Introduction to Clinical Medicine

Dr. Vijay MD

Clinical Medicine

Communication Skills

Interview and Assessment

History talking

• Knowledge

• Ability to elicit information

from patients

• Interpersonal skills to respond to patients’ feelings and concerns

What doctors need

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DUTIES of any doctorDUTIES of any doctor

• Confidentiality and Consent

• Provide good standard of practice and care

• Treat patients as individual and respect their dignity

• Work in partnership with patients

• Be honest and open, act with integrity 4

Personal Responsibilities

Dress and Demeanour

Communication Skills

Expectations and Respect

Hand washing and Cleanliness

Communication skills

• I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

• All that come to my knowledge in the exercise of my profession or in the daily commerce with men, which ought I not to be spread abroad, I will keep secret and will never reveal.

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Task Orientated

Behaviour Orientated

Doctor centred Patient centred

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Clinical Medicine

Communication skills

Examination skills

Problem-solving ability

You are skilled person if you You are skilled person if you have abilities..have abilities..

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Developing rapport to enable

the patient to feel understood,

valued and supported.

Encouraging an environment

Enabling supportive counseling

as an end in itself.

Good Doctors-Patients Good Doctors-Patients Relationship

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• Remember that every patient could be you, your mother, your brother or your sister.

Respecting patient

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• Quality of care may be improved by

– Ensuring that patients’ views

– Wishes are taken into account as a mutual process in decision making.

• Good communication is likely to reduce the incidence of clinical errors.

Clinical errors

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To diagnosis and treat disease and maintain a therapeutic relationship

Data from the patient must be objective, precise and reliable.

You must demonstrate respect, genuineness and empathy.

To be a better practitionerTo be a better practitioner

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Patient Assessment and Clinical Interviewing

Initiating the Session Initiating the Session PreparationPreparation

• Patient Centred Medicine

• Beginning– Preparation

– Where will you see your patient

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Initiating the Session - The Initiating the Session - The EnvironmentEnvironment

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““Always listen to the patient they Always listen to the patient they might be telling you the might be telling you the

diagnosis”.diagnosis”.

(Sir William Osler 1849 - 1919)

Effective Communication Skills

• Improve patients satisfaction

• Improve doctor satisfaction

• Improve health by positive support and empathy

• Use time more effectively

To diagnose and treat disease

To establish and maintain a therapeutic relationship

To offer information and educate

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Assessment (Consultation) ModelAssessment (Consultation) Model

BASICSBASICS• Beginning

• Setting up : – Quiet , private space in medical ward .

• Starting assessment

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First Impressions

• Positive Impression– Appearance– Confidence– Demeanor– Body Language

Maintain a professional appearance

Clean, neat, “conservative,”

See dress code in syllabus

Goal is to inspire confidence

Your appearance increases Your appearance increases confidenceconfidence

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• Active Listening

• Systemic enquiry

• Information Gathering

• Context

• Sharing information – Achieving a shared understanding

– Planning, shared decision making 24

The “Open-ended Interview”

• Open ended questions to begin – least control

• When needed

• Avoid at all times

Non verbal communications

• S

• O

• L

• E

• R

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Sits square on facing the patient

Maintains open body position

Leans slightly forward

Eye contact is maintained

Relaxed (in an appropriate posture)

Responding to cues• A signpost to an area in the history that you might

otherwise ignore but which may be very important to the patient .

• Cues are very common .

• Does the patient – catch his breath, – change breathing pattern,become pale or flushed , look

agitated , – shows restless limb or body movements,– become upset , or change eye contact ? – All these are recognized signs of stress

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P: I hoped it wasn’t anything serious.

P: Its my chest again.

P: Of course it could just be stress .

P: Its no better (what's no better)

P:Im worried (about what)

P:I feel worse (worse than what or when )

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Verbal Cues

• Patients use generalizations to express their concerns :

P : I don’t like hospitals.

P : It never seems to get any better .

Cues may be non-verbal:

• A patient may look sad or anxious and it might be appropriate to respond :

D : You look worried about that .

D : You mentioned earlier that you hadn't wanted to come into hospital . was there anything worrying you in particular about hospital?

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Identifying the reason for the Identifying the reason for the consultationconsultation

• Open questions:– Always start with an open ended question and take the

time to listen to the patient’s ‘story’.

• Closed questions:– Once the patient has completed their narrative to closed

questions which clarify and focus on aspects can be used.

• Leading questions:– Questions based on your own assumptions that lead

the patient to the answer you want to hear. These should not be used at all.

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Identifying the reason for the Identifying the reason for the consultationconsultation

Open questions:- “How can I help you?”

- “You said you have pain on movement, can you tell me which movements makes your pain worse?”

Closed questions:- “Are you still taking the aspirin your GP prescribed?”

- “Is that an accurate summary of your symptoms?”

Leading questions:- “You are not allergic to anything are you?”

- “Are your joints painful in cold weather?”31

• Intellect counts:– knowing how to solve problems,

– knowing how to get by, knowing how to identify an advantage and seize it.

• Functions (Insufficient):

– courage, love,– friendship, compassion and

empathy.

Empathy

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• Empathy: “The ability to understand and share the feelings of another.”

• This sums up what empathy is: I am here with you, I give you hope, and accompany in your feeling

Most important demand from patients

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Assessment (Consultation) ModelsAssessment (Consultation) Models

• The use of assessment models is dependant upon the condition of the patient,

• Systematic, structured and suitable model.

• Inter-professional (i.e. shared understanding and documentation).

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Medical interviewing & communication skills ?

• Evidence supports :

– 69% of interviews were interrupted by the physician within the first 18 seconds of the interview

– 77% of the time, patients’ reason for coming to the physician were not fully elicited

– When patients are asked to discuss their illness and treatment immediately after leaving their physician’s office, they were able to correctly identify only about 50% of the critical information.

Difficult Situations

Communication difficulties

Confused patient

Patient with language barrier

Less intelligent /illeterate patient

Patient with learning difficulties

Patient with hearing impairment/blindness

Cognitive difficulties

Sensitive situations

Your patient is Emotional

Different types

Sensitive topics – that make patient uncomfortable

Silent patient

Overly-talkative patient

Anxious patient

Angry or hostile patient

Intoxicated patient

Depressed/suicidal patient

Cultural Sensitivity

Third- party information

Breaking bad news

Settings

Perception

Invitation

Knowledge

Empathy , Summary and Strategy

Common Pitfalls

• Choosing to ask lots of questions to obtain a history WITHOUT also directing initial care or performing a physical exam

• Patient’s Impression– Not doing anything for

me

– Why are we wasting our time here?

– Stop asking all these silly questions

• Using a tone of voice that sends the wrong message

– “What is your ‘Problem’ TODAY Mrs. Jones?

• Patient’s Impression

– I think I am bothering these nice people

• Poor choice of words or using technical terms (Medical Jargon )

– How many years has your husband been taking these ACE-inhibitors?

– Your wife is experiencing congestive cardiac failure

• Patient’s Impression

– What the heck is he talking about?

– My wife’s heart is failing?!?! Has her heart stopped yet?

– Could you speak English?

Closing the interview

• The closing interaction solidifies the relationship and sets the stage for managing the problem

• Appropriate closure implies a contract

SOAP

Subjective

Objective

Assessment

Plan

Generating and testing diagnostic hypotheses

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History taking in Emergency Room

Patient usually too sick to give history

Patient may be unconscious

Little time for history – low priority

Cardiac arrest or peri-arrest situation

Aim for limited but focussed history from patient or

relative.

Key Principles of Patient AssessmentKey Principles of Patient Assessment

It is estimated that 80% of diagnoses are based on history

taking alone.

Use a systematic approach.

Practice infection control techniques.

Establish a rapport with the patient.

Ensure the patient is as comfortable as possible.

Listen to what the patient says.

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HISTORY TAKING SKILLS

Introduction

• History taking skills essential in medical curriculum.

• Objectively being tested in formal exams

• Forms the base of reaching a correct diagnosis

• Often ignored/ proper emphases not applied by many

What is History Taking?What is History Taking?

• Asking questions of patients to obtain information and aid diagnosis.

• Gathering data both objective and subjective for the purpose of generating differential diagnoses.

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(Kings College London 2013)

The Complete Medical History

Identifying information

Chief complaint

History of present illness

Past medical history

Family history

Social history

Review of systems

• Identifying information

– Often ignored

– Name, age, gender, occupation

– Source of referral

– Source of history, reliability

– PCP, nearest relative, contact information

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1. Presenting complaint(s)

2. History of presenting complaint(s)

3. Past/Previous medical history

4. Drug history and Allergies

4. Personal/Social history

5. Family history (FH)

6. Systems review

• Principle complaint

• Details of current complaint• Effects of complaint on activities of living

• OPQRSST

• Past illnesses, hospitalisations, Surgery • Past treatments

• Occupation, Marital status, Accommodation, Hobbies, Social life

•Smoking, Alcohol consumption•Diet, Sleeping, General wellbeing

• Prescribed medication• Over the counter medication / herbal remedies

• Any side-effects or problems with medication •Any allergies

• Chief Complaint

– One of more symptoms or concerns for which the patient is seeking care or advice

– Eliciting the chief complaint

– Patient’s direct statement in response to an open-ended question, recorded accurately

Documenting the Chief Complaint

The primary reason the patient is seeking medical attention, recorded using the patients own words, in quotes X duration

One sentence, never more than two

The chief complaint is not a diagnosis

History of Present Illness (HPI)

Description of the patient’s chief complaint starting from the last time the patient felt well

Attempt to understand the full story of the development and expression of the chief complaint in the context of the patient’s life

Determine the actual reason for coming in at this particular time

– The “open-ended” interview• Begin with open-ended questions• Move to more directed questions to clarify and

embellish

– You need to know what information is needed and how to get it

– You need to be able to evaluate the relevance of the information obtained

Eliciting the HPI

Physical ExaminationPhysical Examination

• The third Calgary-Cambridge stage concerns physical examination.

• Preparation is key:

– Explanation of the procedure

– Consent sought

– Privacy and dignity maintained

– Chaperone (if required)

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• Sort of pathology does you patient have?

• Physical sign?– Pain

• Associated symptoms• Effects on lifestyle• Attitudes to illness

Symptom analysis (OPQRSTAN)Symptom analysis (OPQRSTAN)

• Onset of disease

• Position/site

• Quality, nature, character, explain depth of pain – superficial or deep.

• Relationship

• Radiation: where moved to

• Relieving or aggravating factors – any activities or position60

• Severity

• Timing

• Treatment received or/and outcome.

• Associated symptoms?.

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Past Medical History

• Start by asking the patient if they have any medical problems

• IHD/DM/Asthma/HT/TB/Jaundice

• Past surgical/operation history

• History of trauma/accidents

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Family History

• Diabetes, HTN, or Renal Disease

• Heart Disease, early AMI, IHD

• TIA

• Asthma or Allergies

• Cancer

• Mental Illness

• Parents marriage- consanguineous

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Personal/ Social History• Unbringing

• Homelife

• Lifestyle: Exercise, Diet,

• Occupation

• Travel History

• lifestyle risk factors– Smoking history - amount, duration and type, S.Index. – Drinking history - amount, duration and type.

• Non-prescribes drug use

• Menarche – LMP

• Regular- amount

• Associated pain

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Menstrual HistoryMenstrual History

Drug History

• Prescribed and other medications

• Which medications are you currently taking

• Any allergies to medications and what was the reaction?

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Treatment abbreviations

• bd (Bis die) - Twice daily

• tds (ter die sumendus)/tid (ter in die) = 3/ day mainly 8 hourly

• qds (quarter die sumendus)/qid (quarter in die) = 4/daily mainly 6

hourly

• Mane/(om – omni mane) = morning

• Nocte/(on – omni nocte) = night

• ac (ante cibum) = before food

• pc (post cibum) = after food

• po (per orum/os) = by mouth

• stat – statim = immediately as initial dose

• Rx (recipe) = treat with68

Tailoring your history

• Patient of Myocardial Infarction ( Assess risk factors)

• Rheumatoid arthritis – Social history

• Bronchial Asthma/COPD – Social History (job, smoking etc.), allergies and related illness

• Drug history – must be thorough

Surface Anatomy

• Why do we have to study surface anatomy?

– To make practical their knowledge of anatomy

– To understand body landmarks in order to describe their observations

Surface Anatomy: Head

Neck

Spinous process of C-spine

Posterior cervical

Location of Cervical lymph nodes

Thyroid

Location of Thyroid

Anterior Chest

Anterior Chest

Posterior Chest

Heart

Right 2nd Interspace Left 2nd Interspace

Right 5th Interspace Left 5th Interspace

Abdomen

Abdominal Organs

Musculo-Skeletal System

Systems ReviewSystems ReviewCentral Nervous System / Neurological:

Eye:

Endocrine: Cardiovascular:

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• Headaches• Head injury• Dizziness• Vertigo • Sensations • Fits / faints • Weakness • Visual disturbances• Memory and concentration changes

• Excessive thirst• Tiredness• Heat intolerance• Hair distribution• Change in appearance of eyes

• Chest pain• Breathlessness • Palpitations• Ankle swelling• Pain in lower legs when walking

• Visual changes• Redness• Weeping• Itching / irritation• Discharge

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Respiratory:• Shortness of breath• Cough • Wheeze• Sputum • Colour of sputum • Blood in sputum• Pain when breathing

Gastrointestinal:• Dental / gum problems• Tongue problems• Difficulty in swallowing• Nausea• Vomiting• Heartburn• Colic• Abdominal pain• Change of bowel habits• Colour of stools

Ear, Nose and Throat• Earache• Hearing deficit• Sore throat

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Genitourinary system:• Pain on urination• Blood in urine• Sexually transmitted infections

Women:• Onset of menstruation• Last menstrual period• Timing and regularity of periods• Length of periods• Type of flow• Vaginal discharge• Incontinence• Pain during sexual intercourse

Men:• Hesitancy passing urine• Frequency of micturition • Incontinence • Urethral discharge • Erectile dysfunction• Change in libido

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(Douglas et al. 2005)

Head to Foot...

... toeAssessment

Musculoskeletal: • Joint pain• Joint stiffness• Mobility • Gait • Falls • Time of day of pain

Skin:• General pallor of patient, e.g. pale, flushed, cyanotic, jaundiced • Rashes• Lumps• Itching• Bruising

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““Medicine is learned at the Medicine is learned at the bedside and not in the bedside and not in the

classroom”. classroom”.

(Sir William Osler 1849 – 1919)

General considerations• You should wash your hand in the presence of

the patient before beginning the physical examination

• A new patient warrants a complete examination, regardless of chief complaint

• The sequence of comprehensive examination should maximize the patient’s comfort

• As a beginner, you should avoid interpreting your findings for the patient

Comprehensive physical examination

• General survey: Handshake and introduction, general state of health; height, weight, build, sexual development, motor activity, facial expression, state of awareness or level of consciousness.

• Vital signs: blood pressure, pulse and respiratory rate.

• Skin: color, lesions. Inspection and palpation of hair and nails.

Face

Acromegaly

The enlargement of the frontal and maxillary

sinuses results in an prominent brow and long

face

Growth of mandible leads to a

jutting jaw (prognathism).

Alveolar bone growth causes the

teeth to separate

Acromegaly

Macroglossia Broadening and enlargement of the hands and feet

Appearence and behavior

• Facial expression

• Memory, attention

Graves’ disease

Facial expressionThe stare in hyperthyroidism

Hypothyroidism

Inspection of the face

• Acromegaly: Enlargement of both bone and soft tissues. The head is elongated, with bony prominence of the forehead, nose and lower jaw

• Cushing’s symdrome: moon face with red cheeks. Excessive hair growth may be present.

• Myxedema: Dull, puffy facies. Edema does not pit with pressure. The lateral eyebrows are thin.

• Nephrotic syndrome: Edematosus and often pale face. Swelling usually appears first around the eyes and in the morning.

Appearence and behavior

• Level of consciousness

– Is the patients awake and alert?

– Does the patient seem to understand your questions and respond appropriately ?

Appearence and behavior

• Posture and motor behavior

– What is the patient’s preferred posture?

– Is the patient restless or quiet?

– Is there any apparent involuntary motor activity?

Typical position: COPD

Inspection of tongue and region under tongue

• Thick white coat on the tongue

• Smooth tongue

• Leukoplakia

• Aphthous ulcer

Inspection of the skin

• Color

• Lesions

Browness and depigmentation

Herpes zoster

•Vesicles in a unilateral dermatomal pattern are typical of herpes zoster

Cyanosis

Clubbing

Grades of Clubbing

• Grade 1 – Fluctuation of the nail bed. 

• Grade 2 – Obliteration of the Lovibond angle

• .

• Grade 3 – Parrot beak appearance or drum stick appearance.

• Grade 4 – Hypertrophic Osteo Arthropathy

Jaundice

Lymphadenopathy

Cervical adenopathy

Lump (Palpable mass)

Comprehensive physical examination• Eyes: Check visual acuity, screen the visual fields.

Inspection of sclera and conjunctiva. Compare the pupils,Asses the extraocular movements.

• Ears: Inspection of auricles, canals. Check auditory acuity.

• Nose-sinuses: Inspection of nasal mucosa and septum. Palpate for tenderness of the frontal and maxillary sinuses.

• Throat: Inspection of lips, oral mucosa, teeth, tongue, tonsils and pharynx.

Inspection of the eyes

• Position and abnormalities of the eyes and eyelids– Ptosis: Dropping of the upper lid

– Exophthalmos

– Periorbital edema

Protruded eyeballs and periorbital edema

• Neck: – Cervical lymph nodes, thyroid gland. – Trachea.

• Thorax and lung: – Spine, muscles of the upper back and chest

• Axillae: – Palpation of axillary nodes.

Ccomprehensive physical examination

• Cardiovascular system: – Observation of jugular venous pulsation– Inspection, palpation and of carotid pulsation. Listen to carotid bruits– Palpation of the apical impulse– Listen to heart sounds

• Abdomen:– Inspection, palpation and percussion of the abdomen. – Asses the liver and spleen – Palpation of abdominal aorta, and its pulsation

• Genitalia and hernias in men:– Examine the penis and scrotal contents and check for hernias

• Nervous system:

– Mental status: orientation, mood, abnormal perceptions, memory,

attention, abilities.

– Cranial nerves: check sense of smell, strength of temporal and

masseter muscles, corneal reflexes, facial movements, gag

reflex.

– Motor system: muscle bulk, tone and strength of muscle.

– Sensory system: pain, temperature, light touch, vibration, and

discrimination.

– Reflexes.

• Additonal examinations: Rectal digital examination

• Upper & Lower extremities:– Peripheral vascular system: palpation of femoral pulses and

peripheral arterial pulses. Inspection for varicose veins.

– Palpation of inguinal lymph nodes

– Palpation for piting edema

– Musculoskeletal system: palpate the joints, check their range of motion.

– Nervous system: Assessing of muscle bulk, tone and strenght; sensation and reflexes.

Purpose of palpation• Examination of the body surface (skin: smoothness,

dryness, irregularities etc.)

• Examination of internal organs (shape, size, consistency etc.)

• To look for abnormal resistances

• Detection of painful areas

• To feel movement of fluids within the body

General rules for palpation

• Cut your fingernails short

• Have warm hands

• Use the pads of your fingers

• Use both hands, Move them smoothly

• Palpate first lightly, than perform deep palpation

• Avoid causing pain to the patient

Percussion and Auscultation

Percussion

• Sounds produced by striking body surface

– Produces different notes depending on underlying mass

– Used to determine size and shape of underlying structures by establishing their borders and indicates if tissue is air-filled , fluid-filled, or solid

– Action is performed in the wrist.

Methods of Percussion

The stethoscope Should be your own!!!

Should have a separate bell and diaphragm

Bell

Low pitched murmurs eg. Mitral Stenosis

Press hard enough only to make a seal with the skin

Diaphragm

Normal / High pitched murmurs.

Use for general purpose auscultation

Auscultation • Listening to sounds produced by the body

– Direct auscultation

– Indirect auscultation

– Know how to use stethoscope properly

– Describe sound characteristics

Areas for Auscultation

1. Apex: Mitral Valve (5LICS)

2. Sternal Edge: Tricuspid Valve (4LICS)

3. L 2nd Space: Pulmonary Valve (2LICS)

4. R 2nd Space: Aortic Valve (2RICS)

Where to Listen (Other sites):

Lungs

Cranium (temples/orbits/fontanelle)

Liver

Neck (carotid area)

Abdomen

Lumbar/abdominal region over renal area

Trachea with respiration

Femoral artery