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.pdf
Karen Fairhurst
https://t.me/medicina_free
Anna R Dover
J Alastair Innes
20
Reaching and communicating
a diagnosis
Reaching a diagnosis 416
Pretest probability 416
Rare diseases 416
Multimorbidity 417
Diagnostic error 417
Biopsychosocial model 417
Approach to the patient with medically unexplained symptoms 417
Communicating a diagnosis 418
Shared decision-making 418
Diagnostic and therapeutic uncertainty 419
Documenting your findings 419
Communicating with colleagues 419
Verbal communication 419
Written communication 422
416 • REACHING AND COMMUNICATING A DIAGNOSIS
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History taking, examination and investigation are the methods by
which clinicians gather information to allow them to understand
patients’ problems. Clinical reasoning is the analytical process by
which this information is translated into diagnoses, therapeutic
possibilities and prognoses. This chapter addresses how the
clinical skills described in this book enable clinicians to reach
diagnoses and other clinical decisions and communicate these
to patients and colleagues in everyday practice.
Reaching a diagnosis
Doctors recognise patterns of symptoms and signs, then apply
clinical reasoning to interpret them and formulate diagnostic
possibilities or probabilities. Sometimes, doctors instantly
recognise a condition based on previous experience (‘spot diagnoses’, p. 38). Visual patterns are particularly likely to lead to
such recognition: for example, a typical rash. More commonly,
elements of the history and examination together trigger pattern
recognition. This process relies on comparing a patient’s presentation to cases encountered before and remembered as
illness scripts. With increasing experience, less typical presentations are encountered and recalled, and doctors are
increasingly able to recognise more exceptional cases.
Pretest probability
When doctors are unable to recognise patterns in presentations
quickly, various refinement strategies are used to arrange the
possible diagnoses in order of probability. The pretest probability
of a disease is the proportion of people in a population at risk
who have the disease. For an individual with a new symptom, the
pretest probability of disease depends on the context in which
the symptom has appeared because the prevalence of disease
varies between populations. In general practice populations, the
incidence of serious disease, for example, colorectal cancer, is
much lower than in hospital populations, although serious conditions still usually need to be excluded. In practice, the pretest
probability of a disease is the clinician’s judgment of the likelihood of a particular disease based on the information gathered
to date and their understanding of the context in which they
work. Clinicians need a mental map of how likely different diseases are and how those probabilities shift as they gather and
synthesise information. This may involve identification of ‘red flag’
or ‘ alarm’ symptoms and signs of serious disease, for example,
or the use of clinical prediction rules, such as the Wells score for
deep vein thrombosis. Positive ‘alarm’ features or abovethreshold prediction scores increase the probability of a disease in individuals and generally trigger further investigation.
Clinicians also rely on understanding the sensitivity, specificity
and predictive value of symptoms for the diagnosis of a particular
condition in the population with which they work. For example,
chest pain is a highly sensitive symptom in the diagnosis of acute
coronary syndromes (ACS) as a high proportion of people who
have an eventual diagnosis of ACS experience chest pain.
However, it is not a specific symptom as many people who do
not have an eventual diagnosis of ACS will also have chest pain.
Gather clues
Formulate hypothesis
Revise hypothesis
Search for other
Revise decision
Response or
progress
unexpected
Fig. 20.1 The hypothetico-deductive method of decision-making.
If the presence of chest pain alone were used to diagnose, ACS
would therefore be overdiagnosed. The predictive value of
symptoms is more useful in clinical practice than either sensitivity
or specificity as it predicts the likelihood that a person with a
particular symptom has the associated condition. Like pretest
probability, it is affected by the prevalence of the disease in the
population. For example, the positive predictive value of rectal
bleeding in the diagnosis of colorectal cancer is higher in older
populations than in younger ones.
Additional factors affecting the pretest probability of disease in
patients with the same presenting symptoms include age,
gender, past medical history, family history and lifestyle. Few
doctors use formal probabilistic reasoning in making diagnoses,
but most know the relationship between these factors and the
likelihood of a specific disease and use this understanding intuitively to select likely diagnoses to subject to hypotheticodeductive reasoning (Fig. 20.1). Initial history, examination and
investigation results are used to develop a list of possible diagnoses – the hypotheses. Further history, examination and
investigation are used to support or refute each of these putative
diagnoses until a final diagnosis is determined. Returning to
clarify the history or re-examine matters when signs are ambiguous allows an iterative approach and more accurate diagnosis.
information to
test hypothesis
History
Examination
Investigations
Make a decision
Diagnosis
Management
Follow up
Rare diseases
While diagnosis by probability works in most cases, rare diseases also occur, and to the affected patients and their families,
they are not rare. Avoid the trap of thinking that all patients have
common conditions, and symptoms that do not fit with common
diagnoses are less important. Indeed, occasional patients with a
Approach to the patient with medically unexplained symptoms • 417
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credible and consistent history of unusual symptoms may
actually merit more, not less, investigation. The art is to listen
carefully, keep an open mind and pick up the uncommon situation when the usual patterns of presentation really do not fit the
facts of a case.
Multimorbidity
The application of clinical skills in diagnosis is complicated when
patients have multiple morbidity. New symptoms arise in the
context of existing physical and psychological illness and may
represent new manifestations or complications of a known
condition, of more than one known condition, or of a new disease altogether. Typically, patients with multiple morbidities do
not experience their diseases discretely and therefore may report
symptoms in an indistinct or incoherent way. Furthermore, their
symptoms might interact with each other, and present differently
compared to a single disease. Faced with this atypical pattern of
symptoms, it is not easy for clinicians to reach distinct
diagnoses.
Diagnostic error
Diagnosis is not easy, and all clinicians, irrespective of expertise,
make diagnostic errors. Errors are more common when presentations are atypical or nonspecific, when patients have
comorbidities, or when the underlying condition is rare. Most
errors occur because of defects in diagnostic thinking, of which
the most common error is heuristic-based thinking. Heuristics
are cognitive shortcuts used to solve problems; they are quick
and reflexive and used to generate an approximate answer to a
reasoning question. They are used, for example, in spot diagnosis, pattern recognition and hypothetico-deductive approaches but are prone to produce error by disproportionately
diagnosing conditions that are at the forefront of the clinician’s
mind. This could be due to:
• seeing several recent cases
• missing a diagnosis
• settling on a hypothetical diagnosis without gathering enough
information to confirm or refute it
• interpreting new information in a way that supports rather
than refutes a hypothetical diagnosis, or
• using stereotyping or profiling in clinical reasoning, for
example, deciding that a drug-using patient presenting with
back pain is seeking drugs rather than investigating the cause
of their pain.
Many strategies have been proposed to debias diagnostic
thinking. Metacognition is one such strategy. It promotes
awareness and understanding of your own thinking as a way of
recognising and minimising unconscious bias or errors. It encourages you to check for conflicting evidence and consider
alternatives to the decision you have arrived at. For example, in
reaching a diagnosis, it may be helpful to stop and ask yourself:
•‘What else could this be?’
•‘How much is my decision being influenced by the fact I am
running late?’
•‘How much is my decision being influenced by the patient I
misdiagnosed last week?’
As a reflective process, metacognition can be learnt and
practised.
Biopsychosocial model
Much of this book deals with the association between a patient’s
history and examination findings and the presence of underlying
disease that can be viewed independently from the person who
is suffering from it. However, patients often experience symptoms that either cannot be explained wholly by disease or occur
in the absence of underlying pathology altogether. Symptoms
are, consequently, not synonymous with disease but subjective
experiences with many possible sources: pathological, physiological, psychological, cultural, behavioural and external. Therefore, understanding what has caused a patient to be ill often
requires the clinician to consider their symptoms within a wider
biopsychosocial framework rather than a limited biomedical one.
Approach to the patient with medically
unexplained symptoms
Symptoms that impair function but do not fit characteristic patterns of disease and persist despite normal examination and
investigations are often called ‘functional’, ‘medically unexplained
symptoms’ (MUS, Fig. 20.2) or, more recently, ‘persistent
physical symptoms’. In this chapter ‘ medically unexplained
symptoms’ will be used. Over 30% of patients attending their
10
Pathological cause
8
6
4
3-year incidence (%)
2
0
Fatigue
Chest pain
Dizziness
Fig. 20.2 Percentage of symptoms presenting in primary care with an
underlying pathological cause.
Headache
Oedema
Back pain
Insomnia
Dyspnoea
Numbness
Abdominal pain
20
418 • REACHING AND COMMUNICATING A DIAGNOSIS
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20.1 Aetiological factors for medically unexplained
symptoms
• Precipitating: stress, depression, anxiety and sometimes disease and
injury, especially if associated with fears of or belief in disease
• Predisposing: fear of disease from previous experience
• Perpetuating: inappropriate attempts to alleviate symptoms (e.g.
excessive rest) failure to address patient’s concerns
general practitioner have MUS, and they are also common in
secondary care, although disease prevalence is much higher
there. Some symptoms are more likely to be medically unexplained than others: for example, persistent fatigue, abdominal
pain and back pain. The causes of MUS are poorly understood,
but various predisposing and precipitating factors (Box 20.1)
may contribute. Most functional symptoms are transient, but
some become persistent, causing similar disability to those
resulting from disease and also significant emotional distress. If
MUS are not recognised and managed appropriately, attempts
to alleviate them can result in harm from fruitless investigations,
inappropriate interventions or drugs, and increased fear of
disease.
Patients with MUS commonly feel that clinicians do not think
their symptoms are real, leading to a breakdown in trust between
patient and clinician and frustration for both. Crucially, clinicians
must use an empathic and non-judgemental approach, so the
patient feels believed. Keep an open mind and accept all the
patient’s symptoms at face value. Remember that patients with
MUS may also have or develop disease. Even if a functional
diagnosis is suspected, a comprehensive history and examination remain imperative. This helps patients to feel that they are
being taken seriously; in addition, organic disease, however
unlikely, is less likely to be missed.
Patients’ illness beliefs matter hugely and should be explicitly
acknowledged. What do they think is wrong? Why have they
come to you now, and what do they hope you can do for them?
Inconsistencies in the history should be explored with the patient;
for example, a patient with severe chest pain and normal coronary angiography may still firmly believe they have angina.
Normal investigations need to be explained clearly to help
demonstrate that the evidence does not support their belief.
Patients may complain about previous clinicians or treatments.
Allowing a patient to express dissatisfaction shows interest and
helps to avoid suggesting treatments they are likely to reject.
Always remain professional and avoid being drawn into criticism
of other healthcare providers.
Patients can be acutely sensitive t o questions that suggest a
clinician thinks there is a psychological basis for their symptoms (‘all in the mind’). Frame questions carefully in terms of
theirsymptoms:forexample,‘Do your symptoms ever make
youfeeldownorfrustrated?’ rather than ‘Do you ever feel
depressed?’ Abuse is one possible prec ipitant of MUS but
seek this history judiciously. Follow local guidelines for any
abuse you discover.
The physical assessment includes observing the patient
throughout the consultation. Watch for inconsistent signs,
although this does not indicate whether they are consciously or
subconsciously produced. Usually, there are no physical signs,
but some non-pathological signs are associated with MUS; for
instance, in irritable bowel syndrome, you may find evidence of
bloating and some tenderness, but otherwise, gastrointestinal
examination will be normal. The history often suggests MUS, so
focus on excluding any unexpected physical findings, as well as
demonstrating to patients that you are taking them seriously. Any
signs you do find may vary between examinations, but overall,
the examination is commonly normal with MUS.
Investigations are used in MUS mainly to reassure both clinician and patient. Exhaustive investigations to exclude all physical
illness are costly and unhelpful, risk side effects, and do not
reassure patients in the longer term. Before requesting investigations, discuss with the patient the likelihood and significance of a normal result. Patients are more likely to be satisfied
when your explanation makes sense to them, removes blame
and helps to generate ideas about how they can manage their
symptoms.
Communicating a diagnosis
Clinicians routinely inform patients about new diagnoses, and,
even if not life threatening, many will be unwelcome to patients.
Inappropriate communication, such as an abrupt or harsh
disclosure, can be psychologically devastating to the patient.
Effectively communicating a diagnosis to a patient requires an
understanding of the key medical and informational needs of the
patient, and an appreciation of the patient’s prior knowledge and
beliefs about their health. Ask, ‘What do you already know about
your illness?’,or‘Would you like me to tell you the details of the
diagnosis?’’ For disclosure of bad news, it is usual to give a
‘warning shot’ (e.g. ‘I’m afraid I have bad news for you’). Information should be given in small chunks and aligned with what
the patient knows or believes already. Misconceptions should be
corrected. The language used should be free from medical jargon. Patients should be given time to absorb the information
given, and clinicians should check their understanding often,
clarify any misunderstandings and reinforce important information. Responding empathetically to the patient’s emotions at this
stage allows the patient to feel heard and provides support if the
news is bad.
Shared decision-making
To share decision-making with the patient about treatment, the
clinician requires an understanding of the patient’s needs, values,
goals and preferences regarding care, including their desired
degree of involvement in decision-making. Available options for
treatment can then be explored with the patient. Again, information should be given in ‘‘chunks’’ and the patient’s understanding of information checked. Choices should be discussed
openly with the patient, and the clinician should be clear about
the potential harms and benefits of different treatment options.
Risk information should be presented numerically whenever
possible, using consistent denominators (e.g. ‘Of 100 children
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with otitis media, 84 would be free from pain at 2 to 3 days even
without antibiotics, 11 will not be pain-free even with antibiotics,
and only 5 will have their pain relieved by receiving antibiotics, so
antibiotics only help in about 1 in 20 cases.’) For complex information such as this, visual decision aids may present information in a way that the patient can better understand; examples
of these can be found at Dr. Chris Cates’ EBM website,
nntonline.net. Information should be provided in absolute as well
as relative terms and attention should be paid to the way information is framed. Equivalent information can be more or less
attractive depending on what features are highlighted, and the
framing of health information can lead to different decisions and
health behaviours. Positive framing (e.g. chance of survival) is
more effective than negative framing (e.g. chance of death) in
persuading people to take risky treatment options, such as
surgery, whereas ‘loss’ framing (e.g. the potential losses from not
having a mammogram) influences screening uptake more than
‘gain’ framing.
Patients should be encouraged to consider ‘what matters
most to them’, and to determine their preferences for treatment. It is often helpful for patients to c onsider what would
happen if they chose not to take up any of the treatment
options. Clinicians should accept that patients may not share
their views about the balance of risks, benefits, and side effects of treatments. Many studies demonstrate a correlation
between effective clinician-patient communication and
improved health outcomes. If patients feel they have been
listened to, and understand the problem and proposed
treatment plan, they are more likely to follow the plan and less
likely to reattend.
Diagnostic and therapeutic uncertainty
In practice, not all diagnoses are reached with certainty despite
diligent application of clinical methods and reasoning to patients’
problems. Patient frailty may, for example, make definitive tests
too risky. Similarly, treatment choices are not always straightforward even when the diagnosis is clear. For some diseases,
there is no clear-cut evidence that one treatment option is superior to others. Sharing uncertainty about diagnosis and treatment with patients is a key component of patient-centred care
and goes beyond simple exchange of information. With careful
explanation, most patients understand and accept unavoidable
uncertainty, but in this situation it is especially important to agree
with the patient on the appropriate course of action after full
discussion.
Documenting your findings
Documenting clinical findings in a clear and concise medical
record is a crucial aspect of medical practice. It should include a
structured account of the history and examination – both positive
and important negative findings. Some circumstances demand
additional detail: for example, forensic documentation of the
length and position of wounds.
The appropriate level of detail varies with the context, but you
should adopt and use a consistent format. This format quickly
becomes a habit, reduces your need to think about what to record
next, and lessens the likelihood of forgetting something important. A
consistent format also allows others to locate specific information
quickly in your documentation. An example of clear and concise
clinical documentation of a case is shown in Fig. 20.3.
Communicating with colleagues
An essential part of a clinician’s work is the accurate and timely
sharing of information about patients with colleagues. Communication failures are strong predictors of healthcare-related harm.
Typical situations include:
• referral of a patient from the community to a hospital
(Box 20.2)
• request for advice or immediate help
• discharge of a patient back to the community from a hospital
(Box 20.3)
• outpatient clinic letter to the general practitioner or referring
consultant
• referral of a patient to another consultant
• referral of a patient to other hospital or community services
(such as a social work referral or referral to a specialist service, such as palliative care).
Verbal communication
Verbal communication about a patient needs to be structured and
concise to be effective. Be clear about your expectations of the
person you are communicating with, especially if you are requesting
that they do something, such as coming to review the patient.
SBAR (situation, background, assessment, recommendation)
is a simple tool to help standardise communication. It is recommended by the World Health Organization for use as a tool to
increase patient safety. It allows staff to share similar expectations about what is to be communicated and how the communication is structured. SBAR can be used face to face, over the
telephone or even in some written communication.
Using situation, background, assessment,
recommendation
First, collect the information you need to pass on, and think
through what you want to achieve by the communication, for
example, informing a colleague, asking for immediate help or
requesting advice. Consider some brief notes under the SBAR
headings.
Attract the attention of the person you are communicating with.
Introduce yourself. If face to face, make eye contact. If possible, use
the person’s name: ‘Hello,DrJones.MynameisDrSmith.I’mone
of the junior doctors in the emergency department.’
• Situation: give a one- or two-sentence description covering
why you are calling, what is happening and what the acute
change is.
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Date: 02.Oct.21 Time: 17.00 Mary Brown
32 Tartan Crescent
Emergency admission to CCU Edinburgh EHx xPX
Consultant: Dr J G Macgregor CHI 1209431111
History
PC: Chest pain, Breathlessness
HPC:
Pain: Severe, band-like, onset while watching TV, has lasted 2 hours despite GTN and aspirin.
Radiates to jaw and inner aspect of L arm. Previous similar pain in past 6/12 only with exertion.
Increased episodes recently, after 200m on flat. GP diagnosed angina 2/12 ago, treated with daily
aspirin and GTN as required
Breathlessness: Began gradually during first hour of pain. Now present at rest, worse if reclining.
PH:
Tonsillectomy 1958, Perf. peptic ulcer 1983, COPD diagnosed by GP 2008. °MI, °DM, °↑BP, °stroke
DH: Dose Frequency Duration
Salbutamol inhaler 2 puffs as required 13 years
GTN spray 1 puff as required 2 months
Aspirin 75mg once daily 2 months
°Known allergies
FH:
Aunt died age 57 of MI, no other significant h/o premature heart disease or other familial diseases.
Nil else of note. NOK: daughter (lives nearby, visits regularly).
SH:
Retired cleaner, widowed 3 years, lives alone in ground floor sheltered housing. Smokes 20/day since
age 19. No alcohol. HH once a week for cleaning and shopping.
SE:
CVS: see above
RS: Chronic morning cough with white sputum. Chronic mild exertional breathlessness on hills and
stairs
GI: Good appetite, weight steady, bowels regular, °blood in stools
CNS/GUS: Nil of note
Fig. 20.3 Example of initial clerking documentation for an acute admission: CHI, Community Health Index (Health Service patient identifier); HH,
home help; NOK, next of kin; ESM, ejection systolic murmur; LLSE, lower left sternal edge; PN, percussion note; LKKS, palpable liver, kidneys,
spleen; VR, vocal resonance.
1
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O/E:
Looks pale, anxious, sweaty, with tachypnoea
CVS: P90 regular, BP 150/100, JVP +3cm
HS I+II + 2/6 ESM at LLSE °radiation, no leg oedema
RS: Tachypnoea 22/minute, mild hyperinflation. No palpable LN. Expansion reduced but symmetrical.
PN normal. Scanty fine inspiratory crackles at both bases. VR normal
AS: Old epigastric surgical scar. Abdo soft and non-tender. °LKKS, °masses. PR not done
CNS: Alert and orientated.
Cranial nerves: Normal except fundoscopy shows mild hypertensive retinopathy (AV nipping)
Limbs – Power, tone sensation normal and symmetrical. Reflexes present and symmetrical.
Summary:
Recent onset of pain at rest typical of cardiac ischemia in a patient with a clinical diagnosis of
angina and a background of mild COPD.
Risk factors: 1. Smoking 2. BP and fundoscopy suggest possible underlying hypertension. 3. ESM
suggests possible aortic valve disease – will need echocardiogram to assess
Breathlessness, tachypnoea and basal crackles suggest early pulmonary oedema
Scar
Provisional diagnosis:
Acute coronary syndrome, possible MI, possible early pulmonary oedema
Immediate plan:
Oxygen to maintain saturation >94%
Establish IV access and ECG monitoring
Give pain relief – morphine and metoclopramide
Give oral aspirin 300mg
12 lead ECG: shows diagnostic ST elevation so refer to cardiology for reperfusion therapy
Blood for FBC, U&E and Troponin
Transfer to specialist cardiology unit for further care
Signed: _______________________ Designation: FY1 doctor, Acute Medicine
Print name:____________________ Date: ____________________
Fig. 20.3 Con’t
Dr. A. P. Smith 2/10/21
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422 • REACHING AND COMMUNICATING A DIAGNOSIS
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20.2 Contents of a referral letter
• Demographic details about the patient and the referring doctor practice
• Consultant/receiving practitioner and/or clinic, ward, or specialty
• The urgency of the referral
Clinical information:
• History of presenting symptoms/examination findings/results of any
investigation
• Reason for referral and expected outcome
• Past medical history
• Current and recent medication (including any complementary therapies
and self-medication known to the referring doctor)
• Clinical warnings (e.g. allergies, blood-borne viruses)
• Smoking status/alcohol history
• Additional relevant information, e.g.:
Relevant social or personal circumstances
Patient/family’s understanding of the condition and their expectations
Information about any advanced directives or resuscitation orders
• Name and contact information of referring clinician.
Similar information will be required when a patient is referred internally to
another hospital consultant.
‘I’m concerned about a 53-year-old man who came into the
emergency department this morning complaining of severe
headache. His headache’s getting worse, and he’s begun
to vomit.’
• Background: the information needed to make an
assessment.
• Relevant history: What were the key events leading up to
the present situation?
• Vital signs:
- ‘Mr Jackson had a sudden onset of severe headache
after waking at about seven this morning. The pain hasn’t
improved despite painkillers, and he appears to be getting worse. He’s hypertensive at 210/110 and vomiting.’
• Assessment: what is your assessment of the problem?
-
‘I’m concerned that Mr Jackson may be having an
intracranial bleed.’
• Recommendation/request: what do you think should be
done? What assistance are you asking for? Be clear about
what you need and when you need it.
-
‘I’d like you to come and review the patient urgently,
please.’
If you are feeling out of your depth and need support from a
senior colleague, be clear about that. It is better to endure the
brief discomfort of having to admit that you need help than put a
patient’s well-being in jeopardy.
SBAR can be applied as a standard framework to transfer
important information in many situations. By using this method,
20.3 Contents of a patient discharge letter following a
hospital admission
Demographic information about the patient, the consultant and the
preferred GP (the GP who has been most involved, if known)
• Ward
• Date of discharge/transfer or date of death
• Reason for admission/transfer
• Mode of admission: elective, emergency, or transfer
• Source of admission
• Diagnosis/problem list
• Significant operations/procedures (dates)
• Relevant investigations
• Complications/adverse reactions
• Medication (including start and stop dates, recommendations for
altering dose or stopping medication after discharge, use of aids such
as a dosette box)
Discharge plans:
• Further information about destination
• Care package
• Primary care support needed
• Information given to patient/carers
• Results awaited
• Hospital review plan/referral to other hospital services
• Other relevant clinical or personal information
• Contact name and telephone number of author
you are proactively giving the listener the information that they
need to assess the problem. You save time by assimilating and
presenting information in a structured way.
Written communication
Conventionally, information was transferred between doctors
by post, but nowadays, much communication is conducted
electronically. Whatever the medium, the quality of written
communication is crucial. Handwritten forms must be clear and
legible. Clinicians should write clear, w ell-structured referral,
dischargeortransferletters(seeBoxes 20.2 and 20.3). More
and more, these letters are copied to or read by patients as well
as other clinicians, so they must always contain appropriate
language.
Clinical information is confidential and sensitive. It should never
be transmitted by insecure electronic means. Nor should it be
stored on or copied to equipment that could be stolen or lost,
breaching confidentiality. Encryption should be used wherever
possible to protect electronic records, and all clinical information
should always be managed in accordance with local information
governance regulations.
J Alastair Innes
https://t.me/medicina_free
Karen Fairhurst
Anna R Dover
21
Adapting skills for practice
Adapting to different presentations 424
Presentation in emergency 424
Presentation with localised illness 424
Presentation with non-specific symptoms 424
Adapting to different working environments 425
Assessing patients in the community 425
Remote consultation 425
Adapting clinical skills over a career 426
424 • ADAPTING SKILLS FOR PRACTICE
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The previous chapters have covered the idealised process of
taking a history and examining each system in depth. This
chapter considers how this ‘toolbox’ of skills can be used
selectively and adaptively to address the patient’s needs in
specific circumstances.
Adapting to different presentations
Presentation in emergency
Patients presenting with collapse or multiple injury may clearly be
unable to engage in the normal systematic process of history
taking and examination. The approach to the acutely ill or
deteriorating patient is covered in depth in Chapter 18, but this
clinical context demands a different approach:
• Triage of airway, breathing and circulation for immediate
stabilisation
• Identifying the key elements of the history from a third party
(witness, family) – including the patient’s normal level of
functioning, the time course of the illness, major prior illnesses
and any key precipitating events (e.g. medication taken, injury
sustained).
• Interleaving further selected elements of examination with
critical investigations (e.g. chest x-ray, ultrasound) and
resuscitation treatments such as establishing intravenous
access and administering fluids and/or emergency drug
treatment.
Seamlessly merging these elements of assessment, triage and
treatment is a skill which becomes highly developed in Emergency Department clinicians but should be practiced by all, as
the sudden need to assist a collapsed or injured patient is
something with which any clinician may be faced unexpectedly
(see below).
Presentation with localised illness
Some patients present with a well-defined clinical problem in a
specific system, for example, an infected insect bite or a localised
bony injury. In this situation, the temptation may be to confine
history and examination to the affected incident and area.
However, despite the resulting saving of time, this may not serve
the patient well. Although a comprehensive history and examination may not be appropriate or even possible in this situation,
nevertheless, some broader questioning is nearly always
required. For example, an infection may indirectly reveal previously undiagnosed diabetes, so a brief enquiry about recent
weight loss, polyuria and polydipsia may be helpful. Similarly, the
injured patient should always be asked about the context of the
injury in case there are underlying episodes of syncope or
seizure, or a background of alcohol excess, which also need to
be addressed. Consider also the impact of the illness in the
context of the patient’s life. For example, a hand injury may
directly threaten the livelihood of a manual labourer, sports
professional or musician, and may compromise the ability of frail
or isolated patients to maintain their self-care.
Presentation with non-specific symptoms
While many patients volunteer distinctive symptoms suggesting
particular disease processes, others offer less specific or more
unusual clues and require a more broad-ranging approach.
There are a number of possible reasons for this:
• The patient finds it hard to express what they are feeling in
terms understandable to the clinician.
• They are actually suffering from more than one ailment at a
time (multimorbidity); this is increasingly common in elderly or
frail patients.
• Their disease is rare and the symptoms are genuine but
unfamiliar to the doctor.
• Their disease process has begun to affect their health insidiously and generally (e.g. chronic poisoning, deficiency states,
haematological malignancies or insidious autoimmune diseases such as Addison’s disease or pernicious anaemia).
In a further group of patients, a wide range of seemingly unrelated symptoms are reported but no abnormality is found on
examination or investigation. These patients are not uncommon,
particularly in primary care, and this presentation is covered on
page 417 (see Chapter 20).
These are the situations where a structured approach to the
integrated general examination (Box 21.1) can be most useful.
Students taught in a system-based approach may initially find
this difficult, however with practice an integrated examination
becomes a quick and efficient tool for excluding serious
21.1 One system for performing an integrated physical
examination
Greeting and
introduction
Observation of
whole patient
Hands Pallor, cyanosis, clubbing, wasting, palmar
Face Symmetry, complexion, spot diagnoses
Mouth Central cyanosis, tongue fasciculation or wasting,
Neck Lymphadenopathy, goitre, trachea
Thorax Scars, respiratory rate/movements, heart, lungs,
Abdomen Tenderness/guarding, liver, spleen, kidneys,
Lower limbs Oedema, circulation, mobility, joints, neurology
Upper limbs Mobility, joints, neurology, blood pressure
Cranial nerves Including eye movements, visual fields and
Bedside testing Temperature, pulse, blood pressure, height,
Clearly identify yourself and establish a rapport
Demeanour, gait, ease of movement, speech, eye
contact, obesity/cachexia, plethora/pallor, ’spot
diagnosis’ signs
erythema, joint deformity, radial pulse
(e.g. myotonic dystrophy)
oropharynx
breasts, axillae
masses, aorta, hernial orifices, (þ if needed, with
consent, genitalia/PR)
fundoscopy
weight, urinalysis
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