Macleod's Clinical Examination 14th Edition PDF

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Any screen. Any time. Anywhere. Activate the eBook version of this title at no additional charge. Student Consult eBooks give you the power to browse and find content, view enhanced images, share notes and highlights—both online and offline. Unlock your eBook today. 1 Visit studentconsult.inkling.com/redeem Scan this QR code to redeem your eBook through your mobile device: 2 Scratch off your code 3 Type code into “Enter Code” box 4 Click “Redeem” 5 Log in or Sign up 6 Go to “My Library” It’s that easy! Place Peel Off Sticker Here For technical assistance: email [email protected] call 1-800-401-9962 (inside the US) call +1-314-447-8200 (outside the US) Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on studentconsult.inkling.com. Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book, at studentconsult.inkling.com and may not be transferred to another party by resale, lending, or other means. 2015v1.0 Macleod’s Clinical Examination  John Macleod (1915–2006) John Macleod was appointed consultant physician at the Western General Hospital, Edinburgh, in 1950. He had major interests in rheumatology and medical education. Medical students who attended his clinical teaching sessions remember him as an inspirational teacher with the ability to present complex problems with great clarity. He was invariably courteous to his patients and students alike. He had an uncanny knack of involving all students equally in clinical discussions and used praise rather than criticism. He paid great attention to the value of history taking and, from this, expected students to identify what particular aspects of the physical examination should help to narrow the diagnostic options. His consultant colleagues at the Western welcomed the opportunity of contributing when he suggested writing a textbook on clinical examination. The book was first published in 1964 and John Macleod edited seven editions. With characteristic modesty he was very embarrassed when the eighth edition was renamed Macleod’s Clinical Examination. This, however, was a small way of recognising his enormous contribution to medical education. He possessed the essential quality of a successful editor – the skill of changing disparate contributions from individual contributors into a uniform style and format without causing offence; everybody accepted his authority. He avoided being dogmatic or condescending. He was generous in teaching others his editorial skills and these attributes were recognised when he was invited to edit Davidson’s Principles and Practice of Medicine. Content Strategist: Laurence Hunter Content Development Specialist: Helen Leng Project Manager: Anne Collett Designer: Miles Hitchen Illustration Manager: Karen Giacomucci Macleod’s 14th Edition Examination Clinical Edited by J Alastair Innes BSc PhD FRCP(Ed) Consultant Physician, Respiratory Unit, Western General Hospital, Edinburgh; Honorary Reader in Respiratory Medicine, University of Edinburgh, UK Anna R Dover PhD FRCP(Ed) Consultant in Diabetes, Endocrinology and General Medicine, Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh; Honorary Clinical Senior Lecturer, University of Edinburgh, UK Karen Fairhurst PhD FRCGP General Practitioner, Mackenzie Medical Centre, Edinburgh; Clinical Senior Lecturer, Centre for Population Health Sciences, University of Edinburgh, UK Illustrations by Robert Britton and Ethan Danielson Edinburgh London New York Oxford Philadelphia St Louis Sydney 2018 © 2018 Elsevier Ltd. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the publisher (other than as may be noted herein). First edition 1964 Sixth edition 1983 Eleventh edition 2005 Second edition 1967 Seventh edition 1986 Twelfth edition 2009 Third edition 1973 Eighth edition 1990 Thirteenth edition 2013 Fourth edition 1976 Ninth edition 1995 Fourteenth edition 2018 Fifth edition 1979 Tenth edition 2000 ISBN 978-0-7020-6993-2 International ISBN 978-0-7020-6992-5 Notices Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. The publisher’s policy is to use paper manufactured from sustainable forests Printed in Europe Last digit is the print number: 9 8 7 6 5 4 3 2 1  Contents Preface vii Acknowledgements ix How to make the most of this book xi Clinical skills videos xiii Contributors xv SECTION 1 PRINCIPLES OF CLINICAL HISTORY AND EXAMINATION 1   1 Managing clinical encounters with patients 3 Karen Fairhurst, Anna R Dover, J Alastair Innes   2 General aspects of history taking 9 J Alastair Innes, Karen Fairhurst, Anna R Dover   3 General aspects of examination 19 Anna R Dover, J Alastair Innes, Karen Fairhurst SECTION 2 SYSTEM-BASED EXAMINATION 37   4 The cardiovascular system 39 Nicholas L Mills, Alan G Japp, Jennifer Robson   5 The respiratory system 75 J Alastair Innes, James Tiernan   6 The gastrointestinal system 93 John Plevris, Rowan Parks   7 The nervous system 119 Richard Davenport, Hadi Manji   8 The visual system 151 Shyamanga Borooah, Naing Latt Tint   9 The ear, nose and throat 171 Iain Hathorn 10 The endocrine system 193 Anna R Dover, Nicola Zammitt 11 The reproductive system 211 Oliver Young, Colin Duncan, Kirsty Dundas, Alexander Laird vi Contents 12 The renal system 237 Neeraj Dhaun, David Kluth 13 The musculoskeletal system 251 Jane Gibson, Ivan Brenkel 14 The skin, hair and nails 283 Michael J Tidman SECTION 3 APPLYING HISTORY AND EXAMINATION SKILLS IN SPECIFIC SITUATIONS 295 15 Babies and children 297 Ben Stenson, Steve Cunningham 16 The patient with mental disorder 319 Stephen Potts 17 The frail elderly patient 329 Andrew Elder, Elizabeth MacDonald 18 The deteriorating patient 339 Ross Paterson, Anna R Dover 19 The dying patient 347 Anthony Bateman, Kirsty Boyd SECTION 4 PUTTING HISTORY AND EXAMINATION SKILLS TO USE 353 20 Preparing for assessment 355 Anna R Dover, Janet Skinner 21 Preparing for practice 361 Karen Fairhurst, Gareth Clegg Index 375  Preface Despite the wealth of diagnostic tools available to the modern to the use of pattern recognition to identify spot diagnoses. physician, the acquisition of information by direct interaction Section 2 deals with symptoms and signs in specific systems with the patient through history taking and clinical examination and Section 3 illustrates the application of these skills to specific remains the bedrock of the physician’s art. These time-honoured clinical situations. Section 4 covers preparation for assessments skills can often allow clinicians to reach a clear diagnosis without of clinical skills and for the use of these skills in everyday practice. recourse to expensive and potentially harmful tests. An expertly performed history and examination of a patient This book aims to assist clinicians in developing the consultation allows the doctor to detect disease and predict prognosis, and is skills required to elicit a clear history, and the practical skills crucial to the principle of making the patient and their concerns needed to detect clinical signs of disease. Where possible, the central to the care process, and also to the avoidance of harm physical basis of clinical signs is explained to aid understanding. from unnecessary or unjustified tests. Formulation of a differential diagnosis from the information gained We hope that if young clinicians are encouraged to adopt is introduced, and the logical initial investigations are included for and adapt these skills, they not only will serve their patients each system. Macleod’s Clinical Examination is designed to be as diagnosticians but also will themselves continue to develop used in conjunction with more detailed texts on pathophysiology, clinical examination techniques and a better understanding of differential diagnosis and clinical medicine, illustrating specifically their mechanisms and diagnostic use. how the history and examination can inform the diagnostic The 14th edition of Macleod’s Clinical Examination has an process. accompanying set of videos available in the online Student In this edition the contents have been restructured and the Consult electronic library. This book is closely integrated with text comprehensively updated by a team of existing and new Davidson’s Principles and Practice of Medicine and is best read authors, with the aim of creating an accessible and user-friendly in conjunction with that text. text relevant to the practice of medicine in the 21st century. Section 1 addresses the general principles of good interaction JAI, ARD, KF with patients, from the basics of taking a history and examining, Edinburgh, 2018 This page intentionally left blank  Acknowledgements The editors would like acknowledge the immense contribution McDonald, Jon Harvey, Alexandra Hawker, Raja K Haynes, Emma made by Graham Douglas, Fiona Nicol and Colin Robertson Hendry, Malik Hina, Bianca Honnekeri, Justina Igwe, Chisom who edited the three previous editions of Macleod’s Clinical Ikeji, Sushrut Ingawale, Mohammad Yousuf ul Islam, Sneha Jain, Examination. Together they re-shaped the format of this textbook Maria Javed, Ravin Jegathnathan, Helge Leander B Jensen, and their efforts were rewarded by a substantial growth in both Li Jie, Ali Al Joboory, Asia Joseph, Christopher Teow Kang its sales and international reputation. Jun, Janpreet Kainth, Ayush Karmacharya, JS Karthik, Aneesh The editors would like to acknowledge and offer grateful thanks Karwande, Adhishesh Kaul, Alper Kaymak, Ali Kenawi, Abdullah for the input of all previous editions’ contributors, without whom Al Arefin Khadem, Haania Khan, Muhammad Hassan Khan, this new edition would not have been possible. In particular, we Sehrish Khan, Shrayash Khare, Laith Khweir, Ankit Kumar, Vinay are indebted to those former authors who step down with the Kumar, Ibrahim Lafi, Armeen Lakhani, Christopher Lee, David Lee, arrival of this new edition. They include: Elaine Anderson, John Benjamin Leeves, Soo Ting Joyce Lim, Chun Hin Lo, Lai Hing Loi, Bevan, Andrew Bradbury, Nicki Colledge, Allan Cumming, Graham Chathura Mihiran Maddumabandara, Joana Sousa Magalhães, Devereux, Jamie Douglas, Rebecca Ford, David Gawkrodger, Aditya Mahajan, Mahabubul Islam Majumder, Aaditya Mallik, Neil Grubb, James Huntley, John Iredale, Robert Laing, Andrew Mithilesh Chandra Malviya, Santosh Banadahally Manjegowda, Longmate, Alastair MacGilchrist, Dilip Nathwani, Jane Norman, Jill Marshall, Balanuj Mazumdar, Alan David McCrorie, Paras John Olson, Paul O’Neill, Stephen Payne, Laura Robertson, Mehmood, Kartik Mittal, Mahmood Kazi Mohammed, Amber David Snadden, James C Spratt, Kum-Ying Tham, Steve Turner Moorcroft, Jayne Murphy, Sana Mustafa, Arvi Nahar, Akshay and Janet Wilson. Prakash Narad, Shehzina Nawal, Namia Nazir, Viswanathan We are particularly grateful to the following medical students, Neelakantan, Albero Nieto, Angelina Choong Kin Ning, Faizul who undertook detailed reviews of the book and gave us a wealth Nordin, Mairead O’Donoghue, Joey O’Halloran, Amit Kumar Ojha, of ideas to implement in this latest edition. We trust we have listed Ifeolu James Oyedele, Anik Pal, Vidit Panchal, Asha Pandu, Bishal all those who contributed, and apologise if any names have been Panthi, Jacob Parker, Ujjawal Paudel, Tanmoy Kumar Paul, Kate accidentally omitted: Layla Raad Abd Al-Majeed, Ali Adel Ne’ma Perry, Daniel Pisaru, David Potter, Dipesh Poudel, Arijalu Syaram Abdullah, Aanchal Agarwal, Hend Almazroa, Alhan Alqinai, Amjed Putra, Janine Qasim, Muhammad Qaunayn Qays, Mohammad Alyasseen, Chidatma Arampady, Christian Børde Arkteg, Maha Qudah, Jacqueline Quinn, Varun MS Venkat Raghavan, Md. Arnaout, Rashmi Arora, Daniel Ashrafi, Herry Asnawi, Hemant Atri, Rahmatullah, Ankit Raj, Jerin Joseph Raju, Prasanna A Ramana, Ahmed Ayyad, Kainath N Azad, Sadaf Azam, Arghya Bandhu, Ashwini Dhanraj Rangari, Anurag Ramesh Rathi, Anam Raza, Jamie Barclay, Prithiv Siddarth Saravana Bavan, Rajarshi Bera, Rakesh Reddy, Sudip Regmi, Amgad Riad, Patel Riya, Emily Craig Betton, Apoorva Bhagat, Prachi Bhageria, Geethanjali Robins, Grace Robinson, Muhammad’Azam Paku Rozi, Cosmin Bhas, Navin Bhatt, Shahzadi Nisar Bhutto, Abhishek Ghosh Rusneac, Ahmed Sabra, Anupama Sahu, Mohammad Saleh, Biswas, Tamoghna Biswas, Debbie Bolton, Claude Borg, Daniel Manjiri Saoji, Saumyadip Sarkar, Rakesh Kumar Shah, Basil Al Buxton, Anup Chalise, Amitesh Kumar Chatterjee, Subhankar Shammaa, Sazzad Sharhiar, Anmol Sharma, Homdutt Sharma, Chatterjee, Farhan Ashraf Chaudhary, Aalia Chaudhry, Jessalynn Shivani Sharma, Shobhit Sharma, Johannes Iikuyu Shilongo, Chia, Bhaswati Chowdhury, Robin Chowdhury, Marshall Colin, Dhan Bahadur Shrestha, Pratima Shrestha, Anurag Singh, Michael Collins, Margaret Cooper, Barbara Corke, Andrea Culmer, Kareshma Kaur Ranjit Singh, Nishansh Singh, Aparna Sinha, Gowtham Varma Dantuluri, Abhishek Das, Sonali Das, Aziz Dauti, Liam Skoda, Ethan-Dean Smith, Prithviraj Solanki, Meenakshi Mark Davies, Adam Denton, Muinul Islam Dewan, Greg Dickman, Sonnilal, Soundarya Soundararajan, Morshedul Islam Sowrav, Hengameh Ahmad Dokhtjavaherian, Amy Edwards, Muhammad Kayleigh Spellar, Siddharth Srinivasan, Pradeep Srivastava, Eimaduddin, Laith Al Ejeilat, Divya G Eluru, Emmanuel Ernest, El Anthony Starr, Michael Suryadisastra, Louisa Sutton, Komal Bushra El Fadil, Fathima Ashfa Mohamed Faleel, Malcolm Falzon, Ashok Tapadiya, Areeba Tariq, Imran Tariq, Jia Chyi Tay, Javaria Emma Farrington, Noor Fazal, Sultana Ferdous, Matthew Formosa, Tehzeeb, Daniel Theron, Michele Tosi, Pagavathbharathi Sri Balaji Brian Forsyth, David Fotheringham, Bhargav Gajula, Dariimaa Vidyapeeth, Amarjit Singh Vij, Cathrine Vincent, Ghassan Wadi, Ganbat, Lauren Gault, Michaela Goodson, Mounika Gopalam, Amirah Abdul Wahab, James Warrington, Luke Watson, Federico Ciaran Grafton-Clarke, Anthony Gunawan, Aditya Gupta, Digvijay Ivan Weckesser, Ben Williamson, Kevin Winston, Kyi Phyu Wint, Gupta, Kshitij Gupta, Sonakshi Gupta, Md. Habibullah, Kareem Harsh Yadav, Saroj Kumar Yadav, Amelia Yong, Awais Zaka Haloub, Akar Jamal Hamasalih, James Harper, Bruce Harper- and Nuzhat Zehra. This page intentionally left blank  How to make the most of this book The purpose of this book is to document and explain how to: Integrated examination sequence: a structured list of steps interact with a patient as their doctor to be followed when examining the system, intended as a take a history from a patient prompt and revision aid. examine a patient Return to this book to refresh your technique if you have formulate your findings into differential diagnoses been away from a particular field for some time. It is surprising rank these in order of probability how quickly your technique deteriorates if you do not use it use investigations to support or refute your differential regularly. Practise at every available opportunity so that you diagnosis. become proficient at examination techniques and gain a full Initially, when you approach a section, we suggest that you understanding of the range of normality. glance through it quickly, looking at the headings and how it Ask a senior colleague to review your examination technique is laid out. This will help you to see in your mind’s eye the regularly; there is no substitute for this and for regular practice. framework to use. Listen also to what patients say – not only about themselves Learn to speed-read. It is invaluable in medicine and in life but also about other health professionals – and learn from these generally. Most probably, the last lesson you had on reading comments. You will pick up good and bad points that you will was at primary school. Most people can dramatically improve want to emulate or avoid. their speed of reading and increase their comprehension by Finally, enjoy your skills. After all, you are learning to be able using and practising simple techniques. to understand, diagnose and help people. For most of us, this Try making mind maps of the details to help you recall and is the reason we became doctors. retain the information as you progress through the chapter. Each of the systems chapters is laid out in the same order: Introduction: anatomy and physiology. The history: common presenting symptoms, what Examination sequences questions to ask and how to follow them up. The physical examination: what and how to examine. Throughout the book there are outlines of techniques that you Investigations: how to select the most relevant and should follow when examining a patient. These are identified informative initial tests, and how these clarify the diagnosis. with a red ‘Examination sequence’ heading. The bullet-point list Objective Structured Clinical Examination (OSCE) provides the exact order in which to undertake the examination. examples: a couple of short clinical scenarios included to To help your understanding of how to perform these techniques illustrate the type of problems students may meet in an many of the examination sequences have been filmed and these OSCE assessment of this system. are marked with an arrowhead. This page intentionally left blank  Clinical skills videos Included with your purchase are clinical examination videos, custom-made for this textbook. Filmed using qualified doctors, with hands-on guidance from the author team, and narrated by former Editor Professor Colin Robertson, these videos offer you the chance to watch trained professionals performing many of the examination routines described in the book. By helping you to memorise the essential examination steps required for each major system and by demonstrating the proper clinical technique, these videos should act as an important bridge between textbook learning and bedside teaching. The videos will be available for you to view again and again as your clinical skills develop and will prove invaluable as you prepare for your clinical OSCE examinations. Each examination routine has a detailed explanatory narrative but for maximum benefit view the videos in conjunction with the book. See the inside front cover for your access instructions. Video production team Director and editor Key points in examinations: photo galleries Dr Iain Hennessey Many of the examination sequences are included as photo Producer galleries, illustrating with captions the key stages of the Dr Alan G Japp examination routine. These will act as a useful reminder of the main points of each sequence. See the inside front cover for Sound and narrators your access instructions. Professor Colin Robertson Dr Nick Morley Video contents Clinical examiners Dr Amy Robb Examination of the cardiovascular system. Dr Ben Waterson Examination of the respiratory system. Examination of the gastrointestinal system. Patients Examination of the neurological system. Abby Cooke Examination of the ear. Omar Ali Examination of the thyroid gland. Examination of the musculoskeletal system. This page intentionally left blank  Contributors Anthony Bateman MD MRCP FRCA FFICM Kirsty Dundas DCH FRCOG Consultant in Critical Care and Long Term Ventilation, Critical Consultant Obstetrician, Royal Infirmary of Edinburgh; Care NHS Lothian, Edinburgh, UK Honorary Senior Lecturer and Associate Senior Tutor, University of Edinburgh, UK Shyamanga Borooah MRCP(UK) MRCS(Ed) FRCOphth PhD Andrew Elder FRCP(Ed) FRCPSG FRCP FACP FICP(Hon) Fulbright Fight for Sight Scholar, Shiley Eye Institute, Consultant in Acute Medicine for the Elderly, Western General University of California, San Diego, USA Hospital, Edinburgh; Honorary Professor, University of Edinburgh, UK Kirsty Boyd PhD FRCP MMedSci Consultant in Palliative Medicine, Royal Infirmary of Edinburgh; Karen Fairhurst PhD FRCGP Honorary Clinical Senior Lecturer, Primary Palliative Care General Practitioner, Mackenzie Medical Centre, Edinburgh; Research Group, University of Edinburgh, UK Clinical Senior Lecturer, Centre for Population Health Sciences, University of Edinburgh, UK Ivan Brenkel FRCS(Ed) Consultant Orthopaedic Surgeon, Orthopaedics, NHS Fife, Jane Gibson MD FRCP(Ed) FSCP(Hon) Kirkcaldy, UK Consultant Rheumatologist, Fife Rheumatic Diseases Unit, NHS Fife, Kirkcaldy, Fife; Honorary Senior Lecturer, University Gareth Clegg PhD MRCP FRCEM of St Andrews, UK Senior Clinical Lecturer, University of Edinburgh; Honorary Consultant in Emergency Medicine, Royal Infirmary of Iain Hathorn DOHNS PGCME FRCS(Ed) (ORL-HNS) Edinburgh, UK Consultant ENT Surgeon, NHS Lothian, Edinburgh, UK; Honorary Clinical Senior Lecturer, University of Edinburgh, UK Steve Cunningham PhD Consultant and Honorary Professor in Paediatric Respiratory Iain Hennessey FRCS MMIS Medicine, Royal Hospital for Sick Children, Edinburgh, UK Clinical Director of Innovation, Consultant Paediatric and Neonatal Surgeon, Alder Hey Children’s Hospital, Richard Davenport DM FRCP(Ed) Liverpool, UK Consultant Neurologist, Western General Hospital and Royal Infirmary of Edinburgh; Honorary Senior Lecturer, University of J Alastair Innes BSc PhD FRCP(Ed) Edinburgh, UK Consultant Physician, Respiratory Unit, Western General Hospital, Edinburgh; Honorary Reader in Respiratory Neeraj Dhaun PhD Medicine, University of Edinburgh, UK Senior Lecturer and Honorary Consultant Nephrologist, University of Edinburgh, UK Alan G Japp PhD MRCP Consultant Cardiologist, Royal Infirmary of Edinburgh; Anna R Dover PhD FRCP(Ed) Honorary Senior Lecturer, University of Edinburgh, UK Consultant in Diabetes, Endocrinology and General Medicine, Edinburgh Centre for Endocrinology and Diabetes, Royal David Kluth PhD FRCP Infirmary of Edinburgh; Honorary Clinical Senior Lecturer, Reader in Nephrology, University of Edinburgh, UK University of Edinburgh, UK Alexander Laird PhD FRCS(Ed) (Urol) Colin Duncan MD FRCOG Consultant Urological Surgeon, Western General Hospital, Professor of Reproductive Medicine and Science, University Edinburgh, UK of Edinburgh; Honorary Consultant Gynaecologist, Royal Infirmary of Edinburgh, UK xvi Contributors Elizabeth MacDonald FRCP(Ed) DMCC Jennifer Robson PhD FRCS Consultant Physician in Medicine of the Elderly, Western Clinical Lecturer in Surgery, University of Edinburgh, UK General Hospital, Edinburgh, UK Janet Skinner FRCS MMedEd FCEM Hadi Manji MA MD FRCP Director of Clinical Skills, University of Edinburgh; Emergency Consultant Neurologist and Honorary Senior Lecturer, Medicine Consultant, Royal Infirmary of Edinburgh, UK National Hospital for Neurology and Neurosurgery, London, UK Ben Stenson FRCPCH FRCP(Ed) Consultant Neonatologist, Royal Infirmary of Edinburgh; Nicholas L Mills PhD FRCP(Ed) FESC Honorary Professor of Neonatology, University of Chair of Cardiology and British Heart Foundation Senior Edinburgh, UK Clinical Research Fellow, University of Edinburgh; Consultant Cardiologist, Royal Infirmary of Edinburgh, UK Michael J Tidman MD FRCP(Ed) FRCP (Lond) Consultant Dermatologist, Royal Infirmary of Edinburgh, UK Nick Morley MRCS(Ed) FRCR FEBNM Consultant Radiologist, University Hospital of Wales, James Tiernan MSc(Clin Ed) MRCP(UK) Cardiff, UK Consultant Respiratory Physician, Royal Infirmary of Edinburgh; Honorary Senior Clinical Lecturer, University of Rowan Parks MD FRCSI FRCS(Ed) Edinburgh, UK Professor of Surgical Sciences, Clinical Surgery, University of Edinburgh; Honorary Consultant Hepatobiliary and Pancreatic Naing Latt Tint FRCOphth PhD Surgeon, Royal Infirmary of Edinburgh, UK Consultant Ophthalmic Surgeon, Ophthalmology, Princess Alexandra Eye Pavilion, Edinburgh, UK Ross Paterson FRCA DICM FFICM Consultant in Critical Care, Western General Hospital, Oliver Young FRCS(Ed) Edinburgh, UK Clinical Director, Edinburgh Breast Unit, Western General Hospital, Edinburgh, UK John Plevris DM PhD FRCP(Ed) FEBGH Professor and Consultant in Gastroenterology, Royal Infirmary Nicola Zammitt MD FRCP(Ed) of Edinburgh, University of Edinburgh, UK Consultant in Diabetes, Endocrinology and General Medicine, Edinburgh Centre for Endocrinology and Diabetes, Royal Stephen Potts FRCPsych FRCP(Ed) Infirmary of Edinburgh; Honorary Clinical Senior Lecturer, Consultant in Transplant Psychiatry, Royal Infirmary of University of Edinburgh, UK Edinburgh; Honorary Senior Clinical Lecturer, University of Edinburgh, UK Colin Robertson FRCP(Ed) FRCS(Ed) FSAScot Honorary Professor of Accident and Emergency Medicine, University of Edinburgh, UK  Section 1 Principles of clinical history and examination 1 Managing clinical encounters with patients 3 2 General aspects of history taking 9 3 General aspects of examination 19 This page intentionally left blank  1 Managing clinical encounters Karen Fairhurst Anna R Dover J Alastair Innes 1 with patients The clinical encounter 4 Alternatives to face-to-face encounters 6 Reasons for the encounter 4 Professional responsibilities 6 The clinical environment 4 Confidentiality and consent 7 Opening the encounter 5 Social media 7 Gathering information 5 Personal responsibilities 7 Handling sensitive information and third parties 5 Managing patient concerns 5 Showing empathy 5 Showing cultural sensitivity 6 Addressing the problem 6 Concluding the encounter 6 4 Managing clinical encounters with patients A range of cultural factors may also influence help-seeking The clinical encounter behaviour. Examples of person-specific factors that reduce the propensity to consult include stoicism, self-reliance, guilt, The clinical encounter between a patient and doctor lies at the unwillingness to acknowledge psychological distress, and heart of most medical practice. At its simplest, it is the means by embarrassment about lifestyle factors such as addictions. These which people who are ill, or believe themselves to be ill, seek the factors may vary between patients and also in the same person advice of a doctor whom they trust. Traditionally, and still most in different circumstances, and may be influenced by gender, often, the clinical encounter is conducted face to face, although education, social class and ethnicity. non-face-to-face or remote consultation using the telephone or digital technology is possible and increasingly common. This The clinical environment chapter describes the general principles that underpin interactions with patients in a clinical environment. You should take all reasonable steps to ensure that the consultation is conducted in a calm, private environment. The Reasons for the encounter layout of the consulting room is important and furniture should be arranged to put the patient at ease (Fig. 1.1A) by avoiding The majority of people who experience symptoms of ill health face-to-face, confrontational positioning across a table and the do not seek professional advice. For the minority who do seek incursion of computer screens between patient and doctor (Fig. help, the decision to consult is usually based on a complex 1.1B). Personal mobile devices can also be intrusive if not used interplay of physical, psychological and social factors (Box 1.1). judiciously. The perceived seriousness of the symptoms and the severity of For hospital inpatients the environment is a challenge, yet the illness experience are very important influences on whether privacy and dignity are always important. There may only be patients seek help. The anticipated severity of symptoms is curtains around the bed space, which afford very little by way determined by their intensity, the patient’s familiarity with them, of privacy for a conversation. If your patient is mobile, try to and their duration and frequency. Beyond this, patients try to use a side room or interview room. If there is no alternative to make sense of their symptoms within the context of their lives. speaking to patients at their bedside, let them know that you They observe and evaluate their symptoms based on evidence understand your conversation may be overheard and give them from their own experience and from information they have permission not to answer sensitive questions about which they gathered from a range of sources, including family and friends, feel uncomfortable. print and broadcast media, and the internet. Patients who present with a symptom are significantly more likely to believe or worry that their symptom indicates a serious or fatal condition than non-consulters with similar symptoms; for example, a family history of sudden death from heart disease may affect how a person interprets an episode of chest pain. Patients also weigh up the relative costs (financial or other, such as inconvenience) and benefits of consulting a doctor. The expectation of benefit from a consultation – for example, in terms of symptom relief or legitimisation of time off work – is a powerful predictor of consultation. There may also be times when other priorities in patients’ lives are more important than their symptoms of ill health and deter or delay consultation. It is important to consider the timing of the consultation. Why has the patient presented now? Sometimes it is not the experience of symptoms themselves that provokes consultation but something else in the patients’ lives A that triggers them to seek help (Box 1.2). 1.1 Deciding to consult a doctor Perceived susceptibility or vulnerability to illness Perceived severity of symptoms Perceived costs of consulting Perceived benefits of consulting 1.2 Triggers to consultation B Interpersonal crisis Interference with social or personal relations Fig. 1.1 Seating arrangements. A In this friendly seating arrangement Sanctioning or pressure from family or friends the doctor sits next to the patient, at an angle. B Barriers to Interference with work or physical activity communication are set up by an oppositional/confrontational seating Reaching the limit of tolerance of symptoms arrangement. The desk acts as a barrier, and the doctor is distracted by looking at a computer screen that is not easily viewable by the patient.  The clinical encounter 5 during the consultation can be clues to difficulties that they Opening the encounter cannot express verbally. If the their body language becomes 1 ‘closed’ – for example, if they cross their arms and legs, turn At the beginning of any encounter it is important to start to away or avoid eye contact – this may indicate discomfort. establish a rapport with the patient. Rapport helps to relax and engage the person in a useful dialogue. This involves greeting the patient and introducing yourself and describing your role Handling sensitive information clearly. A good reminder is to start any encounter with ‘Hello, and third parties my name is ….’ You should wear a name badge that can be read easily. A friendly smile helps to put your patient at Confidentiality is your top priority. Ask your patient’s permission ease. The way you dress is important; your dress style and if you need to obtain information from someone else: usually a demeanour should never make your patients uncomfortable or relative but sometimes a friend or a carer. If the patient cannot distract them. Smart, sensitive and modest dress is appropriate. communicate, you may have to rely on family and carers to Wear short sleeves or roll long sleeves up, away from your understand what has happened to the patient. Third parties may wrists and forearms, particularly before examining patients or approach you without your patient’s knowledge. Find out who carrying out procedures. Avoid hand jewellery to allow effective they are, their relationship to the patient, and whether your patient hand washing and reduce the risk of cross-infection (see Fig. knows the third party is talking to you. Tell third parties that you 3.1). Tie back long hair. You should ensure that the patient is can listen to them but cannot divulge any clinical information physically comfortable and at ease. without the patient’s explicit permission. They may tell you about How you address and speak to a patient depends on the sensitive matters, such as mental illness, sexual abuse or drug person’s age, background and cultural environment. Some older or alcohol addiction. This information needs to be sensitively people prefer not to be called by their first name and it is best to explored with your patient to confirm the truth. ask patients how they would prefer to be addressed. Go on to establish the reason for the encounter: in particular, the problems Managing patient concerns or issues the patient wishes to address or be addressed. Ask an open question to start with to encourage the patient to talk, Patients are not simply the embodiment of disease but individuals such as ‘How can I help you today?’ or ‘What has brought you who experience illness in their own unique way. Identifying their along to see me today?’ disease alone is rarely sufficient to permit full understanding of an individual patient’s problems. In each encounter you should Gathering information therefore also seek a clear understanding of the patient’s personal experience of illness. This involves exploring the patients’ feelings The next task of the doctor in the clinical encounter is to and ideas about their illness, its impact on their lifestyle and understand what is causing the patient to be ill: that is, to reach functioning, and their expectations of its treatment and course. a diagnosis. To do this you need to establish whether or not Patients may even be so fearful of a serious diagnosis that the patient is suffering from an identifiable disease or condition, they conceal their concerns; the only sign that a patient fears and this requires further evaluation of the patient by history cancer may be sitting with crossed fingers while the history is taking, physical examination and investigation where appropriate. taken, hoping inwardly that cancer is not mentioned. Conversely, Chapters 2 and 3 will help you develop a general approach to do not assume that the medical diagnosis is always a patient’s history taking and physical examination; detailed guidance on main concern; anxiety about an inability to continue to work history taking and physical examination in specific systems and or to care for a dependent relative may be equally distressing. circumstances is offered in Sections 2 and 3. The ideas, concerns and expectations that patients have about Fear of the unknown, and of potentially serious illness, their illness often derive from their personal belief system, as well accompanies many patients as they enter the consulting room. as from more widespread social and cultural understandings of Reactions to this vary widely but it can certainly impede clear recall illness. These beliefs can influence which symptoms patients and description. Plain language is essential for all encounters. The choose to present to doctors and when. In some cultures, people use of medical jargon is rarely appropriate because the risk of derive much of their prior knowledge about health, illness and the doctor and the patient having a different understanding of the disease from the media and the internet. Indeed, patients have same words is simply too great. This also applies to words the often sought explanations for their symptoms from the internet patient may use that have multiple possible meanings (such as (or from other trusted sources) prior to consulting a doctor, and ‘indigestion’ or ‘dizziness’); these terms must always be defined may return to these for a second opinion once they have seen precisely in the course of the discussion. a doctor. It is therefore important to establish what a patient Active listening is a key strategy in clinical encounters, as it already understands about the problem. This allows you and the encourages patients to tell their story. Doctors who fill every patient to move towards a mutual understanding of the illness. pause with another specific question will miss the patient’s revealing calm reflection, or the hesitant question that reveals Showing empathy an inner concern. Instead, encourage the patient to talk freely by making encouraging comments or noises, such as ‘Tell me Being empathic is a powerful way to build your relationship with a bit more’ or ‘Uhuh’. Clarify that you understand the meaning patients. Empathy is the ability to identify with and understand of what patients have articulated by reflecting back statements patients’ experiences, thoughts and feelings and to see the world and summarising what you think they have said. as they do. Being empathic also involves being able to convey Non-verbal communication is equally important. Look for that understanding to the patient by making statements such non-verbal cues indicating the patient’s level of distress and as ‘I can understand you must be feeling quite worried about mood. Changes in your patients’ demeanour and body language what this might mean.’ Empathy is not the same as sympathy, 6 Managing clinical encounters with patients which is about the doctor’s own feelings of compassion for or or to offer additional support. When using the telephone, it is sorrow about the difficulties that the patient is experiencing. even more important to listen actively and to check your mutual understanding frequently. Showing cultural sensitivity Similarly, asynchronous communication with patients, using email or web-based applications, has been adopted by some Patients from a culture that is not your own may have different doctors. This is not yet widely seen as a viable alternative social rules regarding eye contact, touch and personal space. to face-to-face consultation, or as a secure way to transmit In some cultures, it is normal to maintain eye contact for confidential information. Despite the communication challenges long periods; in most of the world, however, this is seen as that it can bring, telemedicine (using telecommunication and other confrontational or rude. Shaking hands with the opposite sex information technologies) may be the only means of healthcare is strictly forbidden in certain cultures. Death may be dealt with provision for patients living in remote and rural areas and its use is differently in terms of what the family expectations of physicians likely to increase, as it has the advantage of having the facility to may be, which family members will expect information to be incorporate the digital collection and transmission of medical data. shared with them and what rites will be followed. Appreciate and accept differences in your patients’ cultures and beliefs. When in doubt, ask them. This lets them know that you are aware of, Professional responsibilities and sensitive to, these issues. Clinical encounters take place within a very specific context Addressing the problem configured by the healthcare system within which they occur, the legal, ethical and professional frameworks by which we are Communicating your understanding of the patient’s problem bound, and by society as a whole. to them is crucial. It is good practice to ensure privacy for this, From your first day as a student, you have professional particularly if imparting bad news. Ask the patient who else they obligations placed on you by the public, the law and your would like to be present – this may be a relative or partner – and colleagues, which continue throughout your working life. Patients offer a nurse. Check patients’ current level of understanding and must be able to trust you with their lives and health, and you try to establish what further information they would like. Information will be expected to demonstrate that your practice meets the should be provided in small chunks and be tailored to the patient’s expected standards (Box 1.3). Furthermore, patients want more needs. Try to acknowledge and address the patient’s ideas, from you than merely intellectual and technical proficiency; they concerns and expectations. Check the patient’s understanding will value highly your ability to demonstrate kindness, empathy and recall of what you have said and encourage questions. After and compassion. this, you should agree a management plan together. This might involve discussing and exploring the patient’s understanding of the options for their treatment, including the evidence of benefit 1.3 The duties of a registered doctor and risk for particular treatments and the uncertainties around Knowledge, skills and performance it, or offering recommendations for treatment. Make the care of your patient your first concern Provide a good standard of practice and care: Concluding the encounter Keep your professional knowledge and skills up to date Recognise and work within the limits of your competence Closing the consultation usually involves summarising the Safety and quality important points that have been discussed during the consultation. This aids patient recall and facilitates adherence to treatment. Take prompt action if you think that patient safety, dignity or Any remaining questions that the patient may have should be comfort is being compromised Protect and promote the health of patients and the public addressed, and finally you should check that you have agreed a plan of action together with the patient and confirmed Communication, partnership and teamwork arrangements for follow-up. Treat patients as individuals and respect their dignity: Treat patients politely and considerately Respect patients’ right to confidentiality Alternatives to face-to-face Work in partnership with patients: Listen to, and respond to, their concerns and preferences encounters Give patients the information they want or need in a way they can understand The use of telephone consultation as an alternative to face-to- Respect patients’ right to reach decisions with you about their face consultation has become accepted practice in parts of treatment and care some healthcare systems, such as general practice in the UK. Support patients in caring for themselves to improve and maintain their health However, research suggests that, compared to face-to-face Work with colleagues in the ways that best serve patients’ interests consultations, telephone consultations are shorter, cover fewer problems and include less data gathering, counselling/advice Maintenance of trust and rapport building. They are therefore considered to be most Be honest and open, and act with integrity suitable for uncomplicated presentations. Telephone consultation Never discriminate unfairly against patients or colleagues with patients increases the chance of miscommunication, as Never abuse your patients’ trust in you or the public’s trust in the there are no visual cues regarding body language or demeanour. profession The telephone should not be used to communicate bad news Courtesy General Medical Council (UK). or sensitive results, as there is no opportunity to gauge reaction  Personal responsibilities 7 Fundamentally, patients want doctors who: between countries. In the UK, follow the guidelines issued by the are knowledgeable General Medical Council. There are exceptions to the general 1 respect people, healthy or ill, regardless of who they are rules governing patient confidentiality, where failure to disclose support patients and their loved ones when and where information would put the patient or someone else at risk of needed death or serious harm, or where disclosure might assist in the always ask courteous questions, let people talk and listen prevention, detection or prosecution of a serious crime. If you find to them carefully yourself in this situation, contact the senior doctor in charge of promote health, as well as treat disease the patient’s care immediately and inform them of the situation. give unbiased advice and assess each situation carefully Always obtain consent before undertaking any examination or use evidence as a tool, not as a determinant of practice investigation, or when providing treatment or involving patients let people participate actively in all decisions related to in teaching or research. their health and healthcare humbly accept death as an important part of life, and Social media help people make the best possible choices when death is close Through social media, we are able to create and share web-based work cooperatively with other members of the information. As such, social media has the potential to be a healthcare team valuable tool in communicating with patients, particularly by are advocates for their patients, as well as mentors for facilitating access to information about health and services, and other health professionals, and are ready to learn from by providing invaluable peer support for patients. However, they others, regardless of their age, role or status. also have the potential to expose doctors to risks, especially when One way to reconcile these expectations with your inexperience there is a blurring of the boundaries between their professional and incomplete knowledge or skills is to put yourself in the and personal lives. The obligations on doctors do not change situation of the patient and/or relatives. Consider how you would because they are communicating through social media rather than wish to be cared for in the patient’s situation, acknowledging that face to face or through other conventional media. Indeed, using you are different and your preferences may not be the same. social media creates new circumstances in which the established Most clinicians approach and care for patients differently once principles apply. If patients contact you about their care or other they have had personal experience as a patient or as a relative professional matters through your private profile, you should of a patient. Doctors, nurses and everyone involved in caring for indicate that you cannot mix social and professional relationships patients can have profound influences on how patients experience and, where appropriate, direct them to your professional profile. illness and their sense of dignity. When you are dealing with patients, always consider your: A: attitude – How would I feel in this patient’s situation? Personal responsibilities B: behaviour – Always treat patients with kindness and respect. You should always be aware that you are in a privileged C: compassion – Recognise the human story that professional position that you must not abuse. Do not pursue accompanies each illness. an improper relationship with a patient, and do not give medical D: dialogue – Listen to and acknowledge the patient. care to anyone with whom you have a close personal relationship. Finally, remember that, to be fit to take care of patients, you Confidentiality and consent must first take care of yourself. If you think you have a medical condition that you could pass on to patients, or if your judgement As a student and as a healthcare professional, you will be or performance could be affected by a condition or its treatment, given private and intimate information about patients and their consult your general practitioner. Examples might include serious families. This information is confidential, even after a patient’s communicable disease, significant psychiatric disease, or drug death. This is a general rule, although its legal application varies or alcohol addiction. This page intentionally left blank  2 2 J Alastair Innes Karen Fairhurst Anna R Dover General aspects of history taking The importance of a clear history 10 Difficult situations 16 Gathering information 10 Patients with communication difficulties 16 Beginning the history 10 Patients with cognitive difficulties 16 The history of the presenting symptoms 11 Sensitive situations 16 Past medical history 13 Emotional or angry patients 16 Drug history 13 Family history 14 Social history and lifestyle 14 Systematic enquiry 16 Closing the interview 16 10 General aspects of history taking The way you ask a question is important: The importance of a clear history Open questions are general invitations to talk that avoid anticipating particular answers: for example, ‘What was Understanding the patient’s experience of illness by taking a the first thing you noticed when you became ill?’ or ‘Can history is central to the practice of all branches of medicine. you tell me more about that?’ The process requires patience, care and understanding to yield Closed questions seek specific information and are used the key information leading to correct diagnosis and treatment. for clarification: for example, ‘Have you had a cough In a perfect situation a calm, articulate patient would clearly today?’ or ‘Did you notice any blood in your bowel describe the sequence and nature of their symptoms in the order motions?’ of their occurrence, understanding and answering supplementary Both types of question have their place, and normally clinicians questions where required to add detail and certainty. In reality a move gradually from open to closed questions as the interview multitude of factors may complicate this encounter and confound progresses. the clear communication of information. This chapter is a guide The following history illustrates the mix of question styles to facilitating the taking of a clear history. Information on specific needed to elucidate a clear story: symptoms and presentations is covered in the relevant system chapters. When did you first feel unwell, and what did you feel? (Open questioning) Well, I’ve been getting this funny feeling in my chest Gathering information over the last few months. It’s been getting worse and worse but it was really awful this morning. My husband called 999. The ambulance came and the nurse said I was having a heart attack. It was really scary. Beginning the history When you say a ‘funny feeling’, can you tell me Preparation more about what it felt like? (Open questioning, steering away from events and opinions back to Read your patient’s past records, if they are available, along with symptoms) any referral or transfer correspondence before starting. Well, it was here, across my chest. It was sort of tight, Allowing sufficient time like something heavy sitting on my chest. Consultation length varies. In UK general practice the average And did it go anywhere else? (Open but clarifying) time available is 12 minutes. This is usually adequate, provided the Well, maybe up here in my neck. doctor knows the patient and the family and social background. What were you doing when it came on? (Clarifying In hospital, around 10 minutes is commonly allowed for returning precipitating event) outpatients, although this is challenging for new or temporary staff unfamiliar with the patient. For new and complex problems Just sitting in the kitchen, finishing my breakfast. a full consultation may take 30 minutes or more. For students, How long was the tightness there? (Closed) time spent with patients learning and practising history taking About an hour altogether. is highly valuable, but patients appreciate advance discussion So, you felt a tightness in your chest this morning of the time students need. that went on for about an hour and you also felt it Starting your consultation in your neck? (Reflection) Yes that’s right. Introduce yourself and anyone who is with you, shaking hands if appropriate. Confirm the patient’s name and how they prefer Did you feel anything else at the same time? to be addressed. If you are a student, inform patients; they are (Open, not overlooking secondary symptoms) usually eager to help. Write down facts that are easily forgotten, I felt a bit sick and sweaty. such as blood pressure or family tree, but remember that writing notes must not interfere with the consultation. Showing empathy when taking a history Being empathic helps your relationship with patients and improves Using different styles of question their health outcomes (p. 5). Try to see the problem from their Begin with open questions such as ‘How can I help you point of view and convey that to them in your questions. today?’ or ‘What has brought you along to see me today?’ Consider a young teacher who has recently had disfiguring Listen actively and encourage the patient to talk by looking facial surgery to remove a benign tumour from her upper jaw. interested and making encouraging comments, such as ‘Tell me Her wound has healed but she has a drooping lower eyelid and a bit more.’ Always give the impression that you have plenty of facial swelling. She returns to work. Imagine how you would feel time. Allow patients to tell their story in their own words, ideally in this situation. Express empathy through questions that show without interruption. You may occasionally need to interject to you can relate to your patient’s experience. guide the patient gently back to describing the symptoms, as So, it’s 3 weeks since your operation. How is your anxious patients commonly focus on relating the events or the recovery going? reactions and opinions of others surrounding an episode of illness OK, but I still have to put drops in my eye. rather than what they were feeling. While avoiding unnecessary repetition, it may be helpful occasionally to tell patients what And what about the swelling under your eye? you think they have said and ask if your interpretation is correct That gets worse during the day, and sometimes by the (reflection). afternoon I can’t see that well.  Gathering information 11 And how does that feel at work? increases the likelihood of lung cancer and chronic obstructive Well, it’s really difficult. You know, with the kids and pulmonary disease (COPD). Chest pain does not exclude COPD everything. It’s all a bit awkward. since he could have pulled a muscle on coughing, but the pain may also be pleuritic from infection or thromboembolism. In 2 I can understand that that must feel pretty turn, infection could be caused by obstruction of an airway by uncomfortable and awkward. How do you cope? lung cancer. Haemoptysis lasting 2 months greatly increases the Are there are any other areas that are awkward for chance of lung cancer. If the patient also has weight loss, the you, maybe in other aspects of your life, like the positive predictive value of all these answers is very high for lung social side? cancer. This will focus your examination and investigation plan. What was the first thing you noticed wrong when The history of the presenting symptoms you became ill? (Open question) I’ve had a cough that I just can’t get rid of. It started Using these questioning tools and an empathic approach, you after I’d had flu about 2 months ago. I thought it would are now ready to move to the substance of the history. get better but it hasn’t and it’s driving me mad. Ask the patient to think back to the start of their illness and describe what they felt and how it progressed. Begin with some Could you please tell me more about the cough? open questions to get your patient talking about the symptoms, (Open question) gently steering them back to this topic if they stray into describing Well, it’s bad all the time. I cough and cough, and events or the reactions or opinions of others. As they talk, pick bring up some phlegm. It keeps waking me at night so out the two or three main symptoms they are describing (such I feel rough the next day. Sometimes I get pains in my as pain, cough and shivers); these are the essence of the history chest because I’ve been coughing so much. of the presenting symptoms. It may help to jot these down as Already you have noted ‘Cough’, ‘Phlegm’ and single words, leaving space for associated clarifications by closed ‘Chest pain’ as headings for your history. Follow up questioning as the history progresses. with key questions to clarify each. Experienced clinicians make a diagnosis by recognising patterns of symptoms (p. 362). With experience, you will refine Cough: Are you coughing to try to clear something your questions according to the presenting symptoms, using from your chest or does it come without warning? a mental list of possible diagnoses (a differential diagnosis) to (Closed question, clarifying) guide you. Clarify exactly what patients mean by any specific Oh, I can’t stop it, even when I’m asleep it comes. term they use (such as catarrh, fits or blackouts); common terms Does it feel as if it starts in your throat or your can mean different things to different patients and professionals chest? Can you point to where you feel it first? (Box 2.1). Each answer increases or decreases the probability It’s like a tickle here (points to upper sternum). of a particular diagnosis and excludes others. In the following example, the patient is a 65-year-old male Phlegm: What colour is the phlegm? (Closed smoker. His age and smoking status increase the probability question, focusing on the symptom) of certain diagnoses related to smoking. A cough for 2 months Clear. 2.1 Examples of terms used by patients that should be clarified Patient’s term Common underlying problems Useful distinguishing features Allergy True allergy (immunoglobulin E-mediated reaction) Visible rash or swelling, rapid onset Intolerance of food or drug, often with nausea or Predominantly gastrointestinal symptoms other gastrointestinal upset Indigestion Acid reflux with oesophagitis Retrosternal burning, acid taste Abdominal pain due to: Site and nature of discomfort: Peptic ulcer Epigastric, relieved by eating Gastritis Epigastric, with vomiting Cholecystitis Right upper quadrant, tender Pancreatitis Epigastric, severe, tender Arthritis Joint pain Redness or swelling of joints Muscle pain Muscle tenderness Immobility due to prior skeletal injury Deformity at site Catarrh Purulent sputum from bronchitis Cough, yellow or green sputum Infected sinonasal discharge Yellow or green nasal discharge Nasal blockage Anosmia, prior nasal injury/polyps Fits Transient syncope from cardiac disease Witnessed pallor during syncope Epilepsy Witnessed tonic/clonic movements Abnormal involuntary movement No loss of consciousness Dizziness Labyrinthitis Nystagmus, feeling of room spinning, with no other neurological deficit Syncope from hypotension History of palpitation or cardiac disease, postural element Cerebrovascular event Sudden onset, with other neurological deficit 12 General aspects of history taking Have you ever coughed up any blood? (Closed Having clarified the presenting symptoms, prompt for any question) more associated features, using your initial impression of the Yes, sometimes. likely pathology (lung cancer or chronic respiratory infection) to direct relevant questions: When did it first appear and how often does it Do you ever feel short of breath with your cough? come? (Closed questions) A bit. Oh, most days. I’ve noticed it for over a month. How has your weight been? (Seeking additional How much? (Closed question, clarifying the confirmation of serious pathology) symptom) I’ve lost about a stone since this started. Just streaks. The questions required at this point will vary according to the Is it pure blood or mixed with yellow or green system involved. A summary of useful starting questions for each phlegm? system is shown in Box 2.3. Learn to think, as you listen, about Just streaks of blood in clear phlegm. the broad categories of disease that may present and how these Chest pain: Can you tell me about the chest pains? relate to the history, particularly in relation to the onset and rate (Open question) of progression of symptoms (Box 2.4). Well, they’re here on my side (points) when I cough. To complete the history of presenting symptoms, make an initial assessment of how the illness is impacting on the life of Does anything else bring on the pains? (Open, your patient. For example, breathlessness on heavy exertion clarifying the symptom) may prevent a 40-year-old builder from working but would have Taking a deep breath, and it really hurts when I cough much less impact on a sedentary retired person. ‘Can you tell or sneeze. me how far you can walk on a good day?’ is a question that Pain is a very important symptom common to many areas of can help to clarify the normal level of functioning, and ‘How practice. A general scheme for the detailed characterisation of has this changed since you have been unwell?’ can reveal pain is outlined in Box 2.2. disease impact. Ask if the person undertakes sports or regular exercise, and if they have modified these activities because of illness. 2.2 Characteristics of pain (SOCRATES) Site Somatic pain, often well localised, e.g. sprained ankle Visceral pain, more diffuse, e.g. angina pectoris 2.3 Questions to ask about common symptoms Onset System Question Speed of onset and any associated circumstances Cardiovascular Do you ever have chest pain or tightness? Character Do you ever wake up during the night feeling short of breath? Described by adjectives, e.g. sharp/dull, burning/tingling, boring/ Have you ever noticed your heart racing or stabbing, crushing/tugging, preferably using the patient’s own thumping? description rather than offering suggestions Respiratory Are you ever short of breath? Radiation Have you had a cough? If so, do you cough Through local extension anything up? Referred by a shared neuronal pathway to a distant unaffected site, e.g. What colour is your phlegm? diaphragmatic pain at the shoulder tip via the phrenic nerve (C3, C4) Have you ever coughed up blood? Associated symptoms Gastrointestinal Are you troubled by indigestion or heartburn? Visual aura accompanying migraine with aura Have you noticed any change in your bowel habit Numbness in the leg with back pain suggesting nerve root irritation recently? Have you ever seen any blood or slime in your Timing (duration, course, pattern) stools? Since onset Genitourinary Do you ever have pain or difficulty passing urine? Episodic or continuous: Do you have to get up at night to pass urine? If If episodic, duration and frequency of attacks so, how often? If continuous, any changes in severity Have you noticed any dribbling at the end of Exacerbating and relieving factors passing urine? Circumstances in which pain is provoked or exacerbated, e.g. eating Have your periods been quite regular? Specific activities or postures, and any avoidance measures that Musculoskeletal Do you have any pain, stiffness or swelling in have been taken to prevent onset your joints? Effects of specific activities or postures, including effects of Do you have any difficulty walking or dressing? medication and alternative medical approaches Endocrine Do you tend to feel the heat or cold more than Severity you used to? Difficult to assess, as so subjective Have you been feeling thirstier or drinking more Sometimes helpful to compare with other common pains, e.g. than usual? toothache Neurological Have you ever had any fits, faints or blackouts? Variation by day or night, during the week or month, e.g. relating to Have you noticed any numbness, weakness or the menstrual cycle clumsiness in your arms or legs?  Gathering information 13 2.4 Typical patterns of symptoms related to disease causation Disease causation Onset of symptoms Progression of symptoms Associated symptoms/pattern of symptoms 2 Infection Usually hours, unheralded Usually fairly rapid over hours Fevers, rigors, localising symptoms, e.g. pleuritic pain and or days cough Inflammation May appear acutely Coming and going over weeks Nature may be multifocal, often with local tenderness to months Metabolic Very variable Hours to months Steady progression in severity with no remission Malignant Gradual, insidious Steady progression over weeks Weight loss, fatigue to months Toxic Abrupt Rapid Dramatic onset of symptoms; vomiting often a feature Trauma Abrupt Little change from onset Diagnosis usually clear from history Vascular Sudden Stepwise progression with Rapid development of associated physical signs acute episodes Degenerative Gradual Months to years Gradual worsening with periods of more acute deterioration 2.5 Example of a drug history Drug Dose Duration Indication Side-effects/patient concerns Aspirin 75 mg daily 5 years Started after myocardial infarction Indigestion Atenolol 50 mg daily 5 years Started after myocardial infarction Cold hands (?adherence) Co-codamol (paracetamol + codeine) 8 mg/500mg, up to 4 weeks Back pain Constipation 8 tablets daily Salbutamol MDI 2 puffs as necessary 6 months Asthma Palpitation, agitation MDI, metered-dose inhaler. along with any significant adverse effects, in a clear format (Box Past medical history 2.5). When drugs such as methadone are being prescribed for addiction, ask the community pharmacy to confirm dosage Past medical history may be relevant to the presenting symptoms: and also to stop dispensing for the duration of any hospital for example, previous migraine in a patient with headache, or admission. haematemesis and multiple minor injuries in a patient with suspected alcohol abuse. It may reveal predisposing past or Concordance and adherence underlying illness, such as diabetes in a patient with peripheral vascular disease, or childhood whooping cough in someone Half of all patients do not take prescribed medicines as directed. presenting with bronchiectasis. Patients who take their medication as prescribed are said to be The referral letter and case records often contain useful adherent. Concordance implies that the patient and doctor have headlines but the patient is usually the best source. These negotiated and reached an agreement on management, and questions will elicit the key information in most patients: adherence to therapy is likely (though not guaranteed) to improve. What illnesses have you seen a doctor about in the past? Ask patients to describe how and when they take their Have you been in hospital before or attended a clinic? medication. Give them permission to admit that they do not Have you had any operations? take all their medicines by saying, for example, ‘That must be Do you take any medicines regularly? difficult to remember.’ Drug allergies/reactions Drug history Ask if your patient has ever had an allergic reaction to a medication or vaccine. Clarify exactly what patients mean by allergy, as This follows naturally from asking about past illness. Begin by intolerance (such as nausea) is much more common than true checking any written sources of information, such as the drug list allergy. Drug allergies are over-reported by patients: for example, on the referral letter or patient record. It is useful to compare this only 1 in 7 who report a rash with penicillin will have a positive with the patient’s own recollection of what they take. This can penicillin skin test. Note other allergies, such as foodstuffs or be complicated by patients’ use of brand names, descriptions pollen. Record true allergies prominently in the patient’s case of tablet number and colour and so on, which should always records, drug chart and computer records. If patients have had be translated to generic pharmaceutical names and quantitative a severe or life-threatening allergic reaction, advise them to wear doses for the patient record. Ask about prescribed drugs and an alert necklace or bracelet. other medications, including over-the-counter remedies, herbal and homeopathic remedies, and vitamin or mineral supplements. Non-prescribed drug use Do not forget to ask about inhalers and topical medications, as patients may assume that you are asking only about tablets. Ask all patients who may be using drugs about non-prescribed Note all drug names, dosage regimens and duration of treatment, drugs. In Britain about 30% of the adult population have used 14 General aspects of history taking illegal or non-prescribed drugs (mainly cannabis) at some time. disorder. A further complication is that some illnesses, such as Useful questions are summarised in Box 2.6. asthma and diseases caused by atheroma, are so common in the UK population that their presence in family members may Family history not greatly influence the risk to the patient. Document illness in first-degree relatives: that is, parents, Start with open questions, such as ‘Are there any illnesses that siblings and children. If you suspect an inherited disorder such run in your family?’ Follow up the presenting symptoms with as haemophilia, construct a pedigree chart (Fig. 2.1), noting a question like ‘Have any of your family had heart trouble?’ whether any individuals were adopted. Ask about the health of Single-gene inherited diseases are relatively uncommon in clinical other household members, since this may suggest environmental practice. Even when present, autosomal recessive diseases such risks to the patient. as cystic fibrosis usually arise in patients with healthy parents who are unaffected carriers. Many other illnesses are associated Social history and lifestyle with a positive family history but are not due to a single-gene No medical assessment is complete without determining the social circumstances of your patient. These may be relevant to the causes of their illness and may also influence the management and outcome. Establish who is there to support the patient by 2.6 Non-prescribed drug history asking ‘Who is at home with you, or do you live alone?’ For those who live alone, establish who is their next of kin and who What drugs are you taking? visits regularly to support them. Check if your patient is a carer How often and how much? for someone vulnerable who may be at risk due to your patient’s How long have you been taking drugs? illness. Enquire sensitively if the patient is bereaved, as this can Have you managed to stop at any time? If so, when and why did have profound effects on a patient’s health and wellbeing. you start using drugs again? Next establish the type and condition of the patient’s housing What symptoms do you have if you cannot get drugs? and how well it suits them, given their symptoms. Patients with Do you ever inject? If so, where do you get the needles and severe arthritis may, for example, struggle with stairs. Successful s