthma and minimise other symptoms or signs that suggest that the diagnosis is something different.
 
2. Availability
You may have recently seen a case that is particularly dramatic, or lots of cases of a particular diagnosis, so may fall into the pitfall of availability, e.g. having recently seen several cases of oesophagitis, you may falsely diagnose your next patient with chest pain as having oesophagitis.18
 
3. Attribution
You may immediately make judgements about a patient on first encounter, e.g. if a 22-year-old student presents with vaginal discharge, you may falsely assume that she has a sexually transmitted infection.
 
Clinical examination
Examination of the patient is covered in Chapters 214. Before progressing to the examination, it is worthwhile summarising the history back to the patient. This gives him or her the opportunity to confirm whether your version of events is correct and provides reassurance that you have listened to all of the problems.
 
1.3 Forming a differential diagnosis
 
The differential diagnosis
The aim of the history and examination is to formulate a diagnosis while also planning possible investigations and treatments. A differential diagnosis is a systematic approach used to identify the true diagnosis among many other alternatives, known as the ‘differential diagnoses’ or ‘differentials’.
There are a series of steps in formulating and acting on a list of differential diagnoses:
  1. Gather all the information from the history and examination to form a list (mental or written) of symptoms and signs
  2. List all the possible causes for these symptoms and signs
  3. Prioritise this list based on the most urgent or life threatening and those that are statistically the most likely
  4. List investigations and treatments that should be drawn up, which will either confirm or rule out diagnoses, while treating any active or life-threatening symptoms
This is a complex process of mental reasoning and takes clinicians years to perfect. Using a mnemonic (‘surgical sieve’) can be useful in helping to draw up a list of differential diagnoses.
An easy mnemonic for remembering a surgical sieve is VITAMIN CDE:
  • Vascular
  • Inflammatory (infectious and non-infectious)
  • 19Trauma/toxins
  • Autoimmune
  • Metabolic
  • Idiopathic
  • Neoplastic
  • Congenital
  • Degenerative
  • Environmental
 
Multiple causation
Symptoms and signs rarely give a single clear diagnosis that immediately responds to a single treatment. Often symptoms can be multi-factorial in nature, e.g. a patient may have lower back pain due to a strained muscle and depression. The depression causes an exacerbation of the symptoms of the back pain, in turn exacerbating the depression because the patient may stop leaving the house because of the pain.
 
Management
The term ‘management’ is used to describe a combination of the investigations and treatments that are offered to the patient. Document which investigations you would like to perform and what treatments you would like to start immediately.
 
Planning investigations
Investigations are tests that can be used to define and measure the extent of a diagnosis and/or measure the progress of a disease and the response to treatment. Investigations should be ordered carefully based on the differentials. Patients should not receive a ‘blanket’ series of tests in the hope of unearthing something. Rather the investigations ordered should be rationalised and justified. When deciding which investigations to order, one should consider the following:
  • How will the results affect the management of the patient?
  • Are there any risks to the test?
  • What specimens need to be taken and is it possible in this patient?
  • Does the cost of the test warrant its use?
  • How quickly should the test be arranged?20
 
1.4 After the consultation
At the end of any consultation explain to the patient:
  • What you have found during the history and examination
  • What the likely diagnosis is and any possible alternatives (differentials)
  • What tests, if any, are required, what they involve and how accurate they are
  • What treatments can be started, how these work, how they are taken and what side effects may be seen
 
Documenting in medical notes
Writing good notes that are contemporaneous (Figure 1.2) helps process your thoughts and plans, records what has been done and aids communication with your colleagues.
During the first consultation, often referred to as ‘the clerking’, the documentation follows the same structure as the consultation, i.e. PC, HPC PMH, DH, FH, SH, examination, differentials, management. Documentation is said to be contemporaneous if it is made at the time of, or as soon as possible after, the consultation (Figure 1.2).
zoom view
Figure 1.2: Contemporaneous notes.
21
 
Presenting patients to colleagues
Presenting a case to a colleague or senior improves not only your own learning but also patient care. Presenting a case should follow the same structure as the consultation (Figure 1.3).
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Figure 1.3: Presenting a case.
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1.5 Evidence-based medicine
 
Definition and clinical relevance
Evidence-based medicine (EBM) is the integration of the current best research evidence (e.g. journal articles) with our own clinical expertise, along with the values that are unique to our patients. A common misconception is that EBM is a process of substituting our clinical expertise with research. In reality EBM is a process that combines three key principles:
  1. Clinical expertise
  2. Patient values, circumstances, expectations and beliefs
  3. Best available research evidence
 
Key principles of EBM
 
Clinical expertise
Clinical skills are enhanced by the experience of seeing patients. Underpinned by good communication skills, a thorough history and examination not only assist with differential diagnosis but also allow you to ascertain the patient's personal values and expectations (Figure 1.3). It is impossible to practise EBM without good clinical skills, e.g. without a correct clinical diagnosis, a clinician will search the wrong research evidence.
 
Patient values, circumstances, expectations and beliefs
Patient values are the unique preferences, concerns and expectations that each patient brings to each clinical encounter. These must be woven into clinical decisions to best serve the patient, e.g. the patient with hypertension in Figure 1.4 may have osteoarthritis and find an exercise ECG painful and stressful.
 
Best research evidence
This is clinically relevant research that has been evaluated to assess whether it is of high quality and that it is directly relevant to the patient. It could give you information about diagnostic tests, prognosis or therapy.23
 
Five steps for practising EBM
There are five steps in practising EBM (Figure 1.4):
Step 1 – Ask: convert information needs into questions
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Figure 1.4: Evidence-based medicine in practise.
24Step 2 – Acquire: identify the best evidence to answer the questions (whether from the clinical examination, diagnostic laboratory, published literature or other sources)
Step 3 – Appraise: critically appraise this evidence for its validity (closeness to the truth) and usefulness (clinical applicability)
Step 4 – Apply: apply the results of this appraisal in our clinical practice
Step 5 – Assess: evaluate our performance
 
1.6 Ethicolegal considerations
As a clinician you are expected to adhere to a certain code of practice. This involves the following principles:
  • Keep your knowledge and skills up to date, always working within the limits of your competence
  • If you think that patient safety or dignity is being compromised, take prompt action
  • Always treat patients as individuals and maintain confidentiality
  • Work in partnership with the patients, enabling them to make decisions about their care
  • Finally, never discriminate unfairly against patients or colleagues, or abuse a patient's trust
In the UK this is outlined by the General Medical Council's Duties of a Doctor.
 
Four pillars of medical ethics
There are four pillars of medical ethics: autonomy, beneficence, non-maleficence and justice. Doctors should also reflect on the scope of application of these principles.
 
Autonomy
Autonomy is the capacity for self-determination. It is the right to choose what you want, for yourself, in an unbiased environment. A decision made by an individual may not appear rational but this does not mean that the individual is therefore incapable of acting autonomously or that he or she does not have capacity.25
 
Beneficence
Beneficence is the concept of acting to benefit an individual or a population. In treating a patient autonomously consider that one patient's beneficence may be another patient's maleficence.
 
Non-maleficence
Non-maleficence is the concept of ‘doing no harm’, e.g. stopping a medication that has no benefit but has side effects. Whenever doctors try to benefit a patient (beneficence) there is always the possibility that they may harm them (maleficence); there should always be a ‘net benefit’ for the patient.
 
Justice
Practise in a manner that is fair to all. This should include distributive justice (the fair distribution of resources), respect for people's rights and respect for morally acceptable laws.
 
Other ethical principles
 
Best interests
Work with colleagues in ways that best serve patients’ interests.
 
Confidentiality
All parts of the medical consultation are confidential. There are few cases when confidentiality can be relaxed (see Clinical insight box).
 
Capacity
In order to have capacity, a patient must be able to:
  • Understand the information relevant to the decision
  • Retain the information
  • Use that information as part of the decision-making process
  • 26Communicate his or her decision by talking or signing, or by any other means
 
Key legal concepts
Legal standards vary in different countries. The concepts here describe the general principles that are held to be true in the UK.
 
Consent
Consent is the process of gaining approval or permission after thoughtful consideration. Consent can be implied, verbal or written. Consent is valid if: (1) the patient has capacity, (2) the patient was sufficiently informed, and (3) the consent was voluntary and not coerced. Consent is often regarded as a legal expression of autonomy.
 
Decisions relating to cardiopulmonary resuscitation
Respect the desires of well-informed patients who do not wish to undergo cardiopulmonary resuscitation. This may appear to be a difficult consultation, but most patients who are near the end of life have a desire to discuss the pertinent issues. It also opens a door to a discussion between a patient and their loved ones about their current clinical condition. Clinicians should assist their patients in this discussion.
 
Treat patients with respect
In order to treat a patient autonomously, you must treat patients with respect regardless of their religion, sexual orientation and life choices. You must not unfairly discriminate against them by allowing your personal views to adversely affect your professional relationship with them or the treatment that you provide or arrange.
 
Probity
Probity means being honest and trustworthy and acting with integrity; this is at the heart of medical professionalism be courteous. Let people talk, and show them that you are listening to them carefully:27
  • Give unbiased advise
  • Encourage patients to participate actively in all decisions related to their health and support these decisions even if you disagree with them
  • Accept death as a part of life and help people make the best possible arrangements when death is close
  • Work cooperatively with other members of the healthcare team
  • Live a balanced life and care for yourself and your family as well as your colleagues
  • Be humble28