N 5. Medical examination. Out-patient treatment. Simple Tenses. Active and Passive Voice.
Physical examination or clinical examination is the process by which a health care provider investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.
Although providers have varying approaches as to the sequence of body parts, a systematic examination generally starts at the head and finishes at the extremities. After the main organ systems have been investigated by inspection, palpation, percussion and auscultation, specific tests may follow (such as a neurological investigation, orthopedic examination) or specific tests when a particular disease is suspected (e.g. eliciting Trousseau’s sign in hypocalcemia).
With the clues obtained during the history and physical examination the healthcare provider caow formulate a differential diagnosis, a list of potential causes of the symptoms. Specific diagnostic tests (or occasionally empirical therapy) generally confirm the cause, or shed light on other, previously overlooked, causes.
Whilst the format of examination as listed below is largely as taught and expected of students, a specialist will focus on their particular field and the nature of the problem described by the patient. Hence a cardiologist will not in routine practice undertake neurological parts of the examination other thaoting that the patient is able to use all four limbs on entering the consultation room and during the consultation become aware of their hearing, eyesight and speech. Likewise an Orthopaedic surgeon will examine the affected joint, but may only briefly check the heart sounds and chest to ensure that there is not likely to be any contraindication to surgery raised by the anaesthetist. Non-specialists generally examine the genitals only upon request of the patient.
A complete physical examination includes evaluation of general patient appearance and specific organ systems. It is recorded in the medical record in a standard layout which facilitates others later reading the notes. In practice the Vital signs of Temperature examination, Pulse and Blood pressure are usually measured first.
Vital Signs
Temperature
Temperature recording gives an indication of core body temperature which is normally tightly controlled (thermoregulation) as it affects the rate of chemical reactions.
The main reason for checking body temperature is to solicit any signs of systemic infection or inflammation in the presence of a fever (temp >
Blood pressure
The blood pressure is recorded as two readings, a high systolic pressure which is the maximal contraction of the heart and the lower diastolic or resting pressure. Usually the blood pressure is taken in the right arm unless there is some damage to the arm. The difference between the systolic and diastolic pressure is called the pulse pressure. The measurement of these pressures is now usually done with an aneroid or electronic sphygmomanometer. The classic measurement device is a mercury sphygmomanometer, using a column of mercury measured off in millimeters. In the
Pulse
The pulse is the physical expansion of the artery. Its rate is usually measured either at the wrist or the ankle and is recorded as beats per minute. The pulse commonly is taken is the radial artery at the wrist. Sometimes the pulse cannot be taken at the wrist and is taken at the elbow (brachial artery), at the neck against the carotid artery (carotid pulse), behind the knee (popliteal artery), or in the foot dorsalis pedis or posterior tibial arteries. The pulse rate can also be measured by listening directly to the heartbeat using a stethoscope. The pulse varies with age. A newborn or infant can have a heart rate of about 130-150 beats per minute. A toddler‘s heart will beat about 100-120 times per minute, an older child’s heartbeat is around 90-110 beats per minute, adolescents around 80-100 beats per minute, and adults pulse rate is anywhere between 50 and 80 beats per minute. comment on pulse Rate 60-90 Rhythm regular-irregular force=systolic tension=diastolic volume=difference between the systolic & diastolic equality on both sides status of arterial wall.
Respiratory rate
Varies with age, but the normal reference range is 16-20 breaths/minute.
General medical examination
VIDEO
The general medical examination is a common form of preventive medicine involving visits to a general practitioner by asymptomatic adults on a regular basis. This is generally yearly or less frequently. It is known under several other names, such as the periodic health evaluation, annual physical, comprehensive medical exam, general health check, or preventive health examination.
The term is generally not meant to include visits for the purpose of newborn checks, Pap smears for cervical cancer, or regular visits for people with certain chronic medical disorders (for example, diabetes). The general medical examination generally involves a medical history, a (brief or complete) physical examination and sometimes laboratory tests. Some more advanced tests include ultrasound and mammography.
Usefulness
Although annual medical examinations are a routine practice in several countries, it is poorly supported by scientific evidence in the majority of the population. A 2012 Cochrane review did not find any benefit with respect to the risk of death or poor outcomes related to disease in those who received them. People who undergo yearly medical exams however are more likely to be diagnosed with medical problems.
Some notable health organisations recommend against annual examinations. The American Cancer Society recommends a cancer-related health check-up annually in men and women older than 40, and every three years for those older than 20.
A systematic review of studies until September 2006 concluded that the examination does result in better delivery of some other screening interventions (such as Pap smears, cholesterol screening, and faecal occult blood tests) and less patient worry. Evidence supports several of these individual screening interventions. The effects of annual check-ups on overall costs, patient disability and mortality, disease detection, and intermediate end points such a blood pressure or cholesterol, are inconclusive. A recent study found that the examination is associated with increased participation in cancer screening.
The lack of good evidence contrasts with population surveys showing that the general public is fond of these examinations, especially when they are free of charge. Despite guidelines recommending against routine annual examinations, many family physicians perform them. A fee-for-service healthcare system has been suggested to promote this practice. An alternative would be to tailor the screening interval to the age, sex, medical conditions and risk factors of each patient. This means choosing between a wide variety of tests.
The arguments for and against are similar for many other screening interventions. The possible advantages include detection and subsequent prevention or early treatment for conditions such as high blood pressure, alcohol abuse, smoking, unhealthy diet, obesity and various cancers. Moreover, they could improve the patient-physician relationship and decrease patient anxiety.
Prevalence
It is commonly performed in the
History
The roots of the periodic medical examination are not entirely clear. They seem to have been advocated since the 1920s. Some authors point to pleads from the 19th and early 20th century for the early detection of diseases like tuberculosis, and periodic school health examinations. The advent of medical insurance and related commercial influences seems to have promoted the examination, whereas this practice has been subject to controversy in the age of evidence-based medicine. Several studies have been performed before current evidence-based recommendation for screening were formulated, limiting the applicability of these studies to current-day practice.
Heart sounds
Heart sounds are the noises generated by the beating heart and the resultant flow of blood through it (specifically, the turbulence created when the heart valves snap shut). In cardiac auscultation, an examiner may use a stethoscope to listen for these unique and distinct sounds that provide important auditory data regarding the condition of the heart to a trained observer.
In healthy adults, there are two normal heart sounds often described as a lub and a dub (or dup), that occur in sequence with each heartbeat. These are the first heart sound (S1) and second heart sound (S2), produced by the closing of the AV valves and semilunar valves respectively. In addition to these normal sounds, a variety of other sounds may be present including heart murmurs, adventitious sounds, and gallop rhythms S3 and S4.
Heart murmurs are generated by turbulent flow of blood, which may occur inside or outside the heart. Murmurs may be physiological (benign) or pathological (abnormal). Abnormal murmurs can be caused by stenosis restricting the opening of a heart valve, resulting in turbulence as blood flows through it. Abnormal murmurs may also occur with valvular insufficiency (or regurgitation), which allows backflow of blood when the incompetent valve closes with only partial effectiveness. Different murmurs are audible in different parts of the cardiac cycle, depending on the cause of the murmur.
Front of thorax, showing surface relations of bones, lungs (purple), pleura (blue), and heart (red outline). The location of best auscultation for each heart valve are labeled with “M”, “T”, “A”, and “P”.
First heart sound: caused by atrioventricular valves – Mitral (M) and Tricuspid (T).
Second heart sound caused by semilunar valves — Aortic (A) and Pulmonary/Pulmonic (P)
Primary heart sounds
Normal heart sounds are associated with heart valves closing, causing changes in blood flow.
S1
The first heart tone, or S1, forms the “lub” of “lub-dub” and is composed of components M1 and T1. Normally M1 precedes T1 slightly. It is caused by the sudden block of reverse blood flow due to closure of the atrioventricular valves, i.e. tricuspid and mitral (bicuspid), at the beginning of ventricular contraction, or systole. When the ventricles begin to contract, so do the papillary muscles in each ventricle. The papillary muscles are attached to the tricuspid and mitral valves via chordae tendineae, which bring the cusps or leaflets of the valve closed (chordae tendineae also prevent the valves from blowing into the atria as ventricular pressure rises due to contraction). The closing of the inlet valves prevents regurgitation of blood from the ventricles back into the atria. The S1 sound results from reverberation within the blood associated with the sudden block of flow reversal by the valves. If M1 occurs slightly after T1, then the patient likely has a dysfunction of conduction of the left side of the heart such as a left bundle branch block.
S2
The second heart tone, or S2, forms the “dub” of “lub-dub” and is composed of components A2 and P2. Normally A2 precedes P2 especially during inspiration when a split of S2 can be heard. It is caused by the sudden block of reversing blood flow due to closure of the semilunar valves (the aortic valve and pulmonary valve) at the end of ventricular systole, i.e. beginning of ventricular diastole. As the left ventricle empties, its pressure falls below the pressure in the aorta. Aortic blood flow quickly reverses back toward the left ventricle, catching the pocket-like cusps of the aortic valve, and is stopped by aortic (outlet) valve closure. Similarly, as the pressure in the right ventricle falls below the pressure in the pulmonary artery, the pulmonary (outlet) valve closes. The S2 sound results from reverberation within the blood associated with the sudden block of flow reversal.
Splitting of S2, also known as physiological split, normally occurs during inspiration because the decrease in intrathoracic pressure increases the time needed for pulmonary pressure to exceed that of the right ventricular pressure. A widely split S2 can be associated with several different cardiovascular conditions, including right bundle branch block, pulmonary stenosis and atrial septal defect.
Diagram showing relations of opened heart to front of thoracic wall. Ant. Anterior segment of tricuspid valve. A O. Aorta. A.P. Anterior papillary muscle. In. Innominate artery. L.C.C. Left common carotid artery. L.S. Left subclavian artery. L.V. Left ventricle. P.A. Pulmonary artery. R.A. Right atrium. R.V. Right ventricle. V.S. Ventricular septum
Extra heart sounds
The rarer extra heart sounds form gallop rhythms and are heard in both normal and abnormal situations.
S3
Rarely, there may be a third heart sound also called a protodiastolic gallop, ventricular gallop, or informally the “Kentucky” gallop as an onomatopoeic reference to the rhythm and stress of S1 followed by S2 and S3 together (S1=Ken; S2=tuck; S3=y)(S1=Mon S2=TRE S3=AL).
“lub-dub-ta” or “slosh-ing-in” If new indicates heart failure or volume overload.
It occurs at the beginning of diastole after S2 and is lower in pitch than S1 or S2 as it is not of valvular origin. The third heart sound is benign in youth, some trained athletes, and sometimes in pregnancy but if it re-emerges later in life it may signal cardiac problems like a failing left ventricle as in dilated congestive heart failure (CHF). S3 is thought to be caused by the oscillation of blood back and forth between the walls of the ventricles initiated by blood rushing in from the atria. The reason the third heart sound does not occur until the middle third of diastole is probably that during the early part of diastole, the ventricles are not filled sufficiently to create enough tension for reverberation.
It may also be a result of tensing of the chordae tendineae during rapid filling and expansion of the ventricle. In other words, an S3 heart sound indicates increased volume of blood within the ventricle. An S3 heart sound is best heard with the bell-side of the stethoscope (used for lower frequency sounds). A left-sided S3 is best heard in the left lateral decubitus position and at the apex of the heart, which is normally located in the 5th left intercostal space at the midclavicular line.[2] A right-sided S3 is best heard at the lower-left sternal border. The way to distinguish between a left and right-sided S3 is to observe whether it increases in intensity with inspiration or expiration. A right-sided S3 will increase on inspiration whereas a left-sided S3 will increase on expiration.
An S3 corresponds to rapid ventricular filling during early diastole. It is caused by vibration of the ventricular wall when blood from the atrium hits the ventricular wall. It is heard just after S2 (just after the mitral valve opens and the aortic valve shuts). The third heart sound is low in frequency and intensity (hear better with the bell at the apex in the left lateral decubitus position). It may occur iormal children and young adults, especially if stroke volume is increased. After about 40 years of age an S3 should be considered abnormal; It is caused by conditions that increase the volume of ventricular filling during early diastole (e.g., mitral regurgitation), by filling into a ventricle with decreased compliance, or from filling into overfilled ventricles with large end-systolic volumes.
S4
S4 when audible in an adult is called a presystolic gallop or atrial gallop. This gallop is produced by the sound of blood being forced into a stiff/hypertrophic ventricle.
“ta-lub-dub” or “a-stiff-wall”
It is a sign of a pathologic state, usually a failing left ventricle, but can also be heard in other conditions such as restrictive cardiomyopathy. The sound occurs just after atrial contraction (“atrial kick”) at the end of diastole and immediately before S1, producing a rhythm sometimes referred to as the “
Under pathologic conditions, forceful atrial contraction (“atrial kick”) late in diastole can generates a low-frequency sound (S4) just before S1 (AKA the presystolic gallop). An S4 is common in adults older than 40 or 50 years because of reduced ventricular compliance (increase resistance to ventricular filling) during atrial contraction; A forceful atrial contraction into a hypertrophied, noncompliant ventricle almost always produces an early and easily audible S4. The severe
Atrial contraction must be present for production of an S4. It is absent in atrial fibrillation and in other rhythms in which atrial contraction does not precede ventricular contraction.
Murmurs
Auscultogram from normal and abnormal heart sounds from guyton&hall physiology
Heart murmurs are produced as a result of turbulent flow of blood, turbulence sufficient to produce audible noise. They are usually heard as a whooshing sound. The term murmur only refers to a sound believed to originate within blood flow through or near the heart; rapid blood velocity is necessary to produce a murmur. It should be noted that most heart problems do not produce any murmur and most valve problems also do not produce an audible murmur.
The following paragraphs overview the murmurs most commonly heard in adults who do not have major congenital heart abnormalities.
Regurgitation through the mitral valve is by far the most commonly heard murmur, producing a pansystolic/holosystolic murmur which is sometimes fairly loud to a practiced ear, even though the volume of regurgitant blood flow may be quite small. Yet, though obvious using echocardiography visualization, probably about 20% of cases of mitral regurgitation do not produce an audible murmur.
Stenosis of the aortic valve is typically the next most common heart murmur, a systolic ejection murmur. This is more common in older adults or in those individuals having a two, not a three leaflet aortic valve.
Regurgitation through the aortic valve, if marked, is sometimes audible to a practiced ear with a high quality, especially electronically amplified, stethoscope. Generally, this is a very rarely heard murmur, even though aortic valve regurgitation is not so rare. Aortic regurgitation, though obvious using echocardiography visualization, usually does not produce an audible murmur.
Stenosis of the mitral valve, if severe, also rarely produces an audible, low frequency soft rumbling murmur, best recognized by a practiced ear using a high quality, especially electronically amplified, stethoscope.
Other audible murmurs are associated with abnormal openings between the left ventricle and right heart or from the aortic or pulmonary arteries back into a lower pressure heart chamber.
Effects of inhalation/expiration
Inhalation pressure causes an increase in the venous blood return to the right side of the heart. Therefore, right-sided murmurs generally increase in intensity with inspiration. The increased volume of blood entering the right sided chambers of the heart restricts the amount of blood entering the left sided chambers of the heart. This causes left-sided murmurs to generally decrease in intensity during inspiration.
With expiration, the opposite haemodynamic changes occur. This means that left-sided murmurs generally increase in intensity with expiration. Having the patient lie supine and raising their legs up to a 45 degree angle facilitates an increase in venous return to the right side of the heart producing effects similar to inhalation-increased blood flow.
Interventions that change murmurs
There are a number of interventions that can be performed that alter the intensity and characteristics of abnormal heart sounds. These interventions can differentiate the different heart sounds to more effectively obtain a diagnosis of the cardiac anomaly that causes the heart sound.
Other abnormal sounds
Clicks: With the advent of newer, non-invasive imaging techniques, the origin of other, so-called adventitial sounds or “clicks” has been appreciated. These are short, high-pitched sounds.
Rubs: Patients with pericarditis, an inflammation of the sac surrounding the heart (pericardium), may have an audible pericardial friction rub. This is a characteristic scratching, creaking, high-pitched sound emanating from the rubbing of both layers of inflamed pericardium. It is the loudest in systole, but can often be heard at the beginning and at the end of diastole. It is very dependent on body position and breathing, and changes from hour to hour.
Recording heart sounds
Using electronic stethoscopes, it is possible to record heart sounds via direct output to an external recording device, such as a laptop or MP3 recorder. The same connection can be used to listen to the previously-recorded auscultation through the stethoscope headphones, allowing for more detailed study of murmurs and other heart sounds, for general research as well as evaluation of a particular patient’s condition.
Medical record
The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient’s medical history and care across time within one particular health care provider’s jurisdiction. The medical record includes a variety of types of “notes” entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.
The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein.
Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites. This concept is supported by US national health administration entities and by AHIMA, the American Health Information Management Association.
A medical record folder being pulled from the records
Because many consider information in medical records to be sensitive personal information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal. Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.
The history of the use of medical records is beyond the scope of this article. However a brief summary of the origins of the medical record in the West may be found at the following website: “History of medical record-keeping”, Casebooks Project (http://www.magicandmedicine.hps.cam.ac.uk/on-astrological-medicine/further-reading/history-of-medical-record-keeping/) (Accessed 2012-09-25).
Purpose
The information contained in the medical record allows health care providers to determine the patient’s medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient’s care.
The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.
Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.
Auxiliary purpose
In addition, the individual medical record anonymised may serve as a document to educate medical students/resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research.
A patient’s individual medical record identifies the patient and contains information regarding the patient’s case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient. Further information varies with the individual medical history of the patient.
The contents are written by medical providers, and patients until relatively recently had no say in what was contained in it. Recent advances in health care records privacy and access rules have generally provided for a patient’s right to review and have recorded in the medical record objections to the accuracy of certain entries.
Media applied
Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records are often archived offsite.
The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for medical research.
Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.
Medical history
The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease states. It includes several subsets detailed below.
Surgical history
The surgical history is a chronicle of surgery performed for the patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did.
Obstetric history
The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of these pregnancies.
Medications and medical allergies
The medical record may contain a summary of the patient’s current and previous medications as well as any medical allergies.
Family history
The family history lists the health status of immediate family members as well as their causes of death (if known). It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart. It is a valuable asset in predicting some outcomes for the patient.
Social history
The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos).
Habits
Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and sexual orientation.
Immunization history
The history of vaccination is included. Any blood tests proving immunity will also be included in this section.
Growth chart and developmental history
For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child’s growth over time. Many diseases and social stresses can affect growth and longitudinal charting and can thus provide a clue to underlying illness. Additionally, a child’s behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.
Medical encounters
Within the medical record, individual medical encounters are marked by discrete summations of a patient’s medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (POMR), which includes a problem list of diagnoses or a “SOAP” method of documentation for each visit. Each encounter will generally contain the aspects below:
Chief complaint
This is the main problem (traditionally called a complaint) that has brought the patient to see the doctor or other clinician. Information on the nature and duration of the problem will be explored.
History of the present illness
A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.
Physical examination
The physical examination is the recording of observations of the patient. This includes the vital signs , muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.
Assessment and plan
The assessment is a written summation of what are the most likely causes of the patient’s current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).
Orders and prescriptions
Written orders by medical providers are included in the medical record. These detail the instructions given to other members of the health care team by the primary providers.
Progress notes
When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are kept in chronological order and document the sequence of events leading to the current state of health.
Test results
The results of testing, such as blood tests (e.g., complete blood count) radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing (e.g., pulmonary function testing) are included. Often, as in the case of X-rays, a written report of the findings is included in lieu of the actual film.
Other information
Many other items are variably kept within the medical record. Digital images of the patient, flowsheets from operations/intensive care units, informed consent forms, EKG tracings, outputs from medical devices (such as pacemakers), chemotherapy protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.
There are several types of informatioeeded to be recorded while tracing the state of a patient’s daily health:
· vital signs: body temperature, pulse rate (heart rate), blood pressure and respiratory rate;
· intake: medication, fluid, nutrition, water and blood, etc.;
· output: blood, urine, excrement, vomitus, sweat, etc.;
· observation of pupil size;
· capability of four limbs of body.
Administrative issues
Medical records are legal documents, and are subject to the laws of the country/state in which they are produced. As such, there is great variability in rules governing production, ownership, accessibility, and destruction. There is some controversy regarding proof verifying the facts, or absence of facts in the record, apart from the medical record itself.
Demographics
Demographics include patient information that is not medical iature. It is often information to locate the patient, including identifying numbers, addresses, and contact numbers. It may contain information about race and religion as well as workplace and type of occupation. It may also contain information regarding the patient’s health insurance. It is common to also find emergency contacts located in this section of the medical chart.
Production
In the
Informational self-determination
The informational self-determination is a basic human right. Hence a patient’s record should belong to the patient, but it seldom happens so.
Ownership for patient’s record
Ownership and keeping of patient’s records varies from country to country.
In the
In the
German law and customs
In
Accessibility
In the
Capacity
When a patient does not have capacity (is not legally able) to make decisions regarding his or her own care, a legal guardian is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians have the ability to access the medical record in order to make medical decisions on the patient’s behalf. Those without capacity include the comatose, minors (unless emancipated), and patients with incapacitating psychiatric illness or intoxication.
Medical emergency
In the event of a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been previously drafted (such as an advance directive)
Research, auditing, and evaluation
Individuals involved in medical research, financial or management audits, or program evaluation have access to the medical record. They are not allowed access to any identifying information, however.
Risk of death or harm
Information within the record can be shared with authorities without permission when failure to do so would result in death or harm, either to the patient or to others. Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (i.e., information from illicit drug testing cannot be used to bring charges of possession against a patient). This rule was established in the United States Supreme Court case Jaffe v.
In the United Kingdom, the Data Protection Acts and later the Freedom of Information Act 2000 gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g., information from another family member or where a patient has asked for informatioot to be disclosed to third parties) or would be harmful to the patient’s wellbeing (e.g., some psychiatric assessments). Also, the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required.
Destruction
In general, entities in possession of medical records are required to maintain those records for a given period. In the
Abuses
The outsourcing of medical record transcription and storage has the potential to violate patient-physician confidentiality by possibly allowing unaccountable persons access to patient data.
Falsification of a medical record by a medical professional is a felony in most
Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.
Data Breach
Given the series of medical data breaches and the lack of public trust, some countries have enacted laws requiring safeguards to be put in place to protect the security and confidentiality of medical information as it is shared electronically and to give patients some important rights to monitor their medical records and receive notification for loss and unauthorized acquisition of health information. The
Patients’ medical information can be shared by a number of people both within the health care industry and beyond. The Health Insurance Portability and Accessibility Act (HIPAA) is a federal law pertaining to medical privacy that went into effect in 2003. This law established standards for patient privacy in all 50 states, including the right of patients to access to their own records. HIPAA provides some protection, but does not resolve the issues involving medical records privacy.
Medical and healthcare providers have experienced 767 security breaches resulting in the compromised confidential health information of 23,625,933 patients during the period of 2006-2012.
Privacy The examples and perspective in this section deal primarily with
The federal Health Insurance Portability and Accessibility Act (HIPAA) addresses the issue of privacy by providing medical information handling guidelines.
Mental status examination
The mental status examination in the
The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient’s mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning.
The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalised psychological tests.
The MSE is not to be confused with the mini-mental state examination (MMSE), which is a brief neuro-psychological screening test for dementia.
Theoretical foundations
The MSE derives from an approach to psychiatry known as descriptive psychopathology or descriptive phenomenology which developed from the work of the philosopher and psychiatrist Karl Jaspers. From Jaspers’ perspective it was assumed that the only way to comprehend a patient’s experience is through his or her own description (through an approach of empathic and non-theoretical enquiry), as distinct from an interpretive or psychoanalytic approach which assumes the analyst might understand experiences or processes of which the patient is unaware, such as defense mechanisms or unconscious drives.
In practice, the MSE is a blend of empathic descriptive phenomenology and empirical clinical observation. It has been argued that the term phenomenology has become corrupted in clinical psychiatry: current usage, as a set of supposedly objective descriptions of a psychiatric patient (a synonym for signs and symptoms), is incompatible with the original meaning which was concerned with comprehending a patient’s subjective experience.
Application
The mental status examination is a core skill of qualified (mental) health personnel. It is a key part of the initial psychiatric assessment in an out-patient or psychiatric hospital setting. It is a systematic collection of data based on observation of the patient’s behavior while the patient is in the clinician’s view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patient’s insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting. It is carried out in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. The MSE can also be considered part of the comprehensive physical examination performed by physicians and nurses although it may be performed in a cursory and abbreviated way ion-mental-health settings. Information is usually recorded as free-form text using the standard headings, but brief MSE checklists are available for use in emergency situations, for example by paramedics or emergency department staff. The information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan.
Domains
Appearance
Clinicians assess the physical aspects such as the appearance of a patient, including apparent age, height, weight, and manner of dress and grooming. Colorful or bizarre clothing might suggest mania, while unkempt, dirty clothes might suggest schizophrenia or depression. If the patient appears much older than his or her chronological age this can suggest chronic poor self-care or ill-health. Clothing and accessories of a particular subculture, body modifications, or clothing not typical of the patient’s gender, might give clues to personality. Observations of physical appearance might include the physical features of alcoholism or drug abuse, such as signs of malnutrition, nicotine stains, dental erosion, a rash around the mouth from inhalant abuse, or needle track marks from intravenous drug abuse. Observations can also include any odor which might suggest poor personal hygiene due to extreme self-neglect, or alcohol intoxication.Gelder, Mayou & Geddes (2005) tells us to look out for weight loss. This could signify a depressive disorder, physical illness, anorexia nervosa or chronic anxiety.
Attitude
Attitude, also known as rapport, refers to the patient’s approach to the interview process and the interaction with the examiner. The patient’s attitude may be described for example as cooperative, uncooperative, hostile, guarded, suspicious or regressed. The most subjective element of the mental status examination, attitude depends on the interview situation, the skill and behaviour of the clinician, and the pre-existing relationship between the clinician and the patient. However, attitude is important for the clinician’s evaluation of the quality of information obtained during the assessment.
Behavior
Abnormalities of behavior, also called abnormalities of activity, include observations of specific abnormal movements, as well as more general observations of the patient’s level of activity and arousal, and observations of the patient’s eye contact and gait. Abnormal movements, for example choreiform, athetoid or choreoathetoid movements may indicate a neurological disorder. A tremor or dystonia may indicate a neurological condition or the side effects of antipsychotic medication. The patient may have tics (involuntary but quasi-purposeful movements or vocalizations) which may be a symptom of Tourette’s syndrome. There are a range of abnormalities of movement which are typical of catatonia, such as echopraxia, catalepsy, waxy flexibility and paratonia (or gegenhalten). Stereotypies (repetitive purposeless movements such a rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait) may be a feature of chronic schizophrenia or autism. More global behavioural abnormalities may be noted, such as an increase in arousal and movement (described as psychomotor agitation or hyperactivity) which might reflect mania or delirium. An inability to sit still might represent akathisia, a side effect of antipsychotic medication. Similarly a global decrease in arousal and movement (described as psychomotor retardation, akinesia or stupor) might indicate depression or a medical condition such as Parkinson’s disease, dementia or delirium. The examiner would also comment on eye movements (repeatedly glancing to one side can suggest that the patient is experiencing hallucinations), and the quality of eye contact (which can provide clues to the patient’s emotional state). Lack of eye contact may suggest depression or autism.
Mood and affect
The distinction between mood and affect in the MSE is subject to some disagreement. For example Trzepacz and Baker (1993) describe affect as “the external and dynamic manifestations of a person’s internal emotional state” and mood as “a person’s predominant internal state at any one time”, whereas Sims (1995) refers to affect as “differentiated specific feelings” and mood as “a more prolonged state or disposition”. This article will use the Trzepacz and Baker (1993) definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner’s inferences of the quality of the patient’s emotional state based on objective observation.
Mood is described using the patient’s own words, and can also be described in summary terms such as neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. Alexithymic individuals may be unable to describe their subjective mood state. An individual who is unable to experience any pleasure may be suffering from anhedonia.
Affect is described by labelling the apparent emotion conveyed by the person’s nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. Affect may be described as appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. For example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia. The intensity of the affect may be described as normal, blunted, exaggerated, flat, heightened or overly dramatic. A flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorders. Mobility refers to the extent to which affect changes during the interview: the affect may be described as mobile, constricted, fixed, immobile or labile. The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect. The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive. A bland lack of concern for one’s disability may be described as showing belle indifférence, a feature of conversion disorder, which is historically termed “hysteria” in older texts.
Speech
The patient’s speech is assessed by observing the patient’s spontaneous speech, and also by using structured tests of specific language functions. This heading is concerned with the production of speech rather than the content of speech, which is addressed under thought form and thought content (see below). When observing the patient’s spontaneous speech, the interviewer will note and comment on paralinguistic features such as the loudness, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate, spontaneity and latency of speech. A structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests form part of the mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under Cognition (see below).
Language assessment will allow the recognition of medical conditions presenting with aphonia or dysarthria, neurological conditions such as stroke or dementia presenting with aphasia, and specific language disorders such as stuttering, cluttering or mutism. People with autism or Asperger syndrome may have abnormalities in paralinguistic and pragmatic aspects of their speech. Echolalia (repetition of another person’s words) and palilalia (repetition of the subject’s own words) can be heard with patients with autism, schizophrenia or Alzheimer’s disease. A person with schizophrenia might use neologisms, which are made-up words which have a specific meaning to the person using them. Speech assessment also contributes to assessment of mood, for example people with mania or anxiety may have rapid, loud and pressured speech; on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner.
Thought process
Thought process in the MSE refers to the quantity, tempo (rate of flow) and form (or logical coherence) of thought. Thought process cannot be directly observed but can only be described by the patient, or inferred from a patient’s speech. Regarding the tempo of thought, some people may experience flight of ideas, when their thoughts are so rapid that their speech seems incoherent, although a careful observer can discern a chain of poetic associations in the patient’s speech. Alternatively an individual may be described as having retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. Poverty of thought is a global reduction in the quantity of thought and thought perseveration refers to a pattern where a person keeps returning to the same limited set of ideas. A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, or knight’s move thinking. Thought may be described as circumstantial when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic. Flight of ideas is typical of mania. Conversely, patients with depression may have retarded or inhibited thinking. Poverty of thought is one of the negative symptoms of schizophrenia, and might also be a feature of severe depression or dementia. A patient with dementia might also experience thought perseveration. Formal thought disorder is a common feature of schizophrenia. Circumstantial thinking might be observed in anxiety disorders or certain kinds of personality disorders.
Thought content
A description of thought content would describe a patient’s delusions, overvalued ideas, obsessions, phobias and preoccupations. Abnormalities of thought content are established by exploring individual’s thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one’s own and under one’s control, and the degree of belief or conviction associated with the thoughts.
A delusion can be defined as “a false, unshakeable idea or belief which is out of keeping with the patient’s educational, cultural and social background … held with extraordinary conviction and subjective certainty”, and is a core feature of psychotic disorders. The patient’s delusions may be described as persecutory or paranoid delusions, delusions of reference, grandiose delusions, erotomanic delusions, delusional jealousy or delusional misidentification. Delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychoses, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. Delusions of control, or passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency), are typical of schizophrenia. Examples of this include experiences of thought withdrawal, thought insertion, thought broadcasting, and somatic passivity. Schneiderian first rank symptoms are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychoses.
An overvalued idea is a false belief that is held with conviction but not with delusional intensity. Hypochondriasis is an overvalued idea that one is suffering from an illness, dysmorphophobia is an overvalued idea that a part of one’s body is abnormal, and people with anorexia nervosa may have an overvalued idea of being overweight.
An obsession is an “undesired, unpleasant, intrusive thought that cannot be suppressed through the patient’s volition”, but unlike passivity experiences described above, they are not experienced as imposed from outside the patient’s mind. Obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes. A person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. In obsessive-compulsive disorder, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes).
A phobia is “a dread of an object or situation that does not in reality pose any threat”, and is distinct from a delusion in that the patient is aware that the fear is irrational. A phobia is usually highly specific to certain situations and will usually be reported by the patient rather than being observed by the clinician in the assessment interview.
Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person’s mind. Clinically significant preoccupations would include thoughts of suicide, homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or the cognitive distortions of anxiety and depression. The MSE contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought content. Assessment of suicide risk includes detailed questioning about the nature of the person’s suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life.
Perceptions
A perception in this context is any sensory experience, and the three broad types of perceptual disturbance are hallucinations, pseudohallucinations and illusions. A hallucination is defined as a sensory perception in the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by the subject as real). An illusion is defined as a false sensory perception in the presence of an external stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject. A pseudohallucination is experienced in internal or subjective space (for example as “voices in my head”) and is regarded as akin to fantasy. Other sensory abnormalities include a distortion of the patient’s sense of time, for example déjà vu, or a distortion of the sense of self (depersonalization) or sense of reality (derealization).
Hallucinations can occur in any of the five senses, although auditory and visual hallucinations are encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinations. Auditory hallucinations are typical of psychoses: third-person hallucinations (i.e. voices talking about the patient) and hearing one’s thoughts spoken aloud (gedankenlautwerden or écho de la pensée) are among the Schneiderian first rank symptoms indicative of schizophrenia, whereas second-person hallucinations (voices talking to the patient) threatening or insulting or telling them to commit suicide, may be a feature of psychotic depression or schizophrenia. Visual hallucinations are generally suggestive of organic conditions such as epilepsy, drug intoxication or drug withdrawal. Many of the visual effects of hallucinogenic drugs are more correctly described as visual illusions or visual pseudohallucinations, as they are distortions of sensory experiences, and are not experienced as existing in objective reality. Auditory pseudohallucinations are suggestive of dissociative disorders. Déjà vu, derealization and depersonalization are associated with temporal lobe epilepsy and dissociative disorders.
Cognition
This section of the MSE covers the patient’s level of alertness, orientation, attention, memory, visuospatial functioning, language functions and executive functions. Unlike other sections of the MSE, use is made of structured tests in addition to unstructured observation. Alertness is a global observation of level of consciousness i.e. awareness of, and responsiveness to the environment, and this might be described as alert, clouded, drowsy, or stuporose. Orientation is assessed by asking the patient where he or she is (for example what building, town and state) and what time it is (time, day, date). Attention and concentration are assessed by the serial sevens test (or alternatively by spelling a five-letter word backwards), and by testing digit span. Memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). Visuospatial functioning can be assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room. Language is assessed through the ability to name objects, repeat phrases, and by observing the individual’s spontaneous speech and response to instructions. Executive functioning can be screened for by asking the “similarities” questions (“what do x and y have in common?”) and by means of a verbal fluency task (e.g. “list as many words as you can starting with the letter F, in one minute”). The mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the MSE.
Mild impairment of attention and concentration may occur in any mental illness where people are anxious and distractible (including psychotic states), but more extensive cognitive abnormalities are likely to indicate a gross disturbance of brain functioning such as delirium, dementia or intoxication. Specific language abnormalities may be associated with pathology in Wernicke’s area or Broca’s area of the brain. In Korsakoff’s syndrome there is dramatic memory impairment with relative preservation of other cognitive functions. Visuospatial or constructional abnormalities here may be associated with parietal lobe pathology, and abnormalities in executive functioning tests may indicate frontal lobe pathology. This kind of brief cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed using formal neuropsychological testing.
The MSE may include a brief neuropsychiatric examination in some situations. Frontal lobe pathology is suggested if the person cannot repetitively execute a motor sequence (e.g. “paper-scissors-stone”). The posterior columns are assessed by the person’s ability to feel the vibrations of a tuning fork on the wrists and ankles. The parietal lobe can be assessed by the person’s ability to identify objects by touch alone and with eyes closed. A cerebellar disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (Romberg’s sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again. Pathology in the basal ganglia may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements. A lesion in the posterior fossa can be detected by asking the patient to roll his or her eyes upwards (Perinaud’s sign). Focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head injuries, tumors or other brain disorders.
Insight
The person’s understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options. In this context, insight can be said to have three components: recognition that one has a mental illness, compliance with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological. As insight is on a continuum, the clinician should not describe it as simply present or absent, but should report the patient’s explanatory account descriptively.
Impaired insight is characteristic of psychosis and dementia, and is an important consideration in treatment planning and in assessing the capacity to consent to treatment.
Judgment
Judgment refers to the patient’s capacity to make sound, reasoned and responsible decisions. Traditionally, the MSE included the use of standard hypothetical questions such as “what would you do if you found a stamped, addressed envelope lying in the street?”; however contemporary practice is to inquire about how the patient has responded or would respond to real-life challenges and contingencies. Assessment would take into account the individual’s executive system capacity in terms of impulsiveness, social cognition, self-awareness and planning ability.
Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the frontal lobe of the brain. If a person’s judgment is impaired due to mental illness, there might be implications for the person’s safety or the safety of others.
Cultural considerations
There are potential problems when the MSE is applied in a cross-cultural context, when the clinician and patient are from different cultural backgrounds. For example, the patient’s culture might have different norms for appearance, behavior and display of emotions. Culturally normative spiritual and religious beliefs need to be distinguished from delusions and hallucinations – without understanding may seem similar though they have different roots. Cognitive assessment must also take the patient’s language and educational background into account. Clinician’s racial bias is another potential confounder.
Children
There are particular challenges in carrying out an MSE with young children and others with limited language such as people with intellectual impairment. The examiner would explore and clarify the individual’s use of words to describe mood, thought content or perceptions, as words may be used idiosyncratically with a different meaning from that assumed by the examiner. In this group, tools such as play materials, puppets, art materials or diagrams (for instance with multiple choices of facial expressions depicting emotions) may be used to facilitate recall and explanation of experiences.
Basic biometrics
Height
Height is the anthropometric longitudinal growth of an individual. A statiometer is the device used to measure height although often a height stick is more frequently used for vertical measurement of adults or children older than 2. The patient is asked to stand barefoot. Height declines during the day because of compression of the intervertebral discs. Children under age 2 are measured lying horizontally.
Weight
Weight is the anthropometric mass of an individual. A scale is used to measure weight.
Body mass index or BMI is used to calculate the relationship between healthy height and weight and obesity or being overweight or underweight.
Medical professionals generally prefer to use the SI unit of kilograms, and many medical facilities have ready-reckoner conversion charts available for professionals to use, when patients describe their weight ion-SI units. (In the US, pounds and ounces are common, while in the UK stones and pounds are frequently used; in most other countries the metric system predominates.)
Pain
Because of the importance of pain to the overall wellness of the patient, subjective measurement is considered to be a vital sign. Clinically pain is measured using a FACES scale which is a series of faces from ‘0’ (no pain at all showing a normal happy face) to ‘5’ (the worst pain ever experienced by the patient). There is also an analog scale from ‘0’ to maximum ’10’. It is important to allow patients to make their own choices on a pain scale. Physicians and health care workers frequently understate patient pain (citatioeeded).
Structure of the written examination record
General appearance
Obvious apparent features as the patient enters the consulting room and in the course of taking the history (e.g. mobility problem or deafness)
· JACCOL, a mnemonic for Jaundice, suggestion of Anaemia (pale colour of skin or conjunctiva), Cyanosis (blue coloration of lips or extremities), Clubbing of fingernails, Oedema of ankles, Lymph nodes of neck, armpits, groins.
Organ systems
o Blood pressure, pulse rate and rhythm.
o Jugular venous pressure (JVP), peripheral oedema and evidence for pulmonary oedema.
o Precordial exam (cardiac exam)
· Lungs
o Respiratory rate, chest expansion, lung auscultation
· Breasts
· Abdomen
o Abdominal examination notes in particular any tenderness, bloating, organ enlargement, or aortic aneurysm.
o No abdominal examination is complete without a Rectal examination
· Nervous system, including mental status
· Skin
o Check of the hair to see if the hair growth is receding (baldness) or there is loss of hair (alopecia).
o Check of the skin will tell if there are marks such as hemangioma or strawberry marks or changes to the skin. Dark spots on the skin, nevi are also places where cancerous changes can appear because the face, head and neck are most usually sun exposed. Specific skin conditions (e.g. pyoderma gangrenosum, erythema nodosum, acanthosis nigricans) may be associated with specific diseases (ulcerative colitis, sarcoidosis and polycystic ovary syndrome, respectively).
Medical examination form (Form 47A)
Polyclinic
Freud’s couch used during psychoanalytic sessions
A clinic or outpatient clinic are originally small private or public health facility that provide health care for ambulatory patients or clients in a community, in contrast to inpatients treated in a hospital. Some grow to be institutions as large as major hospitals, whilst retaining the name Clinic. General practice clinics are run by one or more general practitioners or practice managers. Physiotherapy clinics are usually operated by physiotherapists and psychology clinics by clinical psychologists, and so on for each health profession. Some clinics are operated in-house by employers, government organizations or hospitals and some clinical services are outsourced to private corporations, specialising in provision of health services. In China, for example, owners of those clinics do not have formal medical education. Healthcare in India, China,
The function of clinics will differ from country to country. For instance, a local general practice run by a single general practitioner will provide primary health care and will usually be run as a for-profit business by the owner whereas a government specialist clinic may provide subsidized specialized health care.
Some clinics function as a place for people with injuries or illnesses to come and be seen by triage nurse or other health worker. In these clinics, the injury or illness may not be serious enough to warrant a visit to an emergency room, but the person can be moved to one if required Treatment at these clinics is often less expensive than it would be at a casualty department. Also, unlike an ER these clinics are often not open on a 24 x 7 x 365 basis. They sometimes have access to diagnostic equipment such as X-ray machines, especially if the clinic is part of a larger facility. Doctors at such clinics can often refer patients to specialists if the need arises.
Function
A typical polyclinic is an outpatient facility that houses general medical practitioners (GPs) such as doctors and nurses to provide ambulatory care and some acute care services but lacks the major surgical and pre- and post-operative care facilities commonly associated with hospitals. Besides GPs a polyclinic can house outpatient departments of some medical specialties i.e. gynecology, dermatology, ophthalmology, ENT, neurology, pulmonology, cardiology, endocrinology etc. In some university cities polyclinics house outpatient departments of all the teaching hospital in one building.
Internationally
Polyclinics are common type of healthcare facility in many countries incl. France, Germany (long tradition), Switzerland and most of the countries of Central and Eastern Europe (mixed Soviet-German model), as well as in former Soviet republics such as Russia and Ukraine; and in many countries across Asia and Africa. Recent Russian governments have attempted to replace the polyclinic model introduced during Soviet times with a more western model. However, this has failed. India has also set up huge numbers of polyclinics for former defence personnel. The network envisages 426 polyclinics in 343 districts of the country which will benefit about 33 lakh (3.3 million) ex-servicemen residing in remote and far-flung areas. Polyclinics are also the backbone of
Ethymology
The word derives from the Greek klinein meaning to slope, lean or recline. Hence kline a couch or bed, klinikos sloping or reclining and to Latin clinicus [1]. An early use of the word clinic was, ‘one who receives baptism on a sick bed’ [2]. Psychoanalytic clinics tradtionally have the patient reclining on a couch to undergo analysis.
Types of Clinics
· A free clinic provide free or low cost health care for those without insurance.
· A Retail Based Clinic is housed in supermarkets and similar retail outlets providing walk in health care, which may be staffed by nurse practitioners.
· A general out-patient clinic is a clinic offering a community general diagnoses or treatments without an overnight stay.
· A polyclinic is a clinic, hospital, or school where many diseases are treated and studied.
· A fertility clinic aims to help those couples and individuals to become pregnant. An abortion clinic is a medical facility providing certain kinds of outpatient medical care, including abortion to women. Such clinics may be public medical centers or private medical practices.
· A specialist clinic is a clinic with in-depth diagnosis or treatment on diseases of specific parts of the body. This type of clinic contrasts with general out-patient clinics, which deal with general diseases.
Free clinic
A free clinic is a medical facility offering community healthcare on a free or very low-cost basis in countries with marginal or no universal health care. Care is generally provided in these clinics to persons who have lower or limited income and no health insurance, including persons who are not eligible for US Medicaid or Medicare programs. In the
The Free Clinic of Greater
History
The moderotion of a free clinic began in the 1960s in
During the 1970s and 80s free clinics continued to evolve and change to meet the needs of their individual communities, however some were unable to survive. Each free clinic was unique in its development and services, based on the particular needs and resources of the local community. There is a saying among free clinic organizations that if you have been to one free clinic you have been to one free clinic. The common denominator is that care is made possible through the service of volunteers, the donation of goods and community support. Funding is generally donated on the local level and there is little —if any— government funding. Some free clinics were established to provide medical services in the inner cities while others opened in the suburbs and many student-run free clinics have emerged that serve the under-served as well as provide a medical training site for students in the health professions.
While both free and community clinics provide many similar services, free clinics today are defined by the US National Association of Free Clinics as “private, non-profit, community based organizations that provide medical, dental, pharmaceutical and/or mental health services at little or no cost to low-income, uninsured and under insured people. They accomplish this through the use of volunteer health professionals and community volunteers, along with partnerships with other health providers.” Some free clinics rival local government health departments in size and scope of service with multi-million dollar budgets, specialized clinics and numerous locations.
What is a Retail-based Clinic (RBC)?
Various vendors have developed limited scope, primary care clinics that are housed at retail sites (Target, Wal-Mart, Walgreens, CVS Pharmacy). In most cases these are staffed by nurse practitioners providing basic primary care and treatment for minor conditions such as strep throat, ear infections, bronchitis, sore throat, and immunizations. No appointments are necessary and posted fees generally are less than at a physician’s office. They are also referred to as “store-based clinics,” “retail health clinics,” and “convenient care clinics.”
The chart below lists the major retail based clinics. In addition, in some areas, local hospitals and physician groups are developing clinics with local retailers or providing staff for these clinics.
A general out-patient clinic
The term outpatient clinic can refer to a number of different medical facilities. These can have highly specialized types of care, or they may offer general care, like urgent care facilities. Such clinics may be designated “outpatient” because they are attached to hospitals but do not serve those requiring overnight hospitalization. However, an outpatient clinic does not have to share facilities with a hospital, and some are not located on hospital campuses.
Some of the most common outpatient clinic types are urgent care centers, and these aim to provide a convenient and cheaper way to receive care for minor illnesses and injuries. As opposed to using an emergency room for things like a sudden ear infection, people might use an outpatient clinic that offers urgent care instead. These clinics are staffed by doctors and nurses, in addition to many other medical specialists, and can quickly take care of most minor problems. Urgent clinics vary in hours, and some may be open until late evening, generally more hours than those offered by doctor’s offices. Many of these clinics are on hospital campuses, but may not be located in the main hospital building or buildings.
Instead of practicing general medicine, an outpatient clinic may be designed to practice some form of specialized medicine. There are lots of these clinics, which may or may not be located in hospitals. Outpatient clinics exist to work with patients taking blood thinners like Coumadin® and may be called anti-coagulation clinics. Other examples include cardiology clinics, which might offer cardiology testing services like echocardiograms, electrocardiograms (EKGs), and stress testing.
Sometimes specialists see patients at a once a week or once a month clinic. On these designated days, care is given to those patients not requiring inpatient hospital services. For instance a pediatric neurologist who has a main hospital practice would use his outpatient clinic to follow up on patients he’s treating. Clinic hours and days would depend on degree of need for outpatient care and number of patients. Though these services might take place in a hospital, they’re still outpatient clinic services.
Other types of outpatient clinics can work with certain populations. For instance there are clinics that work specifically with veterans returning from the wars in
Outpatient clinic types exist in many variations. These include clinics addressing the needs of those requiring physical therapy, facilities that specialize in women’s health issues, and clinics devoted to caring for people with inability to pay for services. All share a common element; they are designed to give care to people who are not presently hospitalized.
Polyclinic
For anyone from the former Soviet bloc—and there are quite a few doctors from the new member states of the European Unioow working in the United Kingdom—the current discussion about the introduction of polyclinics in the English NHS must be utterly perplexing. Polyclinics were a centrepiece of the Soviet model of healthcare delivery, but many countries of Central and
Although there is still considerable debate about what an English polyclinic might look like,1 they will share with their predecessors in Central and
Despite their limitations and a widely held view that the concept was outdated, polyclinics have proved remarkably resilient. Most countries of the former
The situation in
What lessons does this experience offer for
Either scenario is possible. However, change will incur substantial costs, both in the construction of new facilities and, much more importantly, in the organisational turmoil that will ensue. Furthermore, while greater provision of specialist services outside hospital may improve patient access, quality of care may decline, and costs may increase.7 There are also local specificities. Many English hospitals are now funded through private finance initiative schemes, so even if specialist services move out, they may still have to be paid for.
When introducing an idea that has previously been tried elsewhere, it is important to draw on relevant experience. There is a strong case for piloting the proposed new model, to allow enough time to learn. Unfortunately, as the past two decades have shown, that is not how things work here.
Fertility clinics are staffed medical clinics that assist couples, and sometimes individuals, who want to become parents but for medical reasons have been unable to achieve this goal via the natural course. Clinics apply a number of diagnosis tests and sometimes very advanced medical treatments to obtain the desired conceptions and pregnancies.
Clinic Staff
Fertility clinics are staffed with highly trained personnel including Reproductive Endocrinologists, Embryologists, Sonographers, and Nurses. Additional specialists from Acupuncture, Hypnotherapy, and Nutrition may also be part of the team.
Diagnosis
Fertility Clinics look to both males and females for diagnosis of fertility problems. Diagnosis has shown that fertility problems arise 35% of the time from males, 35% from female, 20% from combined issues, and 10% from unexplained causes. For the male, semen collection is a standard diagnostic test to ascertain problems with the semen quality. While females may undergo a multitude of tests including an ovulation analysis, x-ray of fallopian tubes and uterus, and laparoscopy.
Treatment
Treatment may include ovulation induction, surgical interventions, intrauterine insemination, in vitro fertilization or the use of an egg donor or a sperm donor. They also perform ultrasounds by a sonograher and advance pregnacy testes. In vitro fertilisation is the most well known of the assisted reproductive technology procedures performed at a fertility clinic.
Comparing Clinics
The Centers for Disease Control requires outcome data be reported to the Society of Assisted Reproductive Technology (SART) which is the organization that creates these statistics. Fertility clinics are often compared by these IVF Success Rates. However, it’s important to note that SART puts a caution at bottom of each report that reads “Patient characteristics vary among programs; therefore, these data should not be used for comparing clinics.”. A consultation with many fertility clinics is always a good option to get a more complete comparison for a patients specific situation and needs.
Strategy Discussions must consider, in consultation with the paediatrician (if not part of the discussion or meeting), the need for and timing of a medical examination. Consideration must also be given as to whether there are any other children in the household who may also require a medical examination.
Medical examinations should always be considered necessary where there has been a disclosure or there is a suspicion of any form of abuse to a child.
Additional considerations are the need to:
Secure forensic evidence;
Obtain medical documentation and treatment if required.
In cases of severe neglect, physical injury or acute (recent) penetrative sexual abuse, the examination should be undertaken on the day of the referral, where compatible with the welfare of the child.
Only suitably qualified health specialists may physically examine the child for the purposes of a medical examination. Other staff should note any visible marks or injuries on a body map and document details in their recording.
Purpose of a Medical Examination
The purpose of a medical examination is:
To diagnose any injury or harm to the child and to initiate treatment as required;
To document the findings;
To provide a medical report on the findings, including an opinion as to the probable cause of any injury or other harm reported;
To assess the overall health and development of the child;
To provide reassurance for the child and parent;
To arrange for follow up and review of the child as required, noting new symptoms including psychological effects.
Consent for Medical Examination / Medical Treatment
The following may give consent to a medical examination:
A young person of 16 and over;
A child of under 16 where a doctor considers he or she is of sufficient age and understanding to give informed consent and is Fraser Competent;
Any person with Parental Responsibility;
The local authority when the child is the subject of a Interim Care Order (although the parent/carer should be informed);
The local authority when the child is Accommodated and the parent/carers have abandoned the child or are physically or mentally unable to give such authority;
The High Court when the child is a Ward of Court;
as part of a direction attached to an Emergency Protection Order, an Interim Care Order or a Child Assessment Order.
Where the child is the subject of ongoing Court proceedings, legal advice should be obtained about obtaining the Court’s permission to the medical examination.
It is generally good practice to seek wherever possible the permission of a parent for children under 16 prior to any medical examination and/or other medical treatment even if the child is judged to be of sufficient understanding to give consent in their own right. If this is not considered possible or appropriate, then the reasons should be clearly recorded.
When a child is Looked After and a parent/carer has given general consent authorising medical treatment for the child, legal advice must be taken about whether this provides consent for a medical examination for child protection purposes (the parent/carer still has full parental responsibility for the child). Where the local authority shares Parental Responsibility for the child, the local authority must also consent to the medical examination.
A child who is of sufficient understanding may refuse some or all of the medical examination, although refusal can potentially be overridden by a court.
In emergency situations where the child needs urgent medical treatment and there is insufficient time to obtain parental consent:
The medical practitioner may decide to proceed without consent; and/or
The medical practitioner may regard the child to be of an age and level of understanding to give her/his own consent and be Fraser Competent.
In these circumstances, parents must be informed as soon as possible and a full record must be made at the time.
Ion-emergency situations, when parental permission is not obtained, the social worker and manager must seek legal advice – see above.
For additional guidance to doctors, see the GMC Guidance for Doctors Working with 0 to 18 Year Olds.
4. Arranging the Medical Examination
Medical examinations must take into account the need for both specialist medical expertise and forensic requirements in relation to the gathering of evidence.
Only approved Consultant Paediatricians, Police Surgeons or other suitably qualified specialists may undertake medical examinations carried out as part of a Section 47 Enquiry. There should be only one medical examination of the child.
Where child sexual abuse is suspected, usually two doctors with complementary skills will conduct a joint medical examination. A single doctor may carry out the examination where he or she has the necessary knowledge, skills and experience for the particular case. For further guidance, see Guidance on Paediatric Forensic Examinations in relation to possible child sexual abuse, 2007, issued by the Royal College of Paediatrics and Child Health and the Association of Forensic Physicians.
Consideration should be given to the gender of the examining doctor in consultation with the child and the parents.
In planning the medical examination, the social worker, the manager responsible, the Police CPPU and relevant doctor(s) must consider whether it might be necessary to take photographic evidence, for example, for use in care or criminal proceedings or where a second opinion may be necessary. Where such arrangements are necessary, the child and parents must be informed and prepared and careful consideration given to the impact on the child.
If the child refuses to be examined or becomes distressed during the examination, consideration must be given to arranging a further examination.
In circumstances where medical examination of a child is required, the child should be examined by a paediatrician at the Rainbow Centre,
After 5.00pm or at weekends, a medical examination of a child should be arranged by contacting the
Any police officer or social worker requesting medical examination of a child should ensure that someone with Parental Responsibility:
Accompanies the child to the hospital and is prepared to sign the Rainbow Centre consent form; or
Has signed the Rainbow Centre consent form and agrees to the child attending the hospital without a parent.
Without such consent the social worker or police officer will need to consider legal advice with a view to making application for an Order which will enable consent to be dispensed with.
5. Recording of the Medical Examination
At the conclusion of the medical examination, the doctor must give a verbal report explaining his or her findings to the social worker/Police officer attending, followed by a written report as soon as practicable.
Disclosure of the information contained in the report to the parent(s) of the child and/or the child should be agreed in consultation with the Children’s Social Care Service and the Police.
The report should include:
Date, time and place of examination;
Those present;
Who gave consent and how (child/parent, written, phone or in person);
A verbatim record of the carer’s and child’s accounts of injuries and concerns noting any discrepancies or changes of story;
Documentary findings in both words and diagrams;
Site, size, shape and where possible age of any marks or injuries;
Other findings relevant to the child e.g. squint, learning problems, speech problems etc.;
Confirmation of the child’s developmental progress (especially important in cases of neglect);
Time examination ended;
Medical opinion of the likely cause of injury or harm.
All reports and diagrams should be signed and dated by the doctor undertaking the examination.
If criminal or family proceedings are instituted, the doctor’s written report may be filed and served as well as the doctor’s statement of evidence. The doctor’s attendance at subsequent Court hearings may also be required.
Where there has been a joint medical examination, the doctors involved should agree which of them will provide the report. If they disagree in their clinical findings and interpretations, they should both provide full reports and usually a further independent medical opinion should be obtained.
Ultrasound medical examination
Child Medical Examination
Types of medical examination
A medical test is a kind of medical procedure performed to detect, diagnose, or monitor diseases, disease processes, susceptibility, and determine a course of treatment.
Types of tests
By utilization
Medical tests can be classified by what the test result will be used for, mainly including usage for diagnosis, screening or evaluation, as separately detailed below.
Diagnostic
Lung scintigraphy evaluating lung cancer
A diagnostic test is a procedure performed to confirm, or determine the presence of disease in an individual suspected of having the disease, usually following the report of symptoms, or based on the results of other medical tests. Such tests include:
Utilizing nuclear medicine techniques to examine a patient having a lymphoma.
Measuring the blood sugar in a person suspected of having diabetes mellitus, after periods of increased urination.
Taking a complete blood count of an individual experiencing a high fever, to check for a bacterial infection.
Monitoring electrocardiogram readings on a patient suffering chest pain, to diagnose or determine any heart irregularities.
Screening
Main article: Screening (medicine)
A screening is a medical test or series used to detect or predict the presence of disease in individuals at risk for disease within a defined group, such as a population, family, or workforce. Screenings may be performed to monitor disease prevalence, manage epidemiology, aid in prevention, or strictly for statistical purposes.
Examples of screenings include measuring the level of TSH in the blood of a newborn infant as part of newborn screening for congenital hypothyroidism, checking for Lung cancer ion-smoking individuals who are exposed to second-hand smoke in an unregulated working environment, and Pap smear screening for prevention or early detection of cervical cancer.
Monitoring
Some medical tests are used to monitor the progress of, or response to medical treatment.
By method
Most test methods can be classified into either of the following broad groups:
· Tests performed in a physical examination
· Questions asked in the taking of a medical history of an individual.
· Radiologic tests, in which, for example, x-rays are used to form an image of a body target.
· Microbiological culture, which determines the presence or absence of microbes in a sample from the body, usually targeted at detecting pathogenic bacteria.
· Genetic testing
· By sample location
Tests can be classified according to the location of the sample being tested, including:
· Blood tests
· Urine tests
Accuracy and precision
Accuracy of a laboratory test is its correspondence with the true value. Accuracy is maximized by calibrating laboratory equipment with reference material and by participation in external quality control programs.
Precision is a measure of tests reproducibility when repeated on the same sample. An imprecise test is one that yield widely varying results on repeated measurement. The precision is monitored in laboratory by using control material.
Detection and quantification
Tests performed in a physical examination are usually aimed at detecting a symptom or sign, and in these cases, a test that detects a symptom or sign is designated a positive test, and a test that indicated absence of a symptom or sign is designated a negative test, as further detailed in separate section below.
A quantification of a target substance, a cell type or another specific entity is a common output of, for example, most blood tests. This is not only answering if a target entity is present or absent, but also how much is present. In blood tests, the quantification is relatively well specified, such as given in mass concentration, while most other tests may be quantifications as well although less specified, such as a sign of being “very pale” rather than “slightly pale”. Similarly, radiologic images are technically quantifications of radiologic opacity of tissues.
Especially in the taking of a medical history, there is no clear limit between a detecting or quantifying test versus rather descriptive information of an individual. For example, questions regarding the occupation or social life of an individual may be regarded as tests that can be regarded as positive or negative for the presence of various risk factors, or they may be regarded as “merely” descriptive, although the latter may be at least as clinically important.
Positive or negative
The result of a test aimed at detection of an entity may be positive or negative: this has nothing to do with a bad prognosis, but rather means that the test worked or not, and a certain parameter that was evaluated was present or not. For example, a negative screening test for breast cancer means that no sign of breast cancer could be found (which is in fact very positive for the patient).
The classification of tests into either positive or negative gives a binary classification, with resultant ability to perform bayesian probability and performance metrics of tests, including calculations of sensitivity and specificity.
Continuous values
Tests whose results are of continuous values, such as most blood values, can be interpreted as they are, or they can be converted to a binary ones by defining a cutoff value, with test results being designated as positive or negative depending on whether the resultant value is higher or lower than the cutoff.
Interpretation
In the finding of a pathognomonic sign or symptom it is almost certain that the target condition is present, and in the absence of finding a sine qua non sign or symptom it is almost certain that the target condition is absent. In reality, however, the subjective probability of the presence of a condition is never exactly 100% or 0%, so tests are rather aimed at estimating a post-test probability of a condition or other entity.
Most diagnostic tests basically use a reference group to establish performance data such as predictive values, likelihood ratios and relative risks, which are then used to interpret the post-test probability for an individual.
In monitoring tests of an individual, the test results from previous tests on that individual may be used as a reference to interpret subsequent tests.
Risks
Some medical testing procedures have health risks, and even require general anesthesia, such as the mediastinoscopy. Other tests, such as the blood test or pap smear have little to no direct risks. Medical tests may also have indirect risks, such as the stress of testing, and riskier tests may be required as follow-up for a (potentially) false positive test result. Consult the physician prescribing any test for further information.
Indications
Each test has its own indications and contraindications, but in a simplified fashion, how much a test is indicated for an individual depends largely on its net benefit for that individual.
Λp is the absolute difference between pre- and posttest probability of conditions (such as diseases) that the test is expected to achieve. A major factor for such an absolute difference is the power of the test itself, such as can be described in terms of, for example, sensitivity and specificity or likelihood ratio. Another factor is the pre-test probability, with a lower pre-test probability resulting in a lower absolute difference, with the consequence that even very powerful tests achieve a low absolute difference for very unlikely conditions in an individual (such as rare diseases in the absence of any other indicating sign), but on the other hand, that even tests with low power can make a great difference for highly suspected conditions. The probabilities in this sense may also need to be considered in context of conditions that are not primary targets of the test, such as profile-relative probabilities in a differential diagnostic procedure.
ri is the rate of how much probability differences are expected to result in changes in interventions (such as a change from “no treatment” to “administration of low-dose medical treatment”). For example, if the only expected effect of a medical test is to make one disease more likely compared to another, but the two diseases have the same treatment (or neither can be treated), then, this factor is very low and the test is probably without value for the individual in this aspect.
bi is the benefit of changes in interventions for the individual
hi is the harm of changes in interventions for the individual, such as side effects of medical treatment
ht is the harm caused by the test itself
Additional factors that influence a decision whether a medical test should be performed or not include: cost of the test, availability of additional tests, potential interference with subsequent test (such as an abdominal palpation potentially inducing intestinal activity whose sounds interfere with a subsequent abdominal auscultation), time taken for the test or other practical or administrative aspects. The possible benefits of a diagnostic test may also be weighed against the costs of unnecessary tests and resulting unnecessary follow-up and possibly even unnecessary treatment of incidental findings. Also, even if not beneficial for the individual being tested, the results may be useful for the establishment of statistics in order to improve health care for other individuals.
Standard for the reporting and assessment of medical tests
The QUADAS-2 revision is available.
Blood test
A venipuncture performed using a vacutainer
A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via fingerprick. Blood tests are used to determine physiological and biochemical states, such as disease, mineral content, drug effectiveness, and organ function. They are also used in drug tests.
Extraction
Venipuncture is useful as it is a relatively non-invasive way to obtain cells and extracellular fluid (plasma) from the body for analysis. Since blood flows throughout the body, acting as a medium for providing oxygen and nutrients, and drawing waste products back to the excretory systems for disposal, the state of the bloodstream affects, or is affected by, many medical conditions. For these reasons, blood tests are the most commonly performed medical tests.
If only a few drops of blood are needed, a fingerstick is performed instead of drawing blood from a vein.
Phlebotomists, laboratory practitioners and nurses are those charged with patient blood extraction. However, in special circumstances, and emergency situations, paramedics and physicians sometimes extract blood. Also, respiratory therapists are trained to extract arterial blood for arterial blood gases.
Types of blood tests
Samples of human blood collected for testing. The barcodes contain information that is used to identify the individual from whom the sample was taken and the blood test requested.
Biochemical analysis
A basic metabolic panel measures sodium, potassium, chloride, bicarbonate, blood urea nitrogen (BUN), magnesium, creatinine, glucose, and sometimes includes calcium. Blood tests focusing on cholesterol levels can determine LDL and HDL cholesterol levels, as well as triglyceride levels.
Some blood tests, such as those that measure glucose, cholesterol, or for determining the existence or lack of STD, require fasting (or no food consumption) eight to twelve hours prior to the drawing of the blood sample.
For the majority of blood tests, blood is usually obtained from the patient’s vein. However, other specialized blood tests, such as the arterial blood gas, require blood extracted from an artery. Blood gas analysis of arterial blood is primarily used to monitor carbon dioxide and oxygen levels related to pulmonary function, but it is also used to measure blood pH and bicarbonate levels for certain metabolic conditions.
While the regular glucose test is taken at a certain point in time, the glucose tolerance test involves repeated testing to determine the rate at which glucose is processed by the body.
Diagnostic test
A diagnostic test is any kind of medical test performed to aid in the diagnosis or detection of disease. For example:
· to diagnose diseases, and preferably sub-classify it regarding, for example, severity and treatability
· to confirm that a person is free from disease
Companion diagnostics have also been developed to preselect patients for specific treatments based on their own biology. Such targeted therapy holds great promise in the treatment of diseases such as cancer.
A drug test can be a specific medical test to ascertain the presence of a certain drug in the body (for example, in drug addicts).
Overview
Some diagnostic tests are parts of a simple physical examination which require only simple tools in the hands of a skilled practitioner, and can be performed in an office environment. Some other tests require elaborate equipment used by medical technologists or the use of a sterile operating theatre environment.
Some tests require samples of tissue or body fluids to be sent off to a pathology lab for further analysis. Some simple chemical tests, such as urine pH, can be measured directly in the doctor’s office.
Most diagnostic tests are conducted on the living; however, some of these tests can also be carried out on a dead person as part of an autopsy.
The validity of diagnostic test results produced in each laboratory is entirely dependent on the measures employed before, during, and after each assay. Consistency in the production of good results requires an overall program that includes quality assurance, quality control, and quality assessment.
Medical tests can be classified into three categories:
· invasive
· minimally invasive
· non-invasive
Psychological effects of diagnostic tests
Medical tests can have value when results are abnormal by explaining to a patient the cause of their symptoms. In addition, normal test results can have value by reassuring patients that serious illness is not present and even reduce the rates of subsequent symptoms. Understanding the meaning of a normal test in advance of learning the test results may also reduce the rates of subsequent symptoms.
Lack of adequate education about the meaning of test results (especially relevant to tests that may have incidental and unimportant findings) may cause an increase in symptoms. In addition, the possible benefits must be weighed against the costs of unnecessary tests and resulting unnecessary follow-up and possibly even unnecessary treatment of incidental findings.
Interpretation
The aim of a diagnostic test is to have an answer whether a condition is present or not in the test target, or at least contributing in estimating a post-test probability of it.
Interpretation of diagnostic tests should always take sources of inaccuracy and imprecision into account. Sources of inaccuracy and imprecision of diagnostic tests may broadly be categorized as:
Physical sources within the diagnostic test taking itself
Interpretational sources of the resultant data in relation to the target condition. Such sources include conversion of continuous values to binary ones (creating artificially binary values), such as designating a blood test for prostate specific antigen as “positive” when having reached a certain cutoff value, which is generally less accurate than considering the value itself.
Genetic testing
Genetic testing (also called DNA-based tests) is among the newest and most sophisticated of techniques used to test for genetic disorders which involves direct examination of the DNA molecule itself. Other genetic tests include biochemical tests for such gene products as enzymes and other proteins and for microscopic examination of stained or fluorescent chromosomes. Genetic tests are used for several reasons, including:
identifying unaffected individuals who carry one copy of a gene for a disease that requires two copies for the disease to be expressed, these are some examples:
preimplantation genetic diagnosis (see the side bar, Screening Embryos for Disease)
· prenatal diagnostic testing
· newborn screening
· Genealogical DNA test (for genetic genealogy purposes)
· presymptomatic testing for predicting adult-onset disorders such as Huntington’s disease
· presymptomatic testing for estimating the risk of developing adult-onset cancers and Alzheimer’s disease
· confirmational diagnosis of a symptomatic individual
· forensic/identity testing
Genetic testing allows the genetic diagnosis of vulnerabilities to inherited diseases, and can also be used to determine a child’s paternity (genetic father) or a person’s ancestry. Normally, every person carries two copies of every gene (with the exception of genes related to sex-linked traits, which are only inherited from the mother by males), one inherited from their mother, one inherited from their father. The human genome is believed to contain around 20,000 – 25,000 genes. In addition to studying chromosomes to the level of individual genes, genetic testing in a broader sense includes biochemical tests for the possible presence of genetic diseases, or mutant forms of genes associated with increased risk of developing genetic disorders. Genetic testing identifies changes in chromosomes, genes, or proteins. Most of the time, testing is used to find changes that are associated with inherited disorders. The results of a genetic test can confirm or rule out a suspected genetic condition or help determine a person’s chance of developing or passing on a genetic disorder. Several hundred genetic tests are currently in use, and more are being developed.
Since genetic testing may open up ethical or psychological problems, genetic testing is often accompanied by genetic counseling
Types
Genetic testing is “the analysis of, chromosomes (DNA), proteins, and certain metabolites in order to detect heritable disease-related genotypes, mutations, phenotypes, or karyotypes for clinical purposes.” It can provide information about a person’s genes and chromosomes throughout life. Available types of testing include:
· Newborn screening: Newborn screening is used just after birth to identify genetic disorders that can be treated early in life. The routine testing of infants for certain disorders is the most widespread use of genetic testing—millions of babies are tested each year in the
· Diagnostic testing: Diagnostic testing is used to diagnose or rule out a specific genetic or chromosomal condition. In many cases, genetic testing is used to confirm a diagnosis when a particular condition is suspected based on physical mutations and symptoms. Diagnostic testing can be performed at any time during a person’s life, but is not available for all genes or all genetic conditions. The results of a diagnostic test can influence a person’s choices about health care and the management of the disease.
· Carrier testing: Carrier testing is used to identify people who carry one copy of a gene mutation that, when present in two copies, causes a genetic disorder. This type of testing is offered to individuals who have a family history of a genetic disorder and to people in ethnic groups with an increased risk of specific genetic conditions. If both parents are tested, the test can provide information about a couple’s risk of having a child with a genetic condition.
· Prenatal testing: Prenatal testing is used to detect changes in a fetus’s genes or chromosomes before birth. This type of testing is offered to couples with an increased risk of having a baby with a genetic or chromosomal disorder. In some cases, prenatal testing can lessen a couple’s uncertainty or help them decide whether to abort the pregnancy. It cannot identify all possible inherited disorders and birth defects, however.
· Preimplantation genetic diagnosis: Genetic testing procedures that are performed on human embryos prior to the implantation as part of an in vitro fertilization procedure.
· Predictive and presymptomatic testing: Predictive and presymptomatic types of testing are used to detect gene mutations associated with disorders that appear after birth, often later in life. These tests can be helpful to people who have a family member with a genetic disorder, but who have no features of the disorder themselves at the time of testing. Predictive testing can identify mutations that increase a person’s chances of developing disorders with a genetic basis, such as certain types of cancer. For example, an individual with a mutation in BRCA1 has a 65% cumulative risk of breast cancer.[6] Presymptomatic testing can determine whether a person will develop a genetic disorder, such as hemochromatosis (an iron overload disorder), before any signs or symptoms appear. The results of predictive and presymptomatic testing can provide information about a person’s risk of developing a specific disorder and help with making decisions about medical care.
· Forensic testing: Forensic testing uses DNA sequences to identify an individual for legal purposes. Unlike the tests described above, forensic testing is not used to detect gene mutations associated with disease. This type of testing can identify crime or catastrophe victims, rule out or implicate a crime suspect, or establish biological relationships between people (for example, paternity).
· Parental testing: This type of genetic test uses special DNA markers to identify the same or similar inheritance patterns between related individuals. Based on the fact that we all inherit half of our DNA from the father, and half from the mother, DNA scientists test individuals to find the match of DNA sequences at some highly differential markers to draw the conclusion of relatedness.
· Research testing: Research testing includes finding unknown genes, learning how genes work and advancing our understanding of genetic conditions. The results of testing done as part of a research study are usually not available to patients or their healthcare providers.
· Pharmacogenomics: type of genetic testing that determines the influence of genetic variation on drug response.
Medical procedure
Genetic testing is often done as part of a genetic consultation and as of mid-2008 there were more than 1,200 clinically applicable genetic tests available. Once a person decides to proceed with genetic testing, a medical geneticist, genetic counselor, primary care doctor, or specialist can order the test after obtaining informed consent.
Genetic tests are performed on a sample of blood, hair, skin, amniotic fluid (the fluid that surrounds a fetus during pregnancy), or other tissue. For example, a medical procedure called a buccal smear uses a small brush or cotton swab to collect a sample of cells from the inside surface of the cheek. Alternatively, a small amount of saline mouthwash may be swished in the mouth to collect the cells. The sample is sent to a laboratory where technicians look for specific changes in chromosomes, DNA, or proteins, depending on the suspected disorder. The laboratory reports the test results in writing to a person’s doctor or genetic counselor.
Routine newborn screening tests are done on a small blood sample obtained by pricking the baby’s heel with a lancet.
Interpreting results
The results of genetic tests are not always straightforward, which often makes them challenging to interpret and explain. May not always be correct. When interpreting test results, healthcare professionals consider a person’s medical history, family history, and the type of genetic test that was done.
In some cases, a negative result might not give any useful information. This type of result is called uninformative, indeterminate, inconclusive, or ambiguous. Uninformative test results sometimes occur because everyone has common, natural variations in their DNA, called polymorphisms, that do not affect health. If a genetic test finds a change in DNA that has not been associated with a disorder in other people, it can be difficult to tell whether it is a natural polymorphism or a disease-causing mutation. An uninformative result cannot confirm or rule out a specific diagnosis, and it cannot indicate whether a person has an increased risk of developing a disorder. In some cases, testing other affected and unaffected family members can help clarify this type of result.
Risks and limitations
The physical risks associated with most genetic tests are very small, particularly for those tests that require only a blood sample or buccal smear (a procedure that samples cells from the inside surface of the cheek). The procedures used for prenatal testing carry a small but real risk of losing the pregnancy (miscarriage) because they require a sample of amniotic fluid or tissue from around the fetus.
Many of the risks associated with genetic testing involve the emotional, social, or financial consequences of the test results. People may feel angry, depressed, anxious, or guilty about their results. The potential negative impact of genetic testing has led to an increasing recognition of a “right not to know”. In some cases, genetic testing creates tension within a family because the results can reveal information about other family members in addition to the person who is tested. The possibility of genetic discrimination in employment or insurance is also a concern. Some individuals avoid genetic testing out of fear it will affect their ability to purchase insurance or find a job. Health insurers do not currently require applicants for coverage to undergo genetic testing, and when insurers encounter genetic information, it is subject to the same confidentiality protections as any other sensitive health information. In the United States, the use of genetic information is governed by the Genetic Information Nondiscrimination Act (GINA) (see discussion below in the section on government regulation).
Genetic testing can provide only limited information about an inherited condition. The test often can’t determine if a person will show symptoms of a disorder, how severe the symptoms will be, or whether the disorder will progress over time. Another major limitation is the lack of treatment strategies for many genetic disorders once they are diagnosed.
A genetics professional can explain in detail the benefits, risks, and limitations of a particular test. It is important that any person who is considering genetic testing understand and weigh these factors before making a decision.
Direct-to-Consumer genetic testing
Direct-to-Consumer (DTC) genetic testing is a type of genetic test that is accessible directly to the consumer without having to go through a health care professional. Usually, to obtain a genetic test, health care professionals such as doctors acquire the permission of the patient and order the desired test. DTC genetic tests, however, allow consumers to bypass this process and order one themselves. There are a variety of DTC tests, ranging from testing for breast cancer alleles to mutations linked to cystic fibrosis. Benefits of DTC testing are the accessibility of tests to consumers, promotion of proactive healthcare and the privacy of genetic information. Possible additional risks of DTC testing are the lack of governmental regulation and the potential misinterpretation of genetic information.
Controversy
DTC genetic testing has been controversial due to outspoken opposition within the scientific community. Critics of DTC testing argue against the risks involved, the unregulated advertising and marketing claims, and the overall lack of governmental oversight.
DTC testing involves many of the same risks associated with any genetic test. One of the more obvious and dangerous of these is the possibility of severe misreading of test results. Without professional guidance, consumers can potentially misinterpret genetic information, causing them to be deluded about their personal health.
Some advertising for direct-to-consumer genetic testing has been criticized as conveying an exaggerated and inaccurate message about the connection between genetic information and disease risk, utilizing emotions as a selling factor. An advertisement for a BRCA-predictive genetic test for breast cancer stated: “There is no stronger antidote for fear than information.”
The Simple Present Tense
The simple present is used to describe an action, an event, or condition that is occurring in the present, at the moment of speaking or writing. The simple present is used when the precise beginning or ending of a present action, event, or condition is unknown or is unimportant to the meaning of the sentence.
Each of the highlighted verbs in the following sentences is in the simple present tense and each sentence describes an action taking place in the present:
Deborah waits patiently while Bridget books the tickets.
The shelf holds three books and a vase of flowers.
The crowd moves across the field in an attempt to see the rock star get into her helicopter.
The Stephens sisters are both very talented; Virginia writes and Vanessa paints.
Ross annoys Walter by turning pages too quickly.
The simple present is used to express general truths such as scientific fact, as in the following sentences:
Rectangles have four sides.
Canada Day takes place on July 1, the anniversary of the signing of the British North America Act.
The moon circles the earth once every 28 days.
Calcium is important to the formation of strong bones.
Menarche and menopause mark the beginning and the ending of a woman’s reproductive history.
The simple present is used to indicate a habitual action, event, or condition, as in the following sentences:
Leonard goes to The Jumping Horse Tavern every Thursday evening.
My grandmother sends me new mittens each spring.
In fairy tales, things happen in threes.
We never finish jigsaw puzzles because the cat always eats some of the pieces.
Jesse polishes the menorah on Wednesdays.
The simple present is also used when writing about works of art, as in the following sentences.
Lolly Willowes is the protagonist of the novel Townsend published in 1926.
One of Artemisia Gentleschi’s best known paintings represents Judith’s beheading of Holofernes.
The Lady of Shallot weaves a tapestry while watching the passers-by in her mirror.
Lear rages against the silence of Cordelia and only belatedly realizes that she, not her more vocal sisters, loves him.
The play ends with an epilogue spoken by the fool.
The simple present can also be used to refer to a future event when used in conjunction with an adverb or adverbial phrase, as in the following sentences.
The doors open in 10 minutes.
The premier arrives on Tuesday.
Classes end next week.
The publisher distributes the galley proofs next Wednesday.
The lunar eclipses begins in exactly 43 minutes.
The Simple Past Tense
The simple past is used to describe an action, an event, or condition that occurred in the past, sometime before the moment of speaking or writing.
Each of the highlighted verbs in the following sentences is in the simple past tense and each sentence describes an action taking place at some point in past.
A flea jumped from the dog to the cat.
Phoebe gripped the hammer tightly and nailed the boards together.
The gem-stones sparkled in a velvet lined display case.
Artemisia Gentilsechi probably died in 1652.
The storyteller began every story by saying “A long time ago when the earth was green.”
The Simple Future Tense
The simple future is used to refer to actions that will take place after the act of speaking or writing.
Each of the highlighted verbs in the following sentences is in the simple future tense.
They will meet us at the newest café in the market.
Will you walk the dog tonight?
At the feast, we will eat heartily.
Bobbie will call you tomorrow with details about the agenda.
The Smiths say that they will not move their chicken coop.
The simple present tense
9.6 Form of the simple present tense
We add s or es to the base form of the verb in the third person singular
/ work
You work
He works
She works in an office
It works
We work
You work
They work
9.7 The third person singular: pronunciation and spelling
9.7.1 Pronunciation of the 3rd person singular [compare > 2.21]
Is/ after /f/, /p/, /k/, /t/ – laughs puffs drops kicks lets
Verbs ending in /z/, /ʤ/, /s/, /ʃ/, /ʧ/ and /ks/ take an extra
syllable in the third person which is pronounced /iz/ loses manages
passes pushes stitches mixes
Other verbs are pronounced with a Izl in the third person after /b/
robs after/d/ adds after /g/ digs after /I/ fills after/m/ dreams
after/n/ runs after/r)/ rings after vowel + w or r draws st rs after
/v/ loves after vowels sees pays Says is normally pronounced /sez/
and does is pronounced /dʌz/
9.7.2 Spelling of the 3rd person singular [compare > 2.20]
Most verbs add s work/works drive/drives play/plays run/runs
Verbs normally add es when they end in o do/does s miss/
misses x mix/mixes -ch catch/catches -sh push/pushes
The simple present tense
When there is a consonant before -y, change to les cry/cries but
compare buy/buys say/says obey/obeys
9.8 Uses of the simple present tense
9.8.1 Permanent truths
We use the simple present for statements that are always true
Summer follows spring Gases expand when heated
9.8.2 ‘The present period’
We use the simple present to refer to events actions or situations
which are true in the present period of time and which for all we
know may continue indefinitely What we are saying in effect, is ‘this
is the situation as it stands at present’
My father works in a bank My sister wears glasses
9.8.3 Habitual actions
The simple present can be used with or without an adverb of time to
describe habitual actions, things that happen repeatedly
/ get up at 7 John smokes a lot
We can be more precise about habitual actions by using the simple
present with adverbs of indefinite frequency (always never, etc [>
7.39]) or with adverbial phrases such as every day [> 7.38]
/ sometimes stay up till midnight
She visits her parents every day
We commonly use the simple present to ask and answer questions
which begin with How often7
How often do you go to the dentist? – I go every six months
Questions relating to habit can be asked with ever and answered with
e g never and sometimes not ever [> 7.40.5]
Do you ever eat meat? – No I never eat meat
9.8.4 Future reference
This use is often related to timetables and programmes or to events in
the calendar
The exhibition opens on January 1st and closes on January 31st
The concert begins at 7.30 and ends at 9.30
We leave tomorrow at 11.15 and arrive at 17.50
Wednesday, May 24th marks our 25th wedding anniversary
For the use of the simple present after when etc [> 1.45.2]
9.8.5 Observations and declarations
We commonly use the simple present with stative and other verbs to
make observations and declarations in the course of conversation e g
/ hope/assume/suppose/promise everything will be all right
I bet you were nervous /ust before your driving test
It says here that the police expect more trouble in the city
I declare this exhibition open
I see/hear there are roadworks in the street again
I love you I hate him
We live in difficult times – I agree
The simple past tense
9.13 Form of the simple past tense with regular verbs
The form is the same for all persons [> App 39].
pronunciation spelling
I
played Id I arrive/arrived
He arrived IdI wait/waited
She worked ltl stop/stopped
dreamed/dreamt /dri:md/or/dremt/ occur/occurred
posted /id/ cry/cried
You
They
The simple past tense
9.14 The regular past: pronunciation and spelling [> App 39]
9.14.1 Pronunciation of the regular past
Verbs in the regular past always end with a -d in their spelling, but the
pronunciation of the past ending is not always the same:
play/played I d /
The most common spelling characteristic of the regular past is that
-ed is added to the base form of the verb: opened, knocked, stayed,
etc. Except in the cases noted below, this -ed is not pronounced as if
it were an extra syllable, so opened is pronounced: / əʊpənd /,
knocked: / nokt/, stayed: /steid/, etc.
arrive/arrived Id/
Verbs which end in the following sounds have their past endings
pronounced Id I: Ibl rubbed; Igl tugged; / ʤ / managed; III filled;
Iml dimmed; Inl listened; vowel + /r/ stirred; Ivl loved; Izl seized.
The -ed ending is not pronounced as an extra syllable.
work/worked It/
Verbs which end in the following sounds have their past endings
pronounced Itl: Ik I packed; Is/ passed; IʧI watched; IʃI washed;
/f/ laughed; Ipl tipped. The -ed ending is not pronounced as an extra
syllable.
dream/dreamed IdI or dreamt Itl
A few verbs function as both regular and irregular and may have their
past forms spelt -ed or -t pronounced Id/ or Itl: e.g. burn, dream,
lean, learn, smell, spell, spill, spoil [> App 40].
post/posted I id /
Verbs which end in the sounds Itl or Id/ have their past endings
pronounced /id/: posted, added. The -ed ending is pronounced as an
extra syllable added to the base form of the verb.
9.14.2 Spelling of the regular past
The regular past always ends in -d:
arrive/arrived
Verbs ending in -e add -d: e.g. phone/phoned, smile/smiled- This rule
applies equally to agree, die, lie, etc.
wait/waited
Verbs not ending in -e add -ed: e.g. ask/asked, clean/cleaned,
follow/followed, video/videoed
stop/stopped
Verbs spelt with a single vowel letter followed by a single consonant
letter double the consonant: beg/begged, rub/rubbed
occur/occurred
In two-syllable verbs the final consonant is doubled when the last
syllable contains a single vowel letter followed by a single consonant
letter and is stressed: pre’fer/preferred, re’ferlreferred- Compare:
‘benefit/benefited, ‘differ/differed and ‘profit/profited which are
stressed on their first syllables and which therefore do not double their
9 Verbs, verb tenses, imperatives
final consonants In AmE labeled, quarreled signaled and traveled
follow the rule In BrE labelled quarrelled, signalled and travelled are
exceptions to the rule [compare > 9.10]
cry/cried [compare > 2.20]
When there is a consonant before -y, the y changes to / before we
add ed eg carry earned deny denied fry fried try tried Compare
delay delayed obey obeyed play played, etc which have a vowel
before -y and therefore simply add -ed in the past
9.15 Form of the simple past tense with irregular verbs
The form is the same for all persons [> App 40]
/
You
He
She shut the suitcase
It sat on
We
You
They
9.16 Notes on the past form of irregular verbs
Unlike regular verbs, irregular verbs (about
past forms which can be predicted
shut/shut
A small number of verbs have the same form in the present as in the
past e g cut/cut hit hit put put It is important to remember,
particularly with such verbs, that the third person singular does not
change in the past eg he shut (past), he shuts (present)
sit/sat
The past form of most irregular verbs is different from the present
bring brought catch caught keep/kept leave/left lose/lost
9.17 Uses of the simple past tense
9.17.1 Completed actions
We normally use the simple past tense to talk about events, actions or
situations which occurred in the past and are now finished They may
have happened recently
Sam phoned a moment ago
or in the distant past
The Goths invaded
A time reference must be given
/ had a word with Julian this morning
or must be understood from the context
/ saw Fred in town (i e when I was there this morning)
/ never met my grandfather (i e he is dead)
When we use the simple past, we are usually concerned with when an
action occurred, not with its duration (how long it lasted)
The simple past tense
9.17.2 Past habit
Like used to [> 11.60], the simple past can be used to describe past
habits [compare present habit > 9.8.3]:
/ smoked forty cigarettes a day till I gave up
9.17.3 The immediate past
We can sometimes use the simple past without a time reference to
describe something that happened a very short time ago-
Jimmy punched me in the stomach
Did the telephone ring?
Who left the door open? (Who’s left the door open? [> 9.26.1])
9.17.4 Polite inquiries, etc.
The simple past does not always refer to past time It can also be
used for polite inquiries (particularly asking for favours), often with
verbs like hope think or wonder Compare:
/ wonder if you could give me a lift
I wondered if you could give me a lift (more tentative/polite)
For the use of ‘the unreal past’ in conditional sentences [> 14.12]
9.18 Adverbials with the simple past tense
The association of the past tense with adverbials that tell us when
something happened is very important. Adverbials used with the past
tense must refer to past (not present) time. This means that adverbials
which link with the present (before now, so far till now yet) are not
used with past tenses.
Some adverbials like yesterday, last summer [> App 48] and
combinations with ago are used only with past tenses
/ saw Jane yesterday/last summer
Ago [> 7.31], meaning ‘back from now’, can combine with a variety of
expressions to refer to the past: e g. two years ago, six months ago,
ten minutes ago, a long time ago
I met Robert Parr many years ago in Czechoslovakia
The past is often used with when to ask and answer questions:
When did you learn about it9 – When I saw it in the papers
When often points to a definite contrast with the present:
/ played football every day when I was a boy
Other adverbials can be used with past tenses when they refer to
past time, but can be used with other tenses as well [> 9.4]:
adverbs: / always liked Gloria
I often saw her in
Did you ever meet Sonia?
I never met Sonia
adverbial/prepositional phrases. We left at 4 o’clock/on Tuesday
We had our holiday in July
adverbial clauses: / waited till he arrived
I met him when I was at college
as + adverb + as: I saw him as recently as last
week
The simple future tense
9.35 Form of the simple future tense
The simple future is formed with will [but > 9.36] and the base form of the verb
affirmative short form negative short forms
/ will I’ll I will not I’ll not I won’t
You will You’ll You will not You’ll not You won’t
He will Hell He will not He’ll not He won’t
She will She’ll She will not She’ll not She won’t stay
It will It’ll It will not It’ll not It won’t
We will We’ll We will not We’ll not We won’t
You will You’ll You will not You’ll not You won’t
They will They’ll They will not They’ll not They won’t
9.36 Notes on the form of the simple future tense
1 Shall and will
Will is used with all persons, but shall can be used as an alternative
with / and we in pure future reference [> 9.37.1]
Shall is usually avoided with you and I:
You and I will work in the same office
2 Contractions
Shall weakens to / Jal/ in speech, but does not contract to ‘II in
writing Will contracts to ‘// in writing and in fluent, rapid speech
after vowels (///, we’ll, you’ll, etc.) but 7/ can also occur after
consonants. So we might find ‘II used: e.g.
– after names: Tom’ll be here soon
– after commoouns: The concert’!! start in a minute
– after question-words: When’ll they arrive?
3 Negatives
Will not contracts to // not or won t, shall not contracts to shan t:
I/We won’t or shan’t go (I/We will not or shall not go)
In AmE shan’t is rare and shall with a future reference is unusual.
4 Future tense
When we use will/shall for simple prediction, they combine with
verbs to form tenses in the ordinary way [> 9.2, 11.7]:
simple future: / will see
future progressive: / will be seeing
future perfect: / will have seen
future perfect progressive: / will have been seeing
9.37 Uses of the ‘will/shall’ future
9.37.1 ‘Will/shall’ for prediction briefly compared with other uses
Will and shall can be used to predict events, for example, to say what
The simple future tense
we think will happen, or to invite prediction:
Tottenham will win on Saturday
It will rain tomorrow Will house prices rise agaiext year7
I don’t know if I shall see you next week
This is sometimes called ‘the pure future’, and it should be
distinguished from many other uses of will and shall: e.g.
/’// buy you a bicycle for your birthday [promise, > 11.73]
(Note that will is not used to mean ‘want to’)
Will you hold the door open for me please? [request, > 11.38]
Shall I get your coat for you? [offer, > 11.39]
Shall we go for a swim tomorrow? [suggestion, > 11.40]
Just wait – you’ll regret this’ [threat, > 11.23, 11.73]
Though all the above examples point to future time, they are not
‘predicting’; they are ‘coloured’ by notions of willingness, etc. Will/shall
have so many uses as modal verbs [> Chapter 11] that some grammar-
ians insist that English does not have a pure future tense [also > 9.2].
9.37.2 ‘Will’ in formal style for scheduled events
Will is used in preference to be going to [> 9.44] when a formal style
,, is required, particularly in the written language:
The wedding will take place at St Andrew’s on June 27th The
reception will be at the Anchor Hotel
9.37.3 ‘Will/shall’ to express hopes, expectations, etc.
The future is often used after verbs and verb phrases like assume, be
afraid, be sure, believe, doubt, expect, hope, suppose, think
I hope she’ll get the job she’s applied tor
The present with a future reference is possible after hope:
I hope she gets the job she’s applied for [compare > 11.42.1]
; Lack of certainty, etc. can be conveyed by using will with adverbs
like perhaps, possibly, probably, surely
Ask him again Perhaps he’ll change his mind
9.38 Time adverbials with the ‘will/shall1 future tense
Some adverbials like tomorrow [> App 48] are used exclusively with
future reference; others like at 4 o’clock, before Friday, etc. are used
with other tenses as well as the future:
/’// meet you at 4 o’clock
Now and just can also have a future reference [> 7.29]:
This shop will now be open on June 23rd (a change of date)
I’m nearly ready I’ll just put my coat on
For in + period of time [> 8.14] and by, not until [> 7.34],
9.39 Other ways of expressing the future
We can express the future in other ways, apart from will/shall:
be going to: I’m going to see him tomorrow [> 9.44]
be to: I’m to see him tomorow [> 9.47]
present progressive: I’m seeing him tomorrow [> 9.11.3]
simple present: / see him tomorrow [> 9.8.4]
These ways of expressing the future are concerned less with simple
prediction and more with intentions, plans, arrangements, etc.
Literature:
1. Адамчик М.В. Великий англо-український словник. – Київ, 2007.
2. Англійська мова за професійним спрямуванням: Медицина: навч. посіб. для студ. вищ. навч. закл. IV рівня акредитації / І. А. Прокоп, В. Я. Рахлецька, Г. Я. Павлишин ; Терноп. держ. мед. ун-т ім. І. Я. Горбачевського. – Тернопіль: ТДМУ : Укрмедкнига, 2010. – 576 с.
3. Балла М.І., Подвезько М.Л. Англо-український словник. – Київ: Освіта, 2006. – Т. 1,2.
4. Hansen J. T. Netter’s Anatomy Coloring Book. – Saunders Elsevier, 2010. – 121 p.
5. Henderson B., Dorsey J. L. Medical Terminology for Dummies. – Willey Publishing, 2009. – P. 189-211.