APPROACH TO THE MEDICAL PATIENT

Chapter 12
APPROACH TO THE MEDICAL PATIENT


With contributions from Dr Magda Sbai


This section provides a practical approach to the history and examination of a medical patient and outlines how to optimize your time in getting to know them and developing a feel for their problems. This chapter also gives a brief outline of common procedures or investigations that you may be expected to explain to patients during your medical post and looks at situations when referral to a speciality is indicated and the necessary investigations you should consider for patients presenting with certain pathologies.


History and examination


With the introduction of shift work, it is inevitable that you will find yourself looking after patients you did not admit and may have never met. It is well worth the effort to re-clerk these patients, albeit briefly. If this is not possible due to time constraints then an alternative is constructing a patient summary or problem list. It takes less time than you may think.


Before seeing a patient, review their medical records, so that you have some idea what their presenting problem might be due to; for example, if they have known inflammatory bowel disease and present with diarrhoea, you should consider if this is a flare of their disease. Information gathering is a key part of medical detective work and developing a thorough approach when tackling problems will protect you from errors in the longer term.


An approach to history taking comprises two essential parts, which enable management to be tailored to the individual patient and their condition:



  1. Getting to know the patient (the person and their medical background)
  2. Getting to know the condition (the presenting problem)

Getting to know the patient as a person



  • Patient identification – age/sex
  • Occupation
  • Social support – family, friends, finances
  • Mobility
  • Home help and other services accessed in the community
  • Problems as perceived by the patient – expectations, worries and fears

The medical background



  • Past medical history (MJ THREADS acronym is helpful – i.e. in addition to any volunteered medical conditions, you should specifically ask about myocardial infarction/heart disease, jaundice, thyroid disorders/tuberculosis (TB), hypertension, rheumatoid arthritis/rheumatic fever, epilepsy, asthma/respiratory disease, diabetes or stroke)
  • Past surgical history
  • Allergies and drug history
  • Family history
  • Social history

Getting to know the disease


Presenting complaint


Identify as clearly as possible the reason for the patient presenting now to the hospital. What was the trigger? Think of the possible causes for the symptoms, so that you establish an early differential diagnosis. Do not take a history blindly without this kind of forethought, as it is likely to be inefficient and will not lead you to a diagnosis quickly.


The present history


This is what the patient tells you about their present illness. Listen carefully and ask clarifying questions. Attempt to live the patient’s life from the onset of the symptoms so that you become aware of important details that will refine your differential diagnosis. This will also help you form a detailed social history.


Next, try to rank your differential diagnosis and identify those features of the most likely diseases that have emerged thus far. Ask about these features now – the specific directed enquiry – and write down your differential diagnosis and problem list before the examination.


The systematic (or functional) enquiry


This is usually the least useful part of the history. Whilst it provides a convenient list of symptoms, it encourages thoughtless history taking that overworked junior doctors do not need! It should therefore be left until last and although it can sometimes be shortened it is inadvisable to omit in its entirety. On an odd occasion it may identify important information that the patient may not have thought was relevant. If you have taken a thorough history of presenting complaint you will find that you have asked many of the questions for the relevant systems already and the systems enquiry should then consist of a short run through of the remaining systems. For the detailed list of symptoms, see Figure 12.1.

c12-fig-0001

Figure 12.1 Approach to history taking.


The examination


The same general examination for all patients should be followed by a directed systemic examination, based on the diagnostic possibilities elicited in your history. For example, you would make a careful check for signs of infective endocarditis in a patient with a history of valvular heart disease and a recent decrease in exercise tolerance with fevers. Note the important negative findings, for example, no splinter haemorrhages, no vasculitic skin lesions, no splenomegaly. Fully document your findings in the medical notes.


We have provided an outline of the general and systematic examination of the medical patient in Figure 12.2. Whilst it is structured in the order for ‘routine’ examination, few patients are ‘routine’, and you should examine some systems in more detail according to your differential diagnosis. Equally, examination may not be possible to a detailed level if your patient is confused or drowsy.

c12-fig-0002

Figure 12.2 Approach to examination.


Once you have examined a few patients, you will develop your own style doing this.


Summing up


At the end of your history and examination, it is a good idea to summarize your findings for presenting on ward rounds, to seniors or to other specialist teams:



  1. Patient ID and salient medical background. Mention what is pertinent to the present problem such as any cardiac risk factors if the patient presented with chest pain.
  2. Presenting complaint.
  3. Current problems – medical, pharmacological and social.
  4. Results of relevant investigations.
  5. Plan for discharge – any anticipated obstacles and the estimated date of discharge from hospital.

Another way of doing this is by summarizing the main problems, starting with medical issues and then any social issues that are likely to prevent discharge.


History and examination


Figures 12.1 and 12.2 provide an outline of the above approach to history and examination. Retype and photocopy if you want.


Clinical stalemate


Your patient sits in bed day after day, and no progress is made. What do you do?



  1. Decide if the patient is improving or deteriorating.
  2. If the patient is ill or deteriorating, then identify the main problems and make a management plan. Ask seniors early on if unsure.
  3. Having addressed any obvious problems, review the case:

    Main complaint



    • History of main complaint
    • PMH
    • Drugs, allergies, habits, foreign travel, etc.

  4. Repeat a complete examination. Examine test results critically – Are they reliable or spurious? If spurious, do they need repeating? Are they up to date? Is a more in-depth investigation needed?
  5. Formulate a list of problems, differential diagnoses and investigations to be requested.
  6. Now write a summary in the notes of your findings at this stage. If appropriate, use tables for important serial data.
  7. Discuss the patient with your seniors, escalate appropriately, and identify if any other specialists need to be involved, for example, intensive care or other medical specialties.

Preparing patients for medical procedures


During your placement, you will prepare patients for many different procedures. It is important to realize that whilst most procedures are routine for you, they are usually frightening for patients and can cause a lot of anxiety. Probably the scariest thing is not knowing what will happen next, so appropriate information and communication can make a big difference. A list of patients’ common concerns about procedures includes:



  1. What does the procedure entail?
  2. Why are they having this done?
  3. How long will the procedure take?
  4. Do they need a general anaesthetic?
  5. Will the procedure be painful?
  6. What should they do if they have pain or other symptoms after the procedure?
  7. When can they eat/drink/drive/have sex?
  8. Will they have any scars/permanent after-effects?
  9. Who is doing the procedure?

The General Medical Council guidance on consent now states that it should only be undertaken by someone who fully understands the procedure and its alternatives/complications and ideally be taken by one who is capable of doing the procedure themselves but as a minimum has training in taking consent. This is usually the consultant in charge of the patients or a nominated deputy. If you are unsure whether you should be taking consent for a particular procedure always clarify with your seniors before proceeding. In medicine the boundaries of where your job begins and where it ends are often blurred. However, consent taking is definitely one area where you should not be acting outside out of your sphere of competence, regardless of how unwell the patient is or urgent the task appears.


Cardiac catheterization


Preparation



  1. Consent (if angioplasty or stenting is planned in addition to diagnostic catheterization, this should be explained). There are variants of the procedure, for example, left and right heart catheters, coronary angiography, electrophysiological studies, depending on the indication. Ask the cardiologists what they intend to do.
  2. Make sure the patient has stopped oral anticoagulants at least 3 days prior to the procedure. In cases where stopping anticoagulants carries a clinical risk, for instance, when a patient has a metal valve replacement and is taking warfarin, the patient should be switched to low molecular weight heparin. If required, they may need to be admitted for heparinization. Low molecular weight heparin is shorter acting and can be omitted prior to the procedure. Always anticipate this issue in advance, and discuss the case with your local anticoagulation team or haematologists to formulate a bridging plan for around the time of the procedure.
  3. Request full blood count (FBC), clotting studies, group and save (G&S), urea and electrolytes (U&E) and creatinine to check renal function.
  4. Secure peripheral venous access.
  5. Check all peripheral pulses (this acts as a baseline, since rarely, cardiac catheterization can cause peripheral arterial thromboembolism).
  6. If the patient has renal impairment or diabetes, seek senior advice regarding delaying procedure and the possibility of a sliding scale.

Tell the patient



  1. Why they require cardiac catheterization.
  2. The procedure will be done under local anaesthetic and sometimes mild sedation, via the blood vessels in the groin, arm or wrist.
  3. The procedure takes place in a special unit (the ‘cath lab’), under X-ray guidance.
  4. The process may be diagnostic (coronary arteriogram) or therapeutic (angioplasty or stent). Explain each of these procedures in further detail as needed, using diagrams if necessary.
  5. Afterwards, the patient will need to lie flat for about 4–6 hours.
  6. Afterwards, there may be some bruising, and sometimes an ache in the groin, but this should subside.

Complications



  1. Bleeding/bruising at groin puncture site
  2. Pseudoaneurysm in the groin
  3. Stroke/death/myocardial infarction (MI)/contrast nephropathy/anaphylaxis to contrast (risk is <1/1000 but varies with procedure and baseline characteristics of the patient – ask the cardiologists what risk should be quoted or defer the question to when consent is being obtained)

Following the procedure



  1. Patients must lie flat for several hours.
  2. Check groin wound is clean, and there is no evidence of pseudoaneurysm/infection before discharge.
  3. Driving – this is something that must be heeded carefully. Different rules apply for different procedures and for group two vehicle licence holders, for example, lorry drivers or bus drivers. Generally post-angioplasty patients must not drive for 1 week. Patients who have had MIs treated by angioplasty should not drive for 1 week; otherwise, the rule is cessation of driving for 1 month. Refer to the DVLA guidance for more information

(https://www.gov.uk/government/publications/at-a-glance).


Elective DC cardioversion


Preparation



  1. Electrocardiogram (ECG) (check if there is still an indication for cardioversion).
  2. International normalized ratio (prothrombin ratio) (INR) (check that INR is between 2 and 3 and has been for the last month).
  3. U&E (check that serum potassium >3.5 mmol/l and that other electrolytes are in the normal range, in particular magnesium).
  4. Patient has been nil by mouth (NBM) for 4 hours prior to attempted cardioversion.
  5. If patient is taking digoxin, exclude symptoms of digoxin toxicity, that is, nausea, diarrhoea, visual disturbance and confusion, and consider sending a digoxin level.
  6. Gain peripheral venous access.
  7. If the patient has renal impairment, seek senior advice.
  8. Inform the anaesthetist and the staff who are required for the procedure. In some centres, the procedure is carried out in theatre recovery or in the induction room, in which case the theatre manager needs to be informed and the patient added to the emergency list. In other places, it is done on the cardiac day ward, in which case the ward staff should be informed.
  9. Obtain informed consent.
  10. Ensure that the skin overlying the right sternal border and the cardiac apex is shaved.

Tell the patient



  1. Why they require DC cardioversion.
  2. It is done under a brief general anaesthetic.
  3. What the procedure involves – a pulse of electricity is delivered to the heart via electrodes/pads on the skin to stimulate the heart back into a normal rhythm.
  4. There is no guarantee that it will cause reversion to sinus rhythm, but that successful cardioversion should bring symptomatic benefit. The probability of success is variable. In young people with no structural heart disease and fairly recent onset, the chances of success are high; in older people with structural abnormalities and chronic disease, the chances are slim. If the procedure is successful, there is still a chance that they will revert back to the abnormal rhythm.
  5. Procedure is usually a day case. The patient can go home once the anaesthetic has worn off, but should be taken home by somebody else, and should not drive or operate machinery for the rest of the day.

Complications

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Related posts:

  1. PAPERWORK AND ELECTRONIC MEDICAL RECORDS
  2. HANDLE WITH CARE
  3. APPROACH TO THE SURGICAL PATIENT
  4. COMMON CALLS

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Sep 27, 2017 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on APPROACH TO THE MEDICAL PATIENT

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