Oxford Handbook of Clinical Examination and Practical Skills (2e 2014)

OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of

Clinical Examination
and Practical Skills


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Oxford Handbook of

Clinical
Examination
and Practical
Skills
2nd edition
Edited by

Dr James Thomas
Consultant Musculoskeletal Radiologist
Nottingham University Hospitals NHS
Trust, Nottingham, UK

and

Dr Tanya Monaghan
Academic Clinical Lecturer in Gastroenterology
NIHR Nottingham Digestive Diseases Centre Biomedical
Research Unit,
Nottingham University Hospitals NHS Trust,
Nottingham, UK

1


1
Great Clarendon Street, Oxford, OX2 6DP,
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© Oxford University Press 204
The moral rights of the authors have been asserted
First Edition published in 2007
Second Edition published in 204
Impression: 
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contained in any third party website referenced in this work.


v

Preface
Since the publication of the first edition of this book, we have been heartened by the many positive comments and emails from readers and have
been very grateful for the suggestions for improvements and modifications.
We have tried to incorporate as many of these as possible.
We have tried hard to update the text to reflect modern practice and to
make changes which, only with the 20–20 vision of hindsight, could we see
were needed.
We have tried to keep an eye on OSCE examinations and the reader
will find new ‘skills stations’ throughout the book to add to the existing
examination frameworks.
Several chapters, including respiratory, paediatrics, skin, and locomotor
have been rewritten from scratch.
We have incorporated new chapters on the eyes, the obstetric
assessment.
The ‘important presentations’ section of each systems chapter has been
greatly expanded and referenced to our sister publications the Oxford
Handbooks Clinical Tutor Study Cards.
The practical procedures chapter has been significantly expanded and
updated.
The photographs throughout the book have been updated to reflect
modern healthcare dress codes.

There is a brand new chapter on ‘other investigations’ so that the reader
can understand what is involved in common tests and how to prepare
patients for them.
Finally, the chapter order has been changed to highlight the import­ance of
the ‘core’ system examinations of the cardiovascular, respiratory, abdominal, and nervous systems.
As always, we welcome any comments and suggestions for improvement
from our reader—this book, after all, is for you.
James D Thomas
Tanya M Monaghan
203


vi

Acknowledgements
We would like to record our thanks to the very many people who have
given their advice and support since the publication of the first edition.
For contributing specialist portions of the book, we thank Dr Caroline
Bodey (Paediatrics), Dr Stuart Cohen (Skin, hair, and nails), Dr John Blakey
(Respiratory), Dr A Abhishek (Locomotor) and Mr Venki Sundaram and Mr
Farid Afshar (Eyes).
Once again, the elderly pages have been penned by the peerless Dr
Richard Fuller who remains a steadfast supporter and is much appreciated.
This edition builds on the work of contributors to the first edition whose
efforts deserve to be recorded again. Thanks then to Heid Ridsdale, Franco
Guarasci, Jeremy Robson, Lyn Dean, Jonathan Bodansky, Mandy Garforth,
and Mike Gaell.
For this edition, Michelle Jie, Muhammad Umer, and Dr Sandeep Tiwari
kindly posed for new and updated photographs. Their bravery made the
process easy and enjoyable. Our continued gratitude goes to our original

models, Adam Swallow, Geoffrey McConnell, and our anonymous female
model. We thank the staff at the Nottingham University Hospitals Medical
Photography Department, in particular Nina Chambers for taking the
photographs.
Additional diagrams for this edition, including the skin pictures, have
been drawn by Dr Ravi Kothari and we thank him for his speedy and
high-quality work.
As well as contributing some material for the procedures chapter, Dr
Yutaro Higashi has remained a grounding force during this process. His wisdom and sagely advice throughout have been much appreciated.
Finally, we would like to thank the staff at Oxford University Press for
originally trusting us with this project, especially Catherine Barnes and
Elizabeth Reeves for their faith, support, and guidance.


vii

Contents
How to use this book  ix
Contributors  x
Symbols and abbreviations  xi
 Communication skills  
2 The history  2
3 General and endocrine examination  4
4 Skin, hair, and nails  75
5 The cardiovascular system  99
6 The respiratory system  39
7 The abdomen  67
8 The nervous system  24
9 The eyes  307
0The locomotor system  349

The ear, nose, and throat  399
2The male reproductive system  42
3The female reproductive system  437
4The obstetric assessment  463
5The breast  48
6The psychiatric assessment  497


viii

Contents

7The paediatric assessment  525
8Practical procedures  557
9Clinical data interpretation  663
20Other investigations  705
Index  735


ix

How to use this book
The systems chapters
In each chapter, there are suggestions as to what questions to ask and how to
proceed depending on the presenting complaint. These are not exhaust­ive and
are intended as guidance. The history parts of each chapter should be used in
conjunction with C
­ hapter 2 to build a full and thorough history.

Practical procedures

This chapter describes those practical procedures that the junior doctor or
senior nurse may be expected to perform. Some should only be performed
once you have been trained specifically in the correct technique by a more
senior colleague.

Reality versus theory
In describing the practical procedures, we have tried to be ‘realistic’. The
methods described are the most commonly used across the profession and
are aimed at helping the reader perform the procedure correctly and safely
within a clinical environment.
There may be slight differences, therefore, between the way that a small
number of the procedures are described here and the way that they are
taught in a clinical skills laboratory. In addition, local trusts may use different
equipment for some procedures. The good practitioner should be flexible
and make changes to their routine accordingly.

Data interpretation
A minority of the reference ranges described for some of the biochemical
tests in the data interpretation chapter may differ very slightly from those
used by your local laboratory—this is dependent on the equipment and
techniques used for measurement. Any differences are likely to be very
small indeed. If in doubt, check with your local trust.


x

Contributors
Dr A Abhishek
Consultant Rheumatologist,
Cambridge University Hospitals NHS Trust,

Cambridge, UK

Mr Farid Afshar
Specialty Registrar in Ophthalmology,
Severn Deanery, UK

Dr John Blakey
Senior Clinical Lecturer and Honorary Consultant in Respiratory Medicine,
Liverpool School of Tropical Medicine,
University of Liverpool,
Liverpool, UK

Dr Caroline Bodey
Specialist Registrar in Paediatric Neurodisability,
Leeds, UK

Dr Stuart N Cohen
Consultant Dermatologist,
Nottingham University Hospitals NHS Trust,
Nottingham, UK

Dr Richard Fuller
Associate Professor and Honorary Consultant Physician,
Leeds Institute of Medical Education,
University of Leeds,
Leeds, UK

Mr Venki Sundaram
Specialty Registrar in Ophthalmology,
London Deanery,

London, UK


xi

Symbols and
abbreviations
i
d
n
2
7
E
0
M
ABG
ACL
ACSM
ACTH
ADH
ADP
AED
AITFL
AMD
AMTS
ANCOVA
ANOVA
ANTT
AP
APC

APH
APKD
APL
AS
ASD
ASIS
ATFL
ATLS
ATP
AV
AVN
a-vO2 diff
BLa
BMD

increased
decreased
normal
this fact or idea is important
approximately
cross-reference
warning
website
arterial blood gas
anterior cruciate ligament
American College of Sports Medicine
adrenocorticotrophic hormone
antidiuretic hormone
adenosine diphosphate
automated external defibrillator

anterior inferior tibiofibular ligament
age-related macular degeneration
Abbreviated Mental Test Score
analysis of covariance
analysis of variance
aseptic non-touch technique
antero-posterior
argon plasma coagulation
ante-partum haemorrhage
adult polycystic kidney disease
antiphospholipid
ankylosing spondylitis
atrial septal defect
anterior superior iliac spine
anterior talofibular ligament
advanced trauma life support
adenosine triphosphate
atrioventricular
avascular necrosis
arterio venous difference in oxygen concentration
blood lactate
bone mineral density


xii

Symbols and abbreviations

BMI
BMR

BPV
BSL
CABG
CAH
CDC
CFL
CHD
CHF
CHO
CISS
CJD
CKD
CMCJ
CNS
CON
COPD
CP
CP
CPAP
CP-IRSA
CPK
CPN
CPPD
CPR
CRP
CRVO
CSF
CT
CTD
CVD

DCO
DCS
DEXA
DIPJ
DKA
DLCO
DM
DVT

body mass index
basal metabolic rate
benign postural vertigo
British Sign Language
coronary artery bypass graft
congenital adrenal hyperplasia
Centers for Disease Control
calcaneofibular ligament
congenital heart disease
congestive heart failure
carbohydrate
Comité International des Sports des Sourds
Creutzfeldt–Jakob disease
chronic kidney disease
carpometacarpal joint
central nervous system
concentric
chronic obstructive pulmonary disease
cerebral palsy 
creatine phosphate
continuous positive airways pressure 

Cerebral Palsy International Sport and Recreation
Association
creatine phosphokinase
community psychiatric nurse
calcium pyrophosphate dihydrate deposition disease
cardio-pulmonary resuscitation
C-reactive protein
central retinal vein occlusion
cerebrospinal fluid
computed tomography
connective tissue disease
cardiovascular disease
doping control officer
diffuse cerebral swelling
dual energy x-ray absorptiometry
distal interphalangeal joint
diabetic ketoacidosis
carbon monoxide diffusion capacity
diabetes mellitus
deep vein thrombosis


Symbols and abbreviations

ECC
ECG
ECRB
ECRL
ECU
EDD

EEA
EIA
EIB
EMG
EMR
ENMG
EPB
EPO
ESR
ESRD
ET
ETT
EVH
EWS
FABER
FBC
FCU
FDS
FeCO2
FeO2
FEV
FHR
FHx
FiO2
FNA
FPL
FSH
FVC
GA
GAD

GALS
GCA
GCS
GFR
GH

eccentric
electrocardiogram
extensor carpi radialis brevis
extensor carpi radialis longus
extensor carpi ulnaris
estimated date of delivery
energy expenditure for activity
exercise-induced asthma
exercise-induced bronchospasm
electromyography
endoscopic mucosal resection
electoneuromyography
extensor pollicis brevis
erythropoietin 
erythrocyte sedimentation rate
end stage renal disease
endotracheal
exercise tolerance test
eucapnic voluntary hyperpnoea
early warning score
flexion abduction external rotation
full blood count
flexor carpi ulnaris
flexor digitorum superficialis

expired air carbon dioxide concentration
expired air oxygen concentration
forced expiratory volume in first second
fetal heart rate
family history
fraction of inspired oxygen
fine needle aspiration
flexor policis longus
follicle stimulating hormone
forced vital capacity
general anaesthetic
generalized anxiety disorder
gait, arms, legs, spine
giant cell arteritis
Glasgow Coma Scale
glomerular filtration rate
growth hormone

xiii


xiv

Symbols and abbreviations

GnRH
GOJ
GORD
GTN
Hb

HCC
hCG
Hct
HDL
HE
HHT
HIS
HMB
HR
HRT
HT
IA
IBD
ICP
IGF-
IHCD
IHD
IIH
IJV
IMB
INO
INR
IUCD
IOC
IOP
IPJ
ITB
ITBFS
IVP
IZ

JVP
LBC
LDH
LDL
LH
LMA

gonadotrophin releasing hormone
gastro-oesophageal junction
gastro-oesophageal reflux disease
glyceryl trinitrate
haemoglobin
hepatocellular carcinoma
human chorionic gonadotropin
haematocrit
high density lipoprotein
hepatic encephalopathy
hereditary haemorrhagic telangiectasia
International Headache Society
beta-hydroxy-beta-methylbutyrate
heart rate
hormone replacement therapy
highly trained
intra-arterial
inflammatory bowel disease
intracranial pressure
insulin-like growth factor 
Institute of Health and Care Development
ischaemic heart disease
idiopathic intracranial hypertension

internal jugular vein
intermenstrual bleeding
internuclear ophthalmoplegia
international normalized ratio
intra-uterine contraceptive device
International Olympic Committee
intraocular pressure
interphalangeal joint
ilio-tibial band
ilio-tibial band friction syndrome
intravenous pyelogram
injury zone
jugular venous pressure
liquid-based cytology
lactate dehydrogenase
low density lipoprotein
luteinizing hormone
laryngeal mask airway


Symbols and abbreviations

LMN
lower motor neuron
LMP
last menstrual period
LOC
loss of consciousness
LRT
lower respiratory tract

LSE
left sternal edge
LV
left ventricle
LVH
left ventricular hypertrophy
MANOVA multivariate analysis of the variance
MCD
minimal change disease
MCL
medial collateral ligament
MCPJ
metacarpophalangeal joint
MCS
microscopy, culture, and sensitivity
MDI
metered dose inhaler
MDT
multi-disciplinary team
MELD
model for end-stage liver disease
MEN
multiple endocrine neoplasia
MG
myasthenia gravis
MI
myocardial infarction
MMSE
Mini-Mental State Examination
MPHR

maximum predicted heart rate
MRI
magnetic resonance imaging
MRSA
methicillin-resistant Staphylococcus aureus
MSU
mid-stream urine sample
MTPJ
metatarsophalangeal joint
MUST
Malnutrition Universal Screening Tool
NASH
non-alcoholic steatohepatitis
NGB
National Governing Body
NIV
non-invasive ventilation
NPL
no perception of light
NSAIDs
non-steroidal anti-inflammatory drugs
NSF
nephrogenic systemic fibrosis
OA
osteoarthritis
OCD
osteochondritis dissecans
OCP
oral contraceptive pill
OGD

oesophagogastroduodenoscopy
OHCM9 Oxford Handbook of Clinical Medicine 9th ed.
OHCS9 Oxford Handbook of Clinical Specialties 9th ed.
ORIF
open reduction and internal fixation
OSA
obstructive sleep apnoea
OTC
over-the-counter
PC
presenting complaint

xv


xvi

Symbols and abbreviations

PCL
posterior cruciate ligament
PCOS
polycystic ovary syndrome
PCR
phospho-creatine (energy system)
PCS
post-concussion syndrome
PDA
patent ductus arteriosus
PEFR

peak expiratory flow rate
PFJ
patello-femoral joint
Pi
inorganic phosphate
PIN
posterior interosseous nerve
PIPJ
proximal interphalangeal joint
PMH
past medical history
PNF
proprioneurofacilitation
POMS
profile of mood states
PPH
post-partum haemorrhage
PRICE
protection, rest, ice, compression, elevation
PSC
primary sclerosing cholangitis
PSIS
posterior superior iliac crest
PSYM
parasympathetic
PTFL
posterior talofibular ligament
PTH
parathyroid hormone
PTHrP

parathyroid hormone related protein
PV per vaginam
Q
cardiac output
QID
four times a day (quater in die)
QSART
quantitative sudomotor axon reflex tests
RA
rheumatoid arthritis
RAPD
relative afferent pupillary defect
RBBB
right bundle branch block
RCC
red cell count
ROM
range of movement
RPE
retinal pigment epithelium
RR
respiratory rate
RSO
resting sweat output
RTA
road traffic accident
RV
residual volume
SA
sinoatrial

SAH
subarachnoid haemorrhage
SAID
specific adaptations to imposed demand
SARA
sexually acquired reactive arthritis
SBAR
situation, background, assessment, recommendation
SBP
spontaneous bacterial peritonitis


Symbols and abbreviations

SCAT
SCBU
SEM
SFJ
SIJ
SLAP
SLE
SLR
SOB
SPECT
STD
SV
SVCO
SYM
TAVI
TBI

TFCC
TGA
TLac
TLC
TNF-α
TOE
TUE
UCL
ULTT
UMN
URT
URTI
US
UT
UV
VA
VE
VEGF
VI
VIP
VMO
VO2
VT
WADA
WCC

Standardised Concussion Assessment Tool
special care baby unit
sports and exercise medicine
sapheno-femoral junction

sacro-iliac joint
superior labrum anterior to posterior
systemic lupus erythematosus
straight leg raise
shortness of breath
single photon emission computed tomography 
sexually transmitted disease
stroke volume
superior vena cava obstruction
sympathetic
transcatheter aortic valve implantation
traumatic brain injury
triangular fibrocartilage complex
transposition of the great arteries
lactate threshold (aerobic/anaerobic threshold)
total lung capacity
tumour necrosis factor alpha
trans-oesophageal echo
therapeutic use exemption
ulnar collateral ligament
upper limb tension test
upper motor neuron
upper respiratory tract
upper respiratory tract infection
ultrasound
untrained
ultraviolet
alveolar ventilation
minute ventilation
vascular derived growth factor

visually impaired
vasoactive intestinal polypeptide
vastus medialis obliquus
oxygen uptake
ventricular tachycardia
World Anti-Doping Agency
white cell count

xvii



Chapter 

Communication skills
Introduction  2
Essential considerations  4
General principles  8
Body language: an introduction  0
Interpreters  2
Communicating with deaf patients  3
Telephone communication  4
Other specific situations  5
Breaking bad news  6
Law, ethics, and consent  8

1


2

Introduction

Introduction
Communication skills are notoriously hard to teach and describe. There
are too many possible situations that one might encounter to be able to
draw rules or guidelines. In addition, your actions will depend greatly on the
personalities present, not least of all your own.

Using this chapter
Throughout this chapter, there is some general advice about communicating
in different situations and to different people. We have not provided rules
to stick to, but rather tried to give the reader an appreciation of the great
many ways the same situation may be tackled.
Ultimately, skill at communication comes from practice and a large
amount of common sense.
A huge amount has been written about communication skills in medicine.
Most is a mix of accepted protocols and personal opinion—this chapter is
no different.

Patient-centred communication
In recent years, there has been a significant change in the way healthcare
workers interact with patients. The biomedical model has fallen out of
favour. Instead, there is an appreciation that the patient has a unique experience of the illness involving the social, psychological, and behavioural effects
of the disease.
The biomedical model
• Doctor is in charge of the consultation.
• Focus is on disease management.
The patient-centred model (see also Box .)
• Power and decision-making is shared.

• Address and treat the whole patient.

Box .  Key points in the patient-centred model
• Explore the disease and the patient’s experience of it:
• Understand the patient’s ideas and feelings about the illness
• Appreciate the impact on the patient’s quality of life and
psychosocial well-being
• Understand the patient’s expectations of the consultation.
• Understand the whole person:
• Family
• Social environment
• Beliefs.
• Find common ground on management
• Establish the doctor–patient relationship
• Be realistic:
• Priorities for treatment.
•Resources.


1  Communication skills
Introduction

Becoming a good communicator
Learning
As in all aspects of medicine, learning is a lifelong process. One part of this,
particularly relevant to communication skills and at the beginning of your
career, is watching others.
The student should take every opportunity to observe doctor–patient
and other interactions. Look carefully at how patients are treated by staff
that you come across and consider every move that is made . . . is that something that you could try yourself ? Would you like to be treated in that way?

You should ask to be present during difficult conversations.
Instead of glazing over during consultations in clinic or on the ward round,
you should watch the interaction and consider if the behaviours you see are
worth emulating or avoiding. Consider how you might adjust your future
behaviour.
‘Cherry-pick’ the things you like and use them as your own—building up
your own repertoire of communication techniques.
Spontaneity versus learnt behaviours
If you watch a good communicator (in any field) you will see them making
friendly conversation, spontaneous jokes, and using words and phrases that
put people at ease. It seems natural, relaxed, and spontaneous.
Watching that same person interact with someone else can shatter the
illusion as you see them using the very same ‘spontaneous’ jokes and other
gambits from their repertoire.
This is one of the keys to good communication—an ability to judge the
situation and pull the appropriate phrase, word, or action from your internal
catalogue. If done well, it leads to a smooth interaction with no hesitations
or misunderstandings. The additional advantage is that your mental processes are free to consider the next move, mull over what has been said,
or consider the findings, whilst externally you are partially on ‘auto-pilot’.
During physical examination, this is particularly relevant. You should be
able to coax the wanted actions from the patient and put them at ease
whilst considering the findings and your next step.
It must be stressed that this is not the same as lacking concentration—
quite the opposite, in fact.

3


4

Essential considerations

Essential considerations
Attitudes
Patients are entrusting their health and personal information to you—they
want someone who is confident, friendly, competent, and above all, is trustworthy. See Box .2 for notes on confidentiality.

Personal appearance
First impressions count—and studies have consistently shown that your
appearance (clothes, hair, make-up) has a great impact on the patients’
opinion of you and their willingness to interact with you. Part of that intangible ‘professionalism’ comes from your image.
The white coat is no longer part of the medical culture in the UK.
National guidance has widely been interpreted as ‘bare below the elbow’
with no long sleeves or jewellery. This does not mean that you should look
scruffy, however. Many hospitals are now adopting uniforms for all their
staff which helps solve some potential appearance issues. Fashions in clothing change rapidly but some basic rules still apply:
• Ensure you have a good standard of personal hygiene.
• Any perfume or deodorant should not be overpowering
• Many people believe men should be clean-shaven. This is obviously
impossible for some religious groups and not a view shared by the
authors. Facial hair should, however, be clean and tidy.
• Neutralize any extreme tastes in fashion that you may have.
• Men should usually wear a shirt. If a tie is worn, it should be tucked
into the shirt when examining patients.
• Women may wear skirts or trousers but the length of the skirts
should not raise any eyebrows.
• The belly should be covered—even during the summer.
• The shoulders, likewise, should usually be covered.
• Shoes should be polished and clean.
• Clean surgical scrubs may be worn if appropriate.

• Hair should be relatively conservatively styled and no hair should be
over the face. It is advised to wear long hair tied up.
• Your name badge should be clearly visible—worn at the belt or on a
lanyard around the neck is acceptable depending on hospital policy.
• Note that lanyards should have a safety mechanism which will allow
them to break open if pulled hard. Most hospitals supply these—be
cautious about using your own lanyard from a shop or conference
• Wearing a name badge at the belt means people have to look at
your crotch – not necessarily ideal!
• Stethoscopes are best carried—worn at the neck is acceptable but a
little pretentious, according to some views.
• Try not to tuck items in your belt—use pockets or belt-holders for
mobile phones, keys, and wallets.
2 Psychiatry, paediatrics, and a handful of other specialties require a different dress code as they deal with patients requiring differing techniques
to bond.


1  Communication skills
Essential considerations

Timing
If in a hospital setting, make sure that your discussion is not during an
allocated quiet time—or immediately before one is to start! You should
also avoid mealtimes or when the patient’s long-lost relative has just come
to visit.
2 If taking the patient from the bedside, ask the supervising doctor (if
not you) and the nursing staff—and let all concerned know where you have
gone in case the patient is needed.

Setting

Students, doctors, and others tend to see patients on busy wards which
provide distractions that can break the interaction. Often this is necessary
during the course of a busy day. However, if you are intending to discuss a
matter of delicacy requiring concentration on both your parts, consider the
following conditions:
• The room should be quiet, private, and free from disturbances.
• There should be enough seating for everyone.
• Chairs should be comfortable enough for an extended conversation.
• Arrange the seats close to yours with no intervening tables or other
furniture.

Box .2  Confidentiality
As a doctor, healthcare worker, or student, you are party to personal and
confidential information. There are certain rules that you should abide by
and times when confidentiality must or should be broken. The essence
for day-to-day practice is:
Never tell anyone about a patient unless it is directly
related to their care.
This includes relatives. Withholding information from family can be very
difficult at times, particularly if a relative asks you directly about something confidential.
You can reinforce the importance of confidentiality to relatives and visitors. If asked by a relative to speak to them about a patient, you should
approach the patient and ask their permission, preferably within view of
the relative.
This rule also applies to friends outside of medicine. As doctors and
others, we come across many amazing, bizarre, amusing, or uplifting stor­
ies on a day-to-day basis but, like any other kind of information, these
should not be shared with anyone, however juicy the story is.
If you do intend to use an anecdote for some after-dinner entertainment, at the very least you should ensure that there is nothing in your
story that could possibly lead to the identification of the person or persons involved.

5


6

Essential considerations

Avoid medical jargon
The problem is that medics are so immersed in jargon that it becomes part
of their daily speech. The patient may not understand the words or may
have a different idea as to the meaning.
Technical words such as ‘myocardial infarction’ are in obvious need of
avoidance or explanation. Consider terms such as ‘exacerbate’, ‘chronic’,
‘numb’, and ‘sputum’—these may seem obvious in meaning to you but
not to the patient. Be very careful to tease out the exact meaning of any
pseudo-medical terms that the patient uses.
You may also think that some terms such as ‘angina’ and ‘migraine’ are
well known—but these are very often misinterpreted.

Fear-words
There are certain words which immediately generate fear, such as ‘cancer’
and ‘leukaemia’. You should only use these if you are sure that the patient
wants to know the full story.
Beware, however, of avoiding these words and causing confusion by not
giving the whole story.
You should also be aware of certain words that people will instinctively
assume mean something more serious. For example, to most people a
‘shadow’ on the lung means cancer. Don’t then use the word when you are
talking about consolidation due to pneumonia!

The importance of silence
In conversations that you may have with friends or colleagues, your aim is to
avoid silence using filler noises such as ‘um’ and ‘ah’ whilst pausing.
In medical situations, silences should be embraced and used to extract
more information from the patient. Use silence to listen.
Practice is needed as the inexperienced may find this uncomfortable. It
is often useful, however, to remain silent once the patient has answered
your question. You will usually find that they start speaking again—and often
impart useful and enlightening facts.

Remember the name
Forgetting someone’s name is what we all fear but is easy to disguise by
simple avoidance. However, the use of a name will make you seem to be
taking a greater interest. It is particularly important that you remember the
patient’s name when talking to family. Getting the name wrong is embarrassing and seriously undermines their confidence in you.
Aside from actually remembering the name, it is a good idea to have it
written down and within sight—either on a piece of paper in your hand or
on the desk, or at the head of the patient’s bed. To be seen visibly glancing
at the name is forgivable.

Standing
Although this might be considered old-fashioned by some younger people,
standing is a universal mark of respect. You should always stand when a
patient enters a room and take your seat at the same time as them. You
should also stand as they leave but, if you have established a good rapport
during the consultation, this isn’t absolutely necessary.