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Interpreting the history and examination 

Interpreting the history and examination
Chapter:
Interpreting the history and examination
Author(s):

Huw Llewelyn

, Hock Aun Ang

, Keir Lewis

, and Anees Al-Abdullah

DOI:
10.1093/med/9780199679867.003.0002
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date: 12 December 2017

Thoughtful history taking

The aim of the diagnostic process is to build up a picture of what is happening to the patient. ‘Diagnosis’ is derived from the Greek ‘to perceive through knowledge’ (i.e. to predict from experience what is beyond the history, examination, etc.).

The diagnosis (or diagnostic formulation) may have to include prediction about past, present, and future, causes, consequences, interactions, and other independent processes. As well as internal medical processes, it has to include external factors such as circumstances at home and the effects on self-care, employment, and leisure.

It is important to establish very clearly why the patient has sought help. This is known as the presenting complaint. Ask about its severity and duration. Be prepared to act immediately to give symptomatic relief (e.g. for pain) if the patient is distressed.

In some cases, the presenting complaint may not explain the decision to seek help. The patient may be too ill, shy, guilty, or embarrassed to describe what is happening accurately. In other cases, it may be someone else who is unduly worried. Be alert to the real reason.

Having established the presenting complaint(s), establish the factual details of ‘place and time’. It is the ability to give a place and time that establishes the complaints as ‘facts’ as opposed to vague ‘anecdote’.

Listen without prompting first but, if necessary, ask where they were and what they were doing when the problem was first noticed. This will help the patient’s recall and help your diagnostic thought process.

Establish the speed of initial onset and subsequent change in severity with time. Onset within seconds suggests a fit or heart rhythm abnormality, over minutes a bleed or clotting process, hours to days an acute infection, days to weeks a chronic infection, weeks to months a tumour, and months to years a degenerative process.

If there are other complaints, note the same details. Ask about other associated, aggravating, and relieving factors, especially as a result of the patient’s own actions and other professional care.

Ask what the patient thinks is going on and is afraid of. This will be the starting point for your own explanation and suggestions to the patient later about what is to be done.

The history also allows patients and supporters to identify the issues that they want addressed in terms of discomfort, loss of function, and difficulties with day-to-day existence. Final diagnoses are based on the initial history because they have to explain it completely. If the diagnoses arrived at cannot explain the entire history and the effects of various treatments, then the diagnoses will be incomplete—others will have to be considered.

Write out your history in a systematic way, e.g. as shown in the next section, and go over it with the patient, if possible, to check that it is right.

This is a lot to remember, especially if you are trying to put it into practice in a busy, noisy environment. However, writing out your findings according to a plan each time will help you to remember.

The plan in Box 2.1 is an example—make up your own.

Interpreting the case history

There are two striking symptoms: (1) a severe sore throat that is getting worse and (2) the sudden loss of consciousness. Both are examples of findings with short lists of causes: good diagnostic ‘leads’ or ‘pivots’.

Most readers will have experienced a sore throat and will be aware that it is usually due to a viral pharyngitis, bacterial tonsillitis (e.g. due to a haemolytic streptococcus), or glandular fever. It could also be due to bone marrow dysfunction (e.g. due to drug effect) or something else in a small proportion of cases (seeInterpreting the history and examination Sore throat, p.[link]). The onset over days is compatible with all these possibilities. A white cell count might give results that would differentiate between these possible causes (see Table 2.1).

Table 2.1 Female. Aged 29. Severe sore throat for 2 days, getting worse. Taking carbimazole for 6 months. Sudden loss of consciousness after getting up from chair, recovery within a minute.

Diagnoses

Outline evidence

Management

Viral pharyngitis?

Severe sore throat for 2 days, getting worse. (19/10/13)

Paracetamol 500mg 6 hourly PRN. Examine throat. Request WCC: ↓neutrophils, ↑lymphocytes?

Acute bacterial (or follicular) tonsillitis (mainly streptococcal)?

Severe sore throat for 2 days, getting worse. (19/10/13)

Paracetamol 500mg 6 hourly PRN. Examine throat. Request WCC: ↑neutrophils?

Glandular fever (infectious mononucleosis due to Epstein–Barr virus)?

Severe sore throat for 2 days, getting worse. (19/10/13)

Paracetamol 500mg 6 hourly PRN. Examine throat. Request WCC: lymphocytes atypical? Paul–Bunnell or Monospot® +ve?

Drug-induced agranulocytosis? (this is what the patient fears)

Severe sore throat for 2 days, getting worse (19/10/13). Taking carbimazole.

Paracetamol 500mg 6 hourly PRN. Examine throat. Request WCC: ↓granulocytes (neutrophils, eosinphils, basophils)?

Postural hypotension syncope? Due to dehydration?

Sudden loss of consciousness after getting up from chair, recovery within a minute (19/10/13). Evidence of acute infection.

Look for fall in BP when standing. Request U&E. Consider fluids IV to rehydrate.

Thyrotoxicosis now controlled?

Taking carbimazole.

Examine for tremor, etc. Carbimazole 5mg od. FT4 and TSH normal?

The sudden loss of consciousness with rapid recovery is known as ‘syncope’. It is also a good lead with a well-defined differential diagnosis. It can be due to a vasovagal attack, cough, micturition or carotid sinus syncope, postural hypotension, transient cerebral ischaemia, a Stokes–Adams attack, aortic stenosis, hypertrophic cardiomyopathy (HOCM), hypoglycaemia, or epilepsy (see Table 2.1). The fact that it happened after the patient got up from a chair suggests postural hypotension (because this always occurs in this condition, but rarely, if ever, in the others). Postural hypotension may be due to fever and dehydration so although the two leads have common causes, postural hypotension could be a consequence of any infection. Therefore, the syncope does not differentiate between any of the causes of a sore throat. The patient has expressed a fear that the sore throat could be drug-induced because she has been warned about this.

These thoughts can be summarized in the problem-structuring note in Table 2.1. You can write this on a sheet of paper, perhaps in pencil for easy editing, on a computer, or on a black or white board when discussing a case with colleagues. Such thoughts are usually considered mentally without writing them down, which is why the diagnostic thought process can be difficult to learn from senior colleagues.

Outline findings

After outlining your thoughts in the problem-structuring note as shown in Table 2.1, turn to the appropriate page in this book by looking up ‘sore throat’. Check that you have not forgotten to include something. The entry in this book for ‘sore throat’ is shown in Interpreting the history and examination Sore throat, p.[link] and in Interpreting the history and examination Sore throat, p.[link]. You may wish to read this before moving on to the next step.

Sore throat

Initial investigations (other tests in bold): FBC, U&E, throat swab, Paul–Bunnell test (Table 2.2).

Table 2.2 Main differential diagnoses and typical outline evidence, etc.

Viral pharyngitis

  • Suggested by: sore throat, pain on swallowing, fever, cervical lymphadenopathy, and injected fauces. WCC: ↑lymphocytes, leucocytes normal.

  • Confirmed by: negative throat swab for bacterial culture, self-limiting: resolution within days.

  • Initial management: analgesics, e.g. paracetamol.

Acute follicular tonsillitis (streptococcal)

  • Suggested by: severe sore throat, pain on swallowing, fever, enlarged tonsils with white patches (like strawberries and creamy lines). Cervical lymphadenopathy, especially in angle of jaw. Fever, WCC: ↑leucocytes.

  • Confirmed by: throat swab for culture and sensitivities of organisms.

  • Initial management: analgesics, antibiotics, e.g. benzyl-penicillin IM or Penicillin V orally; if no allergy, good fluid intake.

Infectious mononucleosis (glandular fever) due to Epstein–Barr virus

  • Suggested by: very severe throat pain with enlarged tonsils covered with grey mucoid membrane. Petechiae on palate. Profound malaise. Generalized lymphadenopathy, splenomegaly. WCC: ↑atypical lymphocytes.

  • Confirmed by: Paul–Bunnell or Monospot® test +ve. Viral titres: ↑Epstein–Barr.

  • Initial management: analgesia, no antibiotics (amoxicillin may cause skin rash).

Candidiasis of buccal or oesophageal mucosa

  • Suggested by: painful dysphagia, white plaque, history of immunosuppression/diabetes/recent antibiotics.

  • Confirmed by: oesophagoscopy showing erythema and plaques, brush cytology: spores and hyphae.

  • Initial management: local antifungal agents, e.g. miconazole oral gel or nystatin oral suspension. Parenteral administration if systemic involvement.

Agranulocytosis

  • Suggested by: sore throat, background history of taking a drug, or contact with noxious substance.

  • Confirmed by: ↓or absent neutrophil count.

  • Initial management: stop potential causative drugs, antibiotic cover until resolved.

The systems enquiry

The systems enquiry may take place at various points in the history. The questions given here are detailed. They can also be asked as broad prompts (e.g. do you have any chest, abdominal, bladder symptoms, etc.?). Some may prefer to perform the systems enquiry immediately after the history of presenting complaint because they would not have enough knowledge to ask the questions to differentiate between the initial differential diagnoses (e.g. asking about generalized lymph node enlargement that might differentiate between glandular fever and the other causes of a sore throat). If the patient said ‘yes’ to a question during the systems enquiry, it could be added to the problem-structuring note and looked up later in this book.

If a direct question turns up a positive response, it has to be treated with caution. It may be a ‘false-positive’ response to a leading question. A positive response has to be treated as an extra presenting complaint, added to the original list and explored carefully with the history of presenting complaint. They can also be looked up in the pages of this book.

If there is a negative response to a direct question, this is more reliable (unless the patient is very forgetful or is purposely withholding information). The absence of all symptoms under a heading indicates that it is less probable that there is an abnormality in that system.

Systems enquiry

Locomotor symptoms

  • No pain and stiffness in the neck, shoulder, elbow, wrist, hand, or back

  • No pain and stiffness in the hip, knee, or foot

  • No pain or stiffness in any joints and muscles.

Negative responses make locomotor abnormalities less probable. If any are positive, then a ‘GALS’ examination screen is performed under the headings of Gait, Arms, Legs, Spine. Care can be taken with painfully inflamed or damaged joints.

Skin, lymph nodes, and endocrine

No heat or cold intolerance

(e.g. wanting to open or close windows when others are comfortable).

Sweats and shivering for 2 days

  • No drenching night sweats

  • No episodes of rigors

  • No rashes and itching.

No skin lumps or lumps elsewhere

No heat or cold intolerance makes an abnormality of thyroid metabolism less probable (suggesting that the carbimazole is probably controlling the thyrotoxicosis). Positive findings (e.g. sweats and shivering for 2 days) can be looked up in this book—they will be found to be poor leads and differentiators (because they occur often in each condition), and not very helpful in differentiating between the causes of a sore throat.

No further information is gained with the following responses. However, they provide an opportunity to reflect on the function of each system.

Cardiovascular symptoms

  • No tiredness and breathlessness on exertion (non-specific)

  • Syncope after rising from chair in A&E—see HPC

  • No leg pain on walking

Negative responses make cardiac output and peripheral vascular disease less probable.

  • No ankle swelling

A negative response makes a right-sided venous return abnormality less probable.

  • No exertional dyspnoea

  • No orthopnoea

  • No paroxysmal nocturnal dyspnoea

Negative responses make a left-sided venous return abnormality less probable.

  • No palpitations

  • No central chest pain on exertion or at rest

Negative responses make a cardiac abnormality less likely.

Respiratory symptoms

  • No chronic breathlessness

  • No acute breathlessness

Negative responses make abnormality of overall respiratory and blood gas abnormality less probable.

  • No hoarseness

  • No cough, sputum, haemoptysis

  • No wheeze

Negative responses make airway disease less probable.

  • No pleuritic chest pain

A negative response makes pleural reactions and chest wall disease less probable.

Alimentary symptoms

  • No loss of appetite (non-specific)

  • No weight loss (non-specific)

  • No jaundice, dark urine, pale stools

  • Negative responses make metabolic gut and liver disease less probable.

  • No nausea or vomiting (non-specific)

  • No haematemesis or melaena

  • No dysphagia but sore throat—see HPC

  • No indigestion

  • No abdominal pain

  • No diarrhoea or constipation

  • No recent change in bowel habit

  • No rectal bleeding ± mucus

Negative responses make gastrointestinal disease less probable.

Genitourinary symptoms

  • Menstrual history—date of menarche, duration of cycle, and flow normal

  • Volume of flow and associated pain normal

  • Any pregnancy outcomes normal

  • No dyspareunia and vaginal bleeding

  • No vaginal discharge

Negative responses make gynaecological disease less probable.

  • No haematuria or other odd colour

  • No urgency or incontinence

  • No dysuria

  • No polyuria or nocturia

  • No loin pain or lower abdominal pain

Negative responses make urological disease less probable.

  • No impotence or loss of libido

  • No urethral discharge

Negative responses make male urological disease less probable.

Nervous system symptoms

  • No vision loss, blurring, or double vision

  • No hearing loss or tinnitus

  • No loss of smell and taste

  • No numbness, pins and needles, or other disturbance of sensation

  • No disturbance of speech

  • No weakness of limbs

  • No imbalance

  • No headache

  • No sudden headache and loss of consciousness

  • Dizziness and blackouts in A&E—see HPC

  • No vertigo

  • No ‘fit’

  • No transient neurological deficit

Negative responses make neurological disease less probable.

Psychiatric symptoms

  • No fatigue, not tired all the time

  • No mood change

  • No odd voices or odd visual effects

  • No anxiety and sleep disturbance

  • No loss of self-confidence

  • No new strong beliefs

  • No phobias, no compulsions, or avoidance of actions

  • No use of recreational drugs

Patients may hide or forget many symptoms. There is a school of thought that regards symptom reviews as being of little value, and that only symptoms that are volunteered are worthwhile investigating. Many doctors do not conduct systemic reviews and only ask these questions if other symptoms have been volunteered already in that system.

The past medical history

The past medical history (PMH) in this case has three components: the diagnosis, the evidence, and the management. The management may be omitted if it is mentioned elsewhere, e.g. if carbimazole is in the drug history together with its indication of thyrotoxicosis.

PMH

Thyrotoxicosis discovered 6 months ago

  • Outline evidence: anxiety, weight loss, abnormal thyroid function tests in Osler Hospital by Dr Miller.

  • Management: taking carbimazole, 5mg daily.

‘Anxiety, weight loss, abnormal thyroid function tests’ outlines the evidence for the thyrotoxicosis. Knowing the doctor responsible and the institution would allow the details to be checked, if necessary. In many cases, patients are not able to provide these details and they would have to be extracted from the records, in which case it is helpful to name the hospital or primary care centre or doctor responsible.

A comprehensive past medical history in this format could be written immediately after any consultation, in hospital or primary care with results and dates given to the patient. This would be more reliable than the next doctor having to do so, but this is not customary. This information can be added to the problem-structuring note No. 2. This can be set out in different formats; in this case, it is set out in subheading style, which is in effect a draft of the ‘next’ past medical history. This problem-structuring approach can also be used to draft discharge summaries on a hospital computer network, which can be updated during the patient’s stay and printed out when the patient leaves hospital.1

The family history

The family history (FH) (Table 2.3) rarely contains features that form powerful leads. In general, there will be risk factors in the FH. For example, the fact that the patient’s mother had type 2 diabetes mellitus means that there is an increased risk of the patient developing type 2 diabetes mellitus. This may have no immediate bearing on the current problems (but she should be checked for diabetes if only to exclude its presence so far). The patient could also be reminded to adopt a healthy diet and lifestyle. The new additions to the problem-structuring note (Box 2.2) are in bold.

Table 2.3 FH

Father

Aged 56—hypertension

Mother

Aged 55—diabetes (onset at 50)

Siblings

male

Aged 34—alive and well

Aged 26—alive and well

female

Aged 30—alive and well

Children

None

The version of the problem-structuring note in Box 2.2 is in the same format as the ‘textbook’ page on ‘Sore throat’ (see Interpreting the history and examination Sore throat, p.[link] and Interpreting the history and examination Sore throat, p.[link]). This makes comparison easier and allows the ‘textbook’ entries to be used as templates that can be copied into the problem-structuring note.

The drug history

The drug history (DH) is often placed near the end of the history. If the patient is on medication, then it indicates that this is for an active medical condition as opposed to a PMH. Therefore, there is something to be said for documenting the drug history immediately after the PMH so and current conditions can be thought about together.

There is nothing to add to the problem-structuring note from the drug history.

Drug history

  • Paracetamol 1g 6 hourly (for ?viral pharyngitis, etc.)

  • Carbimazole 5mg daily for thyrotoxicosis (see PMH for evidence)

  • Alcohol 10 units per week

  • Non-smoker

  • No other recreational drugs

The social history

The social history (SH) is always relevant. The activities of daily living can be considered under the heading of domestic, work, and leisure. Imagine what any person has to do from waking up in the morning to going to sleep at night, and consider whether the patient needs support with any of these activities. Fit young adults who are expected to recover completely may miss school, college, or work, and the timing of their return will have to be considered. Patients who are more dependent on others, such as children and the elderly, may need special provisions. Patients with permanent disabilities may need help with most, if not all, activities of daily living.

The patient has little domestic support and it would be sensible to admit her to be rehydrated until she is in no danger of fainting on discharge. This has been added to the problem-structuring note.

SH

  • Alone in a flat at present (flatmate on holiday for another week)

  • Parents live 200 miles away

  • Works as secretary for insurance firm

When the history is complete

The findings that will differentiate between the causes of a sore throat (see Interpreting the history and examination Sore throat, p.[link]) are the appearance of the throat and the white cell count. Generalized lymphadenopathy, splenomegaly, and petechiae on the palate would also occur commonly in glandular fever and uncommonly in the other differential diagnoses.

Interpreting the history and examination Postural fall in blood pressure, p.[link] shows that a fall in BP on standing would support postural hypotension because it occurs commonly in patients with this diagnosis and rarely in the other causes of syncope. A raised creatinine and urea would support dehydration because this happens often in dehydration, but infrequently in the other causes of postural hypotension.

The diagnostic thoughts so far are represented in the problem-structuring note in Table 2.4.

Table 2.4 Problem-structuring note No. 3

Outline findings: female. Aged 29. Severe sore throat for 2 days, getting worse. Taking carbimazole for 6 months. Sudden loss of consciousness after getting up from chair, recovery within a minute. PMH of thyrotoxicosis (anxiety, weight loss, abnormal thyroid function tests). FH of type 2 diabetes mellitus.

Viral pharyngitis?

Severe sore throat for 2 days, getting worse. (19/10/13)

Paracetamol 500mg 6 hourly PRN. Examine throat. Request WCC: ↓neutrophils, ↑lymphocytes?

Acute bacterial (or follicular) tonsillitis? (mainly streptococcal)

Severe sore throat for 2 days, getting worse. (19/10/13)

Paracetamol 500mg 6 hourly PRN. Examine throat. Request WCC: ↑neutrophils?

Glandular fever (infectious mononucleosis due to Epstein–Barr virus)?

Severe sore throat for 2 days, getting worse. (19/10/13)

Paracetamol 500mg 6 hourly PRN. Examine throat. Request WCC: lymphocytes atypical? Paul–Bunnell or Monospot® +ve?

Drug-induced agranulocytosis? (this is what the patient fears)

Severe sore throat for 2 days, getting worse (19/10/13). Taking carbimazole.

Paracetamol 500mg 6 hourly PRN. Examine throat. Request WCC: ↓granulocytes (neutrophils, eosinophils, basophils)?

Postural hypotension syncope? Due to dehydration from infection?

Sudden loss of consciousness after getting up from chair, recovery within a minute (19/10/13). Evidence of acute infection.

Look for fall in BP when standing. Request U&E. Consider fluids IV to rehydrate.

Thyrotoxicosis now controlled?

Anxiety, weight loss, abnormal thyroid function tests in April 2008. No heat or cold intolerance currently.

Examine for tremor etc. Carbimazole 5mg od. FT4 and TSH normal?

Increased risk of type 2 diabetes mellitus

FH of type 2 diabetes mellitus.

Test urine for sugar. Fasting glucose.

No domestic support

Alone in flat at present.

Consider admission for initial care.

Interpreting the physical examination

The physical examination tends to be focused. The ‘open mind’ approach, where findings are discovered and their meaning looked up later, is described at the end of this section. If this book is referred to before the examination, the reader could focus on the appearance of the throat and palpation of the neck to look for findings that may differentiate between the four differential diagnoses suggested by the history. The reader should also focus on the BP to see if there is a postural fall, and tremor and lid lag for inadequately treated thyrotoxicosis.

General

  • Looks unwell, flushed

  • No tremor or lid lag

  • Temperature 38.5°C

  • Bilaterally swollen tonsils, red with linear creamy patches

  • Bilateral, tender, multiple lymph node enlargement in neck. No lymph node swelling in axillae or groins

CVS

  • Pulse 110/min, regular, low volume

  • BP 110/70 reclining, 90/50 standing

  • Heart sounds normal

  • No murmurs

RS

  • Chest shape and movement normal

  • Breath sounds normal

AS

  • Not jaundiced

  • Liver—1 finger breadth below costal margin

  • Spleen not palpable

CNS

  • Conscious and alert

  • No neck stiffness

  • Hand and leg coordination normal

  • Reflexes all normal and symmetrical

The presence of linear patches of creamy pus in fissures on the surface of enlarged tonsils occurs commonly in patients with bacterial tonsillitis, but less commonly in agranulocytosis, viral pharyngitis, and glandular fever (where there is usually a grey mucoid film). This finding changes the order of the differential diagnoses, but they all remain possible. A high temperature and lymph node enlargement around the jaw occur in all the differential diagnoses of a sore throat and is a poor differentiator. There was no tremor and lid lag to suggest inadequately treated thyrotoxicosis.

The fall in BP when the patient stands up always occurs at some point in postural hypotension and uncommonly in its other differential diagnoses.

Therefore, the order of the possible diagnoses has changed; this is shown in the problem-structuring note in Box 2.3. The format has also changed again from a three-column chart to heading and subheadings.

Interpreting the investigations

Investigations tend to be performed in a focused way like the physical examination. This means that they are done in order to differentiate between diagnostic possibilities created by the history and examination. However, urine testing, full blood count, urea and electrolytes (U&E), and CXR are often done routinely in the same way as aspects of the physical examination, such as the pulse, temperature, and BP. These are done in case that they will reveal a result that is a good diagnostic lead. This is a form of screening, but if the result is abnormal, then it is investigated in the same way as a presenting complaint. In this case, all the tests, except the CXR, were done in order to differentiate between the diagnostic possibilities, and most of the results were helpful.

Investigations

  • Urine testing: + glucose, no protein, no blood, no ketones

  • FBC: Hb 12.4g/dL

  • WCC 19.3×109/L, neutrophils 90%

  • No atypical lymphocytes present

  • Lab blood glucose 8.4mmol/L

  • Na+ 141mmol/L, K+ 4.3mmol/L, urea 10.1mmol/L, creatinine 112micromol/L

  • TSH, T4—results awaited

  • Monospot® test—result awaited

  • Throat swab—result awaited

  • CXR normal

The presence of glucose in the urine and the random glucose of 8.4mmol/L is suspicious of diabetes mellitus. The WCC of 19.3×109/L with 90% neutrophils occurs commonly in bacterial tonsillitis, but never (by definition) in agranulocytosis. This is also very rare in viral pharyngitis and glandular fever so that all these diagnoses drop out of contention. The raised creatinine and urea are common in dehydration and less common in other causes of postural hypotension.

The problem-structuring note in Table 2.5 shows how the diagnostic opinions and management have changed in the light of these test results.

Table 2.5 Problem-structuring note No. 5

Outline findings: female. Aged 29. Severe sore throat for 2 days, getting worse. Taking carbimazole. Sudden loss of consciousness after getting up from chair, recovery within a minute. PMH of thyrotoxicosis. FH of type 2 diabetes mellitus. No tremor, no lid lag. Large red tonsils with linear creamy patches. Fall in BP on standing. Urine testing: +ve glucose. Hb 12.4g/dL, WCC 19.3109/L, neutrophils 90%, no atypical lymphocytes present. Lab blood glucose 8.4mmol/L. Urea 10.1mmol/L. Creatinine 112micromol/L.

Acute bacterial (or follicular) tonsillitis (causing systemic effects, e.g. dehydration)

Severe sore throat for 2 days, getting worse (19/10/13). Large red tonsils with linear creamy patches. WCC of 19.3x109/L with 90% neutrophils.

Paracetamol 500mg 6 hourly PRN. Begin phenoxymethylpenicillin 500mg qds.

Probably not glandular fever (infectious mononucleosis due to Epstein–Barr virus)?

Severe sore throat for 2 days, getting worse (19/10/13). Large red tonsils with linear creamy patches. WCC of 19.3x109/L with 90% neutrophils.

Paracetamol 500mg 6 hourly PRN. Examine throat. Await Monospot® result.

Postural hypotension syncope? Due to dehydration from infection?

Sudden loss of consciousness after getting up from chair, recovery within a minute (19/10/13). Fall in BP on standing. Evidence of acute infection.

Fall in BP when standing. Request U&E. Consider fluids IV to rehydrate.

Dehydration from infection?

Fall in BP on standing. Evidence of acute infection. Urea 10.1mmol/L. Creatinine 112micromol/L.

Admit. Encourage oral fluids. For fluids IV if unable to drink 2L in 12h.

Thyrotoxicosis now controlled?

Anxiety, weight loss, abnormal thyroid function tests in April 2008. No heat or cold intolerance. No tremor or lid lag. Reflexes normal.

Carbimazole 5mg od. Await result of FT4 and TSH.

Probable type 2 diabetes mellitus

FH of type 2 diabetes mellitus. Urine glucose +ve. No ketones. Random glucose 8.4mmol/L.

Monitor blood sugar before and 2h after meals. Plan glucose tolerance test.

No domestic support

Alone in a flat at present. Parents 200 miles away.

Admit for initial care.

Medical and surgical sieves

At this point, you can pause and use the medical and surgical sieves from Interpreting the history and examination Medical and surgical sieves, p.[link]. You can consider whether you have omitted a diagnosis in the social background or environment, the locomotor, nervous, cardiovascular, respiratory, and alimentary systems, the renal system and urinary tract, and the reproductive, endocrine, autonomic, haematological, and immune systems. Within each of these systems, you can consider whether you have forgotten a congenital, infective, traumatic, neoplastic, or degenerative process. If not, you can move on.

Writing the diagnosis and management

The positive finding summary could be written out as follows:

Female. Aged 29. Severe sore throat for 2 days, getting worse. Taking carbimazole for 6 months. Sudden loss of consciousness after getting up from chair, recovery within a minute. PMH of thyrotoxicosis (anxiety, weight loss, abnormal thyroid function tests). FH of type 2 diabetes mellitus. Large red tonsils with linear creamy patches. Fall in BP on standing. Urine testing: +ve glucose. Hb 12.4g/dL, WCC 19.3×109/L, neutrophils 90%, no atypical lymphocytes present. Lab blood glucose 8.4mmol/L, urea 10.1mmol/L, creatinine 112 micromol/L.

The primary diagnosis (that explains the symptoms that led the patient to seek help) can be written as:

Primary diagnosis:

  • Probable acute bacterial (or follicular) tonsillitis (causing systemic effects)

The other diagnoses can be written as:

Other diagnoses:

  • Postural hypotension syncope due to dehydration from infection

  • Thyrotoxicosis probably now controlled

  • Probable type 2 diabetes mellitus

  • No domestic support currently

The initial plan can be written as:

Plan:

  • Reassure patient that there is no agranulocytosis and explain other diagnoses

  • Start phenoxymethylpenicillin 500mg qds (because of systemic effects)

  • Continue paracetamol 1g qds

  • Continue carbimazole 5mg od

  • Encourage oral fluids (e.g. 2L in 16h)

  • Monitor blood glucose before and 2h after meals

  • Help patient to contact family

It should be noted that this traditional way of writing out the findings does not give the reader an indication of the writer’s thought process. It does not provide the particular evidence for each diagnosis or specify at which diagnosis each aspect of the management is directed. This is the approach mostly used in discharge summaries when patients are discharged from hospital. In contrast to this, the problem-structuring notes used here do provide this information.

Case presentations

If you are asked to give a case presentation, then in addition to the positive findings, you should mention negative features. These will imply that you have considered other diagnoses, but were unable to find the supportive features (i.e. that you considered those negative findings to differentiate between your probable diagnosis and those you consider improbable). The information that you require for your case presentation will be found in the ‘evidence’ column of the latest version of your problem-structuring notes. It is customary to give the history of presenting complaint in some detail, as follows in Box 2.4.

Clinical opinions

After giving a case presentation, you will be asked to give a clinical opinion and expected to provide the (particular) evidence for your diagnoses. You may be asked if you do not volunteer this information first. The opinion could be based on the latest problem-structuring note.

Clinical opinion on Ms AM

The probable diagnosis is acute follicular tonsillitis (causing systemic effects, e.g. dehydration). This is because she has had a severe sore throat for 2d, there were large red tonsils with linear creamy patches and a white cell count of 19.3×109/L with 90% neutrophils. This should be treated with benzyl-penicillin IM or Penicillin V orally because of the systemic effects and the symptoms treated with paracetamol.

There is probably no infectious mononucleosis or agranulocytosis because of the raised neutrophils and absence of atypical lymphocytes. She should be reassured about this.

She has suffered postural hypotension syncope because of the sudden loss of consciousness after getting up from chair with recovery within a minute and the fall in BP on standing. She should not be discharged home until this problem has resolved with rehydration.

She is probably dehydrated from infection because of the pulse of 110/min, fall in BP on standing, urea of 10.1mmol/L, and creatinine of 110micromol/L. Fluids need to be encouraged.

The thyrotoxicosis appears to be controlled. The original anxiety and weight loss have resolved and there was no heat or cold intolerance. There was no tremor or lid lag. She should continue on carbimazole 5mg od, pending the result of T4 and TSH measurements.

She probably has type 2 diabetes mellitus because of the FH of this and the random blood sugar of 8.4mmol/L with no urine ketones. She is to have two fasting blood sugars, and her blood sugars monitored before and 2 hours after meals during the admission. A glucose tolerance test will be done if the fasting sugar is not less than 5.6mmol/L or not more than 7.0mmol/L on two occasions.

She has little domestic support because she lives alone in her flat this weekend and her parents live 200 miles away. She will be admitted and kept in hospital until she is well enough to self-care.

The ‘open mind’ approach

The preceding paragraphs described how diagnostic hypotheses were generated as soon as the presenting complaints had been heard. These were displayed in the problem-structuring notes. This approach requires the history taker to have the knowledge to identify the best leads and to know which items of information will differentiate between the possible diagnoses. Alternatively, it depends on the history taker looking up the information in the OHCD at different stages in the history and examination and when the test results become available.

The other option is to take the history and to examine the patient in a mechanical way, without interpreting the findings as they are discovered. The abnormal findings can then be listed at the end and then looked up in the OHCD. The thought process would then follow the same pattern as that described in the problem-structuring notes.

As the history and examination is being performed and the results become known, differential diagnoses may also occur to the assessor consciously or subconsciously in a passive way. This will depend on the assessor’s knowledge, which can be helped by reading this book during private study. This can be done by covering the list of diagnoses, looking at the diagnostic lead above the list, and then reading the suggestive and confirmatory findings. The reader should then try to guess the hidden diagnosis and then see if he or she was correct.

The plan of the remainder of this book

An example of a systems enquiry has been given already in Interpreting the history and examination The systems enquiry, p.[link]. The following shows a typical example of the routine physical examination on which the remainder of this book is based.

The ‘routine’ physical examination

Note the patient’s attire, presence of nebulizer masks, sputum pots, medication packets, etc. The general examination is directed mainly at assessing the skin and reticulo-endothelial system (lymph nodes), and the related matters of temperature control and metabolic rate. During the history, the order of questioning could be decided entirely by thought processes (e.g. probing indirectly for a symptom to chase up a diagnostic possibility that comes to mind), but the physical examination is different. It is more efficient to adopt a routine that is smooth and quick, and not to jump about looking for physical signs that might support the diagnostic idea of that moment.

You have already been looking at the patient’s face, general appearance, and immediate vicinity (e.g. walking stick, medication packets, etc.) when taking the history. So for the general examination, begin with the hands and work your way up by inspecting (and, when appropriate, palpating) the arms to the shoulders, examine the scalp, ears, eyes, cheeks, nose, lips, take the temperature, examine inside the mouth, then the neck, breasts, axillae, and then the skin of the abdomen, legs, and feet.

Plan of the general examination

Hands, arms, and shoulders

  • Fingernails

  • Clubbing

  • Finger nodules

  • Finger joint deformity

  • Rashes

  • Pain and stiffness in the elbow, shoulder, neck.

Head and neck

  • Neck stiffness

  • Patchy hair loss

  • Eardrum redness

  • Perforated eardrum.

Eyes, face, and neck

  • Facial redness, general appearance

  • Red eye

  • Iritis

  • Conjunctival pallor

  • Temperature—high or low

  • Mouth lesions

  • Lumps in the:

    • Face

    • Submandibular region

    • Anterior neck

    • Anterior triangle of neck

    • Posterior triangle

    • Supraclavicular region.

Trunk

  • Breast discharge

  • Nipple eczema

  • Breast lumps

  • Gynaecomastia in male

  • Axillary lymphadenopathy

  • Sparse body hair

  • Hirsutism

  • Scar pigmentation

  • Abdominal striae.

Legs

  • Inguinal and generalized lymphadenopathy

  • Sacral, leg, and heel sores.

Cardiovascular system

Think first of cardiac output, and inspect and feel the hands for warmth or coldness. Feel the radial pulse, take the BP, and check the other pulses in the arms and neck. Next think of venous return and look at the jugular venous pressure (JVP). Then examine the heart itself (palpate, percuss, and then listen to it). Finally, examine output and venous return in the legs by feeling skin temperature, pulses, and looking for oedema of the legs, liver, and lungs.

Cardiac output

  • Peripheral cyanosis

  • Radial pulse

    • Rate

    • Rhythm (compare cardiac apex rate, if irregular)

    • Amplitude

    • Vessel wall

  • Compare pulses for volume and synchrony

    • Radial, brachial, carotid, (femoral, popliteal, posterior, and anterior tibials after the examining the heart)

  • BP standing and lying in right arm, repeat on left.

Venous return

  • JVP

The heart

  • Trachea displaced?

  • Apex beat displaced?

  • Parasternal heave

  • Palpable thrill

  • Auscultation

    • Extra heart sounds

      • —Systolic murmurs

      • —Diastolic murmurs.

Cardiac output and venous return in the legs

  • Skin temperature

  • Posterior and anterior tibials, popliteal, femoral

  • Venous skin changes

  • Vein abnormalities

  • Calf swelling

  • Leg oedema

  • Sacral oedema

  • Liver enlargement

  • Basal lung crackles.

Respiratory system

Think of general respiratory structure and function. Inspect and think of oxygen and carbon dioxide levels, then the ventilation process, which depends on the chest wall and its movement. Palpate by feeling for tactile vocal fremitus. Percuss and then auscultate. Finally, listen for wheezes, thus assessing airways, from small (high-pitched) to large (low-pitched).

General inspection

  • Tremor and muscle twitching

  • Cyanosis of the tongue and lips

  • Clubbing.

Chest inspection

  • Respiratory rate

  • Distorted chest wall

  • Poor expansion

  • Paradoxical movement.

Palpation

  • Mediastinum

    • Position of trachea

    • Position of apex beat.

Tactile vocal fremitus

  • Present or absent (or increased).

Percussion

  • Hyper-resonant, resonant, normal, dull, or stony dull.

Auscultation

  • Diminished breath sounds

  • Bronchial breathing

  • Crackles

  • Rubs

  • Wheezes, high- or low-pitched, or polyphonic during inspiration and expiration.

Alimentary and genitourinary systems

Think first of metabolic issues related to general nutrition (obese, normal, thin, cachexia) and ensure that the patient is weighed. Check the mucous membranes, e.g. for signs of vitamin deficiency. Look for skin and eye signs of low fluid volume, and then liver disease. Next, turn your mind to anatomical aspects of the gastrointestinal and genitourinary systems together by inspecting, palpating, and auscultating. Finally, perform examinations (when indicated) that need special equipment, and do the urine tests.

Inspection

  • Obesity

  • Cachexia

  • Oral lesions

  • Jaundice

  • Hepatic skin stigmata

  • Loss of skin turgor

  • Low eye tension.

Palpation

  • Supraclavicular nodes.

Inspection of the abdomen

  • Abdominal scars

  • Veins

  • General distension

  • Visible peristalsis

  • Poor movement.

Palpation

  • General tenderness

  • Localized tenderness

  • Hepatic enlargement

  • Splenic enlargement

  • Renal enlargement

  • Abdominal masses.

Percussion

  • Dull or resonant

  • Shifting dullness.

Auscultation

  • Silent abdomen

  • Tinkling bowel sounds

  • Bruits.

Inspection and palpation again

  • Groin lumps (lymph nodes?)

  • Scrotal masses

  • Rectal abnormalities

  • Melaena, fresh blood

  • Vaginal and pelvic abnormalities

  • Urine abnormalities.

Nervous system

If there are no neurological symptoms or signs detected up to this point, then it is customary to perform an abbreviated examination. This is done by commenting on the fact that the patient was conscious and alert, speech was normal, and that there were no cranial nerve abnormalities noted when looking at the face during the history and general examination. Also, you will have been able to note the patient’s gait and movements around the hospital bed or consultation room. According to the GALS system, note and record the Gait, appearance, and movement of the Arms, Legs, and Spine.

If the patient was not conscious and alert, then the level of consciousness has to be addressed with the Glasgow Coma Scale.

The brief neurological examination consists of checking coordination and reflexes (because this tests the sensory and motor function of the nerves and central connections involved). The findings may be recorded as in Box 2.5.

Table 2.6 Short CNS examination: reflexes

Reflexes

Right

Left

Biceps normal

+

+

Supinators normal

+

+

Triceps normal

+

+

Knees normal

+

+

Ankles normal

+

+

Plantars normally flexor

The full neurological assessment

The system of examination described here is typical. The general approach is to assess the conscious level (if the patient is not conscious and alert, then it will not be possible to conduct a full neurological examination, which needs the patient’s cooperation).

The cranial nerve sequence follows in their numbered sequence. Motor function can be assessed next, beginning with inspection for wasting and involuntary movements, and then ‘palpation’ by testing tone and power. The upper limbs are examined first and then the lower limbs. Sensation is then tested in the upper, then lower limbs, and finally coordination, reflexes, and gait. The order can be changed by addressing the area of abnormality suggested by the history. For example, if the patient complains of difficulty in walking, then it would be sensible to examine gait, then motor and sensory function, and cranial nerves last.

Nervous system

  • Conscious level

  • Glasgow Coma Score

  • Speech.

Cranial nerves

  • Absent sense of smell

  • Visual field defects

  • Decreased acuity.

Ophthalmoscopy

  • Corneal opacity

  • Lens opacity

  • Papilloedema

  • Pale optic disc

  • Cupped disc

  • Hypertensive retinopathy

  • Dot and blot haemorrhages

  • New vessel formation

  • Pale/black retinal patches

  • Ptosis

  • Pupil

    • Constriction

    • Irregularities

    • Dilatation

  • Diplopia

  • Nystagmus

  • Absent corneal reflex

  • Loss of facial sensation

  • Deviation of jaw

  • Jaw jerk

  • Facial weakness

  • Deafness

  • Loss of taste

  • Palatal weakness

  • Neck or shoulder weakness

  • Paresis of tongue.

Motor function

Upper limbs

  • Arm posture

  • Hand tremor

  • Wasting of hand

  • Wasting of arm

  • Tone abnormalities.

Weakness of

  • Shoulder abduction and addiction

  • Elbow flexion

  • Elbow extension

  • Wrist extension and flexion

  • Handgrip

  • Finger adduction and abduction

  • Thumb abduction and opposition

  • Arm incoordination.

Lower limbs

  • Limitation of movement

  • Wasting

  • Fasciculation

  • Tone abnormalities.

Weakness of

  • Hip flexion

  • Knee extension and flexion

  • Foot

    • Plantar flexion

    • Dorsiflexion

    • Eversion and inversion

  • Bilateral spastic paraparesis

  • Spastic hemiparesis.

Sensation

Upper limb sensation

  • Hypoaesthesia of

    • Palm

    • Dorsum of hand

    • Lateral arm

    • Ulnar border of arm

  • Dissociated sensory loss

  • Progressive sensory loss

  • Cortical sensory loss.

Lower limb

  • Hypoaesthesia of

    • Inguinal area

    • Anterior thigh

    • Shin

    • Lateral foot

  • Progressive downward loss

  • Dissociated sensory loss

  • Multiple areas of loss.

Reflexes

  • Brisk or

  • Diminished, in biceps, supinator, triceps, knee, ankle, and plantars

  • Gait abnormalities.

Mental state examination

Think of the sequence of perception, ‘affect’, drive and arousal, cognitive processes (check memory of different duration, ability to reason with that memory, and then the nature of beliefs arrived at with such reasoning), and then actions in response to these:

  • Perception: attentiveness and any hallucination, visual or auditory

  • Mood: depression or elation

  • Mental: drive rate of speech, anxiety

  • Cognition: (6/10 or less correct implies impairment)

  • Orientation: time to nearest hour, year, address of hospital

  • Short-term memory: repeat a given name and address, name 2 staff

  • Long-term memory: own age, date of birth, current monarch, dates of wars

  • Concentration: count backwards from 20 to 1

  • Beliefs: patient’s perception and insight of health, self-confidence, any extreme convictions

  • Activity: physical and social activity, employment, physical signs of drug use.

Basic blood and urine test results

First check the patient’s name, gender, age, and address to make sure whose sample you are handling and whose results you are interpreting. The following are interpreted in Chapter 11:

Urine testing

  • Microscopic haematuria

  • Asymptomatic proteinuria

  • Glycosuria

  • Raised urine or plasma bilirubin

    • Hepatocellular jaundice

    • Obstructive jaundice.

Biochemistry

  • Hypernatraemia

  • Hyponatraemia

  • Hyperkalaemia

  • Hypokalaemia

  • Hypercalcaemia

  • Hypocalcaemia

  • Raised alkaline phosphatase.

Haematology

  • Low haemoglobin

  • Microcytic anaemia

  • Macrocytic anaemia

  • Normocytic anaemia

  • Very high ESR or CRP.

Abnormal chest X-ray appearances

Many CXR appearances may be recognizable immediately as indicating a specific diagnosis, but if not, the following appearances are considered in Chapter 12:

  • Area of uniform opacification with a well-defined border

  • Rounded opacity (or opacities)

  • Multiple ‘nodular’ shadows and ‘miliary mottling’

  • Diffuse, poorly defined hazy opacification

  • Increased linear markings

  • Dark lung/lungs

  • Abnormal hilar shadowing

  • Upper mediastinal widening

  • Abnormal cardiac shadow.

Reference

1. Llewelyn DEH, Ewins DL, Horn J, Evans TGR, McGregor AM (1988). Computerised updating of clinical summaries: new opportunities for clinical practice and research. BMJ 297, 1504–6.Find this resource: