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Clinical Skills

This is the ultimate skill of a doctor treating patients. You can improve on this your whole life. It is a
continuous learning process. The way you find out and treat the same disease in different patients can
vary. Verbal and non-verbal communication skills play an important part.
Clinical history and examination
Diagnosis is done by developing associations and connections in your mind as you collect data. It is not
done by having long lists of conditions and for each presenting complaint of patients.
When you read about a sign, try to find out two things. How many conditions cause it? If there are 20
causes for it instead of two, it is not such a useful sign re-diagnosis. In those with this condition, how
many will actually have it? If in the sign of clubbing, only 4% of patients with bronchial cancer has
clubbing, then you must take that into consideration!
History taking should be considered a conversation, where both sides provide and give information.
However you are the director of the conversation. For example you may have to interrupt the patient to
ask or clarify something or even to change the topic.
Do not forget your powers of observation, and to further develop them. Observe the patient and any
others who are with the patient. Study body language expressions, how they sit, how they look at
you, how they are dressed, how they are attired, hair styles etc.
First identify the patient, by asking name, age, date of birth and even the job if necessary.
Second objective is to find the reason patient has come to see you. These are the presenting complaints.
Try to work out the anatomical system, organ and site. Think of anatomy as structural and functional.
Thirdly find the possible broad pathology; if congenital or acquired, if acquired is it
infectious/inflammatory/infestation or neoplastic etc.
Is there structural or functional alteration of the body part involved?
Some features can form a pattern certain symptoms and signs together forming a syndrome.
For each symptom, ask about
How it affects the persons life
Why is the patient concerned or what is his real worry?
Learn to question pain in some detail.
Ask for other associated symptoms regards the anatomical system thought to be involved and the
pathological state.
Then you can ask questions regards all other body systems to find out if there are structural or
functional problems related to those now or in the past.
Eg: Relating to the CVS: Do you have any chest pain? Do you feel short of breath when you walk or

climb a few stairs?

Past medical history any current or previous diseases
Family history this is for identifying genetically transmitted or familial conditions.
Social history job, earning capacity, the family (by marriage), hobbies gardening, painting
Drug history what medications is the patient on and for how long
Habits - smoking, alcohol, street drugs,
Surgical history any surgical procedures in the past; what and when. Were there complications/issues
post surgery or anaesthesia?
Obstetric history children, type of delivery,
Allergies drugs, food, plaster, skin antiseptics ( dettol, savlon, iodine), metal
Review of systems - ask some questions about other systems than the one you think is involved in this
Then summerise the history.
Get consent and examine patient. Keep talking to patient and look at the face to make sure the patient is
comfortable with your examination.
General examination eyelids and tongue for pallor, ankle oedema
System examinations CVS, RS etc.
Local examinations like ulcers and lumps
Order of examination is usually of Inspection with comparison, Palpation, Percussion, Auscultation and
Special tests.
Then summarize the history and examination findings in maximam of three sentences ( This thirty four
year old diabetic patient presents with abdominal distension of sudden onset of three hours duration. He
has no previous abdominal surgery. On examination the abdomen is distended, no free fluid or
masses. )
Come forward with a Diagnosis or a differential diagnosis ( not more than three)
Investigations. Ther reason for the investigation and the order they need to be done must be expressed.
Their value and their shortcomings must be noted as well as the cost and avaoilability.
Investigations can be done for; confirming or refuting the diagnosis, assess the severity or extent of the
disease, assess the patints underlying condition/fitness. Sometimes they are needed before starting
some form of treatment, to find if it is safe in this patient. ( renal function before doing a contrast based
Management of the disease in THIS patient!
Conservative, medical, surgical, other. Getting consent after informing the patient adequately. This
includes possible complications, pros and cons, changes to the body habitus/shape, functional changes
and social changes that maybe needed after treatment.
Follow up plan.
Dr Nandalal Gunaratne
Head of Clinical Sciences