CLME 1402

EXPECTATIONS
• PREPARING YOU FOR CLINICAL PRACTICE
• ETHICS
• HISTORY TAKING
• PHYSICAL EXAMINATIONS
• INVESTIGATIONS
• MAKING A DIAGNOSIS
• 1. History. Take a history (ask questions). 80% of the diagnosis is based on the history. So taking one is
a doctors most important skill. The ‘past medical history’ (previous problems), and carefully going
through the patient’s medications, are very important.

• 2. Examination. Do an examination. 15% of diagnosis comes from this. So it is important but not as
important as the history. If the diagnosis can be made from the history alone, examination is not
always necessary.

• 3. Investigations. These include blood and urine tests, and x-rays and scans. 5% of the diagnosis
comes from these. These confirm the diagnosis (or rule out alternative ones). Investigations are not
always necessary.

• 4. Diagnosis (initial or final). If we are sure at this stage, fine .. and that is the final diagnosis. If this is
not possible, we make an initial diagnosis which is the most probable at this stage, or a ‘differential
diagnosis’. This phrase means a group of possible diagnoses, starting with the three most likely causes
that treatment must cover – if we need to start treatment now. If more information is needed, we
wait for that, and then make the final diagnosis. If we are still not sure at this stage, we discuss with
or refer to a doctor colleague. This is not usually necessary.
• 5. Diagnosis (final).

• Note. Not all 5 are always necessary – e.g. 1 and 4 are often enough for an
experienced doctor to make a diagnosis. Less experienced doctors tend to do
more tests as they want to rule out more things, to feel more confident.

• This leads to a ‘final diagnostic triad’:

• Syndrome. This means a recognisable pattern – e.g. back pain;

• Diagnosis (final). This means the precise cause of the problem – e.g. a prolapsed
(‘slipped’) spinal disc;
• Pathology. This means the underlying disease process – e.g. age-related
weakening of the spinal disc, leading to its expansion, so touching the spinal
nerves.
 Common medical terminologies
• Benign: Not cancerous
• Malignant: Cancerous
• Anti-inflammatory: Reduces swelling, pain, and soreness (such as ibuprofen or naproxen)
• Body Mass Index (BMI): Body fat measurement based on height and weight
• Biopsy: A tissue sample for testing purposes
• Hypotension: Low blood pressure
• Hypertension: High blood pressure
• Lesion: Wound, sore, or cut
• Noninvasive: Doesn’t require entering the body with instruments; usually simple
• Outpatient: Check in and check out the same day
• Inpatient: Plan to stay overnight for one or more days
• In remission: Disease is not getting worse; not to be confused with being cured
• Membrane: Thin layer of pliable tissue that serves as a covering or lining or connection
between two structures
• Acute: Sudden but usually short (e.g., acute illness)
• Angina: Pain in the chest related to the heart that comes and goes
• Gastroesophageal Reflux Disease (GERD): Heartburn
• Cellulitis: Inflamed or infected tissue beneath the skin
• Epidermis: Outermost layer of skin
• Neutrophils: Most common type of white blood cell
• Edema: Swelling
• Embolism: Blood clot
• Sutures: Stitches
• Polyp: Mass or growth of thin tissue
• Compound fracture: Broken bone that protrudes through the skin
• Comminuted fracture: Broken bone that shatters into many pieces
 Bedside and ward etiquete
• We begin with the Greeks in the 4th century bc, as does almost everything in Western
culture. The Greeks were very specific about physician bedside manners. Included in the
Hippocratic corpus is this comment:

• The physician ought also to be confidential, very chaste, sober, not a winebibber, and he
ought to be fastidious in everything, for this is what the profession demands. He ought to
have an appearance and approach that is distinguished. Everything ought to be in
moderation, for these things are advantageous, so it is said. Be solicitous in your approach
to the patient, not with head thrown back (arrogantly) or hesitantly with lowered glance,
but with head inclined slightly as the art demands.

• He ought to hold his head humbly and evenly; his hair should not be too much smoothed
down, nor his beard curled like that of a degenerate youth. Gravity signifies breadth of
experience. He should approach the patient with moderate steps, not noisily, gazing calmly
at the sick bed. He should endure peacefully the insults of the patients since those suffering
from melancholic or frenetic ailments are likely to hurl evil words at physicians (5).