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Clinical Skills Lecture Notes 4 Sub Edition R. Turner
Digital Instant Download
Author(s): R. Turner, Chris Hatton, Roger Blackwood
ISBN(s): 9781405144865, 1405144866
Edition: 4 Sub
File Details: PDF, 2.45 MB
Year: 2003
Language: english
LECTURE NOTES ON
Clinical Skills
ROBERT TURNER
MD, FRCP
The late Professor of Medicine and
Director of the Diabetes Research Laboratories,
University of Oxford,
Oxford
CHRIS HATTON
FRCP, FRCPath
Consultant Haematologist,
Department of Haematology,
The John Radcliffe Hospital,
Oxford
ROGER BLACKWOOD
MA, FRCP
Consultant Physician,Wexham Park Hospital, Slough,
and Honorary Consultant Physician at
Hammersmith Hospital, London
Fourth edition
Blackwell
Science
© 1983, 1991, 1997, 2003 by Blackwell Science Ltd
a Blackwell Publishing company
Blackwell Science, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USA
Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK
Blackwell Science Asia Pty Ltd, 550 Swanston Street, Carlton,Victoria 3053,Australia
The right of the Authors to be identified as the Authors of this Work has been asserted in
accordance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs
and Patents Act 1988, without the prior permission of the publisher.
First published (under the title Lecture Notes on History Taking and Examination) 1983
Second edition 1991
Four Dragons edition 1991
Third edition 1997
International edition 1997
Reprinted 1998 (twice), 2000
Fourth edition 2003
Reprinted 2004
Blackwood, Roger.
Lecture notes on clinical skills.— 4th ed./
Roger Blackwood, Chris Hatton.
p. ; cm.
Rev. ed. of: Lecture notes on clinical skills/
Robert Turner, Roger Blackwood. 3rd ed. 1997.
Includes index.
ISBN 0-632-06511-7
1. Medical history taking—Handbooks, manuals, etc.
2. Physical diagnosis—Handbooks, manuals, etc.
[DNLM: 1. Medical History Taking—Handbooks.
2. Physical Examination—Handbooks. WB 39 B632L 2002]
I. Hatton, Chris. II. Turner, Robert (Robert Charles), 1938—
Lecture notes on clinical skills. III. Title.
RC65 .T87 2002
616.07¢5—dc21
2002002838
ISBN 0-632-06511-7
A catalogue record for this title is available from the British Library
Set in 9/11.5 Gill sans by SNP Best-set Typesetter Ltd., Hong Kong
Printed and bound in India by Replika Pewss Pvt. Ltd.
The publisher’s policy is to use permanent paper from mills that operate a sustainable
forestry policy, and which has been manufactured from pulp processed using acid-free and
elementary chlorine-free practices. Furthermore, the publisher ensures that the text
paper and cover board used have met acceptable environmental accreditation standards.
Contents
Preface, v
Acknowledgements, vii
Introduction:The First Approach, 1
1 History Taking, 6
2 General Examination, 26
3 Examination of the Cardiovascular System, 50
4 Examination of the Chest, 76
5 Examination of the Abdomen, 87
6 Examination of the Mental State, 101
7 Examination of the Nervous System, 111
8 Assessment of Disability Including Care of the
Elderly, 154
9 Basic Examination, Notes and Diagnostic Principles, 161
10 Presenting Cases and Communication, 172
11 Imaging Techniques and Clinical Investigations, 181
12 The 12-Lead Electrocardiogram, 235
13 Interpretation of Investigations, 268
14 Laboratory Results — Normal Values, 271
15 Common Emergency Treatments, 278
Appendices, 289
1: Jaeger reading chart, 289
2:Visual acuity 3 m chart, 292
iii
iv Contents
v
vi Preface
his help with the neurology section. Remember, the most important skill
for any doctor is to be able to take a good history and perform a careful
examination. Good Luck.
Chris Hatton
Oxford 2003
Acknowledgements
We are grateful to many colleagues and students who have made sugges-
tions. The book has benefited from their suggestions, but any faults or
omissions are those of the authors. Specific advice was received from:
vii
viii Acknowledgements
General principles
General objectives
When the student (or doctor) approaches a patient there are four
initial objectives:
Obtain a professional rapport with the patient and gain his
° confidence.
Obtain all relevant information which allows assessment of
° the illness, and provisional diagnoses.
Obtain general information regarding the patient, his back-
° ground, social situation and problems. In particular it is nec-
essary to find out how the illness has affected him, his family,
friends, colleagues and his life.
The assessment of the patient as a whole is of utmost
importance.
Understand the patient’s own ideas about his problems, his
° major concerns and what he expects from the hospital
admission, outpatient or general practice consultation.
Remember medicine is just as much about worry as disease.
Whatever the illness, whether chest infection or cancer,
anxiety about what may happen is often uppermost in the
patient’s mind. Listen attentively.
The following notes provide a guide as to how one obtains the
necessary information.
Specific objectives
In taking a history or making an examination there are two comple-
mentary aims:
1
2 Introduction: The First Approach
Self-reliance
The student must take his own history, make his own examina-
tion and write his own clinical records. After 1 month he should be
sufficiently proficient that his notes could become the final hospital
record. The student should add a summary including his assessment of
the problem list, provisional diagnoses and preliminary investigations.
Initially these will be incomplete and occasionally incorrect. Neverthe-
less, this exercise will help to inculcate an enquiring approach and to
highlight areas in which further questioning, investigation or reading is
needed.
Common sense
Common sense is the cornerstone of medicine
Always be aware of the patient’s needs.
° Always evaluate what important information is needed:
° – to obtain the diagnosis
– to give appropriate therapy
– to ensure continuity of care at home
Many mistakes are made by being side-tracked by aspects that are not
important.
Learning
Your clinical skills and knowledge can soon develop with good
organization.
Take advantage of seeing many patients in hospital, in clinics and
° in the community. It is particularly helpful to be present when patients
are being admitted as emergencies or are being seen in a clinic for the
first time.
Obtain a wide experience of clinical diseases, how they affect
° patients and how they are managed.
Medicine is a practical subject and first-hand experience is
invaluable. The more patients you can clerk yourself, the
sooner you will become proficient and the more you will
learn about patients and their diseases.
4 Introduction: The First Approach
Building up knowledge
At first medicine seems a huge subject and each fact you learn
seems to be an isolated piece of information. How will you ever
be able to learn what is required?You will find after a few months that
the bits of information do interrelate and that you are able to put new bits
of information into context. The pieces of the jigsaw puzzle begin to fit
together and then your confidence will increase. Although you will need
to learn many facts, it is equally important to acquire the attitude of ques-
tioning, reasoning and knowing when and where to go to seek additional
information.
Choose a medium-sized student’s textbook in which you
° read up about each disease you see or each problem you
encounter.
Attaching knowledge to individual patients is a great
help in acquiring and remembering facts. To practise
medicine without a textbook is like a sailor without a chart,
whereas to study books rather than patients is like a sailor
who does not go to sea.
Understand the scientific background of disease, including the ad-
vances that are being made and how these could be applied to improve
care.
Regularly pick up and read the editorials or any articles which
° interest you in a general medical journal such as New England Journal
of Medicine, Lancet or British Medical Journal.
Even if at first you are not able to put information into con-
text, they will keep you in touch with new developments that
add interest. Nevertheless, it is not sensible to delve too
deeply into any one subject when you are just beginning.
Relationships
Training to become a doctor includes the distinct challenges of learning:
to have a natural, sincere, receptive and, when necessary,
° supportive relationship with patients and staff
the optimum means of working with patients and colleagues
° to facilitate good care
General Principles 5
Ancillary investigations
Introductory information about several common clinical investigations is
given in Chapter 11, together with a simple guide to reading an electro-
cardiogram (ECG) in Chapter 12.
Treatment of illness
You will soon witness various treatments being given. Chapter 15 details
the essentials of common emergency therapies that you will encounter.
Bon voyage
In training to become a doctor, you have:
the privilege of developing supportive relationships with
° patients and staff
the chance to develop special practical skills
° the opportunity to appreciate the academic developments
° that are being made
We wish you good luck with your career and the all-important master-
ing of basic clinical skills.
CHAPTER 1
History Taking
General procedures
Approaching the patient
° Look the part of a doctor and put the patient at ease. Be
confident and quietly friendly.
Differential diagnosis
6
General Procedures 7
Supplementary history
When patients are unable to give an adequate or reliable his-
tory, the necessary information must be obtained from friends
or relations. A history from a person who has witnessed a sud-
den event is often helpful.
Accordingly, the student should arrange with the houseman
to be present when the relatives or witnesses are inter-
viewed. This is particularly important with patients suffering
from disease of the central nervous system. The date and
source of such information should be written in the notes.
When necessary, arrange for an interpreter.
Make use of GP’s letter and contact GP if necessary.
Functional enquiry
This is a checklist of symptoms not already discovered.
Do not ask questions already covered in establishing the principal
symptoms.This list may detect other symptoms.
Modify your questioning according to the nature of the
° suspected disease, available time and circumstances.
If during the functional enquiry a positive answer is obtained,
Functional Enquiry 11
General questions
° –Ask*Appetite:‘What
about the following points:
is your appetite like? Do you feel like eating?’
– *Weight:‘Have you lost or gained weight recently?’
– *General well-being:‘Do you feel well in yourself?’
– Fatigue:‘Are you more or less tired than you used to be?’
– Fever or chills:‘Have you felt hot or cold? Have you shivered?’
– Night sweats:‘Have you noticed any sweating at night or any other
time?’
– Aches or pains.
– Rash:‘Have you had any rash recently? Does it itch?’
– Lumps and bumps.
"He eivät tapa sinua", väitti apinamies. "Ei kukaan tapa sinua, kun
Apinain Tarzan on täällä. Kutsu heidät, niin puhumme heille."
Apinain Tarzan kiiti puiden läpi, kunnes yön pimeys oli laskenut
viidakkoon. Sitten hän paneutui nukkumaan ajattelematta huomista
kauemmaksi; myöskin La oli vain hämäränä muistona hänen
tietoisuudessaan.
Tarzan lähti pian samaa tietä, jota pitkin hänen saaliinsa oli
paennut. Jälki kulki aina varjossa ja kylän majojen ja telttojen taitse
— Tarzanille kävi selväksi, että belgialainen oli lähtenyt matkalleen
yksin ja jalan. Hän oli ilmeisesti pelännyt kylän asukkaita; ainakin oli
hänen tekonsa ollut sellainen, ettei hän ollut uskaltanut antautua
ilmitulon vaaraan.
Werperin pako
Hän päätteli aivan oikein, että lady Greystoke oli keksinyt tämän
keinon kiivetä aidan yli, eikä hän itse hukannut hetkeäkään
seuratessaan jäljessä. Päästyään viidakkoon hän suuntasi kulkunsa
suoraan itään päin.
Hänen pakonsa kylästä oli ollut paljon helpompi kuin hän oli
odottanutkaan. Veitsen, jota hän oli käyttänyt, raivatakseen itselleen
majan pensasseinän kautta tien vapauteen, hän oli löytänyt
vankilansa seinään pistettynä — epäilemättä se oli jäänyt sattumalta,
kun joku aikaisempi asukas oli poistunut majasta muille maille. Oli
kulunut vain muutamia hetkiä, kun hän oli hiipinyt tiehensä kylän
taitse, pysyen aina tiheimmässä varjossa. Se onnellinen seikka, että
hän oli huomannut majasalkojen olevan niin lähellä paalutusta, oli
osoittanut hänelle, kuinka voi päästä korkean seinän yli.
Hän ärjyi Numalle ja koetti ajaa valtavaa petoa pois, mutta sai
ainoastaan vihaista murinaa palkakseen. Hän taittoi pieniä varpuja
läheisestä oksasta ja viskasi niitä vanhaa vihollistaan vasten. Numa
katsahti häneen torahampaat paljaina ja irvisti pelottavasti, mutta ei
noussut saaliinsa äärestä.
Ja nyt tapahtui, että Abdul Murak oli juuri tänä päivänä pysähtynyt
puolenpäivän aikaan hieman lepäämään saman polun varrelle, jota
pitkin Werper ja Mugambi samosivat itää kohti.
Mutta ettei hän joutuisi uudelleen rosvon käsiin, kehotti hän Abdul
Murakia lopettamaan takaa-ajonsa ja vakuutti abessinialaiselle, että
Ahmet Zekillä oli johdossaan suuri ja vaarallinen joukko, ja myöskin,
että hän marssi nopeasti etelää kohti.
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