The transition from medical student to junior doctor culminates in independent practice in a variety of clinical settings. This chapter addresses how the clinical skills described in this book are used and adapted in everyday practice.
Whatever the setting, the doctor’s task is to translate patients’ problems into diagnoses, therapeutic possibilities and prognoses. Undergraduate medical students first learn history taking, examination and investigation as a logical sequence, as described in preceding chapters. In reality, however, the application of these skills to a patient’s clinical problem is often a less ordered, more nuanced process.
Adapting history and examination skills appropriately
History and examination skills are adapted by doctors to suit the situation. For example, elective surgical or unscheduled emergency admissions may require a systematic and comprehensive history and examination. Patients attending a specialist outpatient clinic, will already have been screened by a referring clinician, however, and a history and examination focused on the presenting condition is appropriate. If the patient is attending a review clinic, history and examination may be restricted to monitoring an existing condition. The information-gathering process may appear to be sequential: the history suggests a differential diagnosis; examination and then investigation help confirm or refute diagnostic possibilities. In reality, these elements often occur in parallel. For example, sequential history then examination may be abandoned in favour of a more opportunistic approach to avoid distressing a reluctant child. In critically ill patients a highly focused history and examination aimed at rapidly identifying the main problems while initiating resuscitation is imperative.
Integrated examination
Although in an individual it is rarely necessary to carry out a comprehensive history and examination of all systems, a rapid screening examination may be useful to direct more detailed examination if the diagnosis is unclear or when patients are being admitted to hospital. There is no single correct procedure for performing a physical examination and you will develop your own approach, but a reasonable routine is outlined in Box 21.1 .
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Handshake and introduction
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Note general appearances while talking:
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Does the patient look well?
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Any immediate and obvious clues, e.g. obesity, plethora, breathlessness
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Complexion
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Hands and radial pulse
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Face
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Mouth and ears
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Neck
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Thorax:
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Breasts
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Heart
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Lungs
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Abdomen
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Lower limbs:
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Oedema
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Circulation
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Locomotor function and neurology
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Upper limbs:
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Movement and neurology
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Cranial nerves, including fundoscopy
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Blood pressure
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Temperature
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Height and weight
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Urinalysis
Diagnostic strategies
Doctors recognise patterns of symptoms and signs, then apply clinical reasoning to interpret them and to formulate diagnostic possibilities or probabilities. Sometimes doctors instantly recognise a condition based on previous experience (‘spot diagnoses’, p. 34 ). Visual patterns are particularly likely to lead to such recognition: for example, a typical rash. More commonly, elements of the history and examination together trigger pattern recognition. This process relies on comparing a patient’s presentation to cases encountered before and remembered as ‘illness scripts’. With increasing experience, less typical presentations are encountered and recalled, and doctors are increasingly able to recognise more exceptional cases.
Pre-test probability
Where doctors are unable to recognise patterns in presentations quickly, various refinement strategies are used to arrange the possible diagnoses in order of probability. The pre-test probability of a disease in an individual depends on the context in which the symptom has appeared because the prevalence of disease varies between populations. In general practice populations the incidence of serious disease is much lower than in hospital populations; serious conditions still usually need to be excluded, however. This may involve identification of ‘red flag’ symptoms and signs for serious disease, or the use of clinical prediction rules such as the Wells score for deep vein thrombosis. Positive ‘red flag’ features or above-threshold prediction scores increase the probability of a disease in individuals and generally trigger further investigations.
Additional factors affecting the pre-test probability of disease in patients with the same presenting symptoms include age, gender, past medical history, family history and lifestyle. Few doctors use formal probabilistic reasoning in making diagnoses, but most know the relationship between these factors and the likelihood of a specific disease and use this understanding intuitively to select likely diagnoses (hypotheticodeductive reasoning, Fig. 21.1 ). History, examination and investigation results are used to support or refute putative diagnoses. These components are rarely independent, however, and returning to clarify the history or re-examine when signs are ambiguous allows an iterative approach to accurate diagnosis.
Rare diseases
While diagnosis by probability works in most cases, rare diseases also occur, and to the affected patients and their families they are not rare. Avoid the trap of thinking that all patients have common conditions and that symptoms that do not fit with common diagnoses are less important. Indeed, occasional patients with a credible and consistent history of unusual symptoms may actually merit more, not less, investigation. The art is to listen carefully, keep an open mind, and pick up the uncommon situation when the usual patterns of presentation really do not fit the facts of a case.
Other factors that complicate the application of clinical skills in diagnosis include:
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clinical problems involving many organ systems rather than one
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new disease occurring in the context of existing physical and psychological comorbidities
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the presentation being embedded in the context of an individual patient’s story
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symptoms arising in the absence of underlying pathology (see the next section).
Approach to the patient with medically unexplained symptoms
Much of this book deals with the association between a patient’s history and examination findings and the presence of underlying disease. Symptoms are not synonymous with disease, however, but are subjective experiences with many possible sources: pathological, physiological, psychological, cultural, behavioural and external. Many patients experience symptoms that impair function but do not fit characteristic patterns of disease, and persist despite normal examination and investigations. These are called ‘functional’ or ‘medically unexplained symptoms’ (MUS, Fig. 21.2 ). Over 30% of patients attending their general practitioner have MUS and they are also common in secondary care, although disease prevalence is much higher there. Some symptoms are more likely to be medically unexplained than others: for example, persistent fatigue, abdominal pain and back pain. The causes of MUS are poorly understood but various predisposing and precipitating factors ( Box 21.2 ) may contribute. Most functional symptoms are transient but some become persistent, causing similar disability to those resulting from disease and also significant emotional distress. If MUS are not recognised and managed appropriately, attempts to alleviate them can result in harm from fruitless investigations, inappropriate interventions or drugs, and increased fear of disease.
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Precipitating: stress, depression, anxiety and sometimes disease and injury, especially if associated with fears of, or belief in, disease
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Predisposing: fear of disease from previous experience
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Perpetuating: inappropriate attempts to alleviate symptoms, e.g. excessive rest, failure to address patient’s concerns
Patients with MUS commonly feel that doctors do not think their symptoms are real, leading to a breakdown in trust between patient and doctor, and frustration for both. Crucially, doctors must use an empathic and non-judgemental approach so the patient feels believed. Keep an open mind and accept all the patient’s symptoms at face value. Remember that patients with MUS may also have or develop disease. Even if a functional diagnosis is suspected, a comprehensive history and examination remain imperative. This helps patients to feel that they are being taken seriously; in addition, organic disease, however unlikely, is less likely to be missed.
Patients’ illness beliefs matter hugely and should be explicitly acknowledged. What do they think is wrong? Why have they come to you now and what do they hope you can do for them? Inconsistencies in the history should be explored with the patient; for example, a patient with severe chest pain and normal coronary angiography may still firmly believe they have angina. Normal investigations need to be explained clearly to help demonstrate that the evidence does not support their belief.
Patients may complain about previous doctors or treatments. Allowing a patient to express dissatisfaction shows interest, and helps to avoid suggesting treatments they are likely to reject. Always remain professional and avoid being drawn into criticism of other healthcare providers.
Patients can be acutely sensitive to questions that suggest a doctor thinks there is a psychological basis for their symptoms (‘all in the mind’). Frame questions carefully in terms of their symptoms: for example, ‘Do your symptoms ever make you feel down or frustrated?’ rather than ‘Do you ever feel depressed?’ Abuse is one possible precipitant of MUS but seek this history judiciously. Follow local guidelines for any abuse you discover.
The physical assessment includes observing the patient throughout the consultation. Watch for inconsistent signs, though this does not indicate whether they are consciously or subconsciously produced. Usually there are no physical signs but some non-pathological signs are associated with MUS; for instance, in irritable bowel syndrome you may find evidence of bloating and some tenderness, but otherwise gastrointestinal examination will be normal. The history often suggests MUS, so focus on excluding any unexpected physical findings, as well as demonstrating to patients that you are taking them seriously. Any signs you do find may vary between examinations but overall the examination is commonly normal with MUS.
Investigations are used in MUS mainly to reassure both physician and patient. Exhaustive investigations to exclude all physical illness are costly and unhelpful, risk side effects and do not reassure patients in the longer term. Before requesting investigations, discuss with the patient the likelihood and significance of a normal result. Patients are more likely to be satisfied when your explanation makes sense to them, removes blame and helps generate ideas about how they can manage their symptoms.
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