Clinical Method

The four things to hold in mind with every patient MACLEOD’S p21

A — AttitudeHow would I feel in this patient’s situation?

B — BehaviourAlways treat patients with kindness and respect.

C — CompassionRecognise the human story that accompanies each illness.

D — DialogueListen to and acknowledge the patient.

“The best doctors are humble and recognise that humans are infinitely more complex, demanding and fascinating than one can imagine. They understand that much so-called medical ‘wisdom’ is at best incomplete, and often simply wrong.” — p22

Confidentiality, consent, and the notes MACLEOD’S p21

Information is confidential EVEN AFTER a patient’s death. The exceptions: where failure to disclose would put the patient or someone else at risk of death or serious harm, or where disclosure might assist prevention, detection or prosecution of a serious crime. ⚠ In that situation, contact the senior doctor in charge of the patient’s care immediately. Never discuss patients where you can be overheard, or leave records — paper or on screen — where other patients, unauthorised staff or the public can see them. ⚠ Even with signed consent to disclose, only disclose what is being asked for. If in doubt, discuss your report with the patient so he knows what is going to a third party. The case notes are a LEGAL DOCUMENT that could be used in a court of law. Record findings immediately after the consultation. And the patient can ask for and receive access to them — write accordingly.

Yourself — personal responsibilities MACLEOD’S p22

Register with a GP. Do not self-diagnose and self-treat. If you might have a condition you could pass to patients, or one that could affect your judgement or performance, consult your GP and follow the advice. Be immunised (e.g. hepatitis B). Do not use your position to pursue a sexual or improper emotional relationship with a patient or someone close to them. Do not give medical care to anyone with whom you have a close personal relationship. Do not express personal political, religious or moral beliefs in ways that exploit vulnerability or cause distress. ⚠ If a patient under your care has suffered harm or distress: act immediately to put it right, APOLOGISE, and explain fully and promptly what happened and its likely effects. Complaints are often the result of a breakdown in communication. Do not allow a complaint to adversely affect the care you provide.

Dress, and hand hygiene MACLEOD’S p22–23

Bare below the elbows: short or three-quarter sleeves, or roll long sleeves up away from the wrists, before examining or doing procedures — so you can clean your hands effectively. Tie back long hair. Keep jewellery simple and limited. Name badge readable — not at your waist. Smart, sensitive, modest; expressing your personality is not the point. Ask patients how they would prefer to be addressed — many older patients prefer not to be called by their first name. “Hand washing is the single most effective way to prevent the spread of infection.” — p23. Healthcare-acquired infections complicate up to 10% of hospital admissions. 🔑 The rule that actually gets forgotten: alcohol gel removes most organisms — but for INFLUENZA, NOROVIRUS and CLOSTRIDIUM DIFFICILE you must use liquid soap and water. Alcohol does not do it. Visibly soiled hands → soap and water always. Gloves whenever you may contact blood, mucous membranes or non-intact skin.

Tips for effective conversations MACLEOD’S Box 2.3, p25

Speak clearly and audibly	Do not use jargon or emotive words
Ask open questions to start with	Find out about your patient as a person
Don’t interrupt your patient	Clarify and summarise what you understand — you may need to do this more than once
Try and appear unhurried	Make sure the story makes sense to you — keep seeking facts until it does
Use silence to encourage explanations	Acknowledge emotions
Seek ideas, concerns and expectations	Negotiate mutual goals

“A consultation is a meeting of two experts: you as the clinician and the patient as an expert on his own body and mind.” — p22 ⚠ Poor communication skills are associated with increased medicolegal vulnerability AND clinician burnout. Macleod’s does not treat this as a soft skill. 🔑 And the concrete way to improve it, from p22: video yourself consulting with a patient (with informed signed consent) and review it with a senior clinician.

Why people actually come MACLEOD’S Box 2.1, p25

• They have reached their limits of TOLERANCE
• They have reached their limits of ANXIETY
• They have problems of daily living presenting as symptoms
• For prevention
• For administrative reasons “All patients seek explanation and meaning for their symptoms. You need to work out why the patient has come to see you, what he is most concerned about, and then agree with him the best course of action.” — p25

Mine — why this box is worth more than it looks Two of the five reasons are not about the disease at all. A symptom present for months that arrives today usually arrives because tolerance or anxiety ran out — not because the pathology changed. “Why today?” is a diagnostic question, and it is in no symptom mnemonic.

Beginning, and breaking bad news MACLEOD’S p25–30

Read the records and any transfer or admission letters BEFORE you see the patient. Choose a quiet, private space. ⚠ Macleod’s on hospital privacy: “privacy may be afforded only by curtains, which means no privacy at all.” Then: how long you have · how you will sit · non-verbal communication · active listening · empathy · the patient’s context. SPIKES Box 2.7, p30 Setting — privacy, people, and you: be calm and attentive · Perception — what your patient already knows · Invitation — what does the patient want to know? · Knowledge — warn the patient that you have bad news · Empathy — acknowledge and address emotions · Summary and strategy — the patient knows and agrees the next steps.

①② Identifying data and reliability BATES’ p38–39

Identifying data — age, gender, marital status, occupation. And the SOURCE of the history: usually the patient, but it may be a family member, a friend, a letter of referral, or the clinical record. Identify the source of referral too, because a written report may be needed and it tells you the quality of the information you were given. Reliability — “varies according to the patient’s memory, trust, and mood.” Document it, and ⚠ make the judgement at the END of the interview, not the start.
Bates’ own examples: “The patient is vague when describing symptoms, and the details are confusing” or “The patient is a reliable historian.”

MineThis is the field everyone omits, and it is the one that tells the next reader how much weight to put on everything else in the note.

③ Chief complaint BATES’ p39

“Make every attempt to quote the patient’s own words.” Bates’ example: “My stomach hurts and I feel awful.”
If there is no specific complaint, report the reason for the visit — “I have come for my regular check-up”. Date and time. ⚠ “The date is always important. Be sure to document the TIME you evaluate the patient, especially in urgent, emergent, or hospital settings.”

④ Present illness — and the SEVEN ATTRIBUTES BATES’ p39

A complete, clear and chronologic description: the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date.

The seven attributes of a symptom

① Location · ② Quality · ③ Quantity or severity · ④ Timing — onset, duration and frequency · ⑤ The SETTING in which it occurs · ⑥ Aggravating and relieving factors · ⑦ Associated manifestations ⚠ Note what Bates’ has that SOCRATES does not: “the SETTING in which it occurs”. Not the site — the circumstances. What was happening in his life, where he was, what he was doing. And note what it drops: RADIATION, which SOCRATES makes explicit.

Then — pertinent positives and negatives “Query the ‘pertinent positives’ and ‘pertinent negatives’ drawn from sections of the Review of Systems that are relevant to the Chief Complaint. The presence or absence of these additional symptoms helps you generate the differential diagnosis, which includes the most likely and, at times, the most serious diagnoses, even if less likely, which could explain the patient’s condition.” — p39

🔑 Read that last clause again — it is the “must not miss” rule, in Bates’, sourced:
the MOST LIKELY diagnoses — and the MOST SERIOUS, even if less likely.
Two piles, and they are not the same pile. You treat the likely one and you investigate the serious one.

Also in the present illness: relevant risk factors (coronary risk factors in chest pain; current medications in syncope) · the patient’s responses to the symptoms and what effect the illness has had on his life · and ⚠ “each symptom merits its own paragraph and a full description.” Medications, allergies, tobacco, alcohol — Bates’ puts these HERE, in the present illness Medications — name, dose, route and frequency. Plus home remedies, non-prescription drugs, vitamins, mineral and herbal supplements, oral contraceptives.
Allergies — ⚠ “including specific reactions to each medication, such as rash or nausea”; also foods, insects, environmental factors.
Tobacco — in pack-years. Bates’ worked example: 1½ packs a day for 12 years = an 18 pack-year history. If he has quit, note for how long.
Alcohol and drug use — “should always be investigated”.

⑤ Past history — four named categories BATES’ p40

Childhood illnesses — measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, polio, plus any chronic childhood illness. Adult illnesses, with dates, in FOUR areas:

Medical	Diabetes, hypertension, hepatitis, asthma, HIV; hospitalisations; number and gender of sexual partners; risk-taking sexual practices
Surgical	Dates, indications, and types of operation
Obstetric / gynaecologic	Obstetric history, menstrual history, contraception, sexual function
Psychiatric	Illness and time frame, diagnoses, hospitalisations, treatments

Health maintenance — immunisations (tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza, varicella, hepatitis B, HPV, meningococcus, Hib, pneumococcus, herpes zoster) and screening tests (tuberculin, cervical smear, mammogram, faecal occult blood, colonoscopy, cholesterol) with results and dates. If he does not know, written permission may be needed to obtain prior records.

⑥⑦ Family history · Personal and social history BATES’ p40–41

Family history — outline or DIAGRAM the age and health, or age and cause of death, of parents, grandparents, siblings, children and grandchildren. Then record present or absent for: hypertension, coronary artery disease, raised cholesterol, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, allergies. Ask specifically about breast, ovarian, colon and prostate cancer, and about genetically transmitted disease. Personal and social history — Bates’ treats this as far more than habits: “captures the patient’s personality and interests, sources of support, coping style, strengths, and concerns.”
Occupation and last year of schooling · home situation and significant others · sources of stress, recent and long-term · important life experiences (military service, job history, financial situation, retirement) · leisure · religious affiliation and spiritual beliefs · activities of daily living — and ⚠ “baseline level of function is particularly important in older or disabled patients” · exercise and diet · safety: seat belts, helmets, sunblock, smoke detectors · sexual orientation and practices · alternative health practices. “Avoid restricting the Personal and Social History to only tobacco, drug, and alcohol use.” — p41 🔑 And a technique note: “you will learn to intersperse personal and social questions throughout the interview to make the patient feel more at ease.” It is not a block to be got through at the end.

⑧ Review of systems BATES’ p41–43

How Bates’ says to run it: these are yes/no questions, at the END of the interview, working head to toe. With experience they take no more than a few minutes.
🔑 And the line to actually say out loud: “The next part of the history may feel like a hundred questions, but it is important to make sure we have not missed anything.”
For each system, ask: “Have you ever had any…?”

⚠ Two rules that matter more than the list:
• Pertinent positives and negatives get pulled FORWARD into the present illness. After a full description of chest pain, Bates’ example is to ask about high blood pressure, palpitations, shortness of breath, ankle swelling — or move into the respiratory or GI review.
• “Major health events discovered during the Review of Systems should be MOVED to the Present Illness or Past History in your write-up.” The review is a net, not a filing location.

System	Ask about
General	Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, fever
Skin	Rashes, lumps, sores, itching, dryness, colour change; hair and nails; changes in size or colour of moles
Head	Headache, head injury, dizziness, lightheadedness
Eyes	Vision, glasses or lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts
Ears	Hearing, tinnitus, vertigo, earache, infection, discharge; if hearing is decreased, use or non-use of hearing aids
Nose and sinuses	Frequent colds, stuffiness, discharge, itching, hay fever, nosebleeds, sinus trouble
Mouth and throat	Teeth and gums, bleeding gums, dentures and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness
Neck	“Swollen glands”, goitre, lumps, pain, stiffness
Breasts	Lumps, pain or discomfort, nipple discharge, self-examination practices
Respiratory	Cough, sputum (colour, quantity, blood), dyspnoea, wheezing, pleuritic pain, last chest x-ray; asthma, bronchitis, emphysema, pneumonia, tuberculosis
Cardiovascular	“Heart trouble”, high blood pressure, rheumatic fever, murmurs, chest pain, palpitations, dyspnoea, orthopnoea — “need to use pillows at night to ease breathing”, paroxysmal nocturnal dyspnoea — “need to sit up at night to ease breathing”, oedema, past ECGs
Gastrointestinal	Trouble swallowing, heartburn, appetite, nausea; bowel movements, stool colour and size, change in habit, pain on defecation, rectal bleeding or black tarry stools, haemorrhoids, constipation, diarrhoea; abdominal pain, food intolerance, belching or wind; jaundice, liver or gallbladder trouble, hepatitis
Peripheral vascular	Claudication, leg cramps, varicose veins, past clots, swelling in calves/legs/feet, colour change in fingertips or toes in cold weather, swelling with redness or tenderness
Urinary	Frequency, polyuria, nocturia, urgency, burning or pain, haematuria, infections, kidney or flank pain, stones, ureteric colic, suprapubic pain, incontinence; in men: reduced calibre or force of stream, hesitancy, dribbling
Genital — male	Hernias, discharge or sores on the penis, testicular pain or masses, scrotal pain or swelling, sexually transmitted infections and treatment; sexual habits, interest, function, satisfaction, contraception, condom use; concerns about HIV
Genital — female	Age at menarche, regularity, frequency, duration and amount of bleeding; bleeding between periods or after intercourse; last menstrual period; dysmenorrhoea, premenstrual tension; age at menopause, menopausal symptoms, postmenopausal bleeding; vaginal discharge, itching, sores, lumps; STIs and treatment; number of pregnancies, number and type of deliveries, abortions spontaneous and induced, complications; contraception; sexual preference, interest, function, satisfaction, dyspareunia; concerns about HIV
Musculoskeletal	Muscle or joint pain, stiffness, arthritis, gout, backache. If present: location, swelling, redness, pain, tenderness, stiffness, weakness, limitation of motion; TIMING (morning or evening), duration, any trauma. Neck or low back pain. Joint pain WITH systemic symptoms — fever, chills, rash, anorexia, weight loss, weakness
Psychiatric	Nervousness, tension, mood including depression, memory change, suicidal ideation, plans or attempts; past counselling, psychotherapy, or psychiatric admission
Neurologic	Changes in mood, attention or speech; orientation, memory, insight, judgement; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles”, tremor or other involuntary movements, seizures
Haematologic	Anaemia, easy bruising or bleeding, past transfusions and transfusion reactions
Endocrine	“Thyroid trouble”, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size

Mine — the phrasings in that table worth stealing verbatim Bates’ converts jargon into what patients actually understand: orthopnoea becomes “do you need to use pillows at night to ease your breathing?” · PND becomes “do you need to sit up at night to ease your breathing?” · weight loss becomes “does your clothing fit more loosely than before?” · and acromegaly becomes “any change in your glove or shoe size?” Those are better questions than the technical terms, and they are printed in the book.

① First decide WHICH examination you are doing BATES’ p35

COMPREHENSIVE assessment	FOCUSED assessment
Appropriate for NEW patients, in the office or hospital	Appropriate for ESTABLISHED patients, especially routine or urgent-care visits
Provides fundamental and personalised knowledge about the patient	Addresses focused concerns or symptoms
Strengthens the clinician–patient relationship	Assesses symptoms restricted to a specific body system
Helps identify or rule out physical causes related to the patient’s concerns	Applies the examination methods relevant to that concern as thoroughly and carefully as possible
Provides a BASELINE for future assessments
Creates a platform for health promotion
Develops proficiency in the essential skills of physical examination

Bates’ names four things that decide the scope: the magnitude and severity of the patient’s problems · the need for thoroughness · the clinical setting (inpatient or outpatient, primary or subspecialty) · and the time available. “Skill in all the components of a comprehensive assessment allows you to select the elements that are most pertinent to the patient’s concerns, yet meet clinical standards for best practice and diagnostic accuracy.” — Bates’ p35

Mine — the sentence above is the whole answer to “do I do all of it?” You learn the comprehensive examination so that you can safely do a focused one. The short version is only defensible if you know what you chose to leave out and why. That is why Bates’ lists “develops proficiency” as a benefit of the comprehensive exam in its own right.

② The three goals that generate the sequence BATES’ p49

“The key to a thorough and accurate physical examination is developing a systematic sequence… Organize your comprehensive or focused examination around three general goals.”

②a — Maximise the patient’s comfort

②b — Avoid unnecessary changes in position🔑 This is the one that generates the whole route, and it is why Bates’ sequence is organised by POSITION rather than by system.

②c — Enhance clinical efficiency

“In general, move from head to toe.” Some segments are best done sitting (head and neck, thorax and lungs); others supine (cardiovascular, abdominal). ⚠ Bates’ says the same thing Macleod’s does about the route being personal: “clinicians vary in where they place different segments, especially musculoskeletal and nervous system… with practice, you will develop your own sequence.” Two independent standard texts, same message. Stop looking for the one true order.

③ Examine from the patient’s RIGHT side — and the reasons BATES’ p50

Bates’ calls this the standard position, and gives four concrete advantages over the left: • Estimates of jugular venous pressure are more reliable
• The palpating hand rests more comfortably on the apical impulse
• The right kidney is more frequently palpable than the left
• Examining tables are usually positioned for a right-handed approach ⚠ “Left-handed students are encouraged to adopt right-sided positioning, even if it may seem awkward.” The left hand can still percuss, or hold the otoscope or reflex hammer.

④ THE ROUTE — one pass, organised by position BATES’ Fig. 1-6, p50–53

Get the patient into a position. Do EVERYTHING that belongs in that position. Then move them — once.
Four positions for a whole patient. That is the entire efficiency gain, and it is what makes an experienced examination look fast.

The route is Bates’. The “what you are collecting” lines are assembled from Macleod’s sign meanings and standard content — not printed as one table in either book.

📌 POSITION 1 — SITTING (and from the patient’s RIGHT)

General survey & vital signsGeneral state of health, height, build. Posture, motor activity, GAIT. Dress, grooming, hygiene. Odours of body or breath — ketones, fetor hepaticus, uraemia, alcohol. Facial expression, manner, affect. Speech and level of consciousness.
BP · pulse · respiratory rate · temperature. Add: sats and inspired oxygen · capillary glucose.
⚠ And look around the bed: oxygen and how much, catheter and what is in the bag, drips, drains, pumps, mobility aids, sputum pot.

Hands — and this one stop covers seven systemsRespiratory — clubbing, tar staining, CO₂ flap, peripheral cyanosis, small muscle wasting. Cardiac — clubbing, splinter haemorrhages, Osler’s nodes, Janeway lesions, pulse: rate, rhythm, character, volume, capillary refill. Liver — leuconychia, palmar erythema, Dupuytren’s, asterixis. Haematological — koilonychia, pale palmar creases, bruising. Rheumatological — joint swelling and deformity, nail pitting, sclerodactyly. Neurological — wasting, fasciculation, and characterise any tremor: resting (parkinsonian) · postural (essential, thyrotoxic) · intention (cerebellar). Renal — AV fistula, thrill and bruit.
🔑 One manoeuvre, four systems: arms out, wrists cocked back, hold 15 seconds. A flap = CO₂ retention, hepatic encephalopathy, uraemia, or severe heart failure.

Skin — upper torso, front and backMoisture, dryness, temperature. Lesions: location, distribution, arrangement, type, colour. Hair and nails. Both surfaces of the hands.

HEENTFace — malar flush (mitral stenosis), cushingoid or acromegalic features, myxoedematous facies, parotid swelling, asymmetry, the expression itself (the mask of Parkinson’s, or pain).
Eyes — acuity and fields; alignment; lids (ptosis: Horner’s, third nerve, myasthenia); lower lid down for conjunctival pallor; sclerae for jaundice; xanthelasma and corneal arcus; cornea, iris, lens; pupils and their reactions; extraocular movements; fundi.
Ears — auricles, canals, drums, acuity; Weber and Rinne if diminished.
Nose and sinuses.
Mouth and pharynx — central cyanosis is seen UNDER the tongue, not at the lips; ulcers and mucositis; candidiasis (steroids, inhalers, immunosuppression); glossitis; angular stomatitis; dentition — a source of bacteraemia in endocarditis. ⚠ But a dry tongue is an unreliable sign of dehydration (Macleod’s p77) — it happens in mouth breathing.

Neck — thyroid and lymph nodesTrachea — deviated by upper lobe collapse, large effusion, tension pneumothorax. Thyroid — ask him to swallow.
Lymph nodes, properly, once: from behind — submental, submandibular, preauricular, tonsillar, supraclavicular, deep cervical; scalene nodes with your index finger between sternocleidomastoid and clavicle, head tilted to the SAME side, pressing down to the first rib. From the front — posterior triangles, back of the neck, posterior auricular, occipital.
🔑 Consistency discriminates: soft = normal · rubbery = Hodgkin’s · matted = TB · hard = metastatic cancer. Normal adult nodes <0.5 cm.

Musculoskeletal, upper limbs — as indicatedHands, arms, shoulders, neck, temporomandibular joints. Inspect, palpate, range of motion. You may also do upper limb bulk, tone, strength and reflexes here, or leave them to the end.

Thorax and lungs — posterior chest while he is sittingInspect — chest shape and symmetry, scars (sternotomy, thoracotomy, drain sites), pacemaker box, accessory muscles, respiratory pattern.
Palpate — expansion. Percuss — all zones, left against right. Auscultate — breath sounds, added sounds, vocal resonance.
⚠ While he is forward: press down the spine, check the SACRUM for oedema, and look at the pressure areas. All free, all skipped.

BreastsIn a woman: inspect with arms relaxed, then elevated, then hands pressed on the hips. Palpate. Macleod’s: let her replace her bra before you move to the abdomen.

📌 POSITION 2 — SUPINE, HEAD OF BED AT 30°

CardiovascularJVP — measured against the sternal angle. Raised in fluid overload, right heart failure, tamponade, PE, SVC obstruction.
Carotids — pulsation and upstroke character (slow-rising in aortic stenosis), and bruits.
Precordium — inspect and palpate; apical impulse: location, diameter, amplitude, duration; heaves and thrills.
Auscultate — each area with the diaphragm, then apex and lower sternal border with the bell. S1, S2 and physiological splitting of S2. Extra sounds and murmurs.

Anterior thorax and lungs · axillae and epitrochlear nodesAnterior chest if not completed sitting. Feel the axillae — right axilla with your left hand and vice versa; fingertips to the apex, then draw down the medial, anterior and posterior walls. Epitrochlear nodes.

🔑 Two position changes, each for one specific murmur — do them here or you will not hear them BATES’ p50
📌 Roll partly onto the LEFT SIDE → the S3, and the murmur of MITRAL STENOSIS
📌 SIT FORWARD → the murmur of AORTIC INSUFFICIENCY

📌 POSITION 3 — SUPINE, FLAT

Abdomen — note Bates’ orderInspect → AUSCULTATE → percuss → palpate lightly → palpate deeply. ⚠ Auscultation comes BEFORE palpation so handling does not alter bowel sounds.
Inspect — distension, scars, stomas, dilated veins, striae, masses, hernial orifices (“cough for me”).
Kneel to his level. Ask “does anywhere hurt?”. Palpate all nine regions LIGHTLY while watching HIS FACE, not your hand. Then deeply.
Organs — liver and spleen by percussion then palpation; try to palpate the kidneys; palpate the aorta and its pulsations.
Percuss — liver span, shifting dullness, suprapubic dullness = a full bladder. Renal angle tenderness if you suspect kidney infection.

Peripheral vascular & skin of the lower bodyOedema — press over the shin 5 seconds, and note how far up. Pulses — dorsalis pedis and posterior tibial. Temperature, colour, capillary refill, hair loss. Ulcers and their site — arterial at pressure points, venous at the medial malleolus, neuropathic on the sole. The diabetic foot. Calves.

Musculoskeletal & nervous system, lower limbs — same visit, same limbDeformities, enlarged joints, range of motion. Then bulk, tone, power 0–5 MRC, sensation, reflexes and plantars, and any abnormal movements.
🔑 Why pair them: a cold pulseless foot and a foot with absent ankle reflexes look identical from the end of the bed. Doing vascular and neurological in one visit is what separates them, and it costs no extra time.

📌 POSITION 4 — STANDING

The things only visible standingVaricose veins — invisible lying down.
Spine — alignment and range of motion; alignment of the legs; the feet.
Male genitalia and hernias.
Gait — and then heel-to-toe walking, on the toes, on the heels, hopping in place, shallow knee bends, Romberg, and pronator drift.

📌 AS INDICATED — left lateral, or lithotomy Rectal and prostate in men — left lateral, or standing and bending forward. Genital and rectal in women — lithotomy, with a chaperone. PR is indicated in GI bleeding, anaemia, constipation, and any cauda equina concern. 📌 FINISH — and this is Macleod’s ending, deliberately kept Blood pressure (postural if falls or volume depletion are in question) · temperature · height and weight — and weigh serially if fluid balance matters · URINALYSIS.
⚠ Bates’ front-loads the vital signs, which means urinalysis has no natural home and gets forgotten. Macleod’s Box 3.2 ends here instead. Keep the ending — a urine dip costs nothing and answers infection, diabetes, renal disease and haematuria in under a minute. ⚠ The patient who cannot sit up: Bates’ instruction is to roll him onto each side to listen to the lungs, examine the back and inspect the skin, then roll back and finish supine.

⑤ The two routes compared — and what that tells you BATES’ MACLEOD’S

Macleod’s Box 3.2 (p61)	Bates’ Fig. 1-6 (p50)
Organised peripheral to central, by region	Organised by PATIENT POSITION
Hands → face → neck → thorax → abdomen → lower limbs → upper limbs → cranial nerves	Everything sitting → everything at 30° → everything supine → everything standing
Ends with BP, temperature, height/weight, urinalysis	Starts with general survey and vital signs
Neurology split between the limbs	Neurology optionally consolidated at the end
No explicit side of the bed	Explicitly from the patient’s RIGHT, with reasons
No positional cardiac manoeuvres	Left lateral for S3/mitral stenosis; sitting forward for aortic insufficiency

🔑 What they AGREE on is the part that is actually essential:
• Have a fixed routine — both say so explicitly, and both say there is no single correct one
• Head to toe, broadly
• Inspection → palpation → percussion → auscultation within each segment
• Minimise how often you move the patient
• The route becomes automatic, and that is the point — Bates’: “over time, this sequence will become habitual and remind you to return to segments you may have skipped”

Mine — which one to actually use Use Bates’ positional structure and Macleod’s ending. Positional grouping is the better organising principle — it is why an experienced examination looks fast, and it is what you have been watching consultants do. But keep Macleod’s habit of finishing with the numbers and the urine dip, which Bates’ front-loads and which therefore gets forgotten.

Before you start MACLEOD’S p61

The setting: privacy is essential — curtains obscure vision but not sound. Warm, well-lit room. Natural light: subtle abnormalities such as mild jaundice are easier to detect in it. Adjustable couch height with a step; adjustable backrest, particularly for breathless patients who cannot lie flat. Exposure and dignity: seek permission; expose sensitively but adequately; cover the rest with a blanket. Macleod’s specific example: let a female patient replace her bra after the chest examination before you examine her abdomen. Tactfully ask relatives to leave — unless the patient is apprehensive, needs a translator, or requests otherwise. Parents should always be present when you examine children. Chaperone: always offer one for any intimate examination. Record the chaperone’s name and presence. If declined, respect it and record that too. Box 3.1 — equipment for a full examination Stethoscope · pen torch · measuring tape · ophthalmoscope · otoscope · sphygmomanometer · tendon hammer · tuning fork · cotton wool · disposable Neurotips · wooden spatula · thermometer · magnifying glass · accurate scales and a height measure · disposable gloves · facilities for blood samples and urinalysis.

Lumps and swellings — the assessment scheme MACLEOD’S p70–72

Size	Measure it accurately, preferably with callipers, so change over time is detectable
Position	Obvious in breast, thyroid, parotid; less so in the abdomen. Multiple lumps → neurofibromatosis, skin metastases, lipomatosis, lymphoma
Attachments	Attachment to deeper structures is common in malignant disease
Consistency	Soft to ‘stony’ hard. Very hard → malignant, calcified, or dense fibrous tissue. Fluctuation → fluid (abscess, cyst, blister) or a soft encapsulated tumour such as lipoma
Edge	🔑 An indefinite margin suggests INFILTRATING MALIGNANCY; a clearly defined edge suggests a BENIGN tumour. Enlarged organs usually have definable margins
Surface and shape	The liver is smooth in acute hepatitis but often NODULAR in metastatic disease
Pulsation	Aneurysms and vascular tumours pulsate; others may transmit pulsation from a vessel beneath. Increased flow → bruit, and if loud enough a palpable thrill
Inflammation	Redness (vasodilatation) · tenderness — inflammatory lumps are tender, whereas lipomas, skin metastases and neurofibromas are characteristically PAINLESS · warmth from increased blood flow, also in rapidly growing tumours
Transillumination

Lymph nodes MACLEOD’S p72–74

What the findings mean Size: normal adult nodes are <0.5 cm. · Attachments: fixed to deep structures or skin suggests malignancy. · Tenderness: acute viral or bacterial infection — infectious mononucleosis, dental sepsis, tonsillitis.

🔑 Consistency is the discriminator:
SOFT = normal · ‘RUBBERY’ = Hodgkin’s disease · ‘MATTED’ = tuberculosis · HARD = metastatic cancer

Examination sequence Inspect for visible lymphadenopathy. Palpate one side at a time, using the fingers of each hand in turn, and compare with the contralateral side. Assess site, size, fixation (to deep structures and to skin), consistency and tenderness. Cervical — patient sitting. From BEHIND: submental, submandibular, preauricular, tonsillar, supraclavicular and deep cervical nodes in the anterior triangle. Scalene nodes: index finger between sternocleidomastoid and clavicle, ask the patient to tilt his head to the SAME side, and press firmly down towards the first rib. From the FRONT: posterior triangles, up the back of the neck, and the posterior auricular and occipital nodes. Axillary: from the front or side, palpate the right axilla with your LEFT hand and vice versa. Place your fingertips into the apex, then draw them downwards, feeling the medial, anterior and posterior axillary walls in turn.

Hydration MACLEOD’S p77

⚠ Two signs everyone relies on, that Macleod’s says are unreliable:
SKIN TURGOR — “loss of skin turgor occurs in severe dehydration, but adults can lose 4–6 litres before the skin becomes dry and loose.”
A DRY TONGUE — “an unreliable indicator of dehydration, since it often occurs in mouth breathing.”

“It is easy to underestimate the severity of dehydration.” Assess hydration in all patients, especially with vomiting, diarrhoea, sweating, burns, polyuria, or raised ambient temperature. What is actually useful: tachycardia is a common feature · low BP, and POSTURAL hypotension may indicate intravascular volume depletion · and if you know his usual weight, WEIGH HIM — Macleod’s names this specifically as useful information. Then oedema: generalised (fluid overload, hypoproteinaemia) · localised (venous, lymphatic, inflammatory, allergic) · postural.

Mine — the practical consequence Weight and the fluid balance chart beat the bedside signs. If turgor only becomes abnormal after 4–6 litres of loss, a patient can be seriously dry with “normal turgor” written in the notes. Postural BP and serial weights are what would actually have caught it.

Also in this chapter MACLEOD’S p68–81

The hands (deformity, colour, temperature, skin, finger clubbing, joints, muscles) · the tongue · weight and height (nutritional status, vitamin deficiencies, obesity, weight loss, short and tall stature — including Marfan’s: tall stature with reduced upper:lower segment ratio, arachnodactyly, high-arched palate, upward lens dislocation, mitral valve prolapse and aortic root dilatation with regurgitation) · temperature (fever, hypothermia).

This list is much shorter than it was in v2, because checking the book removed four items from it. What remains is real.

① Likelihood ratios, systematically — McGee, Evidence-Based Physical Diagnosis Macleod’s discusses the reliability of signs in prose and has an evidence-based-examination strand, but it does not tabulate likelihood ratios sign by sign. A sign is a diagnostic test: LR+ above 10 is often conclusive; LR near 1 is NO information, and treating it as reassurance is how patients come to harm.
Earn their place: third heart sound for LV dysfunction · raised JVP · pulsus paradoxus >12 mmHg for tamponade · absent flank dullness (rules ascites out) · reduced or delayed carotid upstroke · a sensory level · asterixis · Dix–Hallpike (diagnostic, and treatable at the bedside with Epley).
Survive on tradition alone: Homans’ sign · tactile fremitus and vocal resonance · rebound tenderness · routine carotid auscultation in the asymptomatic · the annual complete physical in a well adult.
⚠ Look every LR up before quoting it. Never cite one from memory.

② POCUS — the fifth pillar Inspection · palpation · percussion · auscultation · ULTRASOUND. Not in a 2013 examination text; now embedded in US internal-medicine curricula. It beats the classical sign for ascites, pleural effusion, LV function, volume status, hydronephrosis, bladder volume, DVT, pneumothorax and tamponade.
⚠ Operator-dependent; needs formal training and credentialing.

③ The problem-oriented record — Weed, NEJM 1968 Macleod’s covers documenting the case notes (p49) but not Weed’s structure: a numbered problem list, most urgent first, each stated at the level of certainty you actually have.
✓ “Hyponatraemia” ✗ “SIADH” (which requires euvolaemia AND normal renal function before you may say it)
Each problem: most likely … because … · also consider · must not miss · what would discriminate · plan.

④ The presentation format — Bowen, NEJM 2006;355(21):2217–2225 “This is a [age]-year-old [man/woman] with [background], presenting with [symptom] for [duration]. Key positives are [three]; importantly he does not have [two negatives]. On examination, [findings that matter]. My impression is [diagnosis], because [two facts]. I’m also considering [second] and [third]. My main concern is [must-not-miss], so I’d like to [the test that excludes it].” That opening sentence is a “problem representation”; the paired descriptors are “semantic qualifiers” (Bordage & Lemieux). Using them is a measured difference between expert and novice reasoning.

⑤ The threshold approach to testing — Pauker & Kassirer, NEJM 1980 · Choosing Wisely Every test must answer a question you can say out loud. Then: “if this comes back normal, does anything change?” If no, do not send it. A test is worth doing only if the result could move you across a treatment or no-treatment threshold.

⑥ Clinical decision rules Wells · PERC · Ottawa ankle and knee · CENTOR · HEART · CHA₂DS₂-VASc · CURB-65 · NEWS2. Post-date or sit outside a general examination text.

⑦ Where the tools themselves are biased Pulse oximetry overestimates saturation in darker skin — roughly threefold more occult hypoxaemia (Sjoding, NEJM 2020, so seven years after this edition). Directly relevant to this patient population. Most dermatology teaching also shows signs on white skin.

Removed from this list on verification — Macleod’s DOES cover these Cognitive bias and anchoring (p61, quoted in Part 2) · ICE (p31, under effects on lifestyle) · summarising and reflecting back (p37, “Putting it all together”) · a pathology-type sieve (Box 2.9, keyed to time course rather than to anatomy) · SPIKES for breaking bad news (Box 2.7) · CAGE and FAST for alcohol.
I claimed all of these were gaps in v2. They are not.

Not from Macleod’s general chapters. This is the additional history a cancer admission needs. The oncological history Date and mode of diagnosis · histology and grade · molecular and biomarker profile · stage then and now · every line of treatment with dates and response · current treatment and its INTENT (curative / adjuvant / palliative / symptom control) · date of the last chemotherapy dose · previous radiotherapy and to which field · previous surgery. Performance status — record the number, and what it was a month ago

ECOG		Karnofsky
0	Fully active	100
1	Restricted in strenuous activity; ambulatory, light work possible	80–90
2	Ambulatory, self-caring, up more than 50% of waking hours, cannot work	60–70
3	Limited self-care, in bed or chair more than 50% of waking hours	40–50
4	Completely disabled, confined to bed or chair	10–30

Performance status decides eligibility for treatment more often than the tumour does. Screen for these on EVERY admission Neutropenic sepsis — temperature ≥38°C with recent chemotherapy means antibiotics within one hour, before the count comes back · Metastatic spinal cord compression — back pain, weakness, sensory level, sphincter change → dexamethasone + WHOLE-spine MRI, treated in hours · Hypercalcaemia — always correct for albumin · SVC obstruction · Raised intracranial pressure · Tumour lysis syndrome · Malignant bowel obstruction · VTE. And the conversation What he understands · what he wants to know · resuscitation status and ceiling of care · preferred place of care · is palliative care involved, and if not, why not.

✓ Verified against Macleod’s Clinical Examination, 13th ed (2013), SECTION 1 — read end to end Ch. 1 Approach to the patient (p20–23) — Box 1.1 (GMC duties), Box 1.2 (hand-transmitted infections), the ABCD framework; quoted passages p21, p22, p23.
Ch. 2 History taking (p24–49) — Box 2.1 (why people visit), Box 2.3 (effective conversations), Box 2.4 (BASICS), Box 2.7 (SPIKES), Box 2.8 (terms to clarify), Box 2.9 (pathology type), Box 2.10 (SOCRATES), Boxes 2.23–2.25 (alcohol, CAGE, FAST), Box 2.28 (systematic enquiry); quoted passages p25, p30, p31, p37.
Ch. 3 The general examination (p60–81) — Box 3.1 (equipment), Box 3.2 (examination sequence), first impressions (p61–67), lumps and swellings (p70–72), lymph nodes and their examination sequence (p72–74), weight/height and Marfan’s (p74–76), hydration (p77), oedema and temperature (p77–81); quoted passages p61, p77. Deliberately out of scope: Ch. 4–14 (the system chapters) and Ch. 15–21 (children, frail elderly, febrile adult, anaesthesia, critically ill, confirming death, OSCEs). Nothing in this book is drawn from them. ✓ Verified against source — primary papers

Citation	Finding
Hampton JR et al. BMJ 1975;2(5969):486. PMID 1148666	Diagnosis agreeing with the final one after referral letter + history in 66/80 (82.5%); examination useful in 7, laboratory in a further 7
Peterson MC et al. West J Med 1992;156:163–165. PMID 1536065	History 61/80 (76%), examination 10 (12%), laboratory 9 (11%). Confidence 7.1→8.2 after examination — examination CONFIRMS and EXCLUDES rather than generates
Singh Ospina N et al. J Gen Intern Med 2019;34(1):36–40	Agenda invited in 40/112 (36%); of those interrupted in 27 (67%) at median 11 s
Bowen JL. N Engl J Med 2006;355(21):2217–2225	Source of problem representation
Weed LL. N Engl J Med 1968;278(11):593–600	The Problem-Oriented Medical Record

✓ Verified against Bates’ Guide to Physical Examination, 12th ed — Ch. 1 p35 — the Comprehensive versus Focused assessment table, and the four factors that set the scope. p49 — “The Comprehensive Physical Examination: Sequence of Examination”, the three goals, and the cardinal techniques. p50 — examining from the patient’s right side with its four stated reasons; Figure 1-6, the sequence organised by patient position. p51–53 — the head-to-toe narrative including the positional cardiac manoeuvres and the standing examination. ⚠ This corrects an earlier overclaim. I asserted three times that Bates’ formalises comprehensive versus focused before having the book. It does — but the claim was unverified when I made it, which is the same failure that produced the Macleod’s errors below. It is now checked. ⚠ Read but NOT yet mined — the one real gap Bates’ Chapter 3, “Interviewing and the Health History” (p95–138), has NOT been read. That is Bates’ own treatment of the consultation — the interviewing skills, the questions about alcohol and drug use it cross-references, and its handling of difficult situations. Part 2 of this book therefore still runs on Macleod’s communication material (BASICS, Box 2.3, SPIKES), which is verified and good, but is not Bates’. If the spine is to be Bates’ end to end, that chapter is the remaining work. ⚠ Still NOT verified All Talley, Hutchison’s, OHCM and McGee attributions — those books are not in hand. ClinicalKey carries Talley and McGee. · Pauker & Kassirer NEJM 1980 · Sjoding NEJM 2020 · NASEM 2015 · Cochrane general health checks — concepts certain, citation details from recall. ⚠ And every single likelihood ratio in Part 5 — look each one up in McGee. Never quote an LR from memory. Every error corrected by reading the book 1. Systematic enquiry — my list was wrong. Macleod’s folds eyes and ENT into the nervous system, mood and sleep into general health, lumps skin and bleeding as “Other”, and carries an explicit men/women split I had omitted entirely.
2. Examination sequence (Box 3.2) — lower limbs BEFORE upper limbs, cranial nerves near the END, breasts within the thorax, no separate “back” step, and it finishes with BP, temperature, height/weight and URINALYSIS. I had none of that.
3. “The order never changes” — overstated. Macleod’s: “there is no single correct way… a regular routine reduces errors of omission.”
4. SOCRATES — headed “characteristics of pain”, but the book explicitly extends the principles to dizziness and breathlessness. My correction had overshot in the other direction.
5. Six things I wrongly claimed Macleod’s omits: cognitive bias (p61) · ICE (p31) · summarising and reflecting back (p37) · a pathology-type sieve (Box 2.9) · SPIKES (Box 2.7) · and its own consultation framework, BASICS (Box 2.4). All present.
6. “Systematic” enquiry, not “systemic”.
7. Hydration — I had listed a dry mouth and skin turgor as checks. Macleod’s says a dry tongue is unreliable (mouth breathing) and turgor changes only after 4–6 litres of loss.
8. The symptom-specific table in v2 was invented. It has been removed rather than patched; the per-system enquiries live in Ch. 4–14, which are out of scope here.

Afterwards — where the learning actually happens Every miss is one of exactly three things. Name which, every time:

1 · I didn’t lookA discipline problem. Fix the routine, not your knowledge. Macleod’s: “a regular routine reduces errors of omission.”

2 · I looked and didn’t seeA perceptual problem. Fix by volume — examine more patients who have signs.

3 · I didn’t knowA knowledge problem. Read that one specific thing tonight.

Most people never separate these, so they go home and read a textbook when the real problem was that they never percussed the chest.

How this book is built

The four things to hold in mind with every patient MACLEOD’S p21

Confidentiality, consent, and the notes MACLEOD’S p21

Yourself — personal responsibilities MACLEOD’S p22

Dress, and hand hygiene MACLEOD’S p22–23

BASICS — Macleod’s own consultation framework BOX 2.4, p25

Tips for effective conversations MACLEOD’S Box 2.3, p25

Why people actually come MACLEOD’S Box 2.1, p25

Beginning, and breaking bad news MACLEOD’S p25–30

The eight components, in order BATES’ p38

①② Identifying data and reliability BATES’ p38–39

③ Chief complaint BATES’ p39

④ Present illness — and the SEVEN ATTRIBUTES BATES’ p39

The seven attributes of a symptom

⑤ Past history — four named categories BATES’ p40

⑥⑦ Family history · Personal and social history BATES’ p40–41

⑧ Review of systems BATES’ p41–43

① First decide WHICH examination you are doing BATES’ p35

② The three goals that generate the sequence BATES’ p49

③ Examine from the patient’s RIGHT side — and the reasons BATES’ p50

④ THE ROUTE — one pass, organised by position BATES’ Fig. 1-6, p50–53

What this route is FOR — and when to stop and go deep

⑤ The two routes compared — and what that tells you BATES’ MACLEOD’S

Before you start MACLEOD’S p61

⚠ Macleod’s covers cognitive bias — I said in v2 that it did not

Lumps and swellings — the assessment scheme MACLEOD’S p70–72

Lymph nodes MACLEOD’S p72–74

Hydration MACLEOD’S p77

Also in this chapter MACLEOD’S p68–81

Commit in writing BEFORE you open the chart

Patient / date

One-liner

Pathology type (Box 2.9) — from onset + progression

Problem list — most urgent first

Top diagnosis

Differential

Must not miss

What doesn’t fit

Investigations — max 5, and the question each answers

Confidence in top diagnosis