He steered Clinical Methods through no less than 13 editions, at first with the Dr Swash edited the 20th and 21st editions himself, and was joined by Dr. Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (K), or click on a page image below. How can I download Pediatric Clinical Methods by Meharban Singh? Which clinical manual is the best reference for medicine, Alagappan, MacLeod, or Hutchinson? How can I download "Clinical Pathology: A Practical Manual 3ED 3rd Edition"?.
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Available in: Paperback. Knowing how to examine a patient, how to take a full history, and how to interpret the findings is at the core of a. Hutchison's Clinical Methods 21st Edition There is a newer edition of this item: Hutchison's Clinical Methods: An Integrated Approach to Clinical Practice. In this post, we have shared an overview and download link of Hutchison's Clinical Methods 24th Edition. Read the overview below and.
This points to the realization that the cost and consequences of poor clinical leadership greatly outweigh the costs and potential benefits of provision of formal programs to enhance clinical leadership capacity ideally in a multidisciplinary health care team context.
In addition to challenges associated with resources and demand, episodes of poor patient outcomes, cultures of poor care, and a range of workplace difficulties have been associated with poor clinical leadership, 8 , 9 , 14 and these concerns have provided the impetus to examine clinical leadership more closely.
Definitional issues in clinical leadership Within the health care system, it has been acknowledged that clinical leadership is not the exclusive domain of any particular professional group. While effective clinical leadership has been offered up as a way of ensuring optimal care and overcoming the problems of the clinical workplace, a standard definition of what defines effective clinical leadership remains elusive.
A secondary analysis of studies exploring organizational wrongdoing in hospitals highlighted the nature of ineffectual leadership in the clinical environment. The focus of the analysis was on clinical nurse leader responses to nurses raising concerns.
Three forms of avoidant leadership were identified: placating avoidance, where leaders affirmed concerns but abstained from action; equivocal avoidance, where leaders were ambivalent in their response; and hostile avoidance, where the failure of leaders to address concerns escalated hostility towards the complainant.
Similarly, McKee et al employed interviews, surveys, and ethnographic case studies to assess the state of quality practice in the National Health Service NHS ; they report that one of the most important insurances against failures such as those seen in the Mid-Staffordshire NHS Trust Foundation is active and engaged leaders at all levels in the system.
Synthesis of the literature suggests clinical leadership may be framed variously — as situational, as skill driven, as value driven, as vision driven, as collective, co-produced, involving exchange relationships, and as boundary spanning see Table 1. Effective clinical leaders have been characterized as having advocacy skills and the ability to affect change. Table 1 The characteristics of clinical leadership and the attributes of clinical leaders Notes: Table distilled from: Clark ; 31 De Casterle et al ; 47 Edmonton ; 11 McKeon et al ; 73 Stanley ; 32 Patrick et al ; 34 McKee et al While transformational leadership positions the leader as a charismatic shaper of followers, 33 clinical leadership is more patient centered and emphasizes collective and collaborative behaviors.
Edmonstone notes following the implementation of numerous clinical leadership programs in the UK the little research undertaken has largely focused on program evaluation, rather than the nature or outcomes of clinical leadership. Role of hospitals in contemporary health care Globally, hospitals are under increased strain and scrutiny.
Increased demands and fiscal pressures have increased the pressures on all health professionals as well as clinical and non-clinical staff. A number of nationally and internationally influential reports 6 — 8 have resulted in changes in visibility, scrutiny, and accountability in relation to hospital care.
This scrutiny has increased the emphasis on the role of health professionals, including nurses, in monitoring standards, developing and evaluating better ways of working as well as advocating for patients and their families; and led to a substantial momentum in the quality and safety agenda, including the promotion of various strategies such as promoting evidence-based practice. In the hospital sector, the demands placed upon leaders have become more complex, and the need for different forms of leadership is increasingly evident.
To derive cost efficiency and improve productivity, there has been intense reorganization. Coupled with these reforms has been increasing attention upon improving safety and quality, with programs instituted to move attention beyond singular patient—clinician interpretations of safety toward addressing organizational systems and issues of culture.
In part, this shift has been in response to growing recognition that while designated leaders in positions of formal authority within hospitals play a key role in administration and espousing values and mission, such leaders are limited in their capacity to reshape fundamental features of clinical practice or ensure change at the frontline.
This type of work engagement requires forms of citizenship behaviors that are focused upon improving clinical systems and practices. Hospitals are complex socio-political entities, and the ability for engagement and leadership among clinicians can be hampered by power dynamics, disciplinary boundaries, and competing discourses within the organization. The tension inherent between clinical and administrative discourses is evidenced in the findings from the evaluation of clinical directorate structures in Australian hospitals, with close to two thirds of medical and nursing staff surveyed reporting the primary outcome of such structures was increased organizational politics.
Edmonstone 11 cautions that without structural and cultural change within institutions, the move toward clinical leadership can result in devolution of responsibility to clinicians who are unprepared and under resourced for these roles. Evidence emerging from the NHS suggests particular value in leadership coalitions between managers and clinicians. As Gagliano et al comment, there is some evidence that health service provider groups are attempting to address issues pertaining to leadership issues through design and implementation of leadership development programs.
Other countries have developed education and professional development programs in clinical leadership for doctors, nurses, and allied health professionals working in their respective health systems. Some of these programs have similar features to UK NHS leadership frameworks and associated strategies.
For example, in New Zealand medical schools are working to provide leadership training in their undergraduate medical curriculum. Much has been written in the organizational and health care literature about employee work engagement and the benefits derived through promoting work engagement. Considerable evidence confirms positive associations between constructs such as job satisfaction, work performance, improved productivity, and engaged employees.
Although considerable discussion has occurred on the need for clinical leadership, and large scale pubic inquiries evidence the considerable patient harm that has occurred in the absence of such leadership, 7 , 8 there continues to be a major disconnect between clinicians and managers, and clinical and bureaucratic imperatives.
This will also help to avoid the situation in which the doctor and the patient have different agendas. There can often appear to be a conflict if the patient complains of symptoms that are probably not medically serious, such as tension headache, while the doctor is focusing on some potentially serious but relatively asymptomatic condition, such as anaemia or hypertension.
In this situation, a patient-centred approach will allow the patient to air all of his problems and will allow a skilled doctor to educate the patient as to why the other issues are also important and must not be ignored.
A GP may rightly refuse a demand for antibiotics for a sore Box 1. The receptionist has already documented that he is coming in with a problem of chest pain. The GP makes an automatic assumption that the pain is most likely to be angina pectoris, because that is probably the most serious cause and the one that the patient is likely to be most worried about, and therefore starts taking the history with the specific purpose of confirming or refuting that diagnosis.
GP: Is it in the middle of your chest? Patient: Yes. GP: And does it travel to your left arm? Patient: Yes — and to my shoulder. GP: Does it come on when you walk?
GP: And is it relieved by rest? Patient: Yes — usually. The GP has only asked very direct and closed questions. Alternatively, the GP keeps an open mind and starts as follows: GP: Tell me why you have come to see me today. Patient: Well — I have been having some chest pain. GP: Tell me more about that. GP: If the pain comes on when you are walking, what do you do? The GP has asked questions which are either completely open-ended or leave the patient free to describe exactly what happens within a directed area of interest.
Clarifying questions have been used. While being reassuring, the GP expresses some concern about angina and is clear about the exact reason for the specialist referral for clarification. SECTION One Doctor and patient: General principles of history taking throat that is likely to be viral but should use the opportunity to educate and inform the patient about the true place of antibiotic treatment and the risks of excess and inappropriate use.
Judging the severity of symptoms Many symptoms are subjective and the degree of severity expressed by the patient will depend on his own personal reaction and also on how the symptoms interact with his life. A tiny alteration in the neurological function of the hands and fingers will make a huge impression on a professional musician, whereas most others might hardly notice the same dysfunction.
A mild skin complaint might be devastating for a professional model but cause little worry in others. Medical symptomatology often involves pain, which is more subjective than almost anything else. Many patients are stoical and bear severe pain uncomplainingly whereas others seem to complain much more about apparently less severe pain.
A simple pain scale can be very helpful in assessing the severity of pain. The patient is asked to rate his pain on a scale from 1 to 10, with 1 being a pain that is barely noticeable and 10 the worst pain he can imagine or the worst pain he has ever experienced.
The pain scale assessment is useful in diagnosis and in monitoring disease, treatment and analgesia.
Assessing a patient with pain is discussed in more detail in Chapter Which issues are important? Curing disease may not always be possible, so it is important to be aware of the important symptoms since, for example, pain may be relieved even though the underlying cause of the pain is still present.
It is very common for the doctor to be pleased that one condition has been solved, but the patient still complains of the main symptom that he originally came with. A schematic history A suggested schematic history is detailed in Box 1. There will be many clinical situations in which it will be clear that a different scheme should be followed. An important part of learning about history taking is that each doctor develops his own personal scheme that works for him in the situations that he generally comes across.
Nevertheless, it is useful to start with a basic outline in mind. A patient presenting with back pain may have had Box 1. For this reason, any thorough assessment of a patient must include questions about all the bodily systems and not just areas that the patient perceives as problematic. A list of such question areas is given in Box 1.
For example, a GP would not ignore a high blood pressure reading in a patient presenting with a rash, even though the two are probably not connected. In health economic terms, a true screening programme for a particular disease across a whole population such as for cervical cancer has to be evaluated as being useful, economic and with no negative effects.
However, once the patient with a complaint has attended a doctor, a simple screening process can be incorporated into the consultation with little extra time or effort. If the specific questions have been covered by the history of the presenting complaint, they do not need to be included again. Almost all of the history will involve clarification but there are specific areas where this is particularly important.
Of all symptoms, pain is perhaps the most subjective and the hardest for the doctor to truly comprehend. A simple pain scale has been described above. The other characteristics are vital in analysing what might be the cause of pain. Some painful conditions have classic sites for the pain and the radiation myocardial ischaemia is classically felt in the centre of the chest radiating to the left arm. Pain from a hollow organ is classically colicky such as biliary or renal colic.
Some pains have clear aggravating or relieving factors peptic ulcer pain is classically worse when hungry and better after food. Colicky right upper quadrant abdominal pain accompanied by jaundice suggests a gallstone obstructing the bile duct, and a headache accompanied by preceding flashing lights suggests migraine. Are there any illnesses that run in your family?
Drug history At first glance, asking a patient what drugs he is taking would seem to be one of the simplest and most reliable parts of taking a history. In practice, this could not be further from the truth, and there are many pitfalls for the inexperienced.
This is partly because many patients are not very knowledgeable about their own medications and also because patients often misinterpret the question, giving a very narrow answer when the doctor wants to know about medications in the widest sense. The need for clarification in the drug history is given in Box 1. The drug history, almost more than any other, benefits from being repeated at another time and in a slightly different way. For example, in trying to define a possible drug reaction as a cause of liver dysfunction, it is not unusual to find that the patient has taken a few relevant tablets such as over-the-counter nonsteroidal anti-inflammatory drugs just before the onset of the problem and only remembered or realized it was important to say so when asked repeatedly and in great detail.
Family history Like the drug history, the family history would seem at first glance to be simple and reliably quoted. In general this is true, but it can be dissected into sections that will uncover more information. These are set out in Box 1.
The classic industrial illnesses, such as lead poisoning and other Occasionally this will reveal major genetic trends such as haemophilia. Basic family tree of first-degree relatives This should be plotted on a diagram for most patients, including major illnesses and cause and age of any deaths. Other problems, such as asbestosis or silicosis, produce effects many years after exposure, and a careful chronological occupational history may be required to elucidate the exposure. For patients with non-organic problems, the work environment can often be the trigger for the development of the problem.
To make an accurate estimate of alcohol consumption and any possible dependency, it is essential to enquire carefully and not to take what the patient says at face value but to probe the history in different ways Box 1. For documentation, the reported amount should then be converted into units of alcohol per week Box 1. If the reported amount seems at all excessive then an assessment should be made of possible dependency for which the CAGE questions are very useful Box 1.
Retrospective history The concept of retrospective history taking is a refinement of taking the past medical history and develops the theme of never taking what the patient says at face value. Many patients will clearly say that they have had certain illnesses or previous symptoms using medical terminology. This information may not be accurate either because the patient has misinterpreted it or because they were given the wrong information or diagnosis in the first place.
This area becomes particularly important if any new diagnosis is going to rely on this type of information.
For instance, in assessing a patient presenting with chest pain at rest, a past history of angina of effort will be considered a risk factor for acute myocardial infarction 9 1 Doctor and patient: General principles of history taking Box 1. Patient: Oh yes, but not much — just socially. Doctor: Do you drink some every day?
Doctor: Tell me what you drink. Patient: I usually have two pints of beer at lunchtime and two or three on my way home from work. Doctor: And at the weekend? Patient: I usually go out Saturday nights and have four or five pints. Doctor: Do you drink anything other than beer? Patient: On Saturdays I have a double whisky with each pint. The first answer does not suggest a problem, but based on the figures in Box 1. For example, 1 pint ml of beer at 3. Two or more positive answers could indicate a problem of dependency.
However, on closer questioning, it might become clear that what the patient was told was angina perhaps by a relative and not even a doctor was in fact a vague chest ache coming on after a period of heavy work and not a clear central chest pain coming on during exertion.
Clearly the possibility of retaking the history for everything the patient says about his medical past may not be practical in the time available, but the possibility and value of doing this should always be borne in mind and can completely alter the developing differential diagnosis.
Particular situations It is true to say that while there are many themes, patterns and common areas to history taking and some areas of history taking might seem routine, the process of history taking for different patients will never be identical. There are some particular and often challenging situations that deserve some further description. Garrulous patients A new medical student will soon meet a patient who says a huge amount without really revealing any of the information that goes towards a useful medical history.
This will be in marked contrast to some other patients who, from the first introductory question e. A fictitious but typical history from the former type of patient is given in Box 1. When faced with such a patient, the doctor will need to significantly alter the balance of open-ended and direct questions. Open-ended questions will tend to lead to such a patient giving a long recitation but with little useful content.
Angry patients Only a few patients are overtly angry when they see a doctor, but anger expressed during a clinical consultation may be an important diagnostic clue while at the same time get in the way of a smooth diagnostic process. Some patients will be angry with the immediate circumstances such as a late-running outpatient clinic.
Others will have longer-term anger against the surgery, department or institution which will be more difficult to address. It is always important to acknowledge anger and to try to tease out what underlies it. For some patients, anger may be part of the symptomatology or expressed as a reaction to the diagnosis or treatment. Patient: Well doctor, you see, it was like this. Doctor interrupting : Can you tell me what did happen when you woke up last Monday?
Patient: Oh yes — it was like this — I am not sure what woke me up — it may have been the pain — no, more likely it was the dustmen collecting the rubbish — they do come so early and make such a noise — that day it was even worse because their usual dustcart must have been broken and they came with this really old noisy one … Doctor interrupting : So you had some pain when you woke up then?
Patient: Yes — I think it must have been there when I woke up because I lay in bed wondering where on earth there might be some indigestion remedy — I knew I had some but I am one of those people who can never remember where things are — do you know what I managed to lose last year …? Doctor interrupting : Was the pain burning or crushing?
Patient: Well, that depends on what you mean by … Doctor interrupting : Yes, but did you have any crushing pain? There may be obvious secondary gain for the patient such as staying off work and claiming benefits and challenging this pattern of behaviour may provoke anger.
It is the duty of a doctor to attempt to work with and help a wide variety of patients, and those who are angry are no exception. However, occasionally it may be best to acknowledge that the doctor—patient relationship has broken down and that facilitating a change to another doctor may be in the best interests of the patient. This approach is no longer acceptable and it is the duty of a doctor to give the patient as much information about his illness as possible, particularly so that he is able to make informed choices about treatments.
This change of approach has led to many patients seeking out information about their problems from many other sources, particularly the Internet. It is not unusual for a patient to come into the first consultation with a new doctor, armed with printouts from various websites that he feels are relevant or information on their smart phone.
The doctor must take all this in their stride, go through the information with the patient and help him by showing what is relevant and what is not. Many medical websites are created by individuals or groups without proper information for a sound basis of knowledge, but it can be difficult for the patient to make a judgement about this.
Being able to inform patients of a few relevant and reliable websites can be very helpful. In general, it is easy and more rewarding to look after well-informed patients, provided they do not fall into the very small group that have such fixed and erroneous ideas about their problems that the diagnostic and treatment process is impeded.
Accompanying persons Some people come to consultations alone and others with one or more friends or family members. Always spend time during the initial exchange of greetings identifying who is present and getting some idea of the group dynamics. If the patient appears to be alone, ask whether there is someone waiting outside. There is always a reason people come accompanied, but if there appear to be too many people present or if the presence of others might threaten the relationship with the patient at any time in the consultation, it is appropriate to consider asking the others to leave, even if only briefly.
It is very important to be certain that the patient is happy for any others to be present and to be as certain as possible that the patient does not wish to object but feels unable to do so. Consider whether specific questions about the history should be asked of those accompanying, either with the patient or separately, with specific consent. Beware of a situation in which the accompanying people answer all the questions, even if there is not a language difficulty. There may be many reasons that the patient does not speak for himself.
These may include embarrassment in front of those accompanying such as a teenager with his parents. In such circumstances, it may be necessary to leave parts of the 11 1 Doctor and patient: General principles of history taking history until those accompanying can reasonably be asked to leave, such as during the examination. Occasionally it is clear that the patient will not talk for himself, in which case the history from those accompanying will have to be the working information.
In these circumstances, the medical consultation has to be undertaken with an interpreter. The most immediate solution may be to use a family member, but if the issues are private or embarrassing, this often does not work well.
It is also unethical to use an underage family member as an interpreter under Another solution for infrequently encountered languages is a telephone interpreting service. The breadth of history and the clinical clues that can be obtained from a good initial open-ended question may well be lost in the double translation, and the doctor often changes to a much more direct style of questioning for which the answers will be unambiguous even when going through the double translation.
This leaves the doctor bemused as to what is really going on with the patient. This is done by analysis of the symptoms and signs leading to a differential diagnosis a list of possible diagnoses that will account for the symptoms and signs, usually set out in descending order of likelihood. The process of analysis can be likened to detective work, in which the symptoms and signs are the evidence. When a medical student is first faced with the myriad data gleaned on taking a history, he is often baffled as to how to start the analysis, but inevitably the process becomes easier as more medical knowledge is acquired.
An analysis of symptoms from a medical student is more based on facts learned from textbooks, whereas an experienced doctor will tend to base the analysis more on patterns of disease presentation that they have encountered many times. While the analytical process is largely acquired through this type of experience, some principles can be described. This topic is discussed further in Chapter 3. The same principles apply to analysing symptoms.
Examples of these two groupings are given in Box 1. For instance, a vascular event such as a myocardial infarct, stroke or subarachnoid haemorrhage usually has a sudden onset, whereas something that gradually progresses or for Box 1.
There are some pitfalls in this type of analysis which must be borne in mind to avoid confusion. Disease processes that gradually progress may start off by being asymptomatic and the patient may only notice symptoms when they start to interfere with his lifestyle and activities.
For example, exertional breathlessness in a largely sedentary patient may develop late in a cardiorespiratory disease process, whereas a patient who actively exercises is likely to notice symptoms much earlier. This phenomenon is also seen where the relevant bodily organ or system has a lot of reserve and the symptom may show itself only when the reserve is used up. This could be true for a relatively chronic liver disease such as primary biliary cirrhosis apparently presenting acutely.
In addition, the disease process may have a step-wise worsening rather than a linear decline, such as in a situation of multiple small strokes when the patient may not present until a single small stroke makes a big difference to his functional ability.
Pain that is not predictably produced by exertion and is not reliably relieved by rest may well not be angina pectoris. Pattern recognition versus logical analysis What does the patient actually want? It is important to realize that in some clinical situations the diagnosis may be clear based on previous experience, and in others the diagnosis has to be built up through a process of logical analysis of symptoms, signs and special investigations.
The fact that the process of gaining information from symptoms, signs and special investigations is never completely exact must also be borne in mind so that the patient with an atypical presentation is not assigned the wrong diagnosis. The area of medicine that probably most often uses pattern recognition is dermatology, but recently skin biopsies are used much more to clarify diagnoses that were previously assumed.
A patient presenting with chest pain and signs of underperfusion may easily be thought to be having a myocardial infarction but a brief history of the character of the pain tearing and going through to the back may prompt a search for a dissecting aortic aneurysm. If a patient comes to a doctor with a long history, it is always worth trying to find out why he has come for medical help and what he actually wants from the consultation.