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Book Details
Abstract
Hutchison’s Clinical Methods, first published more than a century ago, is the classic textbook on clinical skills. It provides an outstanding source of learning and reference for undergraduate medical students and postgraduate doctors. It seeks to teach an integrated approach to clinical practice, so that new methods and investigations are grafted onto established patterns of clinical practice, rather than added on as something extra. The text is organised so that both system-related and problem-oriented chapters are included. Particular emphasis is placed on the importance of the doctor-patient relationship, the essential skills needed for clinical examination, and for planning the appropriate choice of investigations in diagnosis and management. Hutchison’s Clinical Methods is an invaluable resource for all those learning and training in medicine and is an essential adjunct to a standard textbook of medicine, surgery or other specialty.
- The book provides a comprehensive account of the traditional methods of patient history-taking and examination but is updated with a full account of the role of modern investigative techniques.
- This is a book for students of all ages and all degrees of experience.
- This established textbook of clinical methods has been thoroughly reviewed by an international group of students and trainee doctors to ensure the text concentrates on the basic principles of history and examination in all the various clinical settings which medical students need to master.
- The global perspective of the book has been enhanced with a new International Advisory Board recruited from South Asia and the Middle East.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | cover | ||
| Inside Front Cover | ifc1 | ||
| Hutchison's Clinical Methods | i | ||
| Copyright Page | iv | ||
| Preface to the Twenty-fourth Edition | v | ||
| Sir Robert Hutchison MD FRCP (1871-1960) | vii | ||
| Contributors | ix | ||
| International Advisory Board | xi | ||
| Acknowledgements | xiii | ||
| Table Of Contents | xv | ||
| 1 General patient assessment | 1 | ||
| 1 Doctor and patient | 3 | ||
| Introduction | 3 | ||
| Setting the scene | 3 | ||
| Emergency presentations | 4 | ||
| History taking | 4 | ||
| Beginning the history | 4 | ||
| Developing themes | 5 | ||
| Non-verbal communication | 5 | ||
| Vocabulary | 5 | ||
| Indirect and direct questions | 6 | ||
| Disease-centred versus patient-centred | 6 | ||
| Judging the severity of symptoms | 7 | ||
| Which issues are important? | 7 | ||
| A schematic history | 7 | ||
| Direct questions about bodily systems | 7 | ||
| Clarifying detail | 8 | ||
| Pain | 8 | ||
| Drug history | 9 | ||
| Family history | 9 | ||
| Occupational history | 9 | ||
| Alcohol history | 9 | ||
| Retrospective history | 9 | ||
| Particular situations | 10 | ||
| Garrulous patients | 10 | ||
| Angry patients | 10 | ||
| The well-informed patient | 11 | ||
| Accompanying persons | 11 | ||
| Using interpreters/advocates | 12 | ||
| Analysing symptoms | 12 | ||
| ‘Hard and soft’ symptoms | 12 | ||
| Time course | 12 | ||
| Pattern recognition versus logical analysis | 13 | ||
| Negative data | 13 | ||
| What does the patient actually want? | 13 | ||
| Retaking the history | 13 | ||
| Note taking | 14 | ||
| Conclusion | 14 | ||
| 2 General patient examination and differential diagnosis | 15 | ||
| Introduction | 15 | ||
| General examination of a patient | 15 | ||
| Posture and gait | 16 | ||
| Speech and interaction | 16 | ||
| Physique and nutrition | 16 | ||
| Temperature | 16 | ||
| Hands | 17 | ||
| Odours | 19 | ||
| Face and neck | 19 | ||
| Lymph glands and lymphadenopathy | 20 | ||
| Axillae | 21 | ||
| Skin | 22 | ||
| Pulses | 23 | ||
| Blood pressure | 24 | ||
| Legs and feet | 25 | ||
| Breasts | 26 | ||
| Putting it all together | 27 | ||
| General | 27 | ||
| Mouth and pharynx | 27 | ||
| Hands | 27 | ||
| Cardiovascular and respiratory (anterior, patient semi-recumbent) | 27 | ||
| Cardiovascular and respiratory (posterior, sitting forward) | 27 | ||
| Neck (while sitting forward) | 27 | ||
| Abdomen | 27 | ||
| Upper limbs | 27 | ||
| Lower limbs | 27 | ||
| Cranial nerves | 27 | ||
| Documentation and communication | 27 | ||
| Presenting a case | 29 | ||
| Summary | 29 | ||
| 3 The next steps: | 31 | ||
| Introduction | 31 | ||
| Management plan | 32 | ||
| What to write in the case notes | 32 | ||
| What to say to the patient | 33 | ||
| What to do when the diagnosis is unclear | 34 | ||
| Multiple causation | 34 | ||
| Selecting appropriate investigations | 34 | ||
| 4 Ethical considerations | 37 | ||
| Introduction | 37 | ||
| Autonomy | 37 | ||
| Consent | 37 | ||
| Obtaining consent | 38 | ||
| Setting the scene | 38 | ||
| Implications of consent or refusal | 38 | ||
| Legal requirements for consent | 38 | ||
| Competence and capacity for consent | 38 | ||
| Appropriately informed | 38 | ||
| Confidentiality | 39 | ||
| With permission | 39 | ||
| In the patient’s interests | 39 | ||
| An overriding duty to society | 39 | ||
| Statutory disclosure | 39 | ||
| Inspection of medical records | 39 | ||
| After death | 39 | ||
| Organ donation | 40 | ||
| Resuscitation | 40 | ||
| Not for resuscitation | 40 | ||
| Consent for autopsy | 40 | ||
| Other ethical problems | 40 | ||
| Medical negligence | 40 | ||
| HIV | 41 | ||
| Genetics | 41 | ||
| Genetic counselling | 42 | ||
| Principles of medical ethics | 42 | ||
| 2 Assessment in particular groups | 43 | ||
| 5 Women | 45 | ||
| Introduction | 45 | ||
| Gynaecological history | 45 | ||
| Presenting complaint | 45 | ||
| History of presenting complaint | 45 | ||
| Pain history | 45 | ||
| Menstrual history | 46 | ||
| Vaginal discharge | 46 | ||
| Urinary tract and uterovaginal prolapse symptoms | 46 | ||
| Sexual symptoms | 47 | ||
| Cervical cytology history | 47 | ||
| Past obstetric history | 47 | ||
| Past gynaecological history | 48 | ||
| Past medical/surgical/anaesthetic history | 48 | ||
| Medication or treatment history | 48 | ||
| Social history | 48 | ||
| Family history | 48 | ||
| Gynaecological examination | 48 | ||
| Abdominal examination | 48 | ||
| Pelvic examination | 49 | ||
| Pelvic examination in special circumstances | 50 | ||
| Vaginal bleeding | 50 | ||
| Cervical smear | 50 | ||
| Examination under general anaesthesia | 51 | ||
| Vaginismus | 51 | ||
| Intact hymen | 51 | ||
| Pregnancy | 51 | ||
| Speculum examination | 52 | ||
| Taking a cervical (Papanicolaou) smear | 53 | ||
| Assessment for prolapse | 53 | ||
| History relating to current pregnancy | 53 | ||
| Relevant past obstetric history | 54 | ||
| Drug/smoking/alcohol history | 54 | ||
| Family history | 54 | ||
| Social history | 54 | ||
| Presentation of obstetric cases | 54 | ||
| Obstetric examination | 54 | ||
| General examination | 54 | ||
| Abdominal examination in pregnancy | 54 | ||
| Vaginal examination in pregnancy | 56 | ||
| Vaginal examination in labour | 57 | ||
| Investigations in obstetrics and gynaecology | 57 | ||
| Pregnancy testing | 57 | ||
| Bacteriological and virus tests | 57 | ||
| Imaging | 58 | ||
| Ultrasound | 58 | ||
| Computed tomography and magnetic resonance imaging | 58 | ||
| Hysterosalpingography | 58 | ||
| Endometrial sampling (biopsy) | 58 | ||
| Colposcopy | 59 | ||
| Hysteroscopy | 59 | ||
| Cystoscopy and cystometry | 59 | ||
| Laparoscopy | 60 | ||
| Tests of fetal wellbeing | 60 | ||
| Biochemical tests | 60 | ||
| Early pregnancy markers | 60 | ||
| α-Fetoprotein (AFP), unconjugated oestriol, βhCG, inhibin A, PAPP A | 60 | ||
| Late pregnancy | 60 | ||
| Biological tests | 60 | ||
| Chorion biopsy (chorionic villus sampling, CVS) | 60 | ||
| Amniocentesis | 60 | ||
| Non-invasive prenatal testing | 61 | ||
| Biophysical tests | 61 | ||
| Fetal movements | 61 | ||
| Cardiotocography (CTG) | 61 | ||
| Ultrasound visualization | 61 | ||
| Doppler blood flow | 62 | ||
| 6 Children and adolescents | 63 | ||
| Introduction | 63 | ||
| History | 63 | ||
| Family history | 64 | ||
| Social history | 64 | ||
| Examination | 64 | ||
| General examination | 66 | ||
| The head, face and neck | 66 | ||
| The limbs | 67 | ||
| The abdomen | 67 | ||
| The chest | 68 | ||
| Neurological examination | 69 | ||
| The eyes | 70 | ||
| The genitalia, groins and anus | 71 | ||
| The nose, ears, mouth and throat | 71 | ||
| Signs associated with abuse/child neglect | 72 | ||
| Routine measurements | 72 | ||
| Height and weight | 72 | ||
| Head circumference | 73 | ||
| Blood pressure | 73 | ||
| Temperature | 78 | ||
| Stools | 78 | ||
| Urine | 78 | ||
| Developmental screening examination | 78 | ||
| Techniques used | 78 | ||
| Head control | 79 | ||
| Testing vision | 79 | ||
| Testing hearing | 79 | ||
| Examination of the newborn | 80 | ||
| The skin | 80 | ||
| The face | 81 | ||
| The head | 81 | ||
| The eyes | 81 | ||
| The mouth and tongue | 81 | ||
| The neck | 81 | ||
| The limbs | 81 | ||
| The chest | 81 | ||
| The abdomen | 81 | ||
| The perineum and genitalia | 81 | ||
| Neurological assessment | 82 | ||
| Primitive reflexes | 82 | ||
| Examination of the hips | 82 | ||
| Summary | 83 | ||
| 7 Older people | 85 | ||
| Introduction | 85 | ||
| Presentation of disease in older people | 85 | ||
| History | 87 | ||
| The social history and social networks | 87 | ||
| Activities of daily living | 88 | ||
| Drug history | 88 | ||
| Review of systems | 89 | ||
| Examination | 89 | ||
| General | 89 | ||
| Special considerations | 89 | ||
| Skin | 89 | ||
| Cardiovascular system | 90 | ||
| Respiratory system | 90 | ||
| Gastrointestinal system | 91 | ||
| Nervous system | 91 | ||
| Vision and the eyes | 92 | ||
| Hearing | 93 | ||
| The ‘geriatric giants’ | 93 | ||
| Immobility | 93 | ||
| Instability/falls | 93 | ||
| Incontinence | 94 | ||
| Pressure ulcers | 94 | ||
| Confusion | 95 | ||
| The confused older patient | 95 | ||
| Assessment of capacity | 96 | ||
| Other issues | 96 | ||
| Ethnic elders | 96 | ||
| Inadequate care and elder abuse | 96 | ||
| 8 Psychiatric assessment | 99 | ||
| Introduction | 99 | ||
| History taking | 100 | ||
| Context of the interview | 100 | ||
| Patient factors | 100 | ||
| Factors in the physical environment | 100 | ||
| Safety | 100 | ||
| Privacy | 100 | ||
| Collateral history | 100 | ||
| The psychiatric history | 100 | ||
| Introduction | 100 | ||
| Confidentiality and note keeping | 101 | ||
| Interviewing a patient who does not speak English | 101 | ||
| Interviewing technique | 101 | ||
| Structure of the psychiatric history | 101 | ||
| Order of sections | 101 | ||
| Presenting complaint | 101 | ||
| History of presenting complaint (HPC) | 102 | ||
| History of psychiatric disorder | 103 | ||
| Past medical history | 103 | ||
| Current medication | 103 | ||
| Family history | 103 | ||
| Personal history | 104 | ||
| Birth and early developmental milestones (in most patients only a brief outline is required) | 104 | ||
| Family milieu, childhood health and early relationships with caregivers | 104 | ||
| Schooling | 104 | ||
| Occupational history | 105 | ||
| Psychosexual history, including marital/relationship history and children | 105 | ||
| Current social situation (Box 8.6) | 106 | ||
| Forensic history | 106 | ||
| Use of alcohol and non-prescribed recreational drugs | 106 | ||
| Alcohol | 106 | ||
| Taking a full drinking history | 107 | ||
| Recreational drugs | 107 | ||
| Personality assessment | 107 | ||
| The mental state examination | 107 | ||
| Appearance and behaviour | 107 | ||
| Appearance | 107 | ||
| Behaviour | 108 | ||
| General demeanour | 108 | ||
| Rapport | 108 | ||
| Eye contact | 108 | ||
| Gait | 108 | ||
| Reduced motor activity | 108 | ||
| Increased motor activity | 108 | ||
| Speech | 109 | ||
| Rate | 109 | ||
| Structure | 109 | ||
| Mood | 109 | ||
| Thought | 110 | ||
| Exploring thoughts in elevated mood | 111 | ||
| Obsessional thoughts | 111 | ||
| Abnormal beliefs | 112 | ||
| Perception | 114 | ||
| Abnormal perception | 114 | ||
| Cognition | 115 | ||
| Basic assessment of cognitive function | 115 | ||
| Level of consciousness | 115 | ||
| Orientation | 115 | ||
| Time | 115 | ||
| Place | 116 | ||
| Person | 116 | ||
| Attention and concentration | 116 | ||
| Memory | 116 | ||
| Testing registration and immediate recall | 117 | ||
| Testing short-term memory | 117 | ||
| Testing longer term memory – recent | 117 | ||
| Testing longer term memory – remote | 117 | ||
| Intelligence | 117 | ||
| Abstraction | 118 | ||
| Insight | 118 | ||
| Ending the interview | 118 | ||
| Final reflection | 118 | ||
| Further investigations | 118 | ||
| Mental state evaluation | 118 | ||
| Neuropsychological testing | 119 | ||
| Brain imaging | 119 | ||
| 9 Patients presenting as emergencies | 121 | ||
| Introduction | 121 | ||
| The importance of clinical assessment | 121 | ||
| Diagnosis versus resuscitation | 122 | ||
| The pyrexial and septic patient | 122 | ||
| The patient with chest pain | 122 | ||
| The breathless patient | 124 | ||
| General principles | 124 | ||
| Airway obstruction | 126 | ||
| Acute breathlessness due to ventilatory and/or oxygenation defects | 126 | ||
| The patient with hypotension or shock | 127 | ||
| Hypovolaemic shock | 128 | ||
| Cardiogenic shock | 129 | ||
| Distributive shock | 129 | ||
| Obstructive shock | 130 | ||
| The patient with diminished consciousness | 130 | ||
| The syncopal patient | 132 | ||
| The patient with seizures | 133 | ||
| The patient with acute confusion | 135 | ||
| The patient with acute headache | 136 | ||
| The acutely weak patient | 137 | ||
| The patient with acute abdominal pain | 138 | ||
| The patient with haematemesis and/or melaena | 139 | ||
| 10 Patients with a fever | 141 | ||
| Introduction | 141 | ||
| How is normal core body temperature regulated? | 141 | ||
| What effects on thermoregulation lead to fever? | 141 | ||
| Should you always treat a fever? | 143 | ||
| The patterns of fever | 143 | ||
| Approach to a patient with a fever – causes of fever | 143 | ||
| History | 145 | ||
| Main presenting complaint | 145 | ||
| History of the presenting complaint | 145 | ||
| Personal history | 145 | ||
| History of associated and constitutional symptoms | 146 | ||
| History of behaviours and exposures are important in infectious diseases | 146 | ||
| Past medical and surgical history | 146 | ||
| Systematic history | 147 | ||
| Respiratory tract | 147 | ||
| Genitourinary tract | 147 | ||
| Gastrointestinal tract | 147 | ||
| Nervous system | 147 | ||
| Skin and soft tissue | 148 | ||
| Musculoskeletal system | 148 | ||
| Cardiovascular system | 149 | ||
| Examination | 149 | ||
| General assessment | 149 | ||
| Systematic assessment | 149 | ||
| Skin and mucous membranes | 149 | ||
| Respiratory tract | 150 | ||
| Cardiovascular system | 150 | ||
| Genitourinary tract | 151 | ||
| Gastrointestinal tract | 151 | ||
| Nervous system | 151 | ||
| Musculoskeletal system | 152 | ||
| Multisystem diseases | 152 | ||
| Fever in autoinflammatory periodic syndromes | 152 | ||
| Drug fever | 153 | ||
| Investigations for infectious causes of fever | 153 | ||
| Laboratory | 153 | ||
| Full blood count with differential and film | 153 | ||
| Platelets | 153 | ||
| Inflammatory markers | 153 | ||
| Basic biochemistry tests | 154 | ||
| Microbiology and virology tests | 154 | ||
| Serology | 154 | ||
| Molecular diagnostics | 154 | ||
| Immunological tests | 155 | ||
| Histopathology | 155 | ||
| Radiology | 155 | ||
| Pyrexia of unknown origin | 155 | ||
| 11 Patients in pain | 157 | ||
| Introduction | 157 | ||
| Definition | 157 | ||
| Classification of pain | 157 | ||
| Aetiology/underlying condition | 157 | ||
| Mechanism | 157 | ||
| Duration | 157 | ||
| Mechanisms of pain | 158 | ||
| The patient in pain | 159 | ||
| History | 159 | ||
| Examination | 159 | ||
| Investigation | 161 | ||
| Difficult cases | 161 | ||
| Measuring pain | 162 | ||
| Unidimensional scales | 162 | ||
| Multidimensional (complex) scales | 163 | ||
| Treatment strategies | 163 | ||
| Acute pain | 163 | ||
| Chronic pain | 163 | ||
| Non-pharmacological options | 163 | ||
| Conclusions | 164 | ||
| 3 Basic systems | 165 | ||
| 12 Respiratory system | 167 | ||
| Introduction | 167 | ||
| The history | 167 | ||
| Breathlessness | 167 | ||
| Cough | 167 | ||
| Sputum | 167 | ||
| Haemoptysis | 168 | ||
| Wheezing | 169 | ||
| Pain in the chest | 169 | ||
| Other symptoms | 169 | ||
| Upper airway | 169 | ||
| The smoking and recreational drug history | 169 | ||
| The family history | 170 | ||
| The occupational history | 170 | ||
| The examination | 170 | ||
| General assessment | 170 | ||
| Hands | 171 | ||
| Respiratory rate and rhythm | 171 | ||
| Venous pulses | 172 | ||
| Head | 172 | ||
| Examination of the chest | 172 | ||
| Relevant anatomy | 172 | ||
| Looking: inspection of the chest | 173 | ||
| Appearance of the chest | 173 | ||
| Movement of the chest | 173 | ||
| Feeling: palpation of the chest | 173 | ||
| Lymph nodes | 173 | ||
| Swellings and tenderness | 173 | ||
| Trachea and heart | 175 | ||
| Chest expansion | 175 | ||
| Feeling: percussion of the chest | 175 | ||
| Listening: auscultation of the chest | 176 | ||
| The breath sounds | 176 | ||
| Added sounds | 177 | ||
| Vocal resonance | 177 | ||
| Vocal fremitus | 178 | ||
| Putting it together: an examination of the chest | 178 | ||
| Putting it together: interpreting the signs | 178 | ||
| Other investigations | 178 | ||
| Sputum examination | 178 | ||
| At the bedside | 178 | ||
| In the laboratory | 179 | ||
| Lung function tests | 179 | ||
| Arterial blood sampling | 181 | ||
| Imaging the lung and chest | 181 | ||
| The chest X-ray | 181 | ||
| The position of the patient | 181 | ||
| The outline of the heart and the mediastinum | 181 | ||
| The position of the trachea | 181 | ||
| The diaphragm | 181 | ||
| The lung fields | 182 | ||
| The bony skeleton | 182 | ||
| The computed tomography scan | 182 | ||
| Radioisotope imaging | 182 | ||
| Magnetic resonance imaging | 183 | ||
| Ultrasound | 183 | ||
| Positron emission tomography (PET) scanning | 184 | ||
| Flexible bronchoscopy and endobronchial ultrasound (EBUS) | 184 | ||
| Pleural aspiration and biopsy | 184 | ||
| Ridge thoracoscopy and video-assisted thoracoscopic surgery (VATS) | 186 | ||
| Lung biopsy | 186 | ||
| Immunological tests | 186 | ||
| Tests for Tuberculosis (TB) | 187 | ||
| 13 Cardiovascular system | 189 | ||
| Introduction | 189 | ||
| The cardiac history | 189 | ||
| Chest pain | 189 | ||
| Myocardial ischaemia | 190 | ||
| Acute coronary syndromes | 191 | ||
| Pericarditis | 191 | ||
| Aortic dissection | 191 | ||
| Pulmonary embolism | 192 | ||
| Dyspnoea | 192 | ||
| Exertional dyspnoea | 193 | ||
| Orthopnoea | 194 | ||
| Paroxysmal nocturnal dyspnoea | 194 | ||
| Fatigue | 194 | ||
| Palpitation | 194 | ||
| Dizziness and syncope | 194 | ||
| Postural hypotension | 194 | ||
| Vasovagal syncope | 194 | ||
| Carotid sinus hypersensitivity | 194 | ||
| Valvular obstruction | 194 | ||
| Stokes-Adams attacks | 194 | ||
| The cardiac examination | 194 | ||
| Inspection of the patient | 195 | ||
| Anaemia | 195 | ||
| Cyanosis | 195 | ||
| Clubbing of the fingers and toes | 196 | ||
| Other cutaneous and ocular signs of infective endocarditis | 196 | ||
| Coldness of the extremities | 196 | ||
| Pyrexia | 196 | ||
| Oedema | 196 | ||
| Arterial pulse | 196 | ||
| Rate and rhythm | 196 | ||
| Character | 196 | ||
| Symmetry | 197 | ||
| Measurement of blood pressure | 197 | ||
| Jugular venous pulse | 198 | ||
| Jugular venous pressure | 198 | ||
| Waveform of jugular venous pulses | 199 | ||
| Palpation of the chest wall | 199 | ||
| Auscultation of the heart | 200 | ||
| First sound (S1) | 200 | ||
| Second sound (S2) | 200 | ||
| Third and fourth sounds (S3, S4) | 200 | ||
| Systolic clicks and opening snaps | 201 | ||
| Heart murmurs | 201 | ||
| Friction rubs and venous hums | 203 | ||
| Finishing the cardiovascular examination | 203 | ||
| The electrocardiogram | 203 | ||
| Electrophysiology | 203 | ||
| Generation of electrical activity | 203 | ||
| Inscription of the QRS complex | 203 | ||
| Index | 465 | ||
| A | 465 | ||
| B | 466 | ||
| C | 467 | ||
| D | 468 | ||
| E | 469 | ||
| F | 470 | ||
| G | 471 | ||
| H | 472 | ||
| I | 473 | ||
| J | 473 | ||
| K | 473 | ||
| L | 474 | ||
| M | 474 | ||
| N | 475 | ||
| O | 476 | ||
| P | 476 | ||
| Q | 478 | ||
| R | 478 | ||
| S | 479 | ||
| T | 480 | ||
| U | 481 | ||
| V | 481 | ||
| W | 482 | ||
| X | 482 | ||
| Y | 482 | ||
| Z | 482 |