History and Clinical Examination at a Glance
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About this ebook
History and Clinical Examination at a Glance features:
- Succinct text and full colour illustrations, including many brand new clinical photographs
- A new section on the development of communication skills, which explains how to communicate in different circumstances, and with different groups of people
- A self-assessment framework which can be used individually, by tutors, or in group practice to prepare for OSCEs
History and Clinical Examination at a Glance is the perfect guide for medical, health science students, and junior doctors, as an ideal resource for clinical attachments, last-minute revision, or whenever you need a refresher.
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History and Clinical Examination at a Glance - Jonathan Gleadle
Table of Contents
Cover
Dedication
Title page
Copyright page
Preface
List of abbreviations
Part 1: Communication skills
1 Fundamental communication skills
Open and closed questions
Summarize
2 Communicating information
Explore the use of other information
3 Communicating bad news
Explore the person’s current understanding of their illness or situation
Explore the person’s reactions and understanding
Summarize what you have said
People may cry
4 Communicating with relatives
5 Cultural differences
Specific cultural issues
6 Exploring sensitive issues
Sexual issues
Sexual history
Confidentiality
Drug use
Communicable diseases
Suicide risk
End of life care
7 History and examination in clinical exams
Exam preparation
The exam
Short cases
Long cases
OSCEs
Part 2: Taking a history
8 Relationship with patient
Introduction
Privacy and comfort
Language
Relatives, friends, chaperones
Hand washing
9 History of presenting complaint
Let the patient talk
More specific questioning
Establish the dates and sequence of events
Focus on the main problems
10 Past medical history, drugs and allergies
Drug history
Allergies
Smoking
Alcohol
11 Family and social history
Family history
Social history
Travel history
12 Functional enquiry
Part 3: History and examination of the systems
13 Is the patient ill?
Airway
Breathing
Circulation
Colour
Consciousness
14 Principles of examination
Inspect
Palpate
Percuss
Auscultate
15 The cardiovascular system
History
Past medical history
Family history
Social history
Drugs
Examination
16 The respiratory system
History
Past medical history
Drugs
Allergies
Smoking
Family and social history
Examination
17 The gastrointestinal system
History
Past medical history
Family history
Examination
Examine for specific organs
18 The male genitourinary system
History
Past medical history
Drugs
Alcohol and smoking history
Family and social history
Functional enquiry
Examination
19 Gynaecological history and examination
Menstruation
Sexual activity/contraception/cervix
Urinary symptoms
Past medical history
Past obstetric history
Drugs
Family history
Social history
The gynaecological examination
20 Breast examination
History
Past medical history
Drugs
Family history
Functional enquiry
Examination
21 Obstetric history and examination
History of present pregnancy
Past obstetric history
Obstetric examination
22 The nervous system
History
Past medical history
Drugs
Family history
Social history
Functional enquiry
Examination
23 The musculoskeletal system
History
Past medical history
Drugs
Functional enquiry
Social history
Examination
Examine feet
24 Skin
History
Past medical history
Drugs
Allergies
Family history
Social history
Functional enquiry
Examination
25 The visual system
History
Past medical history
Drugs
Family and social history
Examination
Important fundoscopic abnormalities
26 Examination of the ears, nose, mouth, throat, thyroid and neck
Ears
Nose
Mouth and throat
Neck
Thyroid
27 Examination of urine
28 The psychiatric assessment
History
History of the present illness
Review of systems
Past psychiatric history
Past medical history and medication and allergies
Personal history
Premorbid personality
Social history
History of substance use
Forensic history
Family history
Physical examination
Mental Status Examination
Functional assessment
‘Biological’ features of depression
29 Examination of the legs
Inspection
Examine the skin
Examine the vascular supply
Assess the neurology
Examine the musculoskeletal system
30 General examination
Examination
31 Presenting a history and examination
Part 4: Presentations
32 Chest pain
History
Past medical history
Examination
33 Abdominal pain
History
Past medical history
Drugs
Examination
34 Headache
History
Past medical history
Drugs
Family history
Examination
35 Vomiting, diarrhoea and change in bowel habit
Vomiting
Diarrhoea
Change in bowel habit
Intestinal obstruction
36 Gastrointestinal haemorrhage
History
Past medical history
Drugs
Family history
Examination
37 Indigestion and dysphagia
Indigestion
Dysphagia
38 Weight loss
History
Past medical history
Drugs
Examination
39 Fatigue
History
Past medical history
Examination
Chronic fatigue syndrome
40 The unconscious patient
History
Examination
41 The intensive care unit patient
Examination
42 Back pain
History
Past medical history
Drugs
Family and social history
Examination
Worrying (‘red flag’) features of back pain
43 Hypertension
History
Past medical history
Family history
Drugs
Social history
Direct questioning
Examination
44 Swollen legs
History
Past medical history
Drugs
Family history
Examination
45 Jaundice
History
Past medical history
Drugs
Alcohol
Family history
Examination
46 Postoperative fever
History
Drugs
Allergies
Examination
47 Suspected meningitis
History
Past medical history
Family and social history
Drugs
Examination
48 Anaemia
History
Past medical history and functional enquiry
Family history
Travel
Drugs
Examination
49 Lymphadenopathy
History
Examination
50 Cough
History
Examination
Causes of haemoptysis
51 Confusion
History
Past medical history
Drugs
Alcohol
Family and social history
Functional enquiry
Examination
The confusion assessment method for the diagnosis of delirium
52 Lump
History
Past medical history
Examination
53 Breast lump
History
Past medical history
Drugs
Family history
Examination
54 Palpitations/arrhythmias
History
Past medical history
Drugs
Family history
Examination
55 Joint problems
History
Past medical history
Drugs
Family and social history
Occupational history
Examination
56 Red eye
History
Past medical history
Family history
Examination
57 Dizziness
History
Past medical history
Drugs
Examination
58 Breathlessness
History
Past medical history
Drugs
Social history
Examination
59 Dysuria and haematuria
Dysuria
Haematuria
60 Attempted suicide
History
Past medical history
Drugs
Examination
Suicide risk
If significant risk for suicide is identified what management should be enacted?
61 Immunosuppressed patients
History
Past medical history
Social history
Examination
62 Diagnosing death
History
Past medical history
Family and social history
Examination
Brain stem death
63 Shock
History
Past medical history
Drugs
Allergies
Examination
64 Trauma
History
Past medical history
Drugs
Allergies
Family and social history
Examination
65 Alcohol-related problems
History
CAGE questionnaire
Past medical history and functional enquiry
Social history
Examination
66 Collapse
History
Past medical history
Drugs
Functional enquiry
Family history
Examination
Part 5: Conditions
Cardiovascular
67 Myocardial infarction and angina
History
Past medical history
Drugs
Allergies
Family history
Social history
Examination
68 Hypovolaemia
History
Examination
69 Heart failure
History
Past medical history
Drugs
Functional enquiry
Examination
Causes
Consequences
70 Mitral stenosis
History
Past medical history
Examination
71 Mitral regurgitation
History
Past medical history
Examination
Mitral valve prolapse
72 Aortic stenosis
History
Past medical history
Functional enquiry
Family history
Examination
73 Aortic regurgitation
History
Past medical history
Examination
74 Tricuspid regurgitation
History
Past medical history
Examination
75 Pulmonary stenosis
History
Examination
76 Congenital heart disease
Atrioseptal defect
Ventriculoseptal defect
Aortic coarctation
Patent ductus arteriosus
77 Aortic dissection
History
Past medical history
Family history
Examination
78 Aortic aneurysm
History
Past medical history
Family history
Examination
79 Infective endocarditis
History
Past medical history
Drugs
Allergies
Examination
80 Pulmonary embolism and deep vein thrombosis
Pulmonary embolism
Deep vein thrombosis
Prediction rules
81 Prosthetic cardiac valves
History
Drugs
Examination
82 Peripheral vascular disease
History
Past medical history
Examination
Endocrine/metabolic
83 Diabetes mellitus
History
Diabetic ketoacidosis
Hypoglycaemia
Past medical history
Drugs
Family and social history
Examination
84 Hypothyroidism and hyperthyroidism
Hypothyroidism
Hyperthyroidism
85 Addison’s disease and Cushing’s syndrome
Addison’s disease
Cushing’s syndrome
86 Hypopituitarism
History
Past medical history
Drugs
Examination
87 Acromegaly
History
Past medical history
Drugs
Examination
Nephrology and urology
88 Renal failure
History
Past medical history
Drugs
Family history
Social history
Examination
89 Polycystic kidney disease
History
Past medical history
Drugs
Family history
Examination
90 Nephrotic syndrome
History
Past medical history
Drugs
Examination
91 Urinary symptoms
Urinary retention
Urinary incontinence
92 Testicular lumps
History
Past medical history
Examination
Gastrointestinal
93 Chronic liver disease
History
Past medical history
Family history
Drugs
Alcohol
Examination
Specific clinical findings
Important clinical questions
94 Inflammatory bowel disease
History
Past medical history
Drugs
Family and social history
Examination
95 Splenomegaly/hepatosplenomegaly
History
Past medical history
Family history
Examination
96 Acute abdomen
History
Past medical history
Drugs
Family history
Examination
97 Pancreatitis
History
Past medical history
Drugs
Examination
98 Abdominal mass
History
Past medical history
Family history
Examination
Herniae
99 Appendicitis
History
Examination
Respiratory
100 Asthma
History
Past medical history
Family and social history
Drugs
Examination
Other causes of breathlessness and wheeze
Patients at risk of developing fatal asthma
101 Pneumonia
History
Examination
102 Pleural effusion
History
Examination
103 Fibrosing alveolitis, bronchiectasis, cystic fibrosis and sarcoidosis
Fibrosing alveolitis
Cystic fibrosis
Sarcoidosis
104 Carcinoma of the lung
History
Past medical history
Examination
Rare complications
Clubbing
105 Chronic obstructive pulmonary disease
History
Past medical history
Drugs
Family and social history
Examination
106 Pneumothorax
History
Past medical history
Examination
107 Tuberculosis
History
Past medical history
Drugs
Family and social history
Examination
Neurology
108 Stroke
History
Past medical history
Drugs
Family and social history
Examination
Stroke classification
109 Parkinson’s disease
History
Past medical history
Drugs
Examination
110 Motor neurone disease
History
Family history
Social history
Examination
111 Multiple sclerosis
History
Past medical history
Drugs
Family and social history
Examination
112 Peripheral neuropathy
History
Past medical history
Drugs
Family and history
Social history
Examination
113 Carpal tunnel syndrome
History
Examination
114 Myotonic dystrophy and muscular dystrophy
Myotonic dystrophy (dystrophia myotonica)
Muscular dystrophy
115 Myasthenia gravis
History
Past medical history
Drugs
Examination
116 Cerebellar disorders
History
Past medical history
Family and social history
Drugs
Examination
117 Dementia
History
Past medical history
Drugs
Family and social history
Examination
Causes of dementia
Musculoskeletal
118 Rheumatoid arthritis
History
Past medical history
Drugs
Family and social history
Examination
119 Osteoarthritis and osteoporosis
Osteoarthritis
Osteoporosis
120 Gout and Paget’s disease
Gout
Paget’s disease
121 Ankylosing spondylitis
History
Past medical history
Family history
Examination
Other
122 Systemic lupus erythematosus and vasculitis
Systemic lupus erythematosus
Diagnostic criteria for SLE
Vasculitis
123 Malignant disease
History
Past medical history
Drugs
Family history
Social history
Examination
124 Scleroderma
History
Examination
CREST
125 AIDS and HIV
History
Examination
Appendix: A self-assessment framework of communication skills in history and examination
Initiating the session
Gathering information
Providing structure
Building relationship
Ending the interview
Index
My thanks to Fiona, Ellie, Adam and especially to my Dad
Title pageThis edition first published 2012 © 2012 by John Wiley & Sons, Ltd
Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing.
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All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.
Library of Congress Cataloging-in-Publication Data
Gleadle, Jonathan.
History and clinical examination at a glance / Jonathan Gleadle. – 3rd ed.
p. ; cm.
Rev. ed. of: History and examination at a glance / Jonathan Gleadle. 2nd ed. c2007.
Includes bibliographical references and index.
ISBN-13: 978-0-470-65446-0 (pbk. : alk. paper)
ISBN-10: 0-470-65446-5 (pbk. : alk. paper)
ISBN-13: 978-1-118-28662-3 (epub)
ISBN-13: 978-1-118-28660-9 (mobi)
1. Medical history taking–Handbooks, manuals, etc. 2. Physical diagnosis–Handbooks, manuals, etc. I. Title.
[DNLM: 1. Medical History Taking–Handbooks. 2. Physical Examination–Handbooks. WB 39]
RC65.G544 2012
616.07'54–dc23
2011013469
A catalogue record for this book is available from the British Library.
Preface
The abilities to take an accurate history and perform a physical examination are the most essential skills in becoming a doctor. These skills are difficult to acquire and, above all, require practice. See as many patients as you can and take time to elicit detailed histories, observe carefully for physical signs and generate your own differential diagnoses. Experienced clinicians do not simply ask the same long list of questions of every patient. Instead, they will modify the style of their history taking to elicit the maximum amount of relevant information from each patient. They will also place different emphasis on the importance and reliability of different clinical findings. This book is designed to be used alongside frequent practice of these communication and examination skills with actual patients in order to hone and develop these essential abilities. Once you have taken a history or examined a patient, read the relevant chapters, ask colleagues or other doctors to assess your performance, present your findings to others and check what you did against the communication skills Appendix (p. 216).
The purpose of the history and examination is to develop an understanding of the patient’s medical problems and to generate a differential diagnosis. Despite the advances in modern diagnostic tests, the clinical history and examination are still crucial to achieving an accurate diagnosis. However, this process also enables the doctor to get to know the patient (and vice versa!) and to understand the medical problems in the context of the patient’s personality and social background.
The book is deliberately concise, emphasizes the importance of history taking and is restricted to core topics. For a complete understanding of any medical condition, you should look at other textbooks such as Medicine at a Glance and Surgery at a Glance. For detailed descriptions of particular examination techniques watch and learn from an experienced practitioner or from one of the texts below.
This book has four parts. The first section introduces students to key history-taking skills, including relationships with patients, communication skills, family history and functional enquiry. The second section covers history and examination of the systems of the body and includes chapters on recognizing the ill patient and how to present a clerking. Section three covers history taking and examination of the common clinical presentations whilst section four focuses on common conditions. It thus covers topics in a variety of different ways and this deliberate repetition of important topics is designed to facilitate effective learning.
It is often thought that clinical history and examination is a fixed subject with little change or scientific study. This is incorrect and to emphasize this some subjects have evidence-based sections which have been expanded further in this edition. These sections do not provide exhaustive coverage of the evidence underpinning aspects of clinical skills but have been included to emphasize the importance of scientific analysis of history and examination. It is hoped that they will act as a stimulus for further reading, study and questioning of the scientific basis of history taking and clinical examination.
Jonathan Gleadle
Adelaide
Acknowledgements
I would like to particularly thank R. Arthur Proudfoot for his role in the generation of the photographic images that appear in this new edition. I thank Glen Allen for the images of urinary abnormalities and Professor Jamie Craig for the retinal images. I would like to thank the following for their specialist advice on ways to improve on the first and second editions: Professor Derek Jewell, Dr Maxine Harding, Dr Duncan Young, Dr John Salmon, Dr Bhathiya Wijeyekoon, Dr Andrew McGavigan and Dr Randall Long.
Further Reading
History and Examination
Davey, P. (2010) Medicine at a Glance. Wiley-Blackwell, Oxford.
Epstein, O. et al. (2008) Clinical Examination. Mosby, St. Louis.
Grace, P.A. and Borley, N.R. (2009) Surgery at a Glance. Wiley-Blackwell, Oxford.
Orient, J. (2010) Sapira’s Art and Science of Bedside Diagnosis. Lippincott Williams and Wilkins, Philadelphia.
Talley, N.J. and O’Connor, S. (2009) Clinical Examination: A Systematic Guide to Physical Diagnosis. Churchill Livingstone, Edinburgh.
Evidence
Clinical Examination Research Interest Group of the Society of General Internal Medicine (www.sgim.org/clinexam.cfm).
McGee, S. (2007) Evidence-Based Physical Diagnosis. W.B. Saunders, Philadelphia.
Simel, D.L. and Drummond, R. (2008) The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. McGraw-Hill Medical, New York.
The Rational Clinical Examination Series. Journal of the American Medical Association (1992–2010).
Polmear, A. (2008) Evidence-Based Diagnosis in Primary Care: Practical Solutions to Common Problems. Butterworth-Heinemann, Oxford.
Straus, S.E., Richardson, W.S., Glasziou, P. and Haynes, R.B. (2005) Evidence-Based Medicine. Churchill Livingstone, Edinburgh.
Tierney, L.M. and Henderson, M. (2005). The Patient History: Evidence-Based Approach. McGraw-Hill Medical, New York.
Multimedia
The New England Journal of Medicine has an increasing number of videos in clinical medicine covering topics such as ‘Clinical Evaluation of the Knee’, ‘Blood Pressure Measurement’ and ‘Pelvic Examination’:
www.nejm.org/multimedia/videosinclinicalmedicine
and images in clinical medicine:
www.nejm.org/multimedia/imagesinclinicalmedicine
List of abbreviations
1
Fundamental communication skills
c01uf001Good communication with patients, relatives and colleagues is central and essential for good patient care. Excellent communication is what characterizes excellent doctors above all else. Doctors who are good communicators will have patients who are more satisfied with their care, more likely to follow advice and less anxious about their problems and are preferred by patients. Poor communication is the major cause of medical errors, diagnostic errors and patient complaints.
Excellent communicators are better placed to achieve correct diagnoses, form strong relationships with patients and colleagues, impart difficult news, involve patients in important decisions, detect distress and convey emotion.
Confidence in communication is not the same as having excellent communication skills.
Observing and copying other doctors is not necessarily a good route to acquiring good communication skills. Whilst observing doctor–patient interactions, think:
What are the good communication skills being shown here?
What is the patient thinking?
What is the doctor trying to convey?
What did the patient understand?
What did the patient feel?
What did the patient misunderstand? Why?
What did the doctor misunderstand? Why?
What would I do differently as the doctor?
What questions could the doctor have asked differently?
What aspects of the consultation did I feel uncomfortable about? Why?
What would have improved the consultation? More time? More introduction? Less questioning? Fewer closed questions?
It is important to practise communication skills with real patients, colleagues and simulated patients. Get feedback. Review video recording of your interviews. Reflect on things you feel you do well, things you do poorly and things you find difficult. Throughout your medical career continue to reassess your communication skills and performance and obtain expert feedback.
Consider what could be barriers to good communication, e.g. language fluency, hearing difficulties, visual difficulties, haste, interruptions.
Open and Closed Questions
Use open questions as much as possible and keep them simple and short:
How are you?
How can I help?
Tell me what’s troubling you?
Tell me about the cough.
Avoid
Leading or closed questions:
The referral letter says you coughed up blood; was it bright red?
Avoid
Complex questions:
e.g. You’ve had a cough, chest pain and weight loss for months now?
Avoid
Medical jargon:
Tell me about this haemoptysis.
Further