Senior Clinical Lecturer, University of Edinburgh; Honorary
Consultant in Emergency Medicine, Royal Infirmary of
Consultant and Honorary Professor in Paediatric Respiratory
Medicine, Royal Hospital for Sick Children, Edinburgh, UK
Consultant Neurologist, Western General Hospital and Royal
Infirmary of Edinburgh; Honorary Senior Lecturer, University of
Senior Lecturer and Honorary Consultant Nephrologist,
Consultant in Diabetes, Endocrinology and General Medicine,
Edinburgh Centre for Endocrinology and Diabetes, Royal
Infirmary of Edinburgh; Honorary Clinical Senior Lecturer,
Professor of Reproductive Medicine and Science, University
of Edinburgh; Honorary Consultant Gynaecologist, Royal
Consultant Obstetrician, Royal Infirmary of Edinburgh;
Honorary Senior Lecturer and Associate Senior Tutor,
Andrew Elder FRCP(Ed) FRCPSG FRCP FACP FICP(Hon)
Consultant in Acute Medicine for the Elderly, Western General
Hospital, Edinburgh; Honorary Professor, University of
General Practitioner, Mackenzie Medical Centre, Edinburgh;
Clinical Senior Lecturer, Centre for Population Health
Sciences, University of Edinburgh, UK
Jane Gibson MD FRCP(Ed) FSCP(Hon)
Consultant Rheumatologist, Fife Rheumatic Diseases Unit,
NHS Fife, Kirkcaldy, Fife; Honorary Senior Lecturer, University
Iain Hathorn DOHNS PGCME FRCS(Ed) (ORL-HNS)
Consultant ENT Surgeon, NHS Lothian, Edinburgh, UK;
Honorary Clinical Senior Lecturer, University of Edinburgh, UK
Clinical Director of Innovation, Consultant Paediatric and
Neonatal Surgeon, Alder Hey Children’s Hospital,
J Alastair Innes BSc PhD FRCP(Ed)
Consultant Physician, Respiratory Unit, Western General
Hospital, Edinburgh; Honorary Reader in Respiratory
Medicine, University of Edinburgh, UK
Consultant Cardiologist, Royal Infirmary of Edinburgh;
Honorary Senior Lecturer, University of Edinburgh, UK
Reader in Nephrology, University of Edinburgh, UK
Alexander Laird PhD FRCS(Ed) (Urol)
Consultant Urological Surgeon, Western General Hospital,
Elizabeth MacDonald FRCP(Ed) DMCC
Consultant Physician in Medicine of the Elderly, Western
General Hospital, Edinburgh, UK
Consultant Neurologist and Honorary Senior Lecturer,
National Hospital for Neurology and Neurosurgery,
Nicholas L Mills PhD FRCP(Ed) FESC
Chair of Cardiology and British Heart Foundation Senior
Clinical Research Fellow, University of Edinburgh; Consultant
Cardiologist, Royal Infirmary of Edinburgh, UK
Nick Morley MRCS(Ed) FRCR FEBNM
Consultant Radiologist, University Hospital of Wales,
Professor of Surgical Sciences, Clinical Surgery, University of
Edinburgh; Honorary Consultant Hepatobiliary and Pancreatic
Surgeon, Royal Infirmary of Edinburgh, UK
Consultant in Critical Care, Western General Hospital,
John Plevris DM PhD FRCP(Ed) FEBGH
Professor and Consultant in Gastroenterology, Royal Infirmary
of Edinburgh, University of Edinburgh, UK
Stephen Potts FRCPsych FRCP(Ed)
Consultant in Transplant Psychiatry, Royal Infirmary of
Edinburgh; Honorary Senior Clinical Lecturer, University of
Colin Robertson FRCP(Ed) FRCS(Ed) FSAScot
Honorary Professor of Accident and Emergency Medicine,
Clinical Lecturer in Surgery, University of Edinburgh, UK
Janet Skinner FRCS MMedEd FCEM
Director of Clinical Skills, University of Edinburgh; Emergency
Medicine Consultant, Royal Infirmary of Edinburgh, UK
Consultant Neonatologist, Royal Infirmary of Edinburgh;
Honorary Professor of Neonatology, University of
Michael J Tidman MD FRCP(Ed) FRCP (Lond)
Consultant Dermatologist, Royal Infirmary of Edinburgh, UK
James Tiernan MSc(Clin Ed) MRCP(UK)
Consultant Respiratory Physician, Royal Infirmary of
Edinburgh; Honorary Senior Clinical Lecturer, University of
Consultant Ophthalmic Surgeon, Ophthalmology, Princess
Alexandra Eye Pavilion, Edinburgh, UK
Clinical Director, Edinburgh Breast Unit, Western General
Consultant in Diabetes, Endocrinology and General Medicine,
Edinburgh Centre for Endocrinology and Diabetes, Royal
Infirmary of Edinburgh; Honorary Clinical Senior Lecturer,
Principles of clinical history
1 Managing clinical encounters with patients 3
2 General aspects of history taking 9
3 General aspects of examination 19
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Handling sensitive information and third parties 5
Showing cultural sensitivity 6
Alternatives to face-to-face encounters 6
Professional responsibilities 6
4 • Managing clinical encounters with patients
A range of cultural factors may also influence help-seeking
behaviour. Examples of person-specific factors that reduce
the propensity to consult include stoicism, self-reliance, guilt,
unwillingness to acknowledge psychological distress, and
embarrassment about lifestyle factors such as addictions. These
factors may vary between patients and also in the same person
in different circumstances, and may be influenced by gender,
education, social class and ethnicity.
You should take all reasonable steps to ensure that the
consultation is conducted in a calm, private environment. The
layout of the consulting room is important and furniture should
be arranged to put the patient at ease (Fig. 1.1A) by avoiding
face-to-face, confrontational positioning across a table and the
incursion of computer screens between patient and doctor (Fig.
1.1B). Personal mobile devices can also be intrusive if not used
For hospital inpatients the environment is a challenge, yet
privacy and dignity are always important. There may only be
curtains around the bed space, which afford very little by way
of privacy for a conversation. If your patient is mobile, try to
use a side room or interview room. If there is no alternative to
speaking to patients at their bedside, let them know that you
understand your conversation may be overheard and give them
permission not to answer sensitive questions about which they
The clinical encounter between a patient and doctor lies at the
heart of most medical practice. At its simplest, it is the means by
which people who are ill, or believe themselves to be ill, seek the
advice of a doctor whom they trust. Traditionally, and still most
often, the clinical encounter is conducted face to face, although
non-face-to-face or remote consultation using the telephone or
digital technology is possible and increasingly common. This
chapter describes the general principles that underpin interactions
with patients in a clinical environment.
The majority of people who experience symptoms of ill health
do not seek professional advice. For the minority who do seek
help, the decision to consult is usually based on a complex
interplay of physical, psychological and social factors (Box 1.1).
The perceived seriousness of the symptoms and the severity of
the illness experience are very important influences on whether
patients seek help. The anticipated severity of symptoms is
determined by their intensity, the patient’s familiarity with them,
and their duration and frequency. Beyond this, patients try to
make sense of their symptoms within the context of their lives.
They observe and evaluate their symptoms based on evidence
from their own experience and from information they have
gathered from a range of sources, including family and friends,
print and broadcast media, and the internet. Patients who present
with a symptom are significantly more likely to believe or worry
that their symptom indicates a serious or fatal condition than
non-consulters with similar symptoms; for example, a family
history of sudden death from heart disease may affect how a
person interprets an episode of chest pain. Patients also weigh
up the relative costs (financial or other, such as inconvenience)
and benefits of consulting a doctor. The expectation of benefit
from a consultation – for example, in terms of symptom relief
or legitimisation of time off work – is a powerful predictor of
consultation. There may also be times when other priorities in
patients’ lives are more important than their symptoms of ill health
and deter or delay consultation. It is important to consider the
timing of the consultation. Why has the patient presented now?
Sometimes it is not the experience of symptoms themselves that
provokes consultation but something else in the patients’ lives
that triggers them to seek help (Box 1.2).
1.1 Deciding to consult a doctor
• Perceived susceptibility or vulnerability to illness
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