CHAPTER 1: Foundations for Clinical Proficiency

Intro

Introduction

The techniques of physical examination and history taking that you are about to learn embody the time-honored skills of healing and patient care. Gathering a sensitive and nuanced history and performing a thorough and accurate examination deepen your relationships with patients, focus your assessment, and set the guideposts that direct your clinical decision making (Fig. 1-1).

The quality of your history and physical examination lays the foundation for patient assessment, your recommendations for care, and your choices for further evaluation and testing. As you become an accomplished clinician, you will continually polish these important relational and clinical skills.

FIGURE 1-1 The importance of establishing rapport.

The importance of establishing rapport.

With practice, you will meet the challenge of integrating the essential elements of clinical care: empathic listening; the ability to interview patients of all ages, moods, and backgrounds; the techniques for examining the different body systems; levels of illness; and, finally, the process of clinical reasoning leading to your diagnosis and plan. Your experience with history taking and physical examination will grow, and will trigger the steps of clinical reasoning from the first moments of the patient encounter: identifying symptoms and abnormal findings; linking findings to underlying pathophysiology or psychopathology; and establishing and testing a set of explanatory hypotheses.

Working through these steps will reveal the multifaceted profile of the patient before you. Paradoxically, the skills that allow you to assess all patients also shape the clinical portrait of the unique human being entrusted to your care. The physical examination is more than a means of gathering data and generating hypotheses for causality and testing. It is vital to the “formation of the [clinician]–patient bond, the beginning of a therapeutic partnership and the healing process (Fig. 1-2).”[1]

FIGURE 1-2 The skilled physical examination.

The skilled physical examination.

This chapter, revised in this edition, provides a guide to clinical proficiency in four critical areas: the Health History; the Physical Examination; Clinical Reasoning, Assessment, and Plan; and The Quality Clinical Record. It describes the components of the health history and how to organize the patient’s story; and it gives an overview of the physical examination with a sequence for ensuring patient comfort that briefly describes techniques of examination for each component of the physical examination, from the General Survey through the Nervous System.

In this edition, the chapter also includes Clinical Reasoning, Assessment, and Plan, and The Quality Clinical Record. The new Chapter 2, Evaluating Clinical Evidence, provides the analytic tools for evaluating tests, guidelines, and the clinical literature that will ensure best practices and lifelong clinical learning. Chapter 3, Interviewing and the Health History, completes the foundational chapters that prepare you for performing the physical examination.

You will learn the techniques of physical examination in Chapters 4 through 17. Each chapter is evidence based and includes citations from the clinical literature for easy reference so that you can continue to expand your knowledge. Beginning with Chapter 4, sections on Health Promotion and Counseling: Evidence and Recommendations review current clinical guidelines for preventive care.

The Bates’ Guide to Physical Examination and History Taking follows the sequence described below:

? Chapter 2, Evaluating Clinical Evidence, discusses the history and physical examination as diagnostic tools, evaluation of the validity and reproducibility of diagnostic tests, health promotion, critical appraisal of the clinical research, and grading criteria for clinical guidelines.
? Chapter 3, Interviewing and the Health History, expands on the essential, varied, and often complex skills of building patient rapport and eliciting the patient’s story. It addresses basic and advanced interviewing techniques and the approach to challenging patients as well as cultural competence and professionalism.
? Chapters 4 to 17 are regional examination chapters, which detail the pertinent anatomy and physiology, health history, evidence-based guidelines for health promotion and counseling, techniques of examination, and the written record, followed by tables comparing common symptoms and physical findings and citations from the literature.
? Chapters 18 to 20 extend and adapt the elements of the adult history and physical examination to special populations: newborns, infants, children, and adolescents; pregnant women; and older adults.

As you acquire the skills of physical examination and history taking, you will move to active patient assessment, gradually at first, but then with growing confidence and expertise, and ultimately clinical competence. From mastery of these skills and the mutual trust and respect of caring patient relationships emerge the timeless rewards of the clinical professions.

Patient Assessment: Comprehensive or Focused

Determining the Scope of Your Assessment

At the outset of each patient encounter, you will face the common questions, “How much should I do?” and “Should my assessment be comprehensive or focused?” For patients you are seeing for the first time in the office or hospital, you will usually choose to conduct a comprehensive assessment, which includes all the elements of the health history and the complete physical examination. In many situations, a more flexible focused or problem-oriented assessment is appropriate, particularly for patients you know well returning for routine care, or those with specific “urgent care” concerns like sore throat or knee pain.

You will adjust the scope of your history and physical examination to the situation at hand, keeping several factors in mind: the magnitude and severity of the patient’s problems; the need for thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the time available. Skill in all the components of a comprehensive assessment allows you to select the elements that are most pertinent to the patient’s concerns, yet meet clinical standards for best practice and diagnostic accuracy.


The History and Physical Examination: Comprehensive or Focused?

Comprehensive Assessment Focused Assessment
Is appropriate for new patients in the office or hospital
Provides fundamental and personalized knowledge about the patient
Strengthens the clinician–patient relationship
Helps identify or rule out physical causes related to patient concerns
Provides a baseline for future assessments
Creates a platform for health promotion through education and counseling
Develops proficiency in the essential skills of physical examination
Is appropriate for established patients, especially during routine or urgent care visits
Addresses focused concerns or symptoms
Assesses symptoms restricted to a specific body system
Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible

As you can see, the comprehensive examination does more than assess body systems. It is a source of fundamental and personalized knowledge about the patient that strengthens the clinician–patient relationship. Most people seeking care have specific worries or symptoms. The comprehensive examination provides a more complete basis for assessing these concerns and answering patient questions.
For the focused examination, you will select the methods relevant to thorough assessment of the targeted problem.

The patient’s symptoms, age, and health history help determine the scope of the focused examination, as does your knowledge of disease patterns. Of all the patients with sore throat, for example, you will need to decide who may have infectious mononucleosis and warrants careful palpation of the liver and spleen and who, by contrast, has a common cold amenable to a more focused examination of the head, neck, and lungs. The clinical reasoning that underlies and guides such decisions is discussed later in this chapter.

What about the routine clinical check-up, or periodic health examination? Numerous studies have scrutinized the usefulness of the annual well-patient visit for screening and prevention of illness, in contrast to evaluation of symptoms, without coming to a clear consensus.[2]–[10] A growing body of evidence documents the utility of many components of the physical examination, its vital role in decision making, and its potential for savings through decreased testing.[11]–[15]

Validated examination techniques include blood pressure measurement, assessment of central venous pressure from the jugular venous pulse, listening to the heart for evidence of valvular disease, detection of hepatic and splenic enlargement, and the pelvic examination with Papanicolaou (Pap) smears. Various consensus panels and expert advisory groups have further expanded recommendations for examination and screening, which will be addressed in the regional examination chapters.

What about the newer evidence about the physical examination itself and its relationship to advanced diagnostic testing? Recent studies view the physical examination findings themselves as diagnostic tests and have begun to validate their value by identifying their test characteristics using Bayes’ theorem and the evidence-based tools described in Chapter 2, Evaluating Clinical Evidence.[16],[17]

Over time, “the rational clinical examination” is expected to improve diagnostic decision making, especially as national competencies and best teaching practices for physical examination skills become better understood.[11],[18] Meanwhile, the physical examination yields “the intangible benefits of more time spent … communicating with patients,”[18] a unique therapeutic relationship, more accurate diagnoses, and more selective assessments and plans of care.[1],[11]

Subjective Versus Objective Data

As you acquire the techniques of history taking and physical examination, remember the important differences between subjective information and objective information, summarized in the table below. Symptoms are subjective concerns, or what the patient tells you. Signs are considered one type of objective information, or what you observe. Knowing these differences helps you group together the different types of patient information. These distinctions are equally important for organizing written and oral presentations about patients into a logical and understandable format.


Differences Between Subjective and Objective Data

Subjective Data Objective Data
What the patient tells you What you detect during the examination, laboratory information, and test data
The symptoms and history, from Chief Complaint through Review of Systems All physical examination findings, or signs
Example: Mrs. G. is a 54-year-old hairdresser who reports pressure over her left chest “like an elephant sitting there,” which goes into her left neck and arm. Example: Mrs. G. is an older, overweight white female, who is pleasant and cooperative. Height 5?4?, weight 150 lbs, BMI 26, BP 160/80, HR 96 and regular, respiratory rate 24, temperature 97.5 °F

The Comprehensive Adult Health History


 Components of the Comprehensive Health History

  • Identifying data and source of the history; reliability
  • Chief complaint(s)
  • Present illness
  • Past history
  • Family history
  • Personal and social history
  • Review of systems

See Chapter 18, Assessing Children: Infancy Through Adolescence, for the comprehensive history and examination of infants, children, and adolescents.


As you will learn in Chapter 3, Interviewing and the Health History, when you talk with patients, the health history rarely emerges in this order. The interview is more fluid; you will closely follow the patient’s cues to elicit the patient’s narrative of illness, provide empathy, and strengthen rapport.

You will quickly learn where to fit different aspects of the patient’s story into the more formal format of the oral presentation and written record. You will transform the patient’s language and story into the components of the health history familiar to all members of the health care team. This restructuring organizes your clinical reasoning and provides a template for your expanding clinical expertise.

As you begin your clinical journey, review the components of the adult health history, then study the more detailed explanations that follow.


Overview: Components of the Adult Health History

Identifying Data Identifying data—such as age, gender, occupation, marital status

Source of the history—usually the patient, but can be a family member or friend, letter of referral, or the clinical record

If appropriate, establish the source of referral, because a written report may be needed Reliability Varies according to the patient’s memory, trust, and mood Chief Complaint(s) The one or more symptoms or concerns causing the patient to seek carePresent Illness Amplifies the Chief Complaint; describes how each symptom developed

Includes patient’s thoughts and feelings about the illness

Pulls in relevant portions of the Review of Systems, called “pertinent positives and negatives”

May include medications, allergies, and tobacco use and alcohol, which are frequently pertinent to the present illnessPast History Lists childhood illnesses

Lists adult illnesses with dates for events in at least four categories: medical, surgical, obstetric/gynecologic, and psychiatric

Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety Family History Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents

Documents presence or absence of specific illnesses in family, such as hypertension, diabetes, or type of cancer Personal and Social History Describes educational level, family of origin, current household, personal interests, and lifestyle Review of Systems Documents presence or absence of common symptoms related to each of the major body systems


The Comprehensive Adult Health History—Further Description

Initial Information

Date and Time of History

The date is always important. Be sure to document the time you evaluate the patient, especially in urgent, emergent, or hospital settings.

Identifying Data

These include age, gender, marital status, and occupation. The source of history or referral can be the patient, a family member or friend, an officer, a consultant, or the clinical record. Identifying the source of referral helps you assess the quality of the referral information, questions you may need to address in your assessment and written response.

Reliability

Document this information, if relevant. This judgment reflects the quality of the information provided by the patient and is usually made at the end of the interview. For example, “The patient is vague when describing symptoms, and the details are confusing,” or, “The patient is a reliable historian.”

Chief Complaint(s)

Make every attempt to quote the patient’s own words. For example, “My stomach hurts and I feel awful.” If patients have no specific complaints, report their reason for the visit, such as “I have come for my regular check-up” or “I’ve been admitted for a thorough evaluation of my heart.”

Present Illness

This Present Illness is a complete, clear, and chronologic description of the problems prompting the patient’s visit, including the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date.

? Each principal symptom should be well characterized, and should include the seven attributes of a symptom: (1) location; (2) quality; (3) quantity or severity; (4) timing, including onset, duration, and frequency; (5) the setting in which it occurs; (6) factors that have aggravated or relieved the symptom; and (7) associated manifestations. It is also important to query the “pertinent positives” and “pertinent negatives” drawn from sections of the Review of Systems that are relevant to the Chief Complaint(s). The presence or absence of these additional symptoms helps you generate the differential diagnosis, which includes the most likely and, at times, the most serious diagnoses, even if less likely, which could explain the patient’s condition.


See discussion of the seven attributes of a symptom in Chapter 3, Interviewing and the Health History.


? Other information is frequently relevant, such as risk factors for coronary artery disease in patients with chest pain, or current medications in patients with syncope.
? The Present Illness should reveal the patient’s responses to his or her symptoms and what effect the illness has had on the patient’s life. Always remember, the data flow spontaneously from the patient, but the task of oral and written organization is yours.
? Patients often have more than one symptom or concern. Each symptom merits its own paragraph and a full description.
? Medications should be noted, including name, dose, route, and frequency of use. Also, list home remedies, nonprescription drugs, vitamins, mineral or herbal supplements, oral contraceptives, and medicines borrowed from family members or friends. Ask patients to bring in all their medications so that you can see exactly what they take.
? Allergies, including specific reactions to each medication, such as rash or nausea, must be recorded, as well as allergies to foods, insects, or environmental factors.
? Note tobacco use, including the type. Cigarettes are often reported in pack-years (a person who has smoked 1½ packs a day for 12 years has an 18-pack/year history). If someone has quit, note for how long.
? Alcohol and drug use should always be investigated and is often pertinent to the Presenting Illness.


See Chapter 3, Interviewing and the Health History, for suggested questions about alcohol and drug use.