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History taking and clinical

examination
Clinical assessment of surgical patient

You must be constantly alert from the moment you

first see the patient, and employ your eyes, ears, nose
and hands in a systematic fashion to collect information
from which you can deduce the diagnosis.
Always give the patient your whole attention
and never take short cuts.

In the outpatient clinic try to see patients walk into

the room, rather than finding them lying, undressed,
on a couch, in a cubicle. General malaise and debility,
breathlessness, cyanosis, and difficulty with particular
movements are much more obvious during exercise.

It may also be helpful to see and speak to anyone who is accompanying the patient. A parent, spouse
or friend can often provide valuable information about changes in health and behaviour not noticed
by the patient. Remember, however, that many patients are inhibited from discussing their problems
in front of a third person. It can also be difficult if the
relative or friend, with the best of intentions, constantly replies on behalf of the patient


When the time
comes to examine the patient, the friend or relative
can be asked to leave; further questions can then be
asked in private. It is helpful if a nurse is present.
Patients like to know to whom they are talking.
They are probably expecting to see a specific consultant.
You should tell patients your name and
explain why you are seeing them. It is particularly
important for medical students to do this.

Talk with patients or, better still, let them talk to

you. At first, guide the conversation but do not dictate
it. Treat patients as the rational, intelligent
human beings they are. They know more about
their complaints than you do, but they are usually unable to interpret their significance. At all stages
explain what you are doing, and why you are doing it.

The patient may not be fluent in your own language

and require an interpreter.When conducting
an interview through an interpreter, keep your questions
short and simple, and have them translated
and answered one at a time. You will have to use lay
terms if you are to be easily understood.


You should not use leading questions to which
there is only one answer. All questions should leave
the patient with a free choice of answers.You should
avoid saying, ‘The pain moves to the right-hand
side, doesn’t it?’. This is a ‘leading question’ because
it implies that it should have moved in that direction,
and an obliging patient will answer ‘Yes’ to please you.

The patient should be asked if the pain ever moves?

If the answer is ‘Yes’, you must then ask the supplementary
question, ‘Where does it go?’. Sometimes,
however, patients fail to understand your question
and you may have to suggest a number of possible
answers, which can be confirmed or rejected.

When a patient is having difficulty communicating

with you, remember that a question that you do
not think is a leading one may be interpreted incorrectly
by the patient if they do not realize that there
is more than one answer. For example,‘Has the pain
changed?’ can be a bad question.


There are a variety of
ways in which the pain can change – severity, nature,
site, etc. – but patients may be so disturbed by the
intensity of the pain that they think only of its severity
and forget the other features that have changed.

In
such situations, it often helps to include the possible
answers in the question; for example, ‘Has the pain
moved to the top, bottom, or side of your abdomen
or anywhere else?’,‘Has the pain got worse, better or
stayed the same?’, or ‘Can you walk as far, less far, or
the same distance as you could a year ago?’.

The patient should provide the correct answer

providing you ask the question correctly. Do not be
over-concerned about the questions – worry about
the answers, and accept that it will sometimes take a
long time and a great deal of patience and perseverance
to get a good history.


HOW TO TAKE THE HISTORY
Do not write and talk
to the patient at the same time; however, it is important
to document dates and times and the full drug
history with accuracy, which you may not remember
when you have finished the examination and left
the room. Brief notes are therefore essential.
Make sure you know, and always record, the
patient’s name, age, sex, ethnic group, marital status,
occupation and address; and always record the date
of the examination.

The present complaint

It is customary to ask the patient ‘What are you complaining
of?’ and to record the answer in the patient’s
own words.
It is currently fashionable to talk about ‘problems’
rather than ‘complaints’. There is no difference,
but problem-orientated management sounds more
sympathetic.


If you ask ‘What is the matter?’ the patient will
probably tell you their diagnosis. It is better not to
know the diagnoses made by the patient, or other
doctors, because none may be correct. It is better to
try to seek out the patient’s complaints. These should
be listed in order of severity, with a record of precisely
when and how they started.Whenever possible,
it should be noted why the patient is more concerned
with one complaint than another.

The history of the present complaint

The full history of the main complaint or complaints
must be recorded in detail, with precise dates. It is
important to get right back to the beginning of the
problem. For example, a patient may complain of a
recent sudden attack of indigestion. If further questioning
reveals that similar symptoms occurred some years previously, their description should be included in this section.

Remaining questions about the

affected system
When a patient complains of indigestion it is sensible,
after recording the history of the indigestion, to
ask other questions about the alimentary system
because many of the replies may aid in diagnosing
the main complaint.