This edition first published 2017 © 2017 by Carol Cooper and Martin Block
Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK
The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
350 Main Street, Malden, MA 02148-5020, USA
For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell
The right of the authors to be identified as the authors of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.
Library of Congress Cataloging-in-Publication Data
Names: Cooper, Carol, 1951-, author. | Block, Martin (General practitioner), author.
Title: General practice cases at a glance / Carol Cooper, Martin Block.
Other titles: At a glance series (Oxford, England)
Description: Chichester, West Sussex ; Malden, MA : John Wiley & Sons Inc., 2016. | Series: At a glance | Includes bibliographical references and index.
Identifiers: LCCN 2015045693 | ISBN 9781119043782 (pbk.)
Subjects: | MESH: General Practice—methods—Case Reports. | General Practice—methods—Problems and Exercises.
Classification: LCC RC46 | NLM WB 18.2 | DDC 616—dc23
LC record available at http://lccn.loc.gov/2015045693
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: © Hero Images/Getty
General practice has seen huge changes in the last few years and is on course for many more. Areas once considered the exclusive province of secondary care have shifted to primary care.
The consultation is at the heart of general practice: a one-to-one exchange (unless there are relatives in tow) where the GP can assess the problem, make a working diagnosis, and plan management with the patient. It’s a lot to do in just 10 or 15 minutes
This makes the GP attachment the ideal place for a medical student to learn essential skills, like focused history-taking, examination, clinical decision-making and good communication. Even if you ultimately choose to work in a speciality very unlike general practice, you will find these skills useful.
The book is by two practising GPs who are linked with the academic department of primary care at London’s Imperial College Medical School. It is a companion volume to General Practice at a Glance, but can be used on its own.
These 50 consultations cover all age ranges and a broad spread of clinical areas. Some you could consider ‘bread-and-butter general practice’, while others contain less common conditions that shouldn’t be missed. The book follows the ‘at a Glance’ style: clear and concise, with charts and tables to accompany each case, and clinical guidelines to make sure students are up to speed with current thinking.
Every scenario is symptom-based, because that’s how patients present. The cases reflect the diversity of today’s patient population as well as the spread of common symptoms. Each begins with a short opening quote such as, ‘I am tired all the time‘.
With each one, you’ll have to tease out the relevant history, decide what to examine and which investigations are needed, reach a working diagnosis and formulate a management plan. You will be put on the spot, just as in your exams, and just as you will be in real-life clinical practice.
While the patients are fictionalized, they are complex and realistic, and, as in everyday medicine, some provide lighter moments too.
Each case takes one or two pages and includes:
We suggest you ask yourself at the end of every case, ‘What have I learnt here?’
You can work your way through the book, or dip in wherever you want. The consultations are arranged randomly, to reflect clinical general practice. However the index can guide you to consultations system by system for revision purposes if you like.
We wrote this title to:
We hope you enjoy this book and wish you success and fulfillment in your career.
Carol Cooper
Martin Block
Patients in this book are designed to reflect real life, with their own reports of symptoms and concerns. Please note that all names used are entirely fictitious and any similarity to individuals, alive or dead, is coincidental.
Martin: I would like to offer thanks to my trainees past and present and to Anna Strhan for her support and constant inspiration.
Carol: I would like to thank my colleagues Paul Booton, Graham Easton, Rob Hicks and Sally Mason, and my students at Imperial College.
The vast majority of medical care takes place in general practice, with well over 300 million consultations a year in the UK. That makes general practice the first port of call for every symptom you can imagine, and then some. For many patients, it is the only port of call. So it’s imperative to get the consultation right.
In general practice, you’ll find a microcosm of all the clinical specialities, and there’s no way of knowing what will come in next. All the consultations in this book take place in general practice, either in practice premises or at home, but good consultation skills lie at the heart of good medicine in every field, whether you are a GP or a neurosurgeon. Use your time in general practice wisely and make sure you learn these eminently transferrable skills.
While textbooks are usually disease based, consultations are patient based, most often around a presenting symptom. Teasing out what is wrong requires focused history-taking and clinical reasoning. In time these will become second nature to you, and you will also get faster as you become more experienced.
Some consultations may be straightforward. Others much less so, and your patient may need more than one consultation to do the problem justice.
A traditional medical history is very complete, usually proceeds in a structured way, and takes a long time because it leaves no stone unturned. It is the best way to learn when starting your clinical studies, but not always appropriate for every problem. If your patient has acute chest pain, it is hardly relevant to know if her mother had arthritis – and going into such detail will delay treatment.
A focused history demands clinical judgment as to what to delve into and what to leave. You may want to explore your patient’s eye symptoms in depth, for instance, and ask few or no questions about his bowels and bladder.
Clarify what your patient tells you.
Find out more about the symptoms.
It is equally important to find out about function. What does the pain – or other symptoms – prevent your patient from doing? You will need to know something about his daily life, at work and at home, to make a judgement as to how bad it all is.
This is the place to ask some red flag questions to pick up or rule out serious conditions. ‘Have you ever passed blood when you wee?’
Try questions like, ‘What were you hoping I could do?’, ‘What are your thoughts on all this?’ and ‘What are you most worried about?’ (Figure 1.2). Unless you ask, you may never know.
Summarize to let the patient know you’re on the right wavelength. ‘So let me see: your periods have been heavier for six months, and you’ve had a discharge that is mostly yellow and doesn’t itch. Have I got it right?’ It can also be a useful way of clarifying symptoms in your own mind.
Remember the previous medical history (PMH), including medication history, and recreational drugs and alcohol.
Family history is often relevant. Even if your patient doesn’t have a familial problem, knowing the family history is a good pointer to what might be on his mind.
Examination is equally important. If you don’t examine the patient, you may as well judge a book by its cover. The general gist might be obvious, but you can’t predict how the story might unfold. You need to strike a balance between a comprehensive physical examination, or a limited but well judged foray into one or two systems. However, don’t cut corners. Always perform the examination your patient needs.
Asking yourself, ‘What next?’ This is part of the transition from student to doctor, and a hallmark of clinical responsibility. There’s more on clinical reasoning in Chapter 2.
Share your thoughts with your patient. Your idea of treatment may not chime with his.
This book can’t teach you bedside manners, but they’re vital to building a rapport with your patient. Even if you are rushed, overworked or overwhelmed, patients deserve to see your courteous side.
Introductions are important. Before you ask what you can do for your patient today, give your name. A smile also does a huge amount to boost your patient’s confidence and help concordance too.
Use appropriate body language, and a demeanour that shows your patient he has your full attention, at least for the next 10 minutes.
Books
Articles
All doctors use clinical reasoning, but they rarely stop to think how they go through the process.
According to Henegan and others, clinical reasoning can be split into three stages:
This is called the hypothetico-deductive model.
The initiation stage usually coincides with the history, but can go on longer than that. The trigger for making your working hypothesis might be a spot diagnosis, as in the typical appearance of a BCC, or when you hear an opening snap. Or you might use the patient’s initial complaint (say abdominal pain or sore throat) to guide your hypothesis making. On occasion you may even rely on the patient’s own diagnosis. Self-labelling by patients always needs to be clarified during the consultation, so don’t take it at face value. But it’s not always wrong, either: think of pregnancy, or UTI. When making a hypothesis, another important trigger is pattern recognition. For instance weight gain, irregular periods and increasing facial hair should prompt thoughts of polycystic ovary syndrome.
If you don’t have initial diagnostic thoughts, try to name the problem. In doing so, think of what might be causing it. This should generate some possibilities. Remember to take your patient’s age, gender, occupation and past history into account. Also think of the worst-case scenario. This may be statistically rare, but it needs to be considered in every consultation. Otherwise you may miss important conditions.
The next stage is refinement. Every scientific hypothesis is testable. Think of what you need to verify your theories so far. What are the questions you need to ask to support or oppose your hypotheses? And what clinical findings could you elicit either for or against your hypotheses? This will guide your next steps.
Make sure you rule out important, rare, but serious possibilities. Here red flags, either in the history or the examination, can help. Remember there may be further red flags later, when any investigations come back.
Make use of clinical decision-making tools, if appropriate, like the Ottawa ankle rules or the International Prostate Symptom Score. You’ll find other tools in this book too.
Ask yourself, ‘Is this patient ill?’ It’s especially apt when seeing a child, but applies to most clinical situations. This may clarify your thinking, as well as determine the degree of urgency.
The final definition phase can include further tests, a trial of treatment, or discussion with a colleague. If you can’t make a diagnosis now, consider whether a diagnosis needs to be made this minute, or whether it can wait. Reviewing the patient in a few days, or a week, may allow time for the natural history of the condition to evolve, although this is obviously not always appropriate.
This afternoon Jay is brought in by his mother who tells you he’s burning up. He’s had a high fever since yesterday evening and wouldn’t have any breakfast today. He only picked at his lunch. Jay seems reasonably happy sitting in his buggy.
Ms Evans tells you that she didn’t take the temperature, but she just knows Jay has a fever. Apart from being off his food, he vomited once after lunch, about two hours before coming to see you. He isn’t coughing, and doesn’t have hoarseness or diarrhoea. There may have been a rash last night, but Ms Evans thinks it is just Jay’s eczema making a comeback. There has been no travel. Nobody at home has been unwell lately, but, ever since big sister Megan began playschool, both she and Jay have had a lot of snuffles.
Yes. Many children dislike being examined, especially when they don’t feel well, but don’t rush or skimp. You need to check for red flags that tell you this child may be seriously ill, and this includes taking the temperature.
You must also look for clues as to the cause of the fever. Remember that this may be the only chance to assess this child during his illness, and it must be done properly. The child will be more comfortable if you examine him on his mother’s lap, and you don’t undress him all at once: just get the mother to remove the clothes from his top half when you examine his chest, and the bottom half later in the examination.
The traffic light system can be useful for assessing febrile children (see Resources), but it is easier to remember red flags such as:
Table 1.1 Chart of routine childhood immunizations.
No. Jay has a moderately high temperature, is off his food and you don’t know what’s wrong. The fact that you haven’t found a focus of infection isn’t necessarily reassuring. It could be a UTI, or the evolving stages of an illness, before any localizing signs appear. He may have one of the childhood exanthems, or septic arthritis or some other potentially serious infection.
Urine dipstick for WBCs, protein and nitrites.
Unfortunately Jay will not pass urine on demand. Your choice lies between giving the mother a bag to collect urine, or a sample pot and asking her to leave the child’s nappy off until she has managed to collect a sample. Either way, you are unlikely to get a urine sample while he is still in the surgery.
As there are no red flags (yet), it is reasonable to leave the urine sample till the morning. Meanwhile advise Ms Evans to keep Jay cool by dressing him in lightweight clothes and giving him plenty of fluids. Tepid sponging is unhelpful and can be unpleasant.
If the temperature rises further or he seems uncomfortable, she could give paracetamol or ibuprofen in a formulation appropriate to his age, but fever is a normal physiological response to inflammation and it does not always need lowering.
It is wise to keep him away from other children, for example at nursery.
Give Ms Evans clear advice about when to return, and make sure she understands which symptoms are important. Include drowsiness, clammy skin and rapid breathing. Many parents fixate on the presence or absence of a non-blanching rash in meningitis/septicaemia and fail to realize that their child’s general condition is at least as significant.
As it turns out, Jay’s urine is normal the following morning. However his fever continues and he is irritable. When you see him two days later, he still has no focus of infection, and no red flags. Ms Evans has done some reading online and asks you if it is Kawasaki disease.
To make the diagnosis, you would need fever and at least four of the other criteria. Kawasaki disease is rare but 80% of cases occur in the under-fives. It must be treated, usually as a paediatric or paediatric cardiology inpatient, to prevent complications such as coronary artery aneurysm.
Jay has none of the other features. He improves over the next couple of days without a precise diagnosis being made. When she comes to see you, you take the opportunity of mentioning routine immunizations.
Clare Davey is a history student whose last two consultations were for constipation. Three months ago, one of your colleagues prescribed ispaghula husk. This did not help, so she returned to see another doctor. He noted she looked thin, and prescribed lactulose.
Today she wants something for hay fever that won’t make her drowsy during exams. She has tried loratadine and cetirizine over the counter, but they do not help much, and she finds chlorphenamine too sedating. Her main symptoms are sneezing and runny nose. You therefore hope that a prescription of a steroid nasal spray will send her on her way, leaving you to catch up on lost time.
You ask briefly about her constipation and she says, ‘I’ve got used to it.’ You’ve never seen her before but you can’t help noticing she looks thin, especially around the shoulders, even through a thick jumper. There is no record of her weight on the system.
Clare says her general health is absolutely fine, but admits she’s missed two periods. She can’t possibly be pregnant, she adds, because she broke up with her boyfriend nearly a year ago and there’s been nobody else. Her weight ‘hasn’t really changed’. She does feel the cold, but she just puts on extra layers. Today the sleeves of her jumper cover most of her hands.
You weigh her as this hasn’t been done for quite a while according to the notes. She is 47 kg. At 5’6” (about 1.68 m) tall, her BMI is 16.6, low enough for anorexia nervosa (use centile charts for patients under 18).
You consider a pregnancy test in case what she’s told you about timing is incorrect, but from Clare’s weight and her responses so far you put an eating disorder at the top of your list.
Of these eating disorders, anorexia seems the most likely diagnosis here.