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Clinical Skills

A patient presents to a doctor because of a problem/complaint/symptom/sign. The consultation may be at home/clinic/hospital, and the patient may be walking/supported/ transported. The doctor communicates with the patient to determine what is/is not the cause (diagnosis). This is through a history, examination and investigations – a pattern emerges of a possible diagnosis, together with its severity.

This is followed by frank discussion, with explanation and advice, initiating treatment to make the patient better (and to do no harm). This treatment may have to be started before completing a diagnosis (e.g. trauma, hemorrhage), and may be just reassurance – for self-limiting or trivial diseases, and addressing any fears or anxiety about potential disease. The problem may be social or psychological. When discussing follow-up, consider whether the patient is likely to come back.

History

The history is the single most important aspect of diagnosis – let the patient talk and listen without interruption.

Communication depends on the patient’s understanding, intelligence, education, background and personality, and is based on the mutual confidence and comfort of the patient/doctor relationship, and the environment.

If the patient is unable to give a history, e.g. a child, a poor historian, because of physical or mental handicap, an unreliable witness or linguistic problems, a third party is used, but the responses are more difficulty to interpret (make a note of the informant).

Although there may be physical (organic/pathological) disease, the primary or secondary features may be due to socio-psychological effects.

The initial questions concern identity: date, name, age, occupation (present/previous), marital status and children.

Presenting problem (see also appendix 2)

Use simple, single and understandable questions; wait for and listen carefully to the answers; never be confrontational

Don’t suggest, direct, shape, flavour or elaborate answers

If leading questions (as with the review of the systems), allow free choice of answers

Avoid fitting questions and answers to a classical picture, as this can lead to a misdiagnosis

Enquire of recent illness, trauma, weight loss, medication, contacts and overseas visits

Note previous bouts of the same problem, the diagnosis, investigations, treatment, and precipitating and associated features.

NB: When recording the problem, use the patient’s own words and place events chronologically; if there is more than one problem, document these separately (e.g. breathless for two weeks/vomited fresh blood last night).

 

Pain

Pain is a frequent presenting problem, it is often diagnostic, but it can be subjective, influenced by potential implications and its effect on lifestyle: its presence may also influence history taking and examination.

In its diagnosis, consider the following headings, turning them into a memorable form, such as a flow chart or an anagram.

Site

Focal: can be pinpointed and pointed out (e.g. trauma, superficial infection)

Diffuse: (e.g. from thoracic and abdominal viscera)

Referred: from a viscus to its somatic nerve root (e.g. diaphragm to the tip of the shoulder)

Radiating: along a nerve root (e.g. down the leg, due to pressure from an intervertebral disc),

Timing of current episode

Onset: when first noticed – sudden (e.g. related to an activity, trauma, vascular ischemic event, perforation of a viscus) – gradual (e.g. inflammatory)

Duration: continuous, fluctuating, intermittent, colic, frequency, progress, changing pattern

Offset: sudden/gradual, modification (see below)

Previous episode: when, frequency, course, differences, diagnosis, management

Quality: sharp, stabbing, aching, burning, throbbing, crushing, bloated, distended

Severity: on a scale of 0 to 10, percentage disability, what do you do, pain tolerance. Anxiety about effect and implication of diagnosis on way of life

Modification

Aggravation: cough, movement, posture, feet up/down, bright light, food

Relief: lying down, staying still, sitting, standing, feet down/up, closing eyes, food, medication, intervention

Effect on systems and lifestyle

Sweating, pyrexia, malaise, photophobia, loss of sleep

Vomiting, diarrhoea, focal effects (e.g. paraesthesia, muscle wasting)

Inactivity at home, reduction of sport and social activity

Stopping work and socio-economic effect.

 

Past Medical History

Previous non-trivial illnesses, operations, accidents, admissions to hospital; with dates

In children, note illnesses, investigations and immunizations

In adults, note relevant childhood problems, e.g. chronic respiratory disease, rheumatic fever.

 

Drugs and Allergies

Drugs being taken – doses, duration

Previous drugs – when, what, why

Allergies/allergic symptoms (describe), precipitating causes.

 

Social and Personal History

Smoking – number per day (number of years), changes

Alcohol – units per day (week), what drunk, ever heavy drinker

Recreational drugs – which – current/previous

Difficulties with job, family or finance, recent mental stress or sleeping problems

Social arrangements, spouse, partner, living arrangements

Accommodation, ownership, which floor/lifts; toilet same floor

Friends/relatives nearby

Receives or needs meals on wheels/home help

Pets

Able to return to previous residence or employment.

 

Family History

State of health/cause of death, parents, siblings, other close relatives, spouse, children

Members of family suffering from the same or other disorder, or serious illnesses (draw a family tree).

 

Clinical Examination

Examination of a patient commences from the moment you first meet, observing them carefully from this point onwards; throughout the history, examination and subsequent discussion

Observation

When you observe a person sitting in a restaurant or walking down the street, you gain an impression of their general well-being. Although the “first impressions can be deceiving”, when they are, you usually look for the reason why this is so. Similarly, when a patient arrives for a consultation, you should carefully observe their body language for evidence of disease and discomfort, and how this is affecting them.

From the referral letter, you will know a patient’s presenting complaint, and something of their social and cultural background. You can therefore decide whether their clothing and state of cleanliness are in keeping with these expectations. Physical as well as mental problems can reflect in a patient’s face, showing discomfort, anxiety and cachexia – skin discolouration, weight loss and drawn features. Posture may indicate discomfort in a part of the body, accompanied by breathlessness and general misery from this condition. Deformity may be present and, if the patient is walking, the above factors, together with any weakness or joint problems, influence their gait, and whether they require physical or any other form of support.

A handshake is an appropriate introduction to most patients, but may not be in some cultures – this should be obvious from a patient’s response. Provided there is no discomfort in this limb, the handshake provides a good deal of information on the confidence of the patient, their reluctance or willingness to communicate, together with local power, muscle wasting, coordination and abnormal limb movement. This is the first skin contact and may indicate dryness, moisture or skin abnormality. Many of the above features are also reflected in your eye contact with a patient during the initial introduction, and subsequent history and examination. It is essential that your own body-language indicates confidence, and offers understanding and support to every patient under your care.

 

Palpation

Palpation is undertaken with the fingers and palm of your hand, and between the thumb and finger, or between the hands, exploring, and defining normal and abnormal anatomy. It confirms what you have already observed and adds information on the feel of the skin and the structures deep to it. This information includes the texture, temperature and dampness of the skin, tenderness due to injury and infection, swelling and deformity, abnormalities of sensation, and in movement, information on the neurological and musculoskeletal systems.

Tactile communication varies in different cultures and societies, but even if an invited handshake is declined, patients realise that palpation is an essential diagnostic tool and may also be a therapeutic measure, as with movement, mobilisation, massage and manipulation.

The confidence with which a patient accepts examination and cooperates with the examiner, relates to the relationship developed during history taking, your tact and diplomacy, and your ability to palpate, defining abnormality and avoiding discomfort. The patient is soon fully aware of your skills and whether they can relax and let you proceed. Palpation is a two way process, building up mutual understanding. As you define abnormality, the patient becomes increasingly aware of the nature of their problem.

Discussion is continued during the examination and, as confidence increases, new factors in the history are defined and sometimes other unexpected topics introduced. Be continually on the lookout for information that the patient has previously, intentionally or unintentionally, withheld.

Palpation requires training and practice and a sound knowledge of normal anatomy. This should begin with self-examination and extend to supervised, directed examination of peers and models, before you examine patients. Confidence, speed and quality, develop with regular use and experience. Although tactile skills vary in different individuals, they can be acquired, developed and improved.

When examining, your hands should be clean with no grease or sticky material that could act as a barrier to tactile sensation. Your nails should be short, smooth and clean. Your palmer surface should be as smooth as possible. Special care is required after rope and rock climbing, rowing and car maintenance, but avoid using aggressive soaps and detergents. Before examining, make sure your hands are warm; if necessary, soak them in warm water.

Tactile awareness can be improved by feeling coins and other common objects, under direct vision, out of sight, and within plastic and canvas bags. Recognition of surface markings, such as the imprint of a coin, is undertaken with the gentle touch of the fingers. The fingers must be firmer, stronger and more rigid to identify ill-defined contours, such as through the canvas bag. The top and sides of an object have to be accessible for examination between finger and thumb or bimanually. The effects of compression can be examined by compressing a water-filled balloon or a squeegee ketchup bottle. Joints can be considered by opening a hinged box or a door, particularly when these have stiff hinges, slam shut, hit doorknobs or are opened too far.

Examination must always begin gently and you must watch the patient’s face throughout, to identify discomfort, before applying deeper pressure or extended movement. Moving structures are best examined with a still hand, such as the placement of two fingers on the superficial temporal artery or the deep placement of fingers, of one or both hands, over, or on either side of, the abdominal aorta. Stationary flat hands are also used to assess thoracic movement and movement of intra-abdominal organs.

Static and fixed, normal and abnormal tissues and organs, require exploratory movement of the fingers or hand, depending on their
relative size, and whether they can be gripped between the finger and thumb, or between the fingers of both hands. Defining features are considered in appendix 3. The smoothness, coarseness or irregularity of surfaces must be defined. Their size is frequently related to common objects, such as fruit and vegetables, but measurement in centimetres is more reproducible. Know the size of parts of your own hand, such as the width of your thumbnail, the distance from the tip of your index finger to the metacarpophalangeal joint and your palmer span.

The hardness of a structure is often difficult to define. Bony hard can be likened to tapping your forehand, firm as pressing the tip of your nose and soft as in squeezing your lip. Superficial palpation may be quick and gentle, avoiding any pressure that could obscure inflammation and its interpretation. This may be for superficial, cutaneous and subcutaneous abnormalities, such as counting thoracic spines, or defining the sternal angle and ribs in a thin individual.

Deeper palpation is with firm, rigid fingers, slowly and gradually searching more deeply, the pressure is applied by one hand or downward pressure of one hand on the other. Remember to keep watching the patient’s face for evidence of discomfort. Deeper pressure may be required in the abdomen or to locate the shape of the spines of the twelfth thoracic and lumbar vertebrae.

Palpation also identifies underlying movement, such as the cardiac impulse, the resonance of vocal reverberation through the chest, and the fluid thrill of abnormal heart valves and vascular malformations.

Palpation must be undertaken in an organised fashion working from outwards to the centre or centrally outwards, defining all aspects of a normal or abnormal structure. It is directed by your knowledge of normal anatomy, e.g. palpating nerves and arteries. The examination of muscles, bones and joints is considered with the musculoskeletal system (page 71).

A specific aspect of palpation that must be considered in every patient is the examination for enlarged lymph nodes. This may be as a general examination, as with a disease of the hemopoetic tissue, or related to focal infection and neoplasia.

 

Percussion

With the tip of the bent middle finger of your dominant hand, gently tap the top of a table, first in the middle and then over a leg. You will note the more hollow sound from the unsupported area. Now place the palm of the other hand over the same two areas and this time tap the middle phalanx of the second or third finger. The sound is amplified and you can both hear, and feel with the resting hand, the difference in the two areas.

This is the principle of percussion that is used in clinical practice. You can directly tap onto a bone or onto your palmed other hand, as just described. First try this out on yourself in the privacy of your room. Tap various bones, such as the skull and patella, and get the feel of the wrist movement, and the force needed to make a noise and feel the impact, without hurting yourself. Next place the palm of your other hand on your belly and tap the middle finger as with the table. Move the palm around and you will find a different noise as you pass over the hollow area of your gut, in the centre of your belly, and the solid liver, as you move over the ribs on the right side.

Repeat this over your chest, and note the difference between the air filled lung laterally and your heart centrally. By moving slowly from a hollow to a solid area, you have a means of defining the edge of an organ, and therefore its size. Percussion can take a lot of practice, to find the appropriate wrist swing, and force required to hear and feel differences, without hurting yourself or a patient, so practice regularly on yourself until you are competent.

 

Auscultation

The sounds emitted by the body include the movements of the heart valves, and blood flow and airflow through the respiratory tract and gut. The stethoscope bell can be applied to most areas of the body and the diaphragm is used to listen to higher pitched sounds. A fetal stethoscope is used over the pregnant uterus.

An ultrasound (US) probe emits and receives reflected sound. A moving column of blood changes the frequency of the reflected beam, due to the Doppler effect, and, through this frequency change, the US probe can be used to detect flow, and analyse its waveform. US probes are also used to build up images of deep structures, from the position and nature of the reflected beam (e.g. intra-abdominal aorta, liver and fluid collections), and to detect movement (e.g. the valves of the heart).

Thus with the techniques of observation, palpation, percussion and auscultation, you have a powerful means for assessing the structures of the body. For the examination of joints, as considered in the musculoskeletal system, use the classic check-list of look, feel, move, measure and X ray.

On completion of your examination ask the patient to dress, and make himself or herself comfortable, on a bed or chair as appropriate. You must now make a preliminary diagnosis, decide on any necessary investigations and formulate a management plan. Consider carefully what the patient thinks is wrong, as this is based on personal experience, reading available literature, an internet search and an informed family history. It is a sobering thought that most patient’s progress as well as they expect to do.