Based on the very good medical book of Thomas J. & Monaghan T. ‘Oxford Handbook of Clinical Examination and Practical Skills’ of Oxford Medical Publications, 2008. www.oup.com

I) DOCTOR’S COMMUNICATION SKILLS
II) EMERGENCY MEDICAL HISTORY TAKING
III) REGURAL MEDICAL HISTORY TAKING
IV) ELDERLY MEDICAL HISTORY TAKING
V) APPENDIX- MEDICAL HISTORY FILES - SYNOPSIS
VI) APPENDIX - MEDICAL HISTORY FILES - EXAMPLE
VII) CLINICAL EXAMINATION
VIII) APENDIX: WRITTING THE MEDICAL NOTE ON THE PATIENT’S FILE (EXAMPLE)
IX) REFERENCE

I) DOCTOR’S COMMUNICATION SKILLS

• The patient centered model. In this model the decision making and generally the power are shared between the doctor and the patient. The doctor also treats, holistically, the whole patient. Explore the nature of the disease and the patient’s experience, feelings, beliefs and notions about his/her disease, the impact on the patient’s psychological status and quality of life, the patient’s expectation from the consultation, explore also his/her social history and his/her family support. Establish a relationship with the patient and give the priorities for the treatment.

• Confidentiality. Do not discuss with anyone else about the patient, unless he/she is directly involved to the patient’s care. If a relative asks you about the patient’s health, ask first the patient’s and take his/her permission to give information about his health to another one. In case you talk with colleagues and say (e.g. a bizarre) story about your patient, then ensure you do not give any clue in your story that would lead to the identification of your patient. Generally, you better avoid talking about your patients, even with colleagues (unless they are directly involved to your patient’s care).

• Personal appearance. Men should were wear shirt and tie and be shaved. Shoes should be polished. Women should wear skirts or trousers but the skirt shouldn’t be very short, and the belly shouldn’t be covered, and the shoulders as well. A clean gown should be worn. Long hair should be tied in both men and women. Hair shouldn’t be over the face. The name badge should be clear. Do not put things (e.g. the Oxford Handbook of Clinical Medicine) on your buttock pocket.

• Examination/ consultation timing is important. Avoid having a conversation during or before an inappropriate time e.g. rest time or meal time. If you take the patient from the word to an examination room or for e.g. a CT, inform first the attending doctor (if not you) and the nurses where have you gone

• The clinical examination/ consultation room should be quite, with enough seats, comfortable. Also yours and your patient’s the seats should be close with no intervening table or other furniture between the 2 seats.

• Avoid medical jargon. Doctors usually can’t help themselves avoiding medical jargon! However they should avoid it! The patient may don’t understand the medical jargon or may misunderstand and misinterpret the meaning of the words e.g. may confuse ‘migraine’ with any kind of headache, ‘acute’ with something bad, ‘angina’ with heart attack, ‘numb’ with weak, ‘chronic’ with something severe, sputum with something bad, and ‘exacerbating’ with exaggerating.

• Patients may misunderstand also a medical description e.g. they may think that a ‘shadow on the CXR’ (Chest X’ Ray) is cancer (however it may be a consolidation due to pneumonia), or a ‘node on CXR’ that is also cancer (but may be benign or artifact e.g. the nipple!). Many think that cancer means a disease that ends up to death, but that is not true for all cancers. There are many patients whose doctors given them 6 month life and they are still alive. So life expectation percentages aren’t always accurate but an average. There are for example some very rare cases of ‘self – healing’ from cancers, or people seropositive with HIV that never developed AIDS. So we should avoid mentioning a 100% possibility that something will occur.

• Remember the patient’s name! Remembering the patient’s name shows that you are interested in his/her health. Remember it especially when you are talking to the patient’s family! Otherwise it will undermine their confidence to you. In order not to forget the patient’s name, write it on a paper note and keep it on your hand or on your desk or on the head of the patient’s bed. If you peep at the paper with the patient’s name is not a crime; however it will undermine you in an extent.

• Greeting. Say simply ‘hello’. Avoid saying ‘good morning’ or ‘good afternoon’ if you are about to announce bad news!

• Shaking hands needs to be judged at the time. A hand shake may be overly intimate or formal for someone. You can use another form of touching such as a brief touch to the forearm or a slight guiding hand on the patient’s arm when he/she enters the room. Touching and greeting subconsciously show that you don’t carry any weapons!

• Introduction. Use the term that better fits to you.

• Patient’s introduction. Old patients may prefer to be called ‘Mr’ or ‘Mrs’. In females that you aren’t aware if they are married or are young may be offended if you call them ‘Ms’. Calling the patient with his/her first name may be also informal and offend him/her. Judge the situation at the time. If unsure, just ask e.g. ‘Is it Mrs or Miss Butterfly? May a call you Ann?’

• Doctor’s introduction.Young doctors may be reluctant to be called with the title ‘Dr’. But is it really the best to be called Dr? It may be better to introduce with your first name in most occasions! However some old patients may expect and prefer the more formal way of ‘Dr’, so judge the situation at the time!

Make clear to the patients who you are and which is your role (e.g. I am a back surgeon, and I will assess if you need an operation for your prolapsed disc’.
You may also mention who your senior doctors are, if this is appropriate.

• Standing! It may be considered old fashioned, however standing shows universally respect and you should always stand when a patient enters a room and seat at the same time the patient seats. You should also stand when the patient leaves, however establishing a good communication during the consultation may make this unnecessary.

• Demeanour during the consultation. Do not look bored! Use appropriate body language (e.g. nodding) and facial expressions.

• Dominance. Touching someone on the back or shoulder shows that you are in charge. Use it in any case you think that is needed.

• Sympathy. You can show sympathy with a brief touch to the patient’s arm or hand.

• Emphasis. Use your body to amplify your words e.g. by nodding or pointing with your hand or with other hand gestures (such as the news broadcast speakers that use their hands to stress their words). Use your hands e.g. by taping the desk or pointing with your finger, or make an ‘O’ shape with your thumb and index (a classic gesture that politicians use in order to avoid the terrible index finger pointing), or hold your hands in a way that each finger touches the opposite – like praying, another classical gesture that politicians also use.

• Open body language. Avoid having your arms or leg crossed! ‘Open body’ indicates that you are receptive and have nothing to hide. It encourages the patient to be also open. Also ‘open body’ can be used to calm down an angry patient or when asking personal/ intimate things. Do not have your legs crossed. Keep your legs e.g. parallel, and point your feet at the patient (we usually ‘show’ with our feet the person we are interested in). Do not keep your arms crossed, but keep them parallel at your side, or wide. Better have your palms open, faced to the patient (it subconsciously shows that you don’t carry any weapons!). Arms wide and palms forward is a classic ‘open gesture’ that politicians are aware and use, as well, frequently.

• Adjust your manner and your speech according to the patient’s educational level! Start in a relatively neutral level and then adjust your manner & speech to the patient’s educational lever from what you hear in the first 1–2 minutes of the consultation. You may make changes accordingly.

• Eye contact. Make eye contact and look at the patient while he/she is speaking. Do not make notes or read medical files or the referral note or look at test results etc while the patient is speaking to you, because you will show disrespect!

• Eye level. The person with the higher eye level is in control of the situation. You can use this to show that you control things. So you may raise your eye level to show that you take charge of a difficult situation e.g. stand over a seated patient. Don’t look down the patient, because he/she will feel not comfortable.

However, when you ask the patient intimate – personal questions and you want them to be open and express themselves, then position yourself in order your eyes to be below your patient’s eyes (so they will slightly have to look down at you, but not look you down!). This will make him/her feel more comfortable. An angry person feels lack of control. You may calm an angry patient by lowering your eye level e.g. sitting when he/she is standing or squatting next to him/her.

• Interruptions. Apologize to the patient if you are interrupted by someone or something!

• Don’t look offended or annoyed or surprised even the patient cause offence when they don’t mean to. Act as a professional!

• Do not be judgmental (e.g. if the patient has sex without protection) and never look surprised or embarrassed from something that the patient says (e.g. ‘I take drugs’, or ‘I made love with a prostitute’ etc.). Be tactful!

• Questioning Style. Avoid ‘closed questions’ because they may lead to an answer that will please you. Closed question may manipulate a specific desired answer you expect from him/her. Use rather ‘open questions’ such as ‘What is the problem?’ or ‘How does it feel?’ The patient will give you the true answer on his/her own words. For example asking the question ‘Does it hurt a lot’ gives the possibility of 2 answers, ‘yes’ or ‘no’. It is a closed question. Contrary, asking ‘Does it hurt a lot?’ gives the patient the opportunity to speak about the real severity of the pain, instead of the previous 2 options of ‘yes’ or ‘no’.

• Multiple Choice Questions (MCQs). In case the patient doesn’t understand a question, you may give him/her a few examples, but leave the list open for the patient to add his/her own words. Do not give the patient the answer you expect from him/her! For example, on a patient with chest pain ask ‘What sort of pain is it?......stabbing, burning, aching, for example?’

• Clarifying Questions. Ask clarifying questions to get details e.g. ‘When you say you feel dizzy, what exactly do you mean?’ (in this example you have to make sure if the case is real vertigo).

• Reflecting comments/ body language. With reflecting comments you encourage your patient to continue his/her story and you show him/her that you are listening! You can say, for example, ‘Yes I see that’, or you may keep nodding.

• Stay on the topic! Do not be afraid to interrupt your patient and keep him/her on the topic or move on a new topic, but be friendly, not abrupt! Many patients may talk for hours if you leave them! For example say ‘Before we move on to your headache, I would just like to get all the details of this chest pain.’ ‘We will come to that in a moment’.

• Repeat important information.

• Allow questions from the patient and give time for feedback.

• Check understanding frequently.

• Be honest.

• The importance of silence. Use silence to extract more information from the patient. Use silence to listen! It is often useful to remain silent once the patients have answered your question. They do start speaking again and in fact may mention very important things!

• Difficult/ embarrassing questions. You have to apologize before a potentially offensive or embarrassing question. Say ‘I am sorry I have to ask you this but…’.

• Multicultural communications. Be aware of the implications of a different culture. Be tactful! For example a Muslim may not take anything by mouth on daylight time during Ramadan, and this may have implications on taking medications for an illness. Another example is if you ask a Sheikh if he is smoking. Smoking is forbidden for Sheikhs, so they may be offended!

• Interpreters. Avoid using relatives as translators, because firstly you never know if they pass on to the patient correct all the information and secondly a relative (especially children) may not be able to explain difficult concepts or may not be suitable to talk about matters that involve sex, death etc.

Briefly introduce to the interpreter on the situation and your role. Allow the interpreter to introduce to the patient. Arrange the seats in order the patient to see equally the interpreter and the doctor. Allow enough time (twice than normal).

Speak to the patient, not the interpreter! Speak and look at the patient at all times! Be patient! Avoid complex text, grammar and jargon, slang or colloquialisms! Check frequently understanding! Allow time for questions. If interpreting written information, read it loud. The interpreter may not be able to translate written language as well!

It is helpful to have written information in variety of foreign languages in your department!

• Deaf patients. Speak clearly, but not too slowly. The patient is not stupid! Don’t repeat a sentence if misunderstood. Write things down. Avoid waffling. Be patient. Check frequently understanding. It is useful to find a hearing aid/ amplifier. Also seek for a sign language interpreter! On lip – readers keep eye contact, don’t shout and don’t exaggerate your oral or facial movements. Also speak clearly, but not slowly.

• Angry patients! Use body language to take charge of things. Remain polite, be professional and avoid confrontation or becoming angry or show offended. Check for your own safety first!
First calm the situation and next establish the facts of the case! Acknowledge the patients emotions. Many feel angry as a reaction to loss, guilt or fear. Say ‘I can see what made you angry’. ‘It is understandable that you should feel like this’. Focus the conversation away from the area of sad things towards positive things and plans. Emphasize any grounds for optimism and/or plans for resolving the problem.

An angry person feels lack of control. You may calm an angry patient by lowering your eye level e.g. sitting when he/she is standing or squatting next to him/her. Do not keep your arms crossed, but keep them parallel at your side, or wide. Better use open body language. Have your palms open, faced to the patient (it subconsciously shows that you don’t carry any weapons!).

• Do not incriminate and judge colleagues in front of the patient. It is unprofessional. Avoid judging such as ‘he/she shouldn’t have done that’.

• Speaking about sex may be embarrassing for the patient and the inexperienced doctor as well! Ask before family and friends to leave the patient for a while alone, because it is inappropriate to take part in this conversation. Try to be familiar with sexual slang and sexual practices; otherwise you will not be able to take part at the conversation. However, you shouldn’t use sexual slang yourself! But instead, you may mirror the patient’s words during the conversation. Ask the patient direct questions. Do not show embarrassed and never show surprise whatever you listen!

• Telephone communication. Do not give to anyone confidential information about the patient unless he/she is directly involved to the patient’s treatment, or you have the patient’s permission. Avoid giving confidential information on a person you are speaking on the phone, but can’t confirm his/her identity. Prefer face to face contact. Don’t give confidential information to relatives that call you on phone. In case the phone call is important, then ask their phone number and call them back. There are also telephone catalog services that can help you confirm the address of a phone number.

• Writing notes is very important. Recording patient’s disease and treatment does not only give the other medical team vital medical information, but can also be used in clinical audit and also on litigation! Remember that (especially in court!) if something isn’t written down, is considered that it has never occurred! Include at your medical notes the date, time, your identity, your signature and your contact number (better write your cell phone and/or beeper). Use only black Inc (its easier in photocopy). Write everything that occur (record the disease & treatment). Record what the patient has been informed about the diagnosis and also discussions with the relatives. You can use drawings (e.g. if you find it hard or time spending to describe a laceration on the patients hand, then draw it!

• Breaking confidentially. Confidentially is the patient’s autonomy and right to control his/her own information. Ask the patient’s consent before you give information to a third person who is not involved directly with the patient’s medical care (e.g. on a relative asking confidential information). Breaking of confidentially may occur on the following occasions:

with the patient’s consent,
if required by the law or a court,
if the disclosure is on the patient’s interest,
if it is overwhelming in the public interest (e.g. a communicable disease such as H1N1 ‘pig flu’)
and/or necessary for national security or prevention or detection of a crime or a communicable disease,
if there is a specific statutory duty (e.g. reporting births, abortions, deaths, and special communicable diseases), and in special cases of medical research.

• Consent and capacity for consenting. The patient in order to consent for a therapy may be able to understand the information it was given to him/her, believe that information and be able to retain and assess the information before he/she makes a decision and be free of any kind of duress. In case you ask an assessment of the patient’s capacity (e.g. by a psychiatrist), then you have to realize that this assessment is valid only for the specific occasion and not generally for the specific patient, because we can’t consider that a patient generally has or hasn’t got the capacity. It’s not black or white. So for each new decision you need a new capacity assessment!

You have also consider that several medical conditions (e.g. hypercapnia, hypoxemia, head injury, delirium tremens, drug/alcohol withdrawal, acute confusional state etc.), drugs, alcohol and illicit drug abuse may influence capacity, so a written consent may not be valid in that occasion and may be debated at a court!

• Young patient’s capacity. All persons aged 18 and over are considered competent adults, unless there is evidence to the contrary.
Patients aged between 16 and 18 years old are treated in the UK as adults; however the refusal for therapy in the UK may be overridden by their parents/ guardian or a court. In the UK, children 16 years old and under are considered competent to give consent if the meet the previous criteria of giving consent. However in the UK their decision for therapy may be overridden by their parents/ guardian or a court.

In the UK, the parent’s/ guardian’s right to consent to a treatment on behalf of the child finishes when the minor has sufficient understanding to give consent itself. The decision of whether or not the child has this competent rests with the treating doctor.

• For further legal information ask your hospital’s legal counselor (lawyer) and your medical union/ association (in the UK www.gmc-uk.org and www.bma.org.uk ) and also check the sites www.the-mdu.com and www.medicalprotection.org

II) EMERGENCY MEDICAL HISTORY TAKING

Do not forget it on an emergency! It may be life saving!

• Vital signs. Temperature, BP, pulse, SpO2 (Oxygen Saturation), RR (respiratory rate), stick blood glucose.

• AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) & pupils reaction to light and irregularities).

• GCS

• Further management. Consider also ABGs (Arterial Blood Gases), 12 lead ECG/ ECG monitoring, F&P (face & profile) CXR, erect and/or decubitus AXR (Abdominal X’ Ray), Neck X’ Ray, folley and perhaps NG (Nasogastral Tube – Levine (e.g. decreased level of consciousness with aspiration risk e.g. child or pregnant or diaphragmatic hernia), Lab tests (FBC – CBC Full/ Complete Blood Count, BUN Blood Urea Nitrogen, Creatinine & Electrolytes, urinalysis, swabs – smears – Gram stain & cultures etc, toxicology screening, βHCG (pregnancy test for all women on child bearing age) & imaging tests (e.g. ultrasound/FAST, X’ Rays, MRI, scintrigraphy, CT e.g. non contrast CT for stroke).

• AMPLE (Allergy, Medication, Past medical history, Last meal, Environment/Event that brought him/her to the hospital) should be asked in ALL the patients that arrive on the ER (A&E).

Medication includes prescribed or over the counter drugs (OTC), herbs, aspirin, paracetamol (acetaminophen), ibuprophen and other agents used wrongly as ‘muscle relaxants’ (and have side effects such as interstitial nephritis), sleeping pills, inhalers, eye – drops, illicit – recreational drug abuse and ‘proteins’ for body building or drugs to lose weight (some products contain caffeine, amphetamines, thyroxin, iodine, ephedrine, diuretics etc), oral contraception (the Pill) and estrogen replacement therapy after menopause, tranquilizers and laxatives.

Ask also about alcohol and illicit drug abuse, smoking, last menstruation (women).
Ask also family members or friends with similar symptoms (exclude bioterrorism if many people arrive on the ER – A&E with the same symptoms).

Ask details about kinetics and biomechanics on a car or motorbike accident (e.g. a spider break of the wind screen shows high energy to the head and neck and necessitates neck protection).

Also, if there is time, ask about hobbies, pets/ animal exposure, family history and child diseases. Environment and event is what happened that brought the patient to the hospital.

• On last meal exclude also food poisoning, toxins/poisons (e.g. fruits with organophosphates), botulism and paralytic fish/ shellfish poisoning. Consider stomach emptying with NG tube if altered mental status and risk for aspiration (which is great on obese, children, pregnant and pts with reflux or diaphragmatic hernia).

III) REGURAL MEDICAL HISTORY TAKING

Τhe example with brown bold letters is from the excellent book of Llewelyn H. et al., ‘Oxford Handbook of Clinical Diagnosis’, Oxford Medical Publications, 2006.

Always use a plan for writing out the history.

On the file write above the history takers name, the date of assessment, the patient’s name, the patient’s DOB (date of birth), the patient’s age and occupation and the patient’s address. Below write ‘admitted as an emergency’ or ‘admitted from the waiting list’ and write date and time of admission.

e.g.
Dr James Manos
12 May 2009, 9.00 p.m.

Miss K.S. Aged 32
(DOB: 4 November 1977)
78 Smith Street, 32NSQW
London
Emergency Admission
12 May 2009 at 9.00p.m.

• Presenting Complaint (PC) Ask the patient to describe in his/her own words his/her main symptom. This should be likely a single sentence. In case the patient has many symptoms, make a list of them. After a brief introduction, ask the patient ‘Tell me the story’ or ‘What is the problem?’ or ‘What made you come to the Dr?’ Don’t ask him/her ‘what brought you here’ because the answer will be ‘an ambulance’ or ‘a cab’.

Write on the file
1st symptom (e.g. nausea) – duration
2nd symptom (e.g. vomiting) – duration etc.

e.g. P.C: Sore throat, fever and malaise for 3 days.

• History of Presenting Complaint (HPC). Let the patient talk about 2 min about what happened. Do not interrupt him/her. Encourage the patient nonverbally (e.g. by nodding), make notes, assess the patient’s personality, stress and educational level and ascertain which of the symptoms seems to bother the patient particularly.

Then ask more detailed questions ‘I would like to go thru the story again and make clear some details’. Have a conversation with the patient, but not an interrogation! Verify the relationship between the symptoms and the time that each symptom occurred. Be careful in pseudo – medical terms the patient may use such as ‘flu’, ‘vertigo’ etc.

At the end, make a problem list, summarize with the patient what have you been told (to make sure you have the information correct) and ask the patient ‘is there anything else you would like to share?’

For each symptom establish (and write on the file)

1)1st associated symptom. Establish the nature of complaint (e.g. chest pain), circumstances and speed of onset & progression, change with time, the exact onset (date it started), how it began (suddenly? gradually?), how long it occurred, why the patient is seeking now medical help, if the symptom is constant or intermittent, how long the symptom lasts each time, what is the nature of the symptom, if it improves or deteriorates, aggravating and relieving factors, other associated symptoms.

2)2nd associated symptom etc. Described as in (1).

e.g. HPC: The patient was well until last Sunday 10 May when she developed shore throat with fever and malaise during at work (she works as an accountant at Royal Bank of Scotland in London). It was relieved by hot drinks and acetaminophen, but the following morning when she woke up the sore throat was worst with painful swallowing that couldn’t relieve with paracetamol. She hadn’t any previous sore throats. She called her GP who found her unwell and because she was living alone he decided to refer her to the hospital.

For pain ascertain the site (‘point me with your finger where the pain is worst’), radiation (‘does the pain move somewhere else?’), character (e.g. stabbing, dull, aching, burning, tearing), severity (scored out of 10, with 10 the worst imaginable pain), how did it began, what is its nature, how long it occurred, duration, exacerbating and relieving factors, frequency, associated symptoms (e.g. shortness of breath, nausea & vomiting, indigestion).

For long standing problem ask ‘why are you seeking help now?’, ‘Does anything changed?’ and ‘When lastly were you Ok’?

• Past Medical History (PMH). Ask the patient ‘Are you seeing a doctor for something else?’ Ask about the date and the location (hospital, GP’s surgery) of each diagnosed problem and ascertain when & where and by whom it was diagnosed, how it was diagnosed and how it has been treated since.
Ask also about immunizations, problems (e.g. allergies) with vaccines, insurance (Medi – Care), previous operations and problems during anesthesia, previous lung function or cardiac tests, if the patient has visited a chest doctor in hospital; if he/she is taking an inhaler (some don’t consider it as medication).

Be careful of a symptom that a patient refers to with a medical term e.g. what the patient calls ‘asthma’ may be in fact a cardiac asthma (due to CHF)!

On the PMH ask specifically about diabetes (DM), blood transfusions (!), previous operations, complications and anaesthetic problems, epilepsy/ fits, TB, asthma, hypertension, angina pectoris, MI, stroke/TIA, hyperlipidaemia, jaundice, liver problems, renal problems, rheumatic fever, psychiatric problems, obstetric problems during his/her birth, developmental problems & child diseases.

On the past medical history write on the file
1st diagnosis, when, where and by whom, evidence, treatment, name of doctor.
2nd diagnosis etc.

Allergies

e.g. PMH: Hyperthyroidism discovered 1 year ago. (Anxiety, insomnia, weight loss, abnormal thyroid function tests in Royal Hospital of London). Taking carbimazole, 5 mg daily.

Doesn’t mention any allergy.

• Allergies should be documented carefully e.g. a rash or allergic shock after penicillin. Ask ‘did you have any reactions to drugs or medication?’ In case of an allergy, establish the exact nature of is and if it is a real allergy or an intolerance or a side effect. In doubt you need to consult an allergiologist.

• Drug History (DHs). Ask about all the medications and herbs/ ‘vitamins’ the patient takes and also about the dose and frequency, the compliance (!), if the patient misses any dose, if the patient is not taking the medication or misses doses (if so, what is the reason?) if he/she knows what drugs he/she is taking and what is the reason of taking the drug, and if he/she has any compliance aid (such as pre – packed weekly dose).

In case the patient can’t remember, ask his/her GP or drug store.

Drug sensitivities & allergies

Many patients do not consider some medications as drugs so ask specifically about herbs, illicit/ recreational drug abuse, ‘vitamins’, over the counter drugs (OTC), ‘proteins’ for body building or drugs to lose weight (some products contain caffeine, amphetamines, thyroxin, iodine, ephedrine, diuretics etc), oral contraception (the Pill) and estrogen replacement therapy after menopause, sleeping pills, tranquilizers, inhalers (e.g. for asthma), eye – drops and laxatives.

For drug history write on the file
Name, dose and frequency of each medication, diagnostic indication, evidence, prescriber.
Next drug etc.
Drug sensitivities & allergies

Alcohol consumption
Tobacco consumption
Recreational drugs and/or medication addiction

e.g. Drug History: acetaminophen 1g 6 hourly (for sore throat that had for 2 days with fever and malaise).Also carbimazole 5mg daily for hyperthyroidism (see PMH).
No drug sensitivities or allergies
Alcohol 10 units per week
Non – smoker
No other recreational drugs or medication addiction

• Alcohol. Ask about the amount of alcohol consumed weekly and if the patient consumes the amount over the week or into a smaller period. Recommended weekly alcohol consumption is 21 units weekly for men and 14 units weekly for women. 1 unit is 10ml of pure alcohol. In some countries alcohol is quantified as ‘standard drinks’ and in the US is equal with 0,54 ounces of alcohol and about 1,5 units.

Do not be judgmental.

About alcohol addiction there is a questionnaire abbreviated CAGE in order to assess dependence. Answering yes in the following questions shows alcohol dependence:

Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

However there is a more aggressive approach and some specialists in the US believe that alcohol dependence occurs in men that had more than 4 drinks the same day, for at least 3 days in one year and women that had more than 3 drinks the same day, for at least 2 days in one year. That will make many of us alcoholic!

Men should consume less than 3 unites daily and women less than 2 units daily.

1 unit is 8 g alcohol or ½ pint of beer (but strong beers may be as much as 1.75 units) or a small glass of wine or sherry or 1 measure of spirits (in Scotland 1 spirit is 1.2 units). One bottle of wine 12% is 9 units.

1 pint of ordinary strength lager is 2 units.
1 pint of strong lager is 3 units.
1 pint of bitter (beer) is 2 units.
1 pint of ordinary strength cider is 2 units.
1 pub measure of spirits is 1 unit.
1 alcopop is 1.5 units.
1 glass of 175 ml of red or white wine is about 2 units.

• Smoking. Quantify is as ‘packs – year’ .1 pack – year is 20 cigarettes daily for 1 year e.g. if someone is smoking 40 cigarettes daily for 1 year then it is considered as 2 pack – years. If someone smoking 10 cigarettes daily, it is considered as 1 pack –year.

Do not be judgmental.
Ask about previous smoking & passive smoking!
Do not ask Sikhs (Indians) about smoking because smoking is forbidden to them and they will be offended!

Alcohol & Smoking history may be unreliable and the patient may lie in order to please you or may feel embarrassed about admitting the true consumption. You should appear non – judgmental, do not act surprised about what you listen. There is a trick for eliciting the real consumption. If the patient says ‘I smoke a few cigarettes’ ask ‘shall we say 70 a day?’ and the patient will give you the real amount ‘no, I smoke about 20’. If you start with a low consumption the same patient will admit less of it!

• Recreational drugs and medication addictions such as cocaine, marihuana, crack, heroin, hash, PCP (phencyclidine), amphetamines, LSD, ecstasy, glue or liquid corrector (fluid corrector for written mistakes e.g. ‘Blanco’) sniffing, mushrooms etc. Also addiction to medication (e.g. hypnotics, tranquilizers, morphine).

• Recent travel abroad, especially in tropical and/or endemic area.

• Does the patient have had any contact with pets, and generally animals, birds, reptiles, and fishes? Does he/she have any hobby that relates to the above e.g. feeding pigeons?

So write on file
Recent travel abroad
Contact with pets, birds, animals.

e.g. No recent travel abroad.
No contact with pets, birds, animals.

• Developmental history (especially useful in pediatrics and psychiatry).

Write on the file
Developmental history and problems in pregnancy, infancy, childhood, puberty and adulthood.

e.g. Developmental history: term baby, vaginal labor with no complications, normal Apgar, no jaundice, no developmental problems, (normal developmental stones), only rubella and measles on childhood but without complications, menarche on 11, normal menstrual flow.

• Family History (FYx) involves the current family, including the age and gender of parents, siblings and children. Ask about any diagnosed medical problems in living family members and also the age and cause of death for all diseased 1st degree relatives (and other family relatives if you think that it is useful). You can draw a family tree which is useful especially in pediatric pts and other occasions such as pts with cancer, hemophilia, epilepsy.

On a family tree men are represented by a square and females by a circle. The patient you are talking to (the ‘propositus’) is indicated by a small arrow. Horizontal lines represent the relationships/ marriages that end up to a child which is connected with its parents with a vertical line. Add also ages and causes of death. Each diseased member is indicated with a diagonal line thru his/her circle or square. Those with the conditions of interest are indicated with a shaded circle or square.

On the FYx ask specifically about diabetes (DM), epilepsy/ fits, asthma, allergies, eczema, hypertension, angina pectoris, MI, stroke/TIA, TB, hyperlipidaemia, jaundice, liver problems, renal problems, neurological & psychiatric problems, obstetric problems & child diseases.

On the family history write down at the file
Family age illness
Parents
Siblings
Children
Spouse

Consider drawing a family tree.

Mention especially TB, asthma, eczema, DM, hypertension and epilepsy.

e.g. FH:
Father aged 60 hypertension, DM (onset at 49)
Mother aged 58 CHF, hyperlipidaemia
Sibling male aged 32 alive and well
Sibling Female aged 25 asthma (onset at 14)
Children none

• Social History (SHx) to the patient’s personality and functional status. Without the social history we can’t have a holistic approach to the patient.

Ask the patient about if he/she has a spouse, if he/she is married and if so his/her married status, his/her sexual orientation, his/her occupation (or previous occupations if retired!) and the exact nature of the job (e.g. labor job or office work), if the patient drives, if has the patient traveled recently (and if the trip was in tropical area), if he/she has any pets or feeds pets (e.g. pigeons), what hobbies does he//she have, if he/she has relatives living near, what type of accommodation does she/he has (e.g. house, apartment – what floor?), if there are any roommates and if he/she is the owner or just rents the accommodation.

Also ask about neighbors that can help him/her, ask if the patient has any aids in his/her house (e.g. rails at the bathroom, stair lift etc), if he/she has walking aid (e.g. stick), if he has any daily nurse care or visits a daily care hospital or service, if he/she has help from relatives/ friends/ neighbors/ social services and also who does the cooking, laundry, cleaning and supermarket shopping.

• Also ask tactfully about abuse (psychological, somatic, sexual, or combination) and/or neglect. Abuse is underdiagnosed and often occurs in children, women – especially pregnant, incapacitated people and old people (here we have also financial abuse).

On the files write
Home and domestic activity support, occupation (in elderly other than retired!), financial security, travel, leisure, abuse/neglect.
Consider the effect of all these on the disease and the effect of the disease on these!

e.g. SH: at present lives alone in an apartment that rents
Parents live 6 khm (3.7 miles) away
Works as an bank accountant.
No abuse/neglect.

• Systematic Enquiry (SE) is a screening of the other body systems.

General symptoms such as weight loss or gain, loss or gain of appetite, malaise, fever, lethargy.

Respiratory symptoms such as couch (productive, non productive), sputum, haemoptysis, shortness of breath, chest pain, wheezing, stridor, acute or chronic breathlessness, hoarseness, pleuritic chest pain.

Cardiovascular symptoms such as tiredness and shortness of breath on exertion or on rest, chest pain on exertion or on rest, palpitations, orthopnea, paroxysmal nocturnal dyspnea, exertional dyspnea, ankle swelling, intermittent claudication, syncope & dizziness.

GI symptoms (Gastrointestinal) (alimentary) such as indigestion, nausea & vomiting (N&V), abdominal pain, constipation, diarrhea, recent change in bowel habit, dysphagia, blood per rectum (rectal bleeding), mucus from rectum, melaena, and hematemesis, loss of appetite, weight loss, jaundice, dark urine, pale stools,

GU symptoms (Genitourinary) such as urine frequency, polyuria, polydispia, dysuria, haematuria (ask if the patient eit beetroots that color the urine red!), nocturia, urgency, loin pain, lower abdominal pain, loss of libido, impotence, incontinence, menstrual problems, menstrual history (date of menarche, duration of cycle, flow normal or not, associated pain), pregnancy, abortions, vaginal discharge, black urine (e.g. rabdomyolysis), urethral discharge.

Neurological symptoms such as headache, dizziness, vertigo, light headiness, syncope/ faints, dizziness & black outs, ‘funny turns’, tingling, numbing, ‘pins and needles’ or other disturbances of sensation, weakness, paresis/ paralysis, malaise, tremor, fits/ convulsions, sphincter problems (bowel, vesicle), incontinence, hearing loss or tinnitus, vertigo, vision loss or blurring or double vision, disturbance of speech, limb weakness, sudden headache & loss of consciousness, transient neurological deficit, neck stiffness.

Psychiatric symptoms such as mood change, fatigue – tired continuously, odd voices, loss of appetite, loss of libido, odd visual effects (delusions, hallucinations), anxiety, sleep disturbance (e.g. insomnia), new strong beliefs, phobias, compulsions, avoidance of actions – social phobia, recreational drug abuse, alcohol.

Locomotor symptoms such as pain and stiffness in the neck, shoulder, elbow, wrist, hand, back, hip, knee, foot, and generally in any joint and any muscle.

Skin symptoms such as lumps, bumps, rash, itch, ulcer, warts, lesion that changes size, color, shape, edge, surface and nature of surrounding skin.

Skin lymph nodes & endocrine skin. Sweats & shivering, heat or cold intolerance, night sweats (e.g. TB, lymphoma), rigors (e.g. pyelonephritis), rashes, itching.

• NAD is an abbreviation of ‘no abnormality detected’. However it may mean ‘not actually done’! Document all the answers on the systems enquiry. If not done write ‘systems enquiry not done’.

e.g. Systems enquiry. Sore throat, dysphagia, fever, sweats, malaise, relative neck stiffness. Rest systems enquiry: NAD.

•Learn to listen to your patient. Be patient! Just listen and interpret things (narrative analysis) and realize your patient’s hopes, fears and what he/she believes. The history of the presenting complaint will be usually no more than 3 – 4 min. Just listen to the patient. Seeming irrelevant details are often useful when you put them together.

Do not rush and ask many questions to ask every fact in the history. If so, it will frustrate the patient because he/she will realize that you aren’t a good listener. However do not miss important information!

• Always involve your patient in key decisions about their medical care.

IV) ELDERLY MEDICAL HISTORY TAKING

• Problem list. Elderly patients may have chronic diseases and/or multiple diagnoses. Consider of braking the history of the presenting complaint to a problem list which may reveal connections between the diagnosis that you haven’t considered e.g. (1) Cardiac arrhythmias. (2)Incontinence. (3)Falls. (4)Constipation.

• Drug history. Elderly take many drugs (polypharmacy) and may not even remember each treatment! Check for each drug about indication, contraindication, side effects, interactions. Consider if the problem is drug induced e.g. the sore throat that the patient complaints is due to carbimazole, a drug taken for hyperthyroidism that caused agranulocytosis! Also delirium (acute confusional state) may be due to drugs or alcohol or drug withdrawal (e.g. sleeping pills).

Many drugs mean more side effects, interactions and less concordance! Ask the patient if he misses any doses or if he doesn’t take at all the medication (if so, why?).

• Social history. Ask about occupation (or previous occupation if retired), ask about help family or neighbors or friends or social service, ask if relatives live far, and ask if he/she has a spouse. Also look above, social history.

• Functional history. Ask about support from family, friends, neighbors, social service, and day care clinics. Ask tactfully about benefits. Many pts do not know that they are eligible for a benefit, so explain them that advice is available. Ask also if the presenting problem has occurred because a friend or neighbor that took care the patient was ill or on holidays.

V) APPENDIX: MEDICAL HISTORY FILES - SYNOPSIS

• On the file write above the history takers name, the date of assessment, the patient’s name, the patient’s DOB (date of birth), the patient’s age and occupation and the patient’s address. Below write ‘admitted as an emergency’ or ‘admitted from the waiting list’ and write date and time of admission.

• Presenting Complaint (PC)
Write on the file
1st symptom (e.g. nausea) – duration
2nd symptom (e.g. vomiting) – duration etc.

• History of Presenting Complaint (HPC).

For each symptom establish (and write on the file)

1)1st associated symptom. Establish the nature of complaint (e.g. chest pain), circumstances and speed of onset & progression, change with time, the exact onset (date it started), how it began (suddenly? gradually?), how long it occurred, why the patient is seeking now medical help, if the symptom is constant or intermittent, how long the symptom lasts each time, what is the nature of the symptom, if it improves or deteriorates, aggravating and relieving factors, other associated symptoms.

2)2nd associated symptom etc. Described as in (1).

• Past Medical History (PMH).

On the PMH ask specifically about diabetes (DM), blood transfusions (!), previous operations, complications and anaesthetic problems, epilepsy/ fits, TB, asthma, hypertension, angina pectoris, MI, stroke/TIA, hyperlipidaemia, jaundice, liver problems, renal problems, rheumatic fever, psychiatric problems, obstetric problems during his/her birth, developmental problems & child diseases.

On the past medical history write on the file
1st diagnosis, when, where and by whom, evidence, treatment, name of doctor.
2nd diagnosis etc.

• Allergies

• Drug History (DHs).

For drug history write on the file
Name, dose and frequency of each medication, diagnostic indication, evidence, prescriber.
Next drug etc.

Drug sensitivities & allergies

• Alcohol consumption

• Tobacco consumption

• Recreational drugs and medication addictions such as cocaine, marihuana, crack, heroin, hash, PCP (phencyclidine), amphetamines, LSD, ecstasy, glue or liquid corrector (fluid corrector for written mistakes e.g. ‘Blanco’) sniffing, mushrooms etc. Also addiction to medication (e.g. hypnotics, tranquilizers, morphine).

• Recent travel abroad, especially in tropical and/or endemic area.

• Does the patient have had any contact with pets, and generally animals, birds, reptiles, and fishes? Does he/she have any hobby that relates to the above e.g. feeding pigeons?

• Developmental history (especially useful in pediatrics and psychiatry).

Write on the file
Developmental history and problems in pregnancy, infancy, childhood, puberty and adulthood.

• Family History (FYx)
On the family history write down at the file
Family age illness
Parents
Siblings
Children
Spouse

Consider drawing a family tree.

Mention especially TB, asthma, eczema, DM, hypertension and epilepsy.

• Social History (SHx)
On the files write
Home and domestic activity support, occupation (in elderly other than retired!), financial security, travel, leisure.
Consider the effect of all these on the disease and the effect of the disease on these!

Also ask tactfully about abuse (psychological, somatic, sexual, or combination) and/or neglect. Abuse is underdiagnosed and often occurs in children, women – especially pregnant, incapacitated people and old people (here we have also financial abuse).

• Systematic Enquiry (SE) is a screening of the other body systems.

General symptoms such as weight loss or gain, loss or gain of appetite, malaise, fever, lethargy.

Respiratory symptoms such as couch (productive, non productive), sputum, haemoptysis, shortness of breath, chest pain, wheezing, stridor, acute or chronic breathlessness, hoarseness, pleuritic chest pain.

Cardiovascular symptoms such as tiredness and shortness of breath on exertion or on rest, chest pain on exertion or on rest, palpitations, orthopnea, paroxysmal nocturnal dyspnea, exertional dyspnea, ankle swelling, intermittent claudication, syncope & dizziness.

GI symptoms (Gastrointestinal) (alimentary) such as indigestion, nausea & vomiting (N&V), abdominal pain, constipation, diarrhea, recent change in bowel habit, dysphagia, blood per rectum (rectal bleeding), mucus from rectum, melaena, and hematemesis, loss of appetite, weight loss, jaundice, dark urine, pale stools,

GU symptoms (Genitourinary) such as urine frequency, polyuria, polydispia, dysuria, haematuria (ask if the patient eit beetroots that color the urine red!), nocturia, urgency, loin pain, lower abdominal pain, loss of libido, impotence, incontinence, menstrual problems, menstrual history (date of menarche, duration of cycle, flow normal or not, associated pain), pregnancy, abortions, vaginal discharge, black urine (e.g. rabdomyolysis), urethral discharge.

Neurological symptoms such as headache, dizziness, vertigo, light headiness, syncope/ faints, dizziness & black outs, ‘funny turns’, tingling, numbing, ‘pins and needles’ or other disturbances of sensation, weakness, paresis/ paralysis, malaise, tremor, fits/ convulsions, sphincter problems (bowel, vesicle), incontinence, hearing loss or tinnitus, vertigo, vision loss or blurring or double vision, disturbance of speech, limb weakness, sudden headache & loss of consciousness, transient neurological deficit, neck stiffness.

Psychiatric symptoms such as mood change, fatigue – tired continuously, odd voices, loss of appetite, loss of libido, odd visual effects (delusions, hallucinations), anxiety, sleep disturbance (e.g. insomnia), new strong beliefs, phobias, compulsions, avoidance of actions – social phobia, recreational drug abuse, alcohol.

Locomotor symptoms such as pain and stiffness in the neck, shoulder, elbow, wrist, hand, back, hip, knee, foot, and generally in any joint and any muscle.

Skin symptoms such as lumps, bumps, rash, itch, ulcer, warts, lesion that changes size, color, shape, edge, surface and nature of surrounding skin.

Skin lymph nodes & endocrine skin. Sweats & shivering, heat or cold intolerance, night sweats (e.g. TB, lymphoma), rigors (e.g. pyelonephritis), rashes, itching.

• NAD is an abbreviation of ‘no abnormality detected’. However it may mean ‘not actually done’! Document all the answers on the systems enquiry. If not done write ‘systems enquiry not done’.

• Preliminary diagnosis. Most of the diagnostic information is contained in the patient’s history! At the end of the history check again the information to confirm or exclude the diagnostic possibilities.

• Vital signs (temperature, BP, pulse/ HR heart rate, RR respiratory rate), ABGs (arterial Blood Gases) & SpO2 (oxygen saturation), fingerstick glucose, 12 Lead ECG

• Physical Examination (WRITE THE SYSTEMIC PHYSICAL EXAMINATION OF EACH SYSTEM).

• Medical or surgical diagnostic sieves e.g. acute MI.

• Basic blood Lab tests

FBC -CBC (Full/ Complete Blood Count), U&E (BUN - Blood Urea Nitrogen and Electrolytes Na, K, Ca, Mg), creatinine, WBC (WCC), Coagulation Studies (Plts Platelets, PT, PTT, INR, D’ Dimmers), blood glucose, LFTs (Liver Function Test), pregnancy test (women childbearing age), CRP, ESR, CK, CK-MB, Troponins, amylase, lipase etc.

• Urine dip stick test

Glucose, casts, blood, protein, bilirubin, nitrogen, etc.

• Urinalysis
• Lumbar Puncture (LP)

• Image studies (e.g. Chest X-ray –CXR, CT).

Fluids (e.g. blood, urine, synovial, peritoneal, pleuritic, CSF)/ pus/ tissues (vaginal, anal, pharynx etc)/ IV line tips/ trauma/ surgical incision swabs/smears and culture, microscopy and sensitivity (C, M &S), Gram stain, other stains, specific cultures (e.g. blood and urine), AFB (Acid Fast Bacilli) etc Also urine and stool C, M & S (and parasite eggs in stool).

• Examination (Lab & image studies) findings.

• The problem list and positive finding summary.

• Differential diagnosis.

• The working diagnosis.

• Therapy plan.

• Further management sieves. Consider any further (Lab or image) test and/or referral and/or any treatment that you need to undertake.

Consider
Medical and/or Surgical specialist referral
Endoscopy
Lab- cytology, hematology
Image studies
ABGs, SpO2
Transfusion, transplantation
ECG/monitor, EEG
ECT, DC cardioversion
Radiology studies, radiotherapy
Social services assessment & support
Advice, assessment and/or treatment from nurse, physio, dietician, occupational therapist, speech therapist, foot therapist etc.

Further management. Consider SpO2 (oxygen Saturation), ABGs (Arterial Blood Gases), 12 lead ECG/ ECG monitoring, F&P (face & profile) CXR (chest X’ Ray), folley (urinary catheter) and perhaps Levine (NG Nasogastral tube e.g. on a patient with decreased level of consciousness with aspiration risk e.g. child or pregnant or patient with diaphragmatic hernia), Lab tests (FBC – CBC Full/ complete Blood Count, BUN Blood Urea Nitrogen, Creatinine, Electrolytes (K, Na, Ca, Mg, Phosphorus), blood glucose, ESR, CRP, CK, CK – MB, Troponins, amylase, lipase, urine dip stick, random glucose blood stick, urinalysis, LP (Lumbar Puncture), fluids (e.g. blood, urine)/swabs/ smears – stain (e.g. Gram, Giemsa, AFB) microscopy, culture and sensitivity. Also EEG, & imaging tests (e.g. non contrast CT for stroke).

EASY MISSED DIAGNOSIS

-endocrinological problems (e.g. neurological problem or myopathy due to thyroid abnormality or Cushing’s)

-poisoning (e.g. mushrooms, botulism), illicit/recreational drugs, medication, toxins

-reumatological diseases (e.g. hand arthropathy from RA or SLE or psoriatic arthritis)

VI) APPENDIX: MEDICAL HISTORY FILES - EXAMPLE

Dr James Manos
12 May 2009, 9.00 p.m.
Miss K.S. Aged 32
(DOB: 4 November 1977)
78 Smith Street, 32NSQW
London
Emergency Admission
12 May 2009 at 9.00p.m.
• P.C.: Sore throat, fever and malaise for 3 days.

• HPC: The patient was well until last Sunday 10 May when she developed shore throat with fever and malaise during at work (she works as an accountant at Royal Bank of Scotland in London). It was relieved by hot drinks and acetaminophen, but the following morning when she woke up the sore throat was worst with painful swallowing that couldn’t relieve with paracetamol (acetaminophen). She hadn’t any previous sore throats. She also had sudden loss of consciousness after getting up from the chair, but she recovered within 1 minute. She called her GP who found her unwell and because she was living alone he decided to refer her to the hospital.
• PMH: Hyperthyroidism discovered 1 year ago. (Anxiety, insomnia, weight loss, abnormal thyroid function tests in Royal Hospital of London). Taking carbimazole, 5 mg daily.

Doesn’t mention any allergy.
• Drug History: acetaminophen 1g 6 hourly (for sore throat that had for 2 days with fever and malaise).Also carbimazole 5mg daily for hyperthyroidism (see PMH).
No drug sensitivities or allergies
• Alcohol 10 units per week

• Non – smoker

• No other recreational drugs or medication addiction

• No recent travel abroad

• No contact with pets, birds, animals.
• Developmental history: term baby, vaginal labour with no complications, normal Apgar, no jaundice, no developmental problems, (normal developmental stones), only rubella and measles on childhood but without complications, menarche on 11, normal menstrual flow.

•FH:
Father aged 60 hypertension, DM (onset at 49)
Mother aged 58 CHF, hyperlipidaemia
Sibling male aged 32 alive and well
Sibling Female aged 25 asthma (onset at 14)
Children none
• SH: at present lives alone in an apartment that rents
Parents live 6 khm (3.7 miles) away
Works as an bank accountant.
No abuse/neglect.
• Systems enquiry. Sore throat, dysphagia, fever, sweats, malaise, relative neck stiffness. Rest systems enquiry: NAD.

• Physical examination:
Looks unwell, flushed

Weight 80 Kg (loss of 5 Kg the last 6 months).

Vital signs: Temperature 38.8 ⁰C (101.840F), HR (heart rate) 108 bpm, RR (respiratory rate) 18, BP 108/68 mmHg. Fall in BP 20mmHg on standing (postural hypotension).

ABG:normal
SpO2:95%.

EAR, NOSE, THROAT & LYMPH NODES

Bilaterally swollen tonsil, large, red, with small white patches
Bilaterally tender multiple lymph nodes enlargement in neck. No lymph node swelling in axillae or groins. Ear drums normal.

OTHER FINDINGS

No tremor, no lid lag.
Anxiety.

GENERAL EXAMINATION

CVS (cardiovascular system)

Pulse 108/min, regular, low volume
BP 108/68
Heart Sounds Normal
No murmurs

RS (respiratory system)

Chest shape & movements normal
Breath sounds normal
Percussion normal

AS (GI) (alimentary/ gastrointestinal system)

No jaundice
Spleen not palpable
Liver 1 finger breaths below costal margin
CNS (central nervous system)
Conscious & alert
No neck stiffness
Hand & leg coordination normal

Reflexes all normal and symmetrical
Babinski (plantars) negative

• Medical or surgical diagnostic sieves acute tonsillitis.

• Initial – preliminary diagnosis and Differential Diagnosis (ΔΔ)

(with ? is possible, ?? less possible)
?Αcute bacterial or follicular tonsillitis (usually streptococcal)
?Viral tonsillitis

?Glandular Fever (infectious mononucleosis) due to
EBV virus

?Agranulocytosis due to carbimazole

??Meningococcal meningitis

?Undiscovered DM type II.

?Postural hypotension syncope due to dehydration from infection.
?Thyrotoxicosis probably now controlled
Inadequate home support currently for acute
illness

• Basic blood Lab test

Urine dip stick test, FBC -CBC (Full/ Complete Blood Count), U&E (BUN - Blood Urea Nitrogen and Electrolytes Na, K, Ca, Mg), creatinine, WBC (WCC), Plts (Platelets), blood glucose, TSH, Monospot test, throat swab, ESR, CRP.

• Image studies.

CXR (Chest X’ Ray)

• Examination (Lab & image studies) findings.

ECG: sinus tachycardia, normal complex, regular
CXR: normal
SpO2: 95%
ABG: normal

Urine dip stick test: no protein, no blood, no casts, no ketones,
+ glucose.

LAB TESTS

Random (blood stick) glucose: 8.4 mmol/L

CBC (FBC): Hb: 12.4 g/dL,
WBC (WCC): 18.3 x 109 /L,
Neutrophils: 90%, no atypical lymphocytes present
Lab blood glucose: 8.4 mmol/L
Urea, Creatinine & Electrolytes: Na+: 141 mmol/L, K+: 4.3 mmol/L
Urea: 10.1 mmol/L, Creatinine: 112mmol/L

Throat swab sent, result waited.
Monospot test , result awaited.

TSH, fT3, fT4 sent, result awaited

NOTE ON THE LAB TESTS

The presence of glucose in the urine and the random glucose 8.4 mmol/L is suspicious of DM.
The WCC (WBC) 18.3 x 109 /L with 90% neutrophils occurs commonly in bacterial tonsillitis, and also excludes agranulocytosis. This WCC are rare in viral pharyngitis/tonsillitis and glandular fever making these diagnoses less possible.
The raised urea and creatinine are common in dehydration and less common in other causes of postural hypotension.

• The problem list and positive finding summary.

Female, 29 years old. Severe sore throat for 2 days getting worse.
Fever, sweats and malaise for 2 days
Hyperthyroidism diagnosed 1 year ago (on
carbimazole the last 6 months)
Unwell, flushed .

Sudden loss of consciousness after getting up from a chair, recovery within a min. PMH (past medical history) of thyreotoxicosis (anxiety, weight loss, abnormal thyroid function tests). FH (family history) of type 2 DM (diabetes mellitus).

Lives alone in an apartment that rents
Temperature 38.8⁰C (101.840 F)

Bilaterally swollen tonsils, large, red, with linear creamy
patches.
Bilaterally tender multiple lymph nodes
enlargement in neck
No tremor, no lid lag. Reflexes normal, anxiety, weight loss, fall in BP on standing,

Urine tests (+) glycose. Hb 12.4 g/dL, WCC 18.3 x 109 /L, neutrophils 90%, no atypical lymphocytes, Lab glucose 8.4 mmol/L,
Urea 10.1mmol/L, Creatinine: 112 μmol/L.

• Differential Diagnosis (ΔΔ) after the Lab & image investigations

-acute bacterial (or follicular) tonsillitis causing systemic effects
-Grandular Fever (infectious mononucleosis) due to EBV
-Postural hypotension syncope due to dehydration from infection.
-Thyrotoxicosis probably now controlled.
-Probable type 2 diabetes mellitus
-No domestic support currently

 

PROBLEM STRUCTURING NOTE

A)Acute bacterial or follicular tonsillitis (causing systemic effects e.g. dehydration). Clues: severe sore throat for 2 days which is getting worse, large red tonsils with linear creamy patches, WCC (WBC) 18.3 x 109 /L with 10% neutrophils. Treatment: paracetamol, 500mg, 6 hourly, PRN. Begin penicillin V 500 mg qds.

B)Probably not grandular fever (infectious mononucleosis due to EBV). Clues: severe sore throat for 2 days which is getting worse, large red tonsils with linear creamy patches, WCC (WBC) 18.3 x 109 /L with 10% neutrophils. Treatment: paracetamol, 500mg, 6 hourly, PRN. Begin penicillin V 500 mg qds. Await Monospot result.

C)Postural hypotension syncope? Due to dehydration from infection? Clues: sudden loss of consciousness after getting up from a chair, recovery within a minute. Fall in BP on standing. Evidence of acute infection. Treatment: Request U&E (BUN & electrolytes). Consider Fluids IV to rehydrate.

D)Dehydration from infection. Clues: Fall in BP on standing, evidence of acute infection, Urea 10.1 mmol/L, Creatinine 112 μmole/L. Treatment: Admit, encourage oral fluids, give IV fluids if unable to drink 2 L in 12 hours.

E)Thyrotoxicosis which is controlled now. Clues: anxiety, weight loss, abnormal TFTs (thyroid function tests) on the past, no heat or cold intolerance, no tremor, no lid-lag, normal reflexes. Therapy: carbimazole 5 mg od. Αwaiting result of TSH and fT4.
F)Probable type 2 DM (Diabetes Mellitus).Clues: FH (family history) of type 2 DM, urine glucose (+), no Ketones, random glucose 8.4 mmol/L. Treatment: Monitor Blood sugar before and 2 h after meals, plan glucose tolerance test.
G)No domestic support. Clues: alone in a flat at present. Parents 200 miles away. Treatment: Αdmit for initial care.

• The working diagnosis.

The main working primary diagnosis is probable acute bacterial (or follicular) tonsillitis causing systemic effects.

Other diagnoses

-Postural hypotension syncope due to dehydration from infection.
-Thyrotoxicosis probably now controlled
-Probable type 2 diabetes mellitus (we prefer the whole name instead of abbreviations such as DM)
-No domestic support currently

• Therapy plan.

Reassure the patient that there is no agranulocytosis. Explain other diagnoses.

Start penicillin V 500 mg qds (4 times daily)

Continue paracetamol 1 g qds

Continue carbimazole 5 mg od (once daily)

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

Monitor blood glucose before and 2 h after meals

Social support: Help patient contact family

DRUG ABBREVIATIONS

od: once daily

bd: twice daily

tds:3 times daily

qds: 4 times daily

prn: when required (state a maximum daily dose)

stat: immediately

• Further management sieves. Consider any further (Lab or image) test and/or referral and/or any treatment that you need to undertake.

-Consider acute follicular tonsillitis complications:
quinsy, retropharyngeal abscess, scarlet fever,
post streptococcal nephritis and rheumatic fever.

VII) APPENDIX: CLINICAL EXAMINATION

First impression. Does the patient look comfortable or distressed? Well or ill? Well nourished or malnourished? Hydrated or dehydrated? Do you recognize any syndrome (e.g. Turner’s) or facies (e.g. moon face on Cushing’s).

Vital signs. Temperature, BP, pulse, SpO2, RR (respiratory rate), stick blood glucose.

Normal temperature is 36 – 37 on axilla, important is said to be the morning temperature and also the temperature diurnal pattern. Normal oral temperature is 37⁰C. Rectal temperature is 0.5⁰C higher and axillary 0.5⁰ C lower.

BP is said to be more important if valued 2 hours after waking up in the morning. Normal BP is maximum 139/89. Check BP on both hands and also on the leg (exclude aorta’s coarctation, aortic dissection, and aortic aneurysm or aortic branches aneurysm). If BP of the arm is bigger than femoral BP then exclude coarctation of aorta. If there is difference between the BP of the 2 upper extremities exclude thoracic outlet syndrome! It will also be decreased about 45 mmHg on the left if stenotic subclavian artery!

Check for postural hypotension. Ask the patient to stay supine for 3 minutes and then to stand up for 1 min. We have postural hypotension when HR has increased equal or more than 30 bpm or SBP (systolic BP) has decreased equal or more than 20 or SBP <90.Check for hemorrhage (including internal bleeding, use FAST/USS and oesophago – gastroscopy/colonoscopy – exclude aortic aneurysm rupture!).

On difference of BP between arm and femoral is more than 15 mmHg (measure it it both sides) exclude aortic aneurysm or aortic dissection or aortic coarctation.

Check for pulsus paradoxus (difference more than 10mmHg between the Korotkoff sounds or doubling of the the Korotkoff sounds – exclude cardiac tamponade, restrictive pericarditis, or obstructive pulmonary disease) and pulsus alterans (LVF left ventricular failure).

If pulse in adults is more than 100 we have tachycardia and if <60 bradycardia. Check pulses on both femoral arteries. If decreased or absent suspect coarctation of aorta. If there is difference between the 2 pulses suspect rupture of aortic aneurysm. Check also the pulse on both upper extremities. If there is difference suspect aortic rupture (if trauma) or aortic arc aneurysm.

AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) & pupil’s reaction to light and irregularities).
GCS

Further management. Consider also ABGs (Arterial Blood Gases), 12 lead ECG/ ECG monitoring.

Set up. Ensure adequate privacy for the patient to undress! Make sure no one will disturb. Check the examination bed is covered with a clean disposable toweling. Check that you have near the necessary equipment (torch, stethoscope, cotton wool, pin prick, tendon hammer etc.). The patient usually is placed supine with the head & shoulders raised about 450 .

• Be careful on examining a male or female patient especially if you perform an intimate examination and especially if you examine a patient of the opposite sex! Have always together a chaperone who should be ideally the same sex with the patient. Never exam a patient alone! Perhaps a patient (even a man!) feels harassment from an intimate physical examination and press charges for sexual abuse! So a chaperone is needed to by an eye witness of the examination (especially needed at the examination of male and female reproductive system, rectum and female breasts) was only professional and nothing else occurred!

Head, neck, face
Neck stiffness, ear drum, (redness, bullae, perforated?), hairy loss (patchy?), eye (red, pain, iritis, conjunctiva pallor, sclera icterus?), facial appearance, facial redness, temperature, mouth & tongue lesions (aphthous, ulcers, leucoplacia, lumps), lumps/lymphnodes on the face, anterior & posterior neck triangle, axillae, submandibular area, supraclavicular (Virchow’s on Left), pre/post auricular, epitrochlear and occipital, carotid pulse (bruits?).

Also scars (e.g. on thyroid surgery), thyroid examination (while drinking a sip of water), thyroid nodes, tracheal position (moved towards the lesion area on atelectasis, or to the opposite hemithorax of the one that has the lesion on pneumothorax!), thyroid tenderness (thyroiditis?), tonsils, pharynx, tongue (enlarged in angioedema or Downs or amyloidosis), tongue symmetry when protruded (hypoglossal nerve palsy), gums (hypertrophy on e.g. leukemia), uvula for enlargement (angioedema), check palate for petechiae (infectious mononucleosis), lips/ mucosa (cyanosis, pale, angular stomatitis), symmetry of soft palate and uvula deviation when the patient says ‘aaaa…’ (X vagus nerve paralysis), periorbital edema (nephrotic syndrome, hypothyroidism, infection of sinuses and/or orbit with risk of cavernous sinus thrombosis!), herpes rash on the external ear (Ramsay Hunt syndrome, unilateral facial nerve palsy!). Nose – sinuses tenderness & translucency with a pen - torch?

Ears
Otoscope examination, pull the pinna (pain at external otitis), tenderness on mastoid? Weber & Rinne’s tests, Romberg test, tinnitus? Nystagmus? Vertigo?

Trunk & skin
Breast lump or discharge or orange texture, nipple eczema or ulcer, gynecomastia in men (alcoholism, Kleinefelter?), sparse body hair or hirsutism, axillary enlarged lymph nodes, scar pigmentation (Kebner phenomenon, e.g. psoriasis), abdominal striae (Cushing’s, cortisone), spider naevi (alcoholism). Medusa navel (ascites), rash, scrotum (lump, swelling?), scars, café au lait spots (neurofibromatosis), telengiectasias (Osler – Weber – Rendu syndrome), Cushing (buffalo hump, moon facies).

Also skin bruises, petechia, porphyra and rash.

Upper extremities & axilla
Finger nails, clubbing, fingers nodules, fingers/elbow/shoulder/neck joints (pain, deformity, swelling, stiffness, tenderness), rash, axilla (lymphnodes, cellulitis, acanthosis nigrans in DM, gastric cancer & obesity), upper extremity edema. Check also for an ischemic limb with the 5 ‘p’ (first pain, then painless – numb, pale, paralyzed, pulsless).

Back
Kyphosis, lordosis, scoliosis, spine palpation. On back pain check Lasegue and reverse Lasegue test (prolapsed disc),

Lower extremities
Inguinal and popliteal enlarged lymphnodes, sacral, leg and heel sores, leg ulcers and discoloration. On all leg joints (including femoro- patellar) check for (pain, deformity, swelling, stiffness and tenderness. Also check for sores, swellings, ulcers, varicose veins and edema (on calf pain and/or swelling exclude DVD) and cellulitis, gangrene and necrotizing fasciitis (especially on DM). Check also for an ischemic limb with the 5 ‘p’ (first pain, then painless – numb, pale, paralyzed, pulsless).

Cardiovascular system (CVS)
Central and peripheral cyanosis, radial pulse (rate, rhythm, amplitude), heart rate (regular?), BP standing and lying in right and next in left arm, compare pulses (radial, brachial, carotid, femoral, popliteal, posterior and anterior tibial) for volume and synchrony, jugular venous pressure (distension?), trachea (displaced?), apex beat (displaced?), palpable thrill, parasternal heave, auscultation (systolic or diastolic murmurs?), leg or sacral edema, liver enlargement, basal lung crackles, calf swelling and/or pain, skin temperature (e.g. hands), capillary refill time, clubbing.

Hear for murmurs in left lateral, erect, supine, squatting and bend on sitting position and also on inspiration, expiration and valsava. Murmur’s volume is graded from 1 (very quite) to 6 (heard without stethoscope).

S1 (mitral valve closure), S2 (aortic valve closure) normal or loud or soft, normal splitting of S2 that increases on inspiration, valves (use also the bell of the stethoscope on tricuspid & mitral), pericardial rub (?), S3 (? May be physiological on pts < 30 years old), S4 (? Never normal), Gallop early diastolic (S1, S2, S3, S1 – on the apex or the area of hearing the tricuspid), or early systolic (S1, S2, S4, S1 at the same area), or mid diastolic gallop.

Respiratory system
Cyanosis of tongue and lip, clubbing, respiratory rate, chest wall (expansion, distorted wall? Paradoxical movement?), trachea palpation (distorted), apex beat, percussion (resonant, hyper – resonant, normal, dull, stony dull?), auscultation: breath sounds (diminished? bronchial breathing? Crackles? Rubs? Wheezing?), vocal fremitus vocal resonance (the last with auscultation), max expiration (if more than 6 sec may have obstructive disease).

GI (gastrointestinal) (alimentary) & GU (genitourinary) system
Obesity, cachexia, jaundice, hepatic disease stigmata, loss of skin turgor, supraclavicular lymph nodes, abdominal scars, veins, abdominal distension, peristalsis, palpation (tenderness generalized or local, hepatic or splenic or renal enlargement, abdominal mass, palpating mass), percussion (dull or resonant, shifting dullness on ascites), auscultation (tinkling bowel sounds, silent, bruit), also groin lumps (lumphnodes?), rectum (mass, melaena, blood), scrotum (masses?), vagina, pelvis, urine, scrotum tenderness, mass, swelling or translucency with a pen - torch?

Abdominal palpation (initially soft and superficial, away from the pain area, the patient supine with legs bended, is the abdomen soft & none tender or there is pain & resistance), auscultation (initially, before the palpation), rebound (?), tenderness? Construction, masses (palsatile – aortic aneurysm), scars, liver, spleen and kidneys enlargement? Percussion, Murphy sign, Giordano sign, Mc Burney sign, pain when we ask the patient to cough? Digital rectum examination (blood? prostate, rectum, mass?), appendicitis (Mc Burney, Rovsing, psoas, thyroid muscle signs), auscultation of aorta/ renal /iliac/ femoral artery (any bruit?), check for hernia (inguinal or femoral, ask the patient to cough & Valsava), percussion of spleen, liver & bladder, shifting dullness test on ascites.

CNS (Central nervous system)
AVPU (Alert, responds to Voice, responds to Pain, Unresponsive& pupils reaction to light and irregularities).
GCS
Normal or not speech, facial appearance (facial nerve palsy?), finger pointing nose and heel (from opposite knee) to toe test, pronation and supination – of forearm, walking pattern, walking to toes, walking to heels, reflexes (check bilateral, biceps, supinator, triceps, knees, ankles, plantars, brisk or diminished?), gait, smell sense, jaw jerk, jaw deviation, facial weakness, deafness, palatal weakness, tongue paresis, neck or shoulder weakness, taste, symmetry of soft palate and uvula deviation when the patient says ‘aaaa…’ (X vagus nerve paralysis).

Check for ptosis when on supine position is elevating the upper extremities and prone is elevating the tibias (stroke?).

Also Romberg test.

Ophthalmoscopy: visual field, visual acuity, cornea (opacity? Put fluroscein), lens (opacity?), papilloedema, fundus examination – optic disc (pale, cupped on glaucoma, edema, dot & blot hemorrhages, new vessels, retinal patches, cotton wool, hypertensive or diabetic retinopathy, edema, red reflex), ptosis, pupils (constriction, irregular, dilation), diplopia, nystagmus, corneal reflex, sclera (jaundice?), conjunctiva (pale?), visual fields (use a pen with a red tip), pupils reaction to light, afferent reflect, response to consensual light, eye muscle movements, anisocoria, squint.

Motor function trunk posture, arm posture, hand tremor, hand muscles wasting, arm wasting, shoulder abduction, elbow flexion/ extension, wrist extension & hand grip, fingers abduction & adduction, thumb abduction & opposition, forearm pronation & supination, fasciculation (e.g. motor neuron disease), tone: spacticity (clasp knife rigidity), rigidity – lead pipe, rigidity – cog wheel in extrapyramidal problems, paratonia, myotonia, dystonia abnormal posture of head or limb.

Sensation
Upper limb hypoaesthesia of palm, dorsum of hand, lateral arm, ulnar side, cortical or progressive or dissociated sensory loss.

Lower limb hypoaesthesia of inguinal area, anterior thigh, shin, lateral foot, progressive or dissociated sensory loss.

Reflexes (check bilateral, biceps, supinator, triceps, knees, ankles, plantars) brisk or diminished?

Gait pattern

Meningitis signs
Neck stiffness, Kerning’s sign, Brudzinski’s sign, fundoscopy, rashes.

• Mental – cognitive examination test (6 CIT, cognitive function examination, Kingshill, 2000)

Helps on the differential diagnosis between dementia and acute confusional state. The last may be caused by infection, drugs, metabolic causes, alcohol/ alcohol withdrawal, hypoxia, MI (heart attack), TIA, stroke, endocrinical disturbance, head trauma, thyroid disease, cancer, epilepsy, malnutrition (e.g. thiamine, vit B12, nicotinic acid), illicit drug abuse.

Dementia has a more long term history and has not fluctuations.

Ask		Answer/score
‘Which is the year ?’		Correct 0, Wrong 4
‘What is the month?’		Correct 0, Wrong 3
‘Remember the following address ‘John Brown 42 West Street, Bedford’.’
‘What time is it?’ (approximately to nearest time)		Correct 0, Wrong 3
‘Count back from 20 to 1’		Correct 0, one mistake 2, more than 1 mistakes 4
‘Mention the months of the year but referring them with opposite sequence’ (i.e. December, November etc.)		Correct 0, one mistake 2, more than one mistakes 4
‘Mention the phrase I said before to remember’		Correct 0, one mistake 2, two mistakes 4, three mistakes 6, four mistakes 8, all mistake 10

Maximum total score 28.
Score
0–7 no important cognitive impairment.
8–9 possible important cognitive impairment, possible dementia. Admit the patient.
10–28 Severe cognitive impairment, strong possibility for dementia. Admit the patient.

See also www.kingshill-research.org

e.g. Physical examination:

Looks unwell, flushed
Weight not recorded
Temperature 38.8 ⁰C (101.84 0 F)

Bilaterally swollen tonsil, large, red, with small white patches
Bilaterally tender multiple lymph nodes enlargement in neck. No lymph node swelling in axillae or groins.

CVS (cardiovascular system)
Pulse 108/min, regular, low volume
BP 108/68
Heart Sounds Normal
No murmurs

RS (respiratory system)
Chest shape & movements normal
Breath sounds normal
Percussion normal

AS (GI) (alimentary/ gastrointestinal system)
No jaundice
Spleen not palpable
Liver 1 finger breaths below costal margin

CNS (central nervous system)
Conscious & alert
No neck stiffness
Hand & leg coordination normal
Reflexes all normal and symmetrical
Babinski (plantars) negative

VIII) APENDIX: WRITTING THE MEDICAL NOTE ON THE PATIENT’S FILE (EXAMPLE)

Female, 29 years old. Severe sore throat for 2 days getting worse.
Fever, sweats and malaise for 2 days
Hyperthyroidism diagnosed 1 year ago (on
carbimazole the last 6 months)
Unwell, flushed .

Sudden loss of consciousness after getting up from a chair, recovery within a min. PMH (past medical history) of thyreotoxicosis (anxiety, weight loss, abnormal thyroid function tests). FH (family history) of type 2 DM (diabetes mellitus).

Lives alone in an apartment that rents
Temperature 38.8⁰C (101.840 F)

 

Bilaterally swollen tonsils, large, red, with linear creamy
patches.
Bilaterally tender multiple lymph nodes
enlargement in neck
No tremor, no lid lag. Reflexes normal, anxiety, weight loss, fall in BP on standing,

Urine tests (+) glucose. Hb 12.4 g/dL, WCC 18.3 x 109 /L, neutrophils 90%, no atypical lymphocytes, Lab glucose 8.4 mmol/L,
Urea 10.1mmol/L, Creatinine: 112 μmol/L.

Primary Diagnosis

Probable acute bacterilal (or follicular) tonsillitis causing systemic effects.

Other diagnosis

Postural hypotension syncope due to dehydration from infection.

Thyrotoxicosis probably now controlled

Probable type 2 diabetes mellitus (we prefer the whole name instead of abbreviations such as DM)

No domestic support currently

Plan (therapy)

Reassure the patient that there is no agranulocytosis. Explain other diagnoses.

Start penicillin V 500 mg qds (4 times daily)

Continue paracetamol 1 g qds

Continue carbimazole 5 mg od (once daily)

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

Monitor blood glucose before and 2 h after meals

Help patient contact family

IX) REFERENCE

1)Thomas J., Monaghan T., Oxford Handbook of Clinical Examination and Practical Skills, Oxford Medical Publications, 2008.

2)Llewelyn H., Aun Ang H., Lewis K., Al – Abdulla A., Oxford Handbook of Clinical Diagnosis, Oxford Medical Publications, 2006.

3)Kasper D.L., Braunwald E., Fauci A.S., Hauser S.L., Longo D.L., Jameson J.L., Harrison’s Manual of Medicine, McGraw – Hill, 16th edition, 2005.

4)Simon C., Everitt H., Kendrick T., Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005.

5)Longmore M., Wilkinson I., Turmezei T., Kay Cheung C., Oxford Handbook of Clinical Medicine, Oxford Medical Publications, 7th edition, 2008.

6)Collier J., Longmore M., Brinsden M., Oxford Handbook of Clinical Specialties, Oxford Medical Publications, 7th edition, 2006.

7)Bickley L.S., Szilagyi P.G., Bate’s Pocket Guide to Physical Examination and History Taking, Lippincott Williams & Willkins, 4th edition, 2004.