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    History and Clinical Examination at a Glance
    History and Clinical Examination at a Glance
    History and Clinical Examination at a Glance
    Ebook1,047 pages3 hours

    History and Clinical Examination at a Glance

    By Jonathan Gleadle

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    About this ebook

    Every medical student must be able to take an accurate history and perform a physical examination. This third edition of History and Clinical Examination at a Glance provides a concise, highly illustrated companion to help you develop these vital skills as you practice on the wards. Building on an overview of the patient/doctor relationship and basic enquiry, the text supports learning either by system or presentation of common conditions, with step-by-step and evidence-based information to support clinical examination and help you formulate a sound differential diagnosis.

    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.

    LanguageEnglish
    PublisherWiley
    Release dateNov 16, 2011
    ISBN9781118286623
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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 page

      This 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.

      Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

      Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK

      The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

      111 River Street, Hoboken, NJ 07030-5774, USA

      For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.

      The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

      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

      c01uf001

      Good 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

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