Descriptive Psychopathology: The Signs and Symptoms of ...

110 Section 2: The neuropsychiatric evaluationAsking questions and eliciting informationThe procedural skills of the physical examination take time to learn. In thegeneral medical examination, how and when to test reflexes, cerebellar function,liver size and consistency, for example, are precise over-learned manipulations ofthe patient. Examining the brain is no different. Questions, comments and socialinteractions are the probes, palpations, and percussions of this part of the medicalexamination, but they are no less precise and also require practice. Specificlanguage is presented below, in the chapter appendix, and in subsequent chapters.The examination should be conversational. Medical jargon should be avoided,and colloquialisms and idioms used freely. Most patients will recognize theirmedications by their trade names, not generic names.Mentioning current events and mundane matters such as the weather early inthe introductory phase of the examination, and using humor appropriately easespatient anxiety. Inpatients expect the same questions that have previouslyannoyed them, and can be disarmed by the unexpected personal approach, suchas with Patient 5.1.Patient 5.1A 50-year-old manic man agreed to participate in a teaching conference, buton the morning of the conference was irritable and mostly uncooperative.The resident warned the examiner that the patient was likely to bolt with theleast provocation.When the patient entered the room, the examiner stood and greeted thepatient, introduced himself, asked if the patient would sit in the chair that waspositioned for him, and when both he and the patient were seated, said “That’sa great hat you have on. I like the colors. Where did you get it?” The patientsmiled broadly and after a brief discussion about his hat, spontaneously begantelling the examiner about his illness.Stating the obvious is often better at putting the patient at ease than beginningwith socially stereotypic greetings. Most patients in critical care settings, indwellingtubes everywhere, and under an array of monitors, have little patience for theautomatic “How are you today?” Articulating the patient’s present experiencefosters confidence that the examiner knows what “is going on”. Helpful openingsare “I’m doctor XX, are you as uncomfortable as you look? ...Youlook likeyou’re in a lot of pain. How bad is it?”Examination structureAlthough a good examination appears conversational, it is systematic andthorough. It has a structure. It follows a reasoned sequence. Chapters 6 through