CLINICAL METHODS SUMMARISED NOTES, Study notes of Nursing

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CLINICAL METHODS

KINGI SAMUEL

OBJECTIVES

• Take and accurately record a comprehensive medical history
• Carry out a complete and thorough physical examination
• Formulate appropriate differential diagnosis
• Make case presentations
• Provide basic life support, triaging and referral decision making
• Perform minor procedures in ward/ side laboratory

Approach to history taking

Clinical manifestations of disease

They are:

• Symptoms: Something the patient feels or observes themselves, which they regard as abnormal, e.g. pain, vomiting or weakness of a limb. These are discovered by taking a “history”, which means a clinical “interrogation” or dialogue between doctor and patient.
• Signs: Physical or functional abnormalities elicited by physical examination, e.g. tenderness, a swelling felt by palpation or a change in a tendon reflex.

Caution:

• Patients may be alarmed by use of common phrases that might be part of a junior student’s differential diagnosis but are unlikely to apply to the individual being examined.
• You should avoid use of words like ‘cancer’ or ‘tumour’ - using neoplasm or mitotic disease instead.
• Other avoidable terms and their suggested replacements would be AIDS / HIV (‘retroviral infection’), enlarged heart (‘Cardiomegaly’), enlarged liver (‘hepatomegaly’), leukaemia (‘white cell disorder’).

The Doctor’s problem

Diagnosis:

• An interpretation of symptoms and signs leading to identification of a disease (or diseases). A complete description involves knowledge of the causation (aetiology) and of the anatomical and functional changes which are present.
• It depends on the assembly of all the relevant facts concerning the past and present history of the illness, together with the condition of the patient, as shown by a full clinical examination.
• Simple laboratory tests, such as examination of the urine or estimation of the haemoglobin content of the blood, can be carried out by the doctor himself. For most patients referred to hospital, more elaborate special investigations are necessary, such as radiological examination and special biochemical investigations.

Syndrome:

• A syndrome is a combination of symptoms and/or signs which commonly occur together, e.g. malabsorption syndrome, consisting of chronic diarrhoea with fatty stools and multiple nutritional deficiencies.

COMMUNICATION SKILLS

Good communication skills are the most important part of being a good doctor. These 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

Setting the scene

• Pleasant environment- clean, quiet, private to ensure confidentiality, avoid interruptions(phone)
• Greet with a smile
• Introduce yourself- trainee, qualified
• Establish a rapport
• Eye contact
• Show empathy, concern
• Observe non-verbal cues from the patient

FORMAT OF HISTORY TAKING

• Patients demographics
• Presenting complaints
• History of presenting complains
• Past medical history
• Obstetric and gynaecological history
• Family and social history
• Drug and allergy history
• Systemic inquiry
• Summary of key findings in the history

2. Presenting complaints

• What are the chief complaints?
• What is the duration of complains?
• Record in chronological order. Example: Cough for one month Hotness of body for three weeks Bloody sputum for one week Inability to walk for 2 days.

Presenting Complaint continued

• PC: The PC should be given briefly in patient’s own words, as far as possible. For example: “Chest Pain”. Duration: in hours, days, months or years, not “since ‘Monday” etc.
• If more than one PC, enumerate in order of importance: (1); (2); (3)

(a) General description

• The history of the present condition may extend over days, weeks, months or even years and should be recorded chronologically.
• As far as possible, the patient’s own account should be written down, unaltered by leading questions but phrased in medical terms.
• When the patient’s own phraseology is used the words should be written in inverted commas, e.g. “giddiness”, “wind”, “palpitation” and an attempt should be made to find out precisely what they mean to the patient.
• The order of onset of symptoms is important. If there is doubt about the date of onset of the disease, the patient should be asked when he last felt quite well and why he first consulted his doctor. Dates may be quoted absolutely or relative to the date of writing e.g. five days ago; but if the latter system is used the date on which the history is written must be clearly shown.
• Notes of any treatment already received and of its effect, if any, must be made

History of presenting illness Continued

Example: For each symptom - SOCRATES

• Site
• Localised / generalised, unilateral / bilateral
• Onset
• Sudden / gradual, situation, following trauma
• Character
• Sharp, dull, burning, tightness
• Radiation
• E.g. down the arm, across the back
  • Associations
  • Any other symptoms e.g. shortness of breath, nausea / vomiting
  • Timing
  • Duration, frequency, changes through the day, constant / fluctuant / episodic
  • Exacerbating & Alleviating Factors
  • Exertion / rest, medications, movement, breathing, eating, stress
  • Severity
  • On a scale of 1-10, with 10 being the worst