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Clinical Examination 6 Ed sample chapter, Dr Talley and Dr O'Connor

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The 6th edition of Clinical Examination continues to serve all medical students with a clear explanation of clinical examination. Set out systematically, this best-selling textbook has comprehensive …

The 6th edition of Clinical Examination continues to serve all medical students with a clear explanation of clinical examination. Set out systematically, this best-selling textbook has comprehensive coverage of essential skills necessary for history taking and examining the patient.

View the sample chapter (Chapter 1 – The general principles of history taking) of this eagerly anticipated new edition.

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  • 1. A systematic guide to physical diagnosis clinical examination 6th edition Nicholas J Talley and Simon O’Connor
  • 2. Contents Foreword v Fundamental considerations when taking Preface xi the history 14 Acknowledgments xii Personal history taking 14 The sexual history Clinical methods: a historical perspective xiv Cross-cultural history taking 16 The Hippocratic oath xvi The ‘uncooperative’ or ‘difficult’ patient Credits xvii and the history 16 History taking for the maintenance of good CHAPTER 1 health 17 The elderly patient 18 The general principles of history Activities of daily living (ADL); mental state; taking 1 specific problems in the elderly Bedside manner and establishing Evidence-based history taking and rapport 1 differential diagnosis 19 Obtaining the history 2 The clinical assessment 19 Introductory questions 2 Concluding the interview 20 The presenting (principal) symptom 3 References 20 History of the presenting illness 3 Suggested reading 21 Current symptoms; associated symptoms; current treatment and drug allergies; CHAPTER 3 menstrual history; the effect of the The general principles of physical illness examination 24 The past history 5 The social and personal history 6 First impressions 24 Smoking; alcohol; occupation and Vital signs 24 education; overseas travel and Facies 25 immunisation; marital status, social Jaundice; cyanosis; pallor; hair support and living conditions Weight, body habitus and posture 26 The family history 8 Hydration 27 Systems review 8 The hands and nails 28 Skills in history taking 11 Temperature 28 References 1 Smell 29 Preparing the patient for examination 30 Evidence-based clinical examination 30 CHAPTER 2 Inter-observer agreement (reliability) and Advanced history taking 13 the κ-statistic Taking a good history 13 References 32 The differential diagnosis 13 Suggested reading 34 vii
  • 3. viii Contents CHAPTER 4 chronic bronchitis; interstitial lung The cardiovascular system 35 disease; tuberculosis; mediastinal The cardiovascular system 35 compression; carcinoma of the lung; Presenting symptoms; risk factors for sarcoidosis; pulmonary embolism coronary artery disease; treatment; past The chest X-ray 137 history; social history Chest X-ray checklist Examination anatomy 45 Summary 141 The cardiovascular examination 47 The respiratory examination: a suggested Positioning the patient; general appearance; method hands; arterial pulse; blood pressure; References 142 face; neck; praecordium; the back; Suggested reading 143 abdomen; lower limbs; peripheral vascular disease; acute arterial CHAPTER 6 occlusion; deep venous thrombosis; The gastrointestinal system 145 varicose veins The gastrointestinal history 145 Correlation of physical signs and Presenting symptoms; treatment; past cardiovascular disease 76 history; social history; family history Cardiac failure; chest pain; pericardial The gastrointestinal examination 153 disease; systemic hypertension; Examination anatomy; positioning pulmonary hypertension; innocent the patient; general appearance; murmurs; valve diseases of the left hands; arms; face; neck and chest; heart; valve diseases of the right heart; abdomen; hernias; rectal examination; cardiomyopathy; acyanotic and cyanotic proctosigmoidoscopy; other congenital heart disease; ‘grown-up’ Examination of the gastrointestinal congenital heart disease contents 183 The chest X-ray: a systematic Faeces; vomitus approach 96 Urinalysis 184 Frontal film; lateral film; Examples of chest Examination of the acute abdomen X-rays in cardiac diseas 185 Summary 102 Correlation of physical signs and The cardiovascular examination: a gastrointestinal disease 187 suggested method Liver disease; portal hypertension; References 104 hepatic encephalopathy; dysphagia; Suggested reading 105 assessment of gastrointestinal bleeding; malabsorption; inflammatory bowel CHAPTER 5 disease The respiratory system 107 The abdominal X-ray: a systematic The respiratory history 107 approach 192 Presenting symptoms; treatment; past Radiography; bowel gas pattern; bowel history; occupational history; social dilatation; calcification; ascites history; family history Summary 194 The respiratory examination 115 The gastrointestinal examination: a Examination anatomy; positioning the suggested method patient; general appearance; hands; References 196 face; trachea; chest; heart; abdomen; Suggested reading 197 other; bedside assessment of lung function CHAPTER 7 Correlation of physical signs and The genitourinary system 199 respiratory disease 128 The genitourinary history 199 Consolidation (lobar pneumonia); Presenting symptoms; menstrual and sexual atelectasis (collapse); pleural effusion; history; treatment; past history; social pneumothorax; tension pneumothorax; history; family history bronchiectasis; bronchial asthma; The genitourinary examination 207 chronic obstructive pulmonary disease; General appearance; hands; arms; face;
  • 4. Contents ix neck; chest; abdominal examination; Rheumatoid arthritis; seronegative back; legs; blood pressure; fundi spondyloarthropathies; gouty The urine 212 arthritis; calcium pyrophosphate Colour; transparency; smell; specific gravity; arthropathy (pseudogout); calcium chemical analysis; pH; protein; glucose hydroxyapatite arthropathy; systemic and ketones; blood; nitrite; the urine lupus erythematosus; scleroderma sediment (progressive systemic sclerosis); Male genitalia 215 rheumatic fever; the vasculitides; soft- Differential diagnosis of a scrotal mass tissue rheumatism; nerve entrapment Pelvic examination 217 syndromes Summary 219 References 292 Examination of a patient with chronic kidney Suggested reading 293 disease: a suggested method References 219 CHAPTER 10 Suggested reading 221 The endocrine system 295 The endocrine history 295 CHAPTER 8 Presenting symptoms; past history; social The haematological system 223 history; family history The haematological history 223 The endocrine examination 297 Presenting symptoms; treatment; past Thyroid; pituitary; adrenals; calcium history; social history; family history metabolism; syndromes associated with The haematological examination 224 short stature; hirsutism; gynaecomastia; Examination anatomy; general appearance; diabetes mellitus; Paget’s disease hands; forearms; epitrochlear nodes; (osteitis deformans) axillary nodes; face; cervical and Summary 322 supraclavicular nodes; bone tenderness; The endocrine system: a suggested method the abdominal examination; inguinal of examination nodes; legs; fundi References 322 Examination of the peripheral blood Suggested reading 322 film 231 Correlation of physical signs and CHAPTER 11 haematological disease 231 Anaemia; pancytopenia; acute leukaemia; The nervous system 323 chronic leukaemia; myeloproliferative The neurological history 323 disease; lymphoma; multiple myeloma Headache and facial pain; faints and fits; Summary 238 dizziness; visual disturbances and The haematological examination: a deafness; disturbances of gait; disturbed suggested method sensation or weakness in the limbs; References 240 tremor and involuntary movements; Suggested reading 240 speech and mental status; past health; medication history; social history; family history CHAPTER 9 The neurological examination 329 The rheumatological system 241 Examination anatomy; general signs; cranial The rheumatological history 241 nerves; head and neck; limbs and trunk; Presenting symptoms; treatment history; upper limbs; lower limbs; gait past history; social history; family history Correlation of physical signs and Examination anatomy 246 neurological disease 383 Joint structures Upper and lower motor neurone The rheumatological examination 247 lesions; motor neurone disease; General inspection; principles of joint peripheral neuropathy; Guillain- examination; assessment of individual Barré syndrome (acute inflammatory joints polyradiculoneuropathy); multiple Correlation of physical signs and sclerosis; thickened peripheral nerves; rheumatological disease 276 spinal cord compression; important
  • 5. x Contents spinal cord syndromes; myopathy; CHAPTER 15 dystrophia myotonica; myasthenia The skin, nails, and lumps 439 gravis; the cerebellum; Parkinson’s The dermatological history 439 disease; other extrapyramidal movement Examination anatomy 440 disorders (dyskinesia) General principles of physical examination The unconscious patient 400 of the skin 441 General inspection; level of consciousness; How to approach the clinical diagnosis of a neck; head and face; upper and lower lump 442 limbs; body; coma scale Correlation of physical signs and skin Summary 403 disease 443 Examining the nervous system: a suggested Pruritus; erythrosquamous eruptions; method blistering eruptions; erythroderma; References 406 pustular and crusted lesions; dermal Suggested reading 407 plaques; erythema nodosum; erythema multiforme; hyperpigmentation; flushing CHAPTER 12 and sweating; skin tumours The psychiatric history and mental The nails 451 state examination 409 Summary 452 Obtaining the history 409 The dermatological examination in internal Introductory questions; history of the medicine: a suggested method presenting illness; past history and treatment history; family history; social CHAPTER 16 and personal history A system for the infectious diseases The mental state examination 416 examination 455 The diagnosis 416 Pyrexia of unknown origin 455 References 422 History; examination Suggested reading 422 HIV infection and the acquired immunodeficiency syndrome CHAPTER 13 (AIDS) 457 The ears, eyes, nose and throat 423 Examination The eyes 423 References 459 Examination anatomy; examination method; Suggested reading 460 diplopia; Horner’s syndrome; iritis; glaucoma; shingles; eyelid Appendix I: Writing and presenting the history The ears 430 and physical examination 461 Examination anatomy; examination method Appendix II: A suggested method for a rapid The nose 433 screening physical examination 465 Examination method; sinusitis Appendix III: The pre-anaesthetic medical The throat 433 examination (PAME) 467 Examination anatomy; examination method; pharyngitis; epiglottitis Index 470 Reference 434 CHAPTER 14 The breasts 435 History 435 Examination 435 Inspection; palpation; evaluation of a breast lump References 437
  • 6. Chapter 1 The general principles of history taking Medicine is learned by the bedside and not in the Bedside manner and classroom. Sir William Osler (1849–1919) establishing rapport History taking requires practice and depends very much on the doctor–patient relationship.3 An extensive knowledge of medical facts is not It is important to try to put the patient at ease useful unless a doctor is able to extract accurate immediately, because unless a rapport is established, and succinct information from a sick person about the history taking is likely to be unrewarding. his or her illness. In all branches of medicine, the There is no doubt that the treatment of a patient development of a rational plan of management begins the moment one reaches the bedside or the depends on a correct diagnosis or sensible, patient enters the consulting rooms. The patient’s differential diagnosis (list of possible diagnoses). first impressions of a doctor’s professional manner Except for patients who are extremely ill, taking will have a lasting effect. One of the axioms of a careful medical history should precede both the medical profession is primum non nocere (the examination and treatment. A medical history is first thing is to cause no harm).4 An unkind and the first step in making a diagnosis; it will often help thoughtless approach to questioning and examining direct the physical examination and will usually a patient can cause harm before any treatment has determine what investigations are appropriate. had the opportunity to do so. You should aim to More often than not, an accurate history suggests leave the patient feeling better for your visit. This the correct diagnosis, whereas the physical is a difficult technique to teach. Much has been examination and subsequent investigations merely written about the correct way to interview patients, serve to confirm this impression.1,2 The history is but each doctor has to develop his or her own also, of course, the least expensive way of making method, guided by experience gained from clinical a diagnosis. teachers and patients.5–8 Changes in medical education mean that much To help establish this good relationship, the student teaching is now conducted away from student or doctor must make a deliberate point of the traditional hospital ward. Students must still introducing him- or herself and explaining his or learn how to take a thorough medical history, her role. This is especially relevant for students or but obviously adjustments to the technique must junior doctors seeing patients in hospital. A student be made for patients seen in busy surgeries or might say: ‘Good afternoon, Mrs Evans. My name outpatient departments. Much information about is Jane Smith; I am Dr Osler’s medical student. She a patient’s previous medical history may already has asked me to come and see you.’ A patient seen be available in hospital or clinic records; the detail at a clinic should be asked to come and sit down, needed will vary depending on the complexity of and be directed to a chair. The door should be shut the presenting problem and whether the visit is a or, if the patient is in the ward, the curtains drawn follow-up or a new consultation. All students must, to give some privacy. The clinician should sit down however, have a comprehensive understanding of beside or near the patient so as to be close to eye how to take a complete medical history. level and give the impression that the interview 1
  • 7. 2 Clinical examination will be an unhurried one.9,10 It is important here TABLE 1.1 History-taking sequence to address the patient respectfully and use his or 1. Presenting (principal) symptom (PS) her name and title. Some general remarks about the weather, hospital food or the crowded waiting 2. History of presenting illness (HPI) room may be appropriate to help put the patient at Details of current illnesses ease, but these must not be patronising. Details of previous similar episodes Current treatment and drug history Obtaining the history Menstrual and reproductive history for women Allow the patient to tell the whole story, then ask Extent of functional disability questions to fill in the gaps. Always listen carefully. 3. Past history (PH) At the end of the history and examination, a Past illnesses and surgical operations detailed record is made. However, many clinicians Past treatments find it useful to make rough notes during the Allergies interview. With practice this can be done without Blood transfusions loss of rapport. In fact, pausing to make a note of 4. Social history (SH) a patient’s answer to a question suggests that it is Occupation, education being taken seriously. Smoking, alcohol, analgesic use Many clinics and hospitals use computer records Overseas travel, immunisation which may be displayed on a computer screen Marital status, social support on the desk. Notes are sometimes added to these Living conditions during the interview via a keyboard. It can be very off-putting for a patient when the interviewing 5. Family history (FH) doctor looks entirely at the computer screen rather 6. Systems review (SR) than at the patient. With practice it is possible See Questions box 1.1, page 9 to enter data while maintaining eye contact with Also refer to Appendix I. a patient, but at first it is probably preferable in most cases to make written notes and transcribe them later. The next step after introducing oneself should be The final record must be a sequential, accurate to find out the patient’s major symptoms or medical account of the development and course of the problems. Asking the patient ‘What brought you illness or illnesses of the patient (Appendix I, page here today?’ can be unwise, as it often promotes 461). There are a number of methods of recording the reply ‘an ambulance’ or ‘a car’. This little joke this information. Hospitals may have printed forms wears thin after some years in clinical practice. It is with spaces for recording specific information. This best to attempt a conversational approach and ask applies especially to routine admissions (e.g. for the patient ‘What has been the trouble or problem minor surgical procedures). Follow-up consultation recently?’ or ‘When were you last quite well?’ For questions and notes will be briefer than those of the a follow-up consultation some reference to the last initial consultation; obviously, many questions are visit is appropriate, for example: ‘How have things only relevant for the initial consultation. When a been going since I saw you last?’ or ‘It’s about … patient is seen repeatedly at a clinic or in a general weeks since I saw you last, isn’t it? What’s been practice setting, the current presenting history may happening since then?’ This lets the patient know be listed as an ‘active’ problem and the past history the clinician hasn’t forgotten him or her. Some as a series of ‘inactive’ or ‘still active’ problems. writers suggest the clinician begin with questions to A sick patient will sometimes emphasise the patient about more general aspects of his or her irrelevant facts and forget about very important life. There is a danger that this attempt to establish symptoms. For this reason, a systematic approach early rapport will seem intrusive to a person who to history taking and recording is crucial (Table has come for help about a specific problem, albeit 1.1).11 one related to other aspects of his or her life. This type of general and personal information may be Introductory questions better approached once the clinician has shown an In order to obtain a good history the clinician must interest in the presenting problem or as part of the establish a good relationship, interview in a logical social history. The best approach and timing of this manner, listen carefully, interrupt appropriately, part of the interview must vary, depending on the note non-verbal clues, and correctly interpret the nature of the presenting problem and the patient’s information obtained. and clinician’s attitude. Encourage patients to tell
  • 8. The general principles of history taking 3 1 their story in their own words from the onset of the led the patient to present. It must be remembered first symptom to the present time. that the patient’s and the doctor’s ideas of what When a patient stops volunteering information, constitutes a serious problem may differ. A patient the question ‘What else?’ may start things up with symptoms of a cold who also, in passing, again.8 However, some direction may be necessary mentions that he has recently had severe crushing to keep a garrulous patient on track later during the retrosternal chest pain needs more attention to interview. It is necessary to ask specific questions to his heart than to his nose. Record each presenting test diagnostic hypotheses. For example, the patient symptom in the patient’s own words, avoiding may not have noticed an association between the technical terms. occurrence of chest discomfort and exercise (typical of angina) unless asked specifically. It may also be History of the presenting illness helpful to give a list of possible answers. A patient Each of the presenting problems has to be talked with suspected angina who is unable to describe about in detail with the patient, but in the first the symptom may be asked if the sensation was part of the interview the patient should lead the sharp, dull, heavy or burning. The reply that it was discussion. In the second part the doctor should burning makes angina less likely. take more control and ask specific questions. When Appropriate (but not exaggerated) reassuring writing down the history of the presenting illness, gestures are of value to maintain the flow of the events should be placed in chronological conversation. If the patient stops giving the story order; this might have to be done later when the spontaneously, it can be useful to provide a short whole history has been obtained. If numerous summary of what has already been said and systems are affected, the events should be placed encourage him or her to continue. in chronological order for each system. The clinician must learn to listen with an open mind.10 The temptation to leap to a diagnostic Current symptoms decision before the patient has had the chance to Certain information should routinely be sought describe all the symptoms in his or her own words for each current symptom if this hasn’t been should be resisted. Avoid using pseudo-medical volunteered by the patient. The mnemonic terms; and if the patient uses these, find out exactly SOCRATES summarises the questions that should what is meant by them, as misinterpretation of be asked about most symptoms: medical terms is common. • Site Patients’ descriptions of their symptoms may • Onset vary as they are subjected to repeated questioning • Character by increasingly senior medical staff. The patient • Radiation (if pain or discomfort) who has described his chest pain as sharp and • Alleviating factors left-sided to the medical student may tell the • Timing registrar that the pain is dull and in the centre of • Exacerbating factors the chest. These discrepancies come as no surprise • Severity. to experienced clinicians; they are sometimes the result of the patient’s having had time to reflect on Site his or her symptoms. This does mean, however, Ask where the symptom is exactly and whether it that very important aspects of the story should be is localised or diffuse. Ask the patient to point to checked by asking follow-up questions, such as: the actual site on the body. ‘Can you show me exactly where the pain is?’ and Some symptoms are not localised. Patients ‘What do you mean by sharp?’ who complain of dizziness do not localise this to Some patients may have medical problems that any particular site—but vertigo may sometimes make the interview difficult for them; these include involve a feeling of movement within the head and deafness and problems with speech and memory. to that extent is localised. Other symptoms that are These must be recognised by the clinician if the not localised include cough, shortness of breath interview is to be successful. See Chapter 2 for (dyspnoea), or change in weight. more details. Onset (Mode of onset and pattern) The presenting (principal) Find out whether the symptom came on rapidly, symptom gradually or instantaneously. Some cardiac Not uncommonly, a patient has many symptoms. arrhythmias are of instantaneous onset and offset. An attempt must be made to decide which symptom Sudden loss of consciousness (syncope) with
  • 9. 4 Clinical examination immediate recovery occurs with cardiac but not Severity neurological disease. Ask whether the symptom This is subjective. The best way to assess severity is to has been present continuously or intermittently. ask the patient whether the symptom interferes with Determine if the symptom is getting worse or normal activities or sleep. Severity can be graded better, and, if so, when the change occurred. For from mild to very severe. A mild symptom can be example, the exertional breathlessness of chronic ignored by the patient, while a moderate symptom obstructive pulmonary disease may come on with cannot be ignored but does not interfere with daily less and less activity as it worsens. Find out what activities. A severe symptom interferes with daily the patient was doing at the time the symptom activities, while a very severe symptom markedly began. For example, severe breathlessness that interferes with most activities. Alternatively, pain wakes a patient from sleep is very suggestive of or discomfort can be graded on a 10-point scale cardiac failure. from 0 (no discomfort) to 10 (unbearable). The severity of some symptoms can be quantified Character more precisely; for example, shortness of breath on Here it is necessary to ask the patient what is meant exertion occurring after walking 10 metres on flat by the symptom; to describe its character. If the ground is more severe than shortness of breath patient complains of dizziness, does this mean occurring after walking 90 metres up a hill. Central the room spins around (vertigo) or is it more a chest pain from angina occurring at rest is more feeling of light-headedness? Does indigestion significant than angina occurring while running mean abdominal pain, heartburn, excess wind or 90 metres to catch a bus. a change in bowel habit? If there is pain, is it sharp, It is crucial to quantify accurately the severity dull, stabbing, boring, burning or cramp-like? of each symptom—but also to remember that symptoms a patient considers mild may be very Radiation of pain or discomfort significant. Determine whether the symptom, if localised, radiates; this mainly applies if the symptom is Associated symptoms pain. Certain patterns of radiation are typical of Here an attempt is made to uncover in a systematic a condition or even diagnostic, e.g. the nerve root way symptoms that might be expected to be distribution of pain associated with herpes zoster associated with disease of a particular area. Initial (shingles). and most thorough attention must be given to the system that includes the presenting complaint (see Alleviating factors Questions box 1.1, page 9). Remember that while a Ask whether anything makes the symptom better. single symptom may provide the clue that leads to For example, the pain of pericarditis may be relieved the correct diagnosis, usually it is the combination when a patient sits up. Have analgesic medications of characteristic symptoms that most reliably been used to control the pain? Have narcotics been suggests the diagnosis. required? Current treatment and drug allergies Timing Ask the patient whether he or she is currently Find out when the symptom first began and try taking any tablets or medicines (the use of the to date this as accurately as possible. For example, word ‘drug’ may cause alarm); the patient will often ask the patient what was the first thing he or she describe these by colour or size rather than by noticed that was ‘unusual’ or ‘wrong’. Ask whether name and dose. Then ask the patient to show you the patient has had a similar illness in the past. all his or her medications, if possible, and list them. It is often helpful to ask patients when they last Note the dose, length of use, and the indication felt entirely well. In a patient with long-standing for each drug. This list may provide a useful clue symptoms, ask why he or she decided to come and to chronic or past illnesses, otherwise forgotten. see the doctor at this time. Remember that some drugs are prescribed as transdermal patches or subcutaneous implants Exacerbating factors (e.g. contraceptives and hormonal treatment of Ask if anything makes the pain or symptom carcinoma of the prostate). Ask whether the drugs worse. The slightest movement may exacerbate were taken as prescribed. Always ask specifically the abdominal pain of peritonitis or the pain in the whether a woman is taking the contraceptive pill, big toe caused by gout. because this is not considered a medicine or tablet by many who take it. The same is true of inhalers,
  • 10. The general principles of history taking 5 1 or what many patients call their ‘puffers’. dietary supplements (e.g. pancreatic enzymes for To remind the patient, it is often useful to chronic pancreatitis) or restrictions (e.g. of gluten ask about the use of classes of drugs. A basic list for coeliac disease). should include questions about treatment for blood pressure, high cholesterol, diabetes, arthritis, Menstrual history anxiety or depression, impotence, contraception, For women, a menstrual history should be hormone replacement, epilepsy, anticoagulation obtained; it is particularly relevant for a patient and the use of antibiotics. Also ask the patient if he with abdominal pain, a suspected endocrine or she is taking any over-the-counter preparations disease or genitourinary symptoms. Write down (e.g. aspirin, antihistamines, vitamins). Aspirin the date of the last menstrual period. Ask about the and standard non-steroidal anti-inflammatory age at which menstruation began, if the periods are drugs (NSAIDs), but not paracetamol, can cause regular, or whether menopause has occurred. Ask gastrointestinal bleeding. Patients with chronic if the symptoms are related to the periods. Do not pain may consume large amounts of analgesics, forget to ask a woman of childbearing age if there including drugs containing opioids such as codeine is a possibility of pregnancy; this, for example, or morphine. A careful history of the period of use may preclude the use of certain investigations or of opioids and the quantities used is important drugs.13 Observing the well-known axiom that because they are drugs of dependence. ‘every woman of childbearing years is pregnant until Approximately 50% of people now use ‘natural proven otherwise’ can prevent unnecessary danger remedies’ of various types. They may not feel these to the unborn child and avoid embarrassment for are a relevant part of their medical history, but the unwary clinician. Ask about any miscarriages. these chemicals, like any drug, may have adverse Record gravida (the number of pregnancies) and effects. Indeed, some of these have been found para (the number of births of babies over 20 weeks’ to be adulterated with drugs such as steroids and gestation). NSAIDs. More information about these substances and their effects is becoming available and there The effect of the illness is an increasing responsibility for clinicians to be A serious illness can change a person’s life—for aware of them. example, a chronic illness may prevent work There may be some medications or treatments the or further education. The psychological and patient has had in the past which remain relevant. physical effects of a serious health problem may These include corticosteroids, chemotherapeutic be devastating and, of course, people respond agents (anti-cancer drugs) and radiotherapy. Often differently to similar problems. Even after full patients, especially those with a chronic disease, recovery from a life-threatening illness, some people are very well informed about their condition and may be permanently affected by loss of confidence their treatment. However, some allowance must or self-esteem. There may be continuing anxieties be made for patients’ non-medical interpretation about the capability of supporting a family. Try of what happened.10 to find out how the patient and his or her family Note any adverse reactions in the past. Also ask have been affected. How has he or she coped so specifically about any allergy to drugs (often a skin far, and what are the patient’s expectations and reaction or episode of bronchospasm) and what the hopes for the future with regard to health? What allergic reaction actually involved, to help judge if explanations of the condition has the patient been it was really an allergic reaction.12 The patient often given or obtained (e.g. from the internet)? confuses an allergy with a side-effect of a drug. Helping a patient manage ill-health is a large part Ask about ‘recreational’ drug use. The use of of the clinician’s duty. This depends on sympathetic intravenous drugs has many implications for the and realistic explanations of the probable future patient’s health. Ask whether any attempt has course of the disease and the effects of treatment. been made to avoid sharing needles. This may protect against the injection of viruses, but not The past history against bacterial infection from the use of impure Ask the patient whether he or she has had any serious substances. illnesses, operations or admissions to hospital in Not all medical problems are treated with drugs. the past. Don’t forget to inquire about childhood Ask about courses of physiotherapy or rehabilitation illnesses and any obstetric or gynaecological for musculoskeletal problems or injuries, or to problems. Previous illnesses or operations may help recovery following surgery or a severe illness. have a direct bearing on the current health of Certain gastrointestinal conditions are treated with the patient. It is worth asking specifically about
  • 11. 6 Clinical examination certain operations that have a continuing effect the places of birth and residence, and the level of on the patient’s health; for example, operations for education obtained. Recent migrants may have been malignancy, bowel surgery or cardiac surgery— exposed to infectious diseases like tuberculosis; especially valve surgery. Implanted prostheses ethnic background is important in some diseases, are common in surgical, orthopaedic and cardiac such as thalassaemia and sickle cell anaemia. procedures. These may involve a risk of infection of the foreign body, while magnetic metals—especially Smoking cardiac pacemakers—are a contraindication to The patient may claim to be a non-smoker if he or magnetic resonance imaging (MRI). Chronic she stopped smoking that morning. Therefore, ask kidney disease may be a contraindication to X-rays whether the patient has ever smoked and, if so, how using iodine contrast materials and MRI scanning many cigarettes (or cigars or pipes) were smoked a using gadolinium contrast. Pregnancy is usually day and for how many years. Find out if the patient a contraindication to radiation exposure (X-rays has stopped smoking, and if so when that was. and nuclear scans—remember that CT scans cause Calculate the number of packet-years of smoking hundreds of times the radiation exposure of simple (20 cigarettes a day for 1 year = a packet-year). X-rays). Cigarette smoking is a risk factor for vascular The patient may believe that he or she has disease, chronic lung disease, several cancers had a particular diagnosis made in the past, but and peptic ulceration, and may damage the fetus careful questioning may reveal this as unlikely. (Table 1.2). Cigar and pipe smokers typically inhale For example, the patient may mention a previous less smoke than cigarette smokers, and overall duodenal ulcer, but not have had any investigations mortality rates are correspondingly lower in this or treatment for it, which makes the diagnosis less group, except from carcinoma of the oral cavity, certain. Therefore it is important to obtain the larynx and oesophagus. particulars of each relevant past illness, including the symptoms experienced, tests performed and treatments prescribed. TABLE 1.2 Smoking and clinical Patients with chronic illnesses such as diabetes associations* mellitus will probably have had their condition 1. Cardiovascular disease managed with the help of various doctors and Premature coronary artery disease at specialised clinics where diabetic educators, Peripheral vascular disease nurses and dieticians will have had a primary Cerebrovascular disease role in management of the illness. Find out what supervision and treatment these have provided. For 2. Respiratory disease example, who does the patient contact if there is a Lung cancer problem with the insulin dose, and does the patient Chronic obstructive pulmonary disease (chronic airflow limitation) know what to do (an action plan) if there is an urgent Increased incidence of respiratory infection or dangerous complication? Patients with chronic Increased incidence of postoperative respiratory diseases are often very much involved in their own complications care and are very well informed about aspects of their treatment. For example, diabetics should 3. Other cancers keep records of their home-measured blood sugar Larynx, oral cavity, oesophagus, nasopharynx, bladder, kidney, pancreas, stomach, uterine cervix levels; heart failure patients should monitor their weight daily, and so on. These patients will often 4. Gastrointestinal disease make their own adjustments to their medication Peptic ulceration doses. Assessing a patient’s understanding of and 5. Pregnancy confidence in making these changes should be part Increased risk of spontaneous abortion, fetal death, of the history taking. neonatal death, sudden infant death syndrome The social and personal history 6. Drug interactions Induces hepatic microsomal enzyme systems, e.g. This is the time to find out more about the patient increased metabolism of propranolol, theophylline as a person. The questions should be asked in an interested and conversational way and should not * Individual risk is influenced by the duration, intensity and type of smoke exposure, as well as by genetic and sound like a routine learned by rote. This history other environmental factors. Passive smoking is also includes the whole economic, social, domestic and associated with respiratory disease. industrial situation of the patient. Ask first about
  • 12. The general principles of history taking 7 1 Alcohol 20 g per day for females) with two alcohol-free Ask whether the patient drinks alcohol.14 If so, ask days a week. Alcoholics are notoriously unreliable what type, how much and how often. If the patient about describing their alcohol intake, so it may be claims to be a social drinker, find out exactly what important to suspend belief and sometimes (with this means. In a glass of wine, a nip (or shot) of the patient’s permission) talk to the relatives. spirits, a glass of port or sherry, or a 200 mL (7 oz) Certain questions can be helpful in making a glass of beer, there are approximately 8–10 g of diagnosis of alcoholism; these are referred to as the alcohol (1 unit = 8 g). In the UK, the current CAGE questions:15 recommended safe limits are 21 units (168 g of 1 Have you ever felt you ought to Cut down on ethanol) a week for men and 14 units (112 g of your drinking? ethanol) for women; weekly consumption of more 2 Have people Annoyed you by criticizing your than 50 units for men and 35 units for women drinking? defines a high-risk group. Alcohol becomes a major 3 Have you ever felt bad or Guilty about your risk factor for liver disease in men if more than drinking? 80 g and in women if more than 40 g are taken 4 Have you ever had a drink first thing in the daily for 5 years or longer. The National Health & morning to steady your nerves or get rid of a Medical Research Council (NHMRC) in Australia hangover? (Eye opener) recommends a maximum alcohol intake of no If the patient answers ‘yes’ to any of these questions, more than 40 g per day for males on average (and this suggests there may be a serious alcohol TABLE 1.3 Alcohol (ethanol) abuse: complications Gastrointestinal system • Acute gastric erosions • Gastrointestinal bleeding from varices, erosions, Mallory-Weiss tear, peptic ulceration • Pancreatitis (acute, recurrent or chronic) • Diarrhoea (watery, due to alcohol itself, or steatorrhoea from chronic alcoholic pancreatitis or, rarely, liver disease) • Hepatomegaly (fatty liver, chronic liver disease) • Chronic liver disease (alcoholic hepatitis, cirrhosis) and associated complications • Cancer (oesophagus, cardia of stomach, liver, pancreas) Cardiovascular system • Cardiomyopathy • Arrhythmias • Hypertension Nervous system • ‘Blackouts’ • Nutrition-related conditions, e.g. Wernicke’s encephalopathy, Korsakoff’s psychosis, peripheral neuropathy (thiamine deficiency), pellagra (dementia, dermatitis and diarrhoea from niacin deficiency) • Withdrawal syndromes, e.g. tremor, hallucinations, ‘rum fits’, delirium tremens • Cerebellar degeneration • Alcoholic dementia • Alcoholic myopathy • Autonomic neuropathy Haematopoietic system • Anaemia (dietary folate deficiency, iron deficiency from blood loss, direct toxic suppression of the bone marrow, rarely B12 deficiency with chronic pancreatitis, or sideroblastic anaemia) • Thrombocytopenia (from bone marrow suppression or hypersplenism) Genitourinary system • Erectile dysfunction (impotence), testicular atrophy in men • Amenorrhoea, infertility, spontaneous abortion, fetal alcohol syndrome in women Other effects • Increased risk of fractures and osteonecrosis of the femoral head
  • 13. 8 Clinical examination dependence problem. The complications of alcohol creation of living wills and in understanding the abuse are summarised in Table 1.3. support network available for the patient. Ask about the adequacy of the patient’s diet, who Occupation and education does the cooking, availability of ‘meals on wheels’ Ask the patient about present occupation;16 the and other services such as house cleaning. Also ask WHACS mnemonic is useful here:17 about the amount of physical activity undertaken. 1 What do you do? The presence of pets in the home may be important 2 How do you do it? if infections or allergies are suspected. 3 Are you concerned about any of your exposures or experiences? The family history 4 Co-workers or others exposed? Many diseases run in families. For example, 5 Satisfied with your job? ischaemic heart disease that has developed at a Finding out exactly what the patient does at work young age in parents or siblings is a major risk can be helpful (page 113). Note particularly any factor for ischaemic heart disease in the offspring. work exposure to dusts, chemicals or disease; Various malignancies, such as breast and large- for example, mine and industrial workers may bowel carcinoma, are more common in certain have the disease asbestosis. Find out if any similar families. Both genetic and common environmental complaints have affected fellow workers. exposures may explain these familial associations. Ask about the education level attained; this can Some diseases (e.g. haemophilia) are directly influence the way things are explained. Checking on inherited.18 hobbies can also be informative (e.g. bird fanciers Ask about any history of a similar illness in the and lung disease). family. Inquire about the health and, if relevant, the causes of death and ages of death of the parents and Overseas travel and immunisation siblings. If there is any suggestion of a hereditary If an infectious disease is a possibility, ask about disease, a complete family tree should be compiled recent overseas travel, destinations reached, and showing all members affected (Figure 1.1). Patients how the patient lived when away (e.g. did he or can be reluctant to mention that they have relatives she drink unbottled water and eat local foods, or with mental illnesses, epilepsy or cancer, so ask dine at expensive international hotels). Ask about tactfully about these diseases. Consanguinity immunisation status and whether any prophylactic (usually first cousins marrying) increases the drugs (e.g. for malaria) were taken during the travel probability of autosomal recessive abnormalities period. Find out whether the patient has had recent in the children; ask about this if the pedigree is immunisations (e.g. for hepatitis B, pneumococcal suggestive. disease, Haemophilus influenzae or influenza). Systems review Marital status, social support As well as detailed questioning about the system and living conditions likely to be diseased, it is essential to ask about To determine the patient’s marital status, ask important symptoms and disorders in other who is living at home with the patient. Find out systems (Questions box 1.1), otherwise important about the health of the spouse and of any children. diseases may be missed. 19,20 An experienced Check if there are any other household members. clinician will perform a targeted systems review, Establish who is the patient’s main ‘caregiver’. based on information already obtained from the Discreet questions about sexual activity may be patient; clearly it is not realistic to put all of the very relevant. For example, erectile dysfunction listed questions to a patient. may occur in neurological conditions, debilitating When recording the systems review, list important illness or psychiatric disease. Questions about negative answers (‘relevant negatives’). Remember: living arrangements are particularly important for if other recent symptoms are unmasked, more chronic or disabling illnesses, where it is necessary details must be sought; relevant information is to know what social support is available and then added to the history of the presenting illness. whether the patient is able to manage at home (for Before completing the history, it is often valuable example, the number of steps required for access to to ask what the patient thinks is wrong, and what the house, or the location of the toilet). he or she is most concerned about. General and Ask if the patient considers him- or herself to sympathetic questions about the effect of a chronic be a spiritual person. Spirituality is an important or severe illness on the patient’s life are important factor, especially in the care of dying patients, in the for establishing rapport and for finding out what
  • 14. The general principles of history taking 9 1 = Unaffected male Female carrier X-linked trait Unaffected female = Consanguineous Affected male Heterozygous (male) Affected female Heterozygous (female) Proband Deceased male Unknown sex Monozygotic twins Spontaneous abortion Dizygotic twins Figure 1.1 Preparing a family tree: note the symbols used for the documentation else might be needed (both medical and non- medical) to help the patient. ! 7 Have you had blackouts without warning?— Major presenting symptoms for each system are Stokes-Adams attacks described in the following chapters. Examples of ! 8 Have you felt dizzy or blacked out when supplementary important questions to ask about exercising?—Severe aortic stenosis or past history, social history and family history are hypertrophic cardiomyopathy also given there for each system. 9 Do you have pain in your legs on exercise? 10 Do you have cold or blue hands or feet? Questions box 1.1 11 Have you ever had rheumatic fever, a heart attack, or high blood pressure? The systems review Enquire about common symptoms and three Respiratory system or four of the common disorders in each ! 1 Are you ever short of breath? Has this come major system listed below. Not all these on suddenly?—Pulmonary embolism questions should be asked of every patient. 2 Have you had any cough? Adjust the detail of questions based on the ! 3 Is your cough associated with shivers and presenting problem, the patient’s age and shakes (rigors) and breathlessness and chest the answers to the preliminary questions. pain?—Pneumonia ! denotes symptoms for the possible diag- 4 Do you cough up anything? nosis of an urgent or dangerous (alarm) problem. ! 5 Have you coughed up blood?—Bronchial carcinoma Cardiovascular system 6 What type of work have you done?— ! 1 Have you had any pain or pressure in your Occupational lung disease chest, neck or arm?—Myocardial ischaemia 7 Do you snore loudly? Do you fall asleep 2 Are you short of breath on exertion? How easily during the day? When? Have you much exertion is necessary? fallen asleep while driving? (Sleep history) ! 3 Have you ever woken up at night short of 8 Do you ever have wheezing when you are breath?—Cardiac failure short of breath? 4 Can you lie flat without feeling breathless? 9 Have you had fevers? 5 Have you had swelling of your ankles? 10 Do you have night sweats? 6 Have you noticed your heart racing or beating irregularly? (Continues over page)
  • 15. 10 Clinical examination Respiratory system continued 9 Have you any problems with your sex life? 11 Have you ever had pneumonia or Difficulty obtaining or maintaining an tuberculosis? erection? 12 Have you had a recent chest X-ray? 10 Have you noticed any rashes or lumps on your genitals? ! 13 Have you had any bleeding or discharge 11 Have you ever had a sexually transmitted from your breasts or felt any lumps there?— Carcinoma of the breast disease? 12 Have you ever had a urinary tract infection Gastrointestinal system or kidney stone? 1 Are you troubled by indigestion? 13 Are your periods regular? 2 Do you have heartburn? 14 Do you have excessive pain or bleeding with ! 3 Have you had any difficulty swallowing?— your periods? Oesophageal cancer Haematological system ! 4 Have you had nausea or vomiting, or 1 Do you bruise easily? vomited blood?—Gastrointestinal bleeding 5 Have you had pain or discomfort in your 2 Have you had fevers, or shivers and shakes abdomen? (rigors)? 6 Have you had any abdominal bloating or ! 3 Do you have difficulty stopping a small cut distension? from bleeding?—Bleeding disorder ! 7 Has your bowel habit changed recently?— ! 4 Have you noticed any lumps under Carcinoma of the colon your arms, or in your neck or groin?— Haematological malignancy 8 How many bowel motions a week do you usually pass? 5 Have you ever had blood clots in your legs or in the lungs? 9 Have you lost control of your bowels or had accidents (faecal incontinence)? Musculoskeletal system ! 10 Have you seen blood in your motions or 1 Do you have painful or stiff joints? vomited blood?—Gastrointestinal bleeding ! 2 Are any of your joints red, swollen and ! 11 Have your bowel motions been black?— painful?—Septic arthritis Gastrointestinal bleeding 3 Have you had a skin rash recently? ! 12 Have you lost weight recently without 4 Do you have any back or neck pain? dieting?—Carcinoma of the colon 5 Have your eyes been dry or red? 13 Have your eyes or skin ever been yellow? 6 Have you ever had a dry mouth or mouth 14 Have you ever had hepatitis, peptic ulcers? ulceration, colitis, or bowel cancer? 7 Have you been diagnosed as having 15 Tell me about your diet recently. rheumatoid arthritis or gout? Genitourinary system 8 Do your fingers ever become painful and 1 Do you have difficulty or pain on passing become white and blue in the cold? urine? Endocrine system 2 Is your urine stream as good as it used to 1 Have you noticed any swelling in your neck? be? 2 Do your hands tremble? 3 Is there a delay before you start to pass 3 Do you prefer hot or cold weather? urine? (Applies mostly to men) 4 Have you had a thyroid problem or 4 Is there dribbling at the end? diabetes? 5 Do you have to get up at night to pass 5 Have you noticed increased sweating? urine? 6 Have you been troubled by fatigue? 6 Are you passing larger or smaller amounts of urine? 7 Have you noticed any change in your appearance, hair, skin or voice? 7 Has the urine colour changed? ! 8 Have you seen blood in your urine?—Urinary ! 8 Have you been unusually thirsty lately?—New onset of diabetes tract malignancy
  • 16. The general principles of history taking 11 1 Reproductive history (women) Skills in history taking 1 How many pregnancies have you had? In summary, several skills are important in obtaining a useful and accurate history.21 First, 2 Have you had any miscarriages? establish rapport and understanding. Second, ask 3 Have you had high blood pressure or questions in a logical sequence. Start with open- diabetes in pregnancy? ended questions. Listen to the answers and adjust 4 Were there any other complications during your interview accordingly. Third, observe and your pregnancies or deliveries? provide non-verbal clues carefully. Encouraging, 5 Have you had a Caesarean section? sympathetic gestures and concentration on the patient that makes it clear he or she has your Neurological system and mental state undivided attention are most important and helpful, 1 Do you get headaches? but are really a form of normal politeness. Fourth, proper interpretation of the history is crucial. ! 2 Is your headache very severe and did Your aim should be to obtain information it begin very suddenly?—Sub-arachnoid haemorrhage that will help establish the likely anatomical and physiological disturbances present, the aetiology 3 Have you had memory problems or trouble of the presenting symptoms and the impact of concentrating? the symptoms on the patient’s ability to function. 4 Have you had fainting episodes, fits or (In Chapter 2, some advice on how to take the blackouts? history in more challenging circumstances is 5 Do you have trouble seeing or hearing? considered.) This type of information will help you 6 Are you dizzy? plan the diagnostic investigations and treatment, 7 Have you had weakness, numbness or and to discuss the findings with, or present them clumsiness in your arms or legs? to, a colleague if necessary (see page 462). First, however, a comprehensive and systematic physical 8 Have you ever had a stroke or head injury? examination is required. 9 Have you had difficulty sleeping? These skills can be obtained and maintained 10 Do you feel sad or depressed, or have only by practice. problems with your ‘nerves’? 11 Have you ever been sexually or physically abused? References 1. Longson D. The clinical consultation. J R Coll The elderly patient Physicians Lond 1983; 17:192–195. Outlines the principles of hypothesis generation and testing ! 1 Have you had problems with falls or loss of during the clinical evaluation. balance?—High fracture risk 2. Nardone DA, Johnson GK, Faryna A et al. A model 2 Do you walk with a frame or stick? for the diagnostic medical interview: nonverbal, 3 Do you take sleeping tablets or sedatives? verbal and cognitive assessments. J Gen Intern Med 1992; 7:437–442. Verbal and non-verbal questions —Falls risk and diagnostic reasoning are reviewed in this 4 Do you take blood pressure tablets?— useful article. Postural hypotension and falls risk 3. Bellet PS, Maloney MJ. The importance of empathy 5 Have you been tested for osteoporosis? as an interviewing skill in medicine. JAMA 1991; 266:1831–1832. Distinguishes between empathy, 6 Can you manage at home without help? reassurance and patient education. 7 Are you affected by arthritis? 4. Brewin T. Primum non nocere? Lancet 1994; 344:1487–1488. Review of a key principle in 8 Have you had problems with your memory clinical management. or with managing things like paying bills?— 5. Platt FW, McMath JC. Clinical hypocompetence: Cognitive decline the interview. Ann Intern Med 1979; 91:898–902. A 9 How do you manage your various tablets?— valuable review of potential flaws in interviewing, Risk of polypharmacy and confusion of condensed into five syndromes: inadequate doses content, database flaws, defects in hypothesis generation, failure to obtain primary data and a Concluding the interview controlling style. Is there anything else you would like to talk 6. Coulehan JL et al. ‘Tell me about yourself ’: the about? patient-centred interview. Ann Intern Med 2001; 134:1079–1084.
  • 17. 12 Clinical examination 7. Fogarty L et al. Can 40 seconds of compassion MR. Comparison of CAGE questionnaire and reduce patient anxiety? J Clin Oncol 1999; 17:371– computer-assisted laboratory profiles in screening 379. for covert alcoholism. Lancet 1990; 336:482–485. 8. Barrier P et al. Two words to improve physician– 16. Newman LS. Occupational illness. N Engl J Med patient communication: What else? Mayo Clin Proc 1995; 333:1128–1134. The importance of knowing 2003; 78:211–214. the occupation for the diagnosis of an illness 9. Blau JN. Time to let the patient speak. BMJ cannot be overemphasised. 1999; 298:39. The average doctor’s uninterrupted 17. Blue AV, Chessman AW, Gilbert GE, Schuman narrative with a patient lasts less than 2 minutes SH, Mainous AG. Medical students’ abilities (and often much less!), which is too brief. Open to take an occupational history: use of the interviewing is vital for accurate history taking. WHACS mnemonic. J Occup Environ Med 2000; 10. Smith RC, Hoppe RB. The patient’s story: 42(11):1050–1053. integrating the patient- and physician-centered 18. Rich EC, Burke W, Heaton CJ, Haga S, Pinsky L, approaches to interviewing. Ann Intern Med 1991; Short MP, Acheson L. Reconsidering the family 115:470–477. Patients tell stories of their illness, history in primary care. J Gen Intern Med 2004; integrating both the medical and psychosocial 19(3):273–280. aspects. Both need to be obtained, and this article 19. Hoffbrand BI. Away with the system review: a plea reviews ways to do this and to interpret the for parsimony. BMJ 1989; 198:817–819. Presents information. the case that the systems review approach is not 11. Beckman H, Markakis K, Suchman A, Frankel valuable. A focused review still seems to be useful R. Getting the most from a 20-minute visit. in practice (see below). Am J Gastroenterol 1994; 89:662–664. A lot of 20. Boland BJ, Wollan PC, Silverstein MD. Review of information can be obtained from a patient systems, physical examination, and routine test for even when time is limited, if the history is taken case-finding in ambulatory patients. Am J Med Sci logically. 1995; 309:194–200. A systems review can identify 12. Salkind AR, Cuddy PG, Foxworth JW. The rational unsuspected clinically important conditions. clinical examination. Is this patient allergic to 21. Simpson M, Buchman R. Stewart M et al. penicillin? An evidence-based analysis of the Doctor–patient communication: the Toronto likelihood of penicillin allergy. JAMA 2001; consensus statement. BMJ 1991; 303:1385–1387. 285(19):2498–2505. Most complaints about doctors relate to failure of 13. Ramosaka EA, Sacchetti AD, Nepp M. Reliability adequate communication. Encouraging patients to of patient history in determining the possibility discuss their major concerns without interruption of pregnancy. Ann Emerg Med 1989; 18:48–50. or premature closure enhances satisfaction and yet One in ten women who denied the possibility of takes little time (average 90 seconds). Factors that pregnancy, in this study, had a positive pregnancy improve communication include use of appropriate test. open-ended questions, giving frequent summaries, 14. Kitchens JM. Does this patient have an alcohol and the use of clarification and negotiation. Giving problem? JAMA 1994; 272:1782–1787. A useful premature advice or reasurance, or inappropriate guide to making this assessment. use of closed questions, badly affects the interview. 15. Beresford TP, Blow FC, Hill E, Singer K, Lucey These skills can be learned but require practice.