CLNICAL MEDICINE

Patient – Doctor relationship

Reasons why people visit doctors
They have reached their limits of tolerance
They have reached their limits of anxiety
They have problems of living presenting as symptoms
For prevention
For administrative reasons
The qualities that patients look for in a doctor
Humaneness
Competence
Accuracy
Honesty
Openness
Responsiveness
Involving the patient in the decision-making process
Trustworthiness
Time to listen
The duties of a registered doctor*
The care of your patient is your first concern
Protect and promote the health of patients and the public
Provide a good standard of practice and care
Keep your professional knowledge and skills up to date
Recognize and work within the limits of your competence
Work with colleagues to serve your patients' interests best
Treat patients as individuals and respect their dignity
Treat patients politely and considerately
Respect patient confidentiality
Work in partnership with the patient
Listen to your patients and respond to their concerns and
preferences
Give information in a way they can understand
Respect their right to reach decisions with you about their care
Support patients in caring for themselves to improve and
maintain their health
Be honest and open, and act with integrity
Act without delay if you have a good reason to believe that you
or a colleague may be putting patients at risk
Never discriminate unfairly against patients or colleagues
Never abuse your patient.
 COMMUNICATION SKILLS
These should always include:
maintaining good eye contact
checking the patient's prior knowledge or understanding
active listening
encouraging verbal and non-verbal communication
avoiding jargon
eliciting and addressing the patient's agenda
ability to discuss difficult issues
going at a pace that is comfortable for the patient.
 Effective communication skills
Improve patient satisfaction
Patients understand what is wrong
They understand what they can do to help
Improve doctor satisfaction
Patients are more likely to follow advice when they agree

mutual goals with their doctor

Improve health by positive support and empathy
Improving health outcomes
Enhancing the relationship between doctor and patient
Use time more effectively
Active listening helps the doctor recognize what is wrong
Active listening leads to fewer patient complaints
 Sages Of Consultation :BUSS
BUSS
Beginning Preparation / Setting / Introduction

Listening Problems / Ideas / Concerns / Expectations /

Clarify / Summarize / Context

Information gathering Systematic enquiry / Clinical examination

Sharing Chunk it / Check it / Share decisions

Setting goals Ending / Follow up

 BUSS : Beginning

1- Place:
Quite & private
2- Time:
Students : 20-30 minutes.
General practice : average 10 minutes.
Out patients : 5-10 minutes.
3- Seating:
No barriers .
Corner of desk / keep eye contact / leveling.
4- Non- verbal communication:
Professional in dress & behavior / Patient’s behavior.
5- Introduction
 BUSS:Listening

1- Active listening ( gather of information):

Let the patient to talk / encouraging comment ( open questions) /

clarification / closed questions.

To find out:
2- Patient’s ideas.
3- Patient’s concerns.
4- Patient’s expectation.
5- Patient’s context ( social history).
6- summary.
 BUSS: Information gathering

1-Systematic enquiry .
2- Clinical examination
 BUSS: Sharing information
1- Clarifying & summarizing:
Use simple & understandable language.
Tailor your explanation to your patient.
Put your information in chunks & check patient’s response.
Bad news should be given accurately, unambiguously & sensiitvely.
2- Enabling:
Share your own ideas with the patients.
Help their decision making.
Discus the plan of investigation & treatment with your patients.
 BUSS: Setting goals
1-Goals should follow the SMART principle :
S Specific.
M Measurable.
A Achievable.
R Relevant.
T Time related.
2- Arrange follow up.
 Situations Influence Communication
1- Transference / Countertransference:
Transference: Is the process where your patient unconsciously
projects on to you thoughts, behaviours &
emotional reactions that originate with other
significant relationships from childhood onwards.
Countertransference:
Is where the doctor responds to patients in a way
similar to significant past relationships.
2- Empathy: It is more than sympathy. It is helping your patients feel
that you understand what they are going through.
3- Sensitive situations: Be sensitive / respect privacy / conscent.
 Situations Influence Communication
4- Breaking bad news:
- Speak in quite & private environment.
- Be honest, always tell the true informations .
- Give the patient enough time to think .
- Answer questions about prognosis in clever way.
- Do not take away hope.
5- Dealing with emotions:
- Be quite with anger patients or relatives.
- Explore the causes of their angriness and calm them.
- Give apology if needed.
- Talkative patients : ask the patient to tell the most important
things to deal with.
- Long list of complaints: Listing the top 6 things that brought him
 Situations Influence Communication
6- Too ill or confused patients who difficult to talk:
- Take the information from 3rd person.
- Review whenever patient can talk.
7- Communications difficulties :
- Interpreter / Write things / Lip reading / sign language.
8- transcultural issues:
-Appropriateness of eye contact /Appropriateness hand gestures
Personal space / Physical contact between sexes.
Culture & beliefs around illness/ What should happen as death
approaches. / What should happen after death.
9- Third party information: Relative / Friend / carer.
 History Taking
1- Hand washing.
2- Introduction & consent.
3-personal data : age / gender / residence / occupation / tribe.
4- Presenting complaint.
5- History of presenting complaint.
6- systemic review.
7- Past medical history.
8- Family medical history.
9- Drug history.
10- Social history.
11- Summary.
 History Taking: 1- Hand washing.
:

Healthcare-acquired infections (HAIs)

Meticillin-resistant Staphylococcus aureus (MRSA)
Clostridium difficile
Diarrhoeal infections: Salmonella / E. coli 0157:H7 / Shigella
Norovirus
Respiratory infections: Influenza / Respiratory syncytial virus (RSV)
Common cold / Corona virus

Other infections: Hepatitis A

History Taking: 2- Introduction & consent.
History Taking: 3-personal data
 History Taking: 4- Presenting complaint.

1- Let the patient to present his c/o with his own language.
2- Encourage the patient to tell the most important C/O.
3- Clarify when necessary:
Allergy / Angina / Arthritis / Diarrhoea / Dizziness / Eczema / Fits
Heart attack / Migraine / Pleurisy / Vertigo.
4- Onset & duration of each C/O.
5- Common presenting C/O:
1- General health: well being / appetite / weight change / sleep.
2- CVS: chest pain / breathlessness / palpitation/ leg pain/ LL swlling

3- RS: shortness of breath/ cough/ wheeze/ sputum/ chest pain/

blood in sputum ( haemoptysis).
4- GIT: mouth ulcer/ difficult swallowing/ nausea & vomiting/
vomiting of blood ( haematemesis)/ heart burn/ abomina
 History Taking: 4- Presenting complaint.

4- GIT: mouth ulcer/ difficult swallowing/ nausea & vomiting/

vomiting of blood ( haematemesis)/ heart burn/ abdominal

pain/ change in bowl habits/ change in color of stool ( pale /

dark/ tarry/ fresh blood).
5- Genitourinary system: pain in passing urine (dysuria)/ frequency in

passing urine ( polyuria & nocturia)/ blood in urine

(haematuria)/ sexual problems.
Men : prostatic symptoms ( difficult starting- hesitancy)/ poor

stream of flow/ terminal dribbling/ retention).

incontinence/ urethral discharge/ libido/ erectile difficulties.
Women: last menstrual (consider pregnancy)/ timing, length &
regularity of period/ abnormal bleeding/ vaginal discharge/
cotraception/ libido, pain during intercourse(dyspareunia)
 History Taking: 4- Presenting complaint.

6- Nervous system: headache/ dizziness (vertigo or light headed)/

faints/ fits/ altered sensation ( numbness or tingling
( paraesthesiae)) / weakness/ visual disturbance/
hearing problems (deafness, tinnitus)/ speech ,
memory & concentration changes .
7- Musculoskeletal: joint pain/ stiffness/ swelling/mobility/ falls.
8- Endocrine: heat or cold intolerance/ change in sweating/
excessive thirst (polydepsia).
9- Skin: itching / rashes/ bleeding/ bruising/ bullae
 History Taking:5- History of presenting complaint.

This means analysis of the presenting C/O, and should involve:

1-Onset: acute / gradual.
2-Duration : hours/ days/ weeks/ months/ years.
3-Site:
4-Frequency : intermittent/ continuous/ episodic/ day or night
5- Severity:
6-Character: pain (burning/ stabbing/ constricting/ sharp/ dull).
7- Radiation: local extension or sharing neuronal pathway.
8- Associated symptoms:
9- Exacerbating & relieving factors.
10- Effect on life style.

NOTE: For fluid ( urine/ vomitus/ stool/ sputum/ blood), estimate:

amount/ color/ odor/
 History Taking: 6- systemic review.

SYSTEM QUESTIONS : Have you

Cardiovascular Chest pain/ shortness o breath/ palpitating

Respiratory Shortness of breath/ cough / coughing blood/ wheezes

Gastrointestinal Haert burn/ abdominal pain/ change bowl habits/ blood by mouth
or rectum/ n&v

Genitourinary Polyuria &noctura/ bloody urine/ urgency, histency, dribbling (for

men)/ period problems, vaginal discharge or bleeding(women)

Musculoskeletal Pain, stiffness or swelling of joints

Endocrine Feel cold or hot / excessive sweating.

Neurological Fits/ headache / visual change/ numbness/ weakness

 History Taking: 7- Past medical history.

1- Ask about past medical problems:

Have you had any serious illness that brought you to doctor?
Have you had to take time off work because of ill health?
Have you had any operations?
Have you attended any hospital clinics?
Have you ever been in hospital? If so, why was that?
2- Ask about more details
- Onset & duration
- Time of diagnosis.
- Management.
- Regular follow up
- How far is connected to current problem.
 History Taking: 8- Family medical history.

1- Ask about diseases in the family ( IHD / DM/ HTN/ Renal stones)).
2-Ask about inherited disorders.
3-Set up pedigree chart to find out single gene hereditary disorders:
Autosomal dominant:
Adult polycystic kidney disease/ Huntington's disease/
Myotonic dystrophy/ Neurofibromatosis .
Autosomal recessive:
Cystic fibrosis/ Sickle cell anaemia/ Alpha thalassaemia/
Alpha-1-antitrypsin deficiency
X-linked
Duchenne muscular dystrophy/ Haemophilia A/
Fragile X syndrome
Family medical history: Family Pedigree
 History Taking: 9- Drug history.

1- Ask about long term drugs.

2- Ask about current drugs.
3- Ask about over-counter drugs.
4- Ask about traditional medicine ( herbs / cautery/ acupuncture).
5- Ask about the details of each drug which include:
Name/ Dose/ duration/ frequency/ indication/ regular taking/
side effects e.g:
Atenolol 50 mg daily for 5 years. Started after myocardial infarction

Causes cold hands. Not taken regularly (? Compliance).

 History Taking: 10- Social history.

1-Upbringing:
Birth injury or complications/ Early parental disruptions/
Schooling.
2-Behaviour problems:
Home life/ Emotional, physical or sexual abuse*
Experiences of death and illness/ Interest and attitude of parents
3-Occupation:
Current and previous (clarify exactly what a job entails)
Exposure to hazards, e.g. chemicals, asbestos, foreign travel,

accidents and compensation claims

Unemployment: reason and duration
Attitude to job
 History Taking: 10- Social history.

4-Finance:
Circumstances, including debts/ Benefits from social security
5-Relationships and domestic circumstances:
Married or long-term partner/ Quality of relationship/ Problems
Partner's health, occupation and attitude to patient's illness
Who else is at home? Any problems, e.g. health, violence,
bereavement?/ Any trouble with the police?
6-House:
Type of home, size, owned or rented/ Details of home, including

stairs, toilets, heating, cooking facilities, neighbours.

7-Community support
Social services involvement, e.g. home help, meals on wheels
 History Taking: 10- Social history.

8- Sexual history*
9-Leisure activities:
Hobbies and pastimes/ Pets
10-Exercise:
What, where and when?
11-Substance misuse*
 History Taking: 11- Summary.

1- Write full informative sentences for:

1- Personal data.
2- Each presenting symptoms.
4- Important negative symptoms of concerned system.
5- Positive symptoms in systemic review.
6- Positive findings in PMH/ FMH/ Drug H / Social H.
7- Positive & negative history of smoking & alcohol.
2- Reflect your findings to your patient for conformation.
3- Put the possible diagnoses.
4- Put plan for examination & investigation.
History Taking: 11- Summary.
 History Taking: Occupation Disorders
Occupation Factor Disorder Presents

Shipyard workers, Asbestos Pleural Over 20 years later

boilermen plaques
Asbestosis

Mesothelioma

Dairy farmers Leptospira hadjo Lymphocytic Within 1 week

meningitis
Fungus spores on mouldy hay Farmer's lung Within 4-18 hours

Divers Surfacing from depth too quickly Decompressio Immediately and

n sickness up to 1 week
Industrial workers Chemical exposure, e.g. Dermatitis on Variable
chromium hands
 History Taking: Occupation Disorders
Occupation Factor Disorder Presents

Bakery workers Flour dust Occupational asthma Variable

Healthcare workers Cuts, needlestick Hepatitis B and C Incubation period >3

injuries months
Work involving noisy Excessive noise Sensorineural Develops over
machinery hearing loss months
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