Surprisingly few tools are required for most clinical examinations. You should wear a watch to count the pulse and respiratory rate, and carry a stethoscope, a torch and a tapemeasure. On the wards and outpatient departments you can expect (but check) disposable gloves, wooden spatulas, and a sphygmomanometer, an ophthalmoscope and an auroscope. Additional tools are required for ENT (nasal speculum, mirror and endoscope), neurological (odorants, Snellen and colour vision charts, cotton wool, sterile pin, tuning fork, 2 point retractor, patellar hammer), musculoskeletal (goniometer) and pelvic examination (proctoscope and vaginal speculum).

Ask the patient to demonstrate an abnormality, to direct your own examination: disease represents loss or modification of form and function, but be aware that the full house of classical signs of a specific disease are not present in every patient.

Table 1 Check list for lumps and ulcers (bold = both)

  • The history and examination are usually sufficient to provide a provisional diagnosis and a management plan; investigations provide further evidence on the diagnosis and help monitor progress

 

  • The systems review (table 2) is an effective means of surveying the activity of the whole body, identifying problems not volunteered or noticed by the patient, and helping the diagnosis of the presenting and subsidiary problems
  • When there is still difficulty in making a diagnosis, consider the anatomy of the region involved, and systematically go through the potential causes of disease (the diagnostic sieve)
  • When considering the anatomical structures (table 2), also think of the nerve supply to the symptomatic area, as the pain could be due to radiation from proximal nerve damage or referred from a deeper structure supplied by the same dermatome
  • The diagnostic sieve originated from the five pathologies of the surgical sieve – congenital, infection, trauma, neoplasia and degenerative disease. The other pathologies in table 2 are less common surgical problems and infection has been expanded to inflammation
  • Inflammation is the “body’s response to injury”, where the injury may be infective (viruses, bacteria, fungi, protozoa, parasites), but also due to trauma, neoplasia and to “foreign” protein, giving rise to an antigen/antibody response, as in autoimmune disease
  • In neoplasia, consider benign and malignant, and in the latter, primary and secondary disease
  • Degenerative disease includes arterial, arthritic, dementia and other diseases of the old, and sometimes not so old

Table 2 Considerations in diagnosis