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Part 1 Approach to the Patient
Part 2 Approach to Clinical Problem-Solving
Part 3 Approach to Reading
Applying “book learning” to a specific clinical situation is one of the most challenging tasks in medicine. To do so, the clinician must not only retain information, organize facts, and recall large amounts of data, but also apply all of this to the patient. The purpose of this text is to facilitate this process.
The first step involves gathering information, also known as establishing the database. This includes taking the history, performing the physical examination, and obtaining selective laboratory examinations, special studies, and/or imaging tests. Sensitivity and respect should always be exercised during the interview of patients. A good clinician also knows how to ask the same question in several different ways, using different terminology. For example, patients may deny having “congestive heart failure” but will answer affirmatively to being treated for “fluid in the lungs.”
The history is usually the single most important tool in obtaining a diagnosis. The art of seeking this information in a nonjudgmental, sensitive, and thorough manner cannot be overemphasized.
Age: Some conditions are more common at certain ages; for instance, chest pain in an elderly patient is more worrisome for coronary artery disease than the same complaint in a teenager.
Gender: Some disorders are more common in men such as abdominal aortic aneurysms. In contrast, women more commonly have autoimmune problems such as chronic idiopathic thrombocytopenic purpura or systemic lupus erythematosus. Also, the possibility of pregnancy must be considered in any woman of childbearing age.
Ethnicity: Some disease processes are more common in certain ethnic groups (such as type 2 diabetes mellitus in the Hispanic population).
The possibility of pregnancy must be entertained in any woman of childbearing age.
Chief complaint: What is it that brought the patient into the hospital? Has there been a change in a chronic or recurring condition or is this a completely new problem? The duration and character of the complaint, associated symptoms, and exacerbating/relieving factors should be recorded. The chief complaint engenders a differential diagnosis, and the possible etiologies should be explored by further inquiry.
The first line of any presentation should include age, ethnicity, gender, and chief complaint. Example: A 32-year-old white man complains of lower abdominal pain of 8-hour duration.
Past medical history:
Major illnesses such as hypertension, diabetes, reactive airway disease, congestive heart failure, angina, or stroke should be detailed.
Age of onset, severity, end-organ involvement.
Medications taken for the particular illness including any recent changes to medications and reason for the change(s).
Last evaluation of the condition (example: when was the last stress test or cardiac catheterization performed in the patient with angina?)
Which physician or clinic is following the patient for the disorder?
Minor illnesses such as recent upper respiratory infections.
Hospitalizations no matter how trivial should be queried.
Past surgical history: Date and type of procedure performed, indication, and outcome. Laparoscopy versus laparotomy should be distinguished. Surgeon and hospital name/location should be listed. This information should be correlated with the surgical scars on the patient’s body. Any complications should be delineated including, for example, anesthetic complications and difficult intubations.
Allergies: Reactions to medications should be recorded, including severity and temporal relationship to the dose of medication. Immediate hypersensitivity should be distinguished from an adverse reaction.
Medications: A list of medications, dosage, route of administration and frequency, and duration of use should be developed. Prescription, over-the-counter, and herbal remedies are all relevant. If the patient is currently taking antibiotics, it is important to note what type of infection is being treated.
Social history: Occupation, marital status, family support, and tendencies toward depression or anxiety are important. Use or abuse of illicit drugs, tobacco, or alcohol should also be recorded.
Family history: Many major medical problems are genetically transmitted (eg, hemophilia, sickle cell disease). In addition, a family history of conditions such as breast cancer and ischemic heart disease can be a risk factor for the development of these diseases.
Review of systems: A systematic review should be performed but focused on the life-threatening and the more common diseases. For example, in a young man with a testicular mass, trauma to the area, weight loss, and infectious symptoms are important to note. In an elderly woman with generalized weakness, symptoms suggestive of cardiac disease should be elicited, such as chest pain, shortness of breath, fatigue, or palpitations.
General appearance: Is the patient in any acute distress? The emergency physician should focus on the ABCs (Airway, Breathing, Circulation). Note cachetic versus well-nourished, anxious versus calm, alert versus obtunded.
Vital signs: Record the temperature, blood pressure, heart rate, and respiratory rate. An oxygen saturation is useful in patients with respiratory symptoms. Height, weight, and body mass index are often placed here.
Head and neck examination: Evidence of trauma, tumors, facial edema, goiter and thyroid nodules, and carotid bruits should be sought. In patients with altered mental status or a head injury, pupillary size, symmetry, and reactivity are important. Mucous membranes should be inspected for pallor, jaundice, and evidence of dehydration. Cervical and supraclavicular nodes should be palpated.
Breast examination: Inspection for symmetry and skin or nipple retraction, as well as palpation for masses. The nipple should be assessed for discharge, and the axillary and supraclavicular regions should be examined.
Cardiac examination: The point of maximal impulse should be ascertained, and the heart auscultated at the apex as well as the base. It is important to note whether the auscultated rhythm is regular or irregular. Heart sounds (including S3 and S4), murmurs, clicks, and rubs should be characterized. Systolic flow murmurs are fairly common in pregnant women because of the increased cardiac output, but significant diastolic murmurs are unusual.
Pulmonary examination: The lung fields should be examined systematically and thoroughly. Stridor, wheezes, rales, and rhonchi should be recorded. The clinician should also search for evidence of consolidation (bronchial breath sounds, egophony) and increased work of breathing (retractions, abdominal breathing, accessory muscle use).
Abdominal examination: The abdomen should be inspected for scars, distension, masses, and discoloration. For instance, the Grey Turner sign of bruising at the flank areas may indicate intra-abdominal or retroperitoneal hemorrhage. Auscultation should identify normal versus high-pitched and hyperactive versus hypoactive bowel sounds. The abdomen should be percussed for the presence of shifting dullness (indicating ascites). Then careful palpation should begin away from the area of pain and progress to include the whole abdomen to assess for tenderness, masses, organomegaly (ie, spleen or liver), and peritoneal signs. Guarding and whether it is voluntary or involuntary should be noted.
Back and spine examination: The back should be assessed for symmetry, tenderness, or masses. The flank regions particularly are important to assess for pain on percussion that may indicate renal disease.
Female: The external genitalia should be inspected and then the speculum used to visualize the cervix and vagina. A bimanual examination should attempt to elicit cervical motion tenderness, uterine size, and ovarian masses or tenderness.
Male: The penis should be examined for hypospadias, lesions, and discharge. The scrotum should be palpated for tenderness and masses. If a mass is present, it can be transilluminated to distinguish between solid and cystic masses. The groin region should be carefully palpated for bulging (hernias) upon rest and provocation (coughing, standing).
Rectal examination: A rectal examination will reveal masses in the posterior pelvis and may identify gross or occult blood in the stool. In females, nodularity and tenderness in the uterosacral ligament may be signs of endometriosis. The posterior uterus and palpable masses in the cul-de-sac may be identified by rectal examination. In the male, the prostate gland should be palpated for tenderness, nodularity, and enlargement.
Extremities/skin: The presence of joint effusions, tenderness, rashes, edema, and cyanosis should be recorded. It is also important to note capillary refill and peripheral pulses.
Neurological examination: Patients who present with neurological complaints require a thorough assessment including mental status, cranial nerves, strength, sensation, reflexes, and cerebellar function. In trauma patients, the Glasgow coma score is important (Table I–1).
A thorough understanding of anatomy is important to optimally interpret the physical examination findings.
Laboratory assessment depends on the circumstances:
CBC (complete blood count) can assess for anemia, leukocytosis (infection), and thrombocytopenia.
Basic metabolic panel: Electrolytes, glucose, blood urea nitrogen, and creatinine (renal function).
Urinalysis and/or urine culture: To assess for hematuria, pyuria, or bacteruria. A pregnancy test is important in women of childbearing age.
AST (aspartate aminotransferase), ALT (alanine aminotransferase), bilirubin, alkaline phosphatase for liver function; amylase and lipase to evaluate the pancreas. Glasgow coma scale score is the sum of the best responses in the three areas: eye opening, motor response, and verbal response.
Cardiac markers (CK-MB [creatine kinase myocardial band], troponin, myoglobin) if coronary artery disease or other cardiac dysfunction is suspected.
Drug levels such as acetaminophen level in possible overdoses.
Arterial blood gas measurements give information about oxygenation, but also carbon dioxide and pH readings.
Electrocardiogram if cardiac ischemia, dysrhythmia, or other cardiac dysfunction is suspected.
Ultrasound examination useful in evaluating pelvic processes in female patients (eg, pelvic inflammatory disease, tubo-ovarian abscess) and in diagnosing gallstones and other gallbladder disease. With the addition of color-flow Doppler, deep venous thrombosis and ovarian or testicular torsion can be detected.
The FAST (focused assessment with sonography for trauma) examination can decrease the time to treating intra-abdominal bleeding. The examination includes views of the hepatorenal recess (Morrison pouch), the perisplenic view, subxiphoid pericardial window, and the perisplenic window (Douglas pouch). In the extended FAST (E-FAST) examination, the bilateral hemithoraces and upper anterior chest wall are also visualized.
Computed tomography (CT) useful in assessing the brain for masses, bleeding, strokes, and skull fractures. CTs of the chest can evaluate for masses, fluid collections, aortic dissections, and pulmonary emboli. Abdominal CTs can detect infection (abscess, appendicitis, diverticulitis), masses, aortic aneurysms, and ureteral stones.
Magnetic resonance imaging (MRI) helps to identify soft tissue planes very well. In the emergency department (ED) setting, this is most commonly used to rule out spinal cord compression, cauda equina syndrome, and epidural abscess or hematoma. MRI may also be useful for patients with acute strokes.
There are typically five distinct steps that an emergency department clinician undertakes to systematically solve most clinical problems:
Addressing the ABCs and other life-threatening conditions
Making the diagnosis
Assessing the severity of the disease
Treating based on the stage of the disease
Following the patient’s response to the treatment
Patients often present to the ED with life-threatening conditions that necessitate simultaneous evaluation and treatment. For example, a patient who is acutely short of breath and hypoxemic requires supplemental oxygen and possibly intubation with mechanical ventilation. While addressing these needs, the clinician must also try to determine whether the patient is dyspneic because of a pneumonia, congestive heart failure, pulmonary embolus, pneumothorax, or for some other reason.
As a general rule, the first priority is stabilization of the ABCs (see Table I–2). For instance, a comatose multi-trauma patient first requires intubation to protect the airway. See Figures I–1, I–2, I–3 regarding management of airway and breathing issues. Then, if the patient has a tension pneumothorax (breathing problem), (s)he needs an immediate needle thoracostomy. If (s)he is hypotensive, large-bore IV access and volume resuscitation are required for circulatory support. Pressure should be applied to any actively bleeding region. Once the ABCs and other life-threatening conditions are stabilized, a more complete history and head-to-toe physical examination should follow.
Because emergency physicians are faced with unexpected illness and injury, they must often perform diagnostic and therapeutic steps simultaneously. In patients with an acutely life-threatening condition, the first and foremost priority is stabilization—the ABCs.
Head-tilt and chin-lift
If cervical spine injury suspected, stabilize neck and use jaw thrust
If obstruction, Heimlich maneuver, chest thrust, finger sweep (unconscious patient only)
Temporizing airway (laryngeal mask airway)
Definitive airway (intubation [nasotracheal or endotracheal], cricothyroidotomy)
Look, listen, and feel for air movement and chest rising
Respiratory rate and effort (accessory muscles, diaphoresis, fatigue)
Effective ventilation (bronchospasm, chest wall deformity, pulmonary embolism)
Resuscitation (mouth-to-mouth, mouth-to-mask, bag and mask)
Supplemental oxygen, chest tube (pneumothorax or hemothorax)
Palpate carotid artery
Assess pulse and blood pressure
Cardiac monitor to assess rhythm
Consider arterial pressure monitoring
Assess capillary refill
If pulseless, chest compressions and determine cardiac rhythm (consider epinephrine, defibrillation)
Intravenous access (central line)
Consider 5 Hs and 5 Ts: Hypovolemia, Hypoxia, Hypothermia, Hyper-/Hypokalemia, Hydrogen (acidosis); Tension pneumothorax, Tamponade (cardiac), Thrombosis (massive pulmonary embolism), Thrombosis (myocardial infarction), Tablets (drug overdose)
Determination of breathlessness. The rescuer “looks, listens, and feels” for breath.
Jaw-thrust maneuver. The rescuer lifts upward on the mandible while keeping the cervical spine in neutral position.
Chest compressions. Rescuer applying chest compressions to an adult victim.
This is achieved by carefully evaluating the patient, analyzing the information, assessing risk factors, and developing a list of possible diagnoses (the differential). Usually a long list of possible diagnoses can be pared down to a few of the most likely or most serious ones, based on the clinician’s knowledge, experience, and selective testing. For example, a patient who complains of upper abdominal pain and who has a history of nonsteroidal anti-inflammatory drug use may have peptic ulcer disease; another patient who has abdominal pain, fatty food intolerance, and abdominal bloating may have cholelithiasis. Yet another individual with a 1-day history of periumbilical pain that now localizes to the right lower quadrant may have acute appendicitis.
The second step in clinical problem-solving is making the diagnosis.
After establishing the diagnosis, the next step is to characterize the severity of the disease process; in other words, to describe “how bad” the disease is. This may be as simple as determining whether a patient is “sick” or “not sick.” Is the patient with a urinary tract infection septic or stable for outpatient therapy? In other cases, a more formal staging may be used. For example, the Glasgow coma scale is used in patients with head trauma to describe the severity of their injury based on eye-opening, verbal, and motor responses.
The third step in clinical problem-solving is to establish the severity or stage of disease. This usually impacts the treatment and/or prognosis.
Many illnesses are characterized by stage or severity because this affects prognosis and treatment. As an example, a formerly healthy young man with pneumonia and no respiratory distress may be treated with oral antibiotics at home. An older person with emphysema and pneumonia would probably be admitted to the hospital for IV antibiotics. A patient with pneumonia and respiratory failure would likely be intubated and admitted to the intensive care unit for further treatment.
The fourth step in clinical problem-solving is tailoring the treatment to fit the severity or “stage” of the disease.
The final step in the approach to disease is to follow the patient’s response to the therapy. Some responses are clinical such as improvement (or lack of improvement) in a patient’s pain. Other responses may be followed by testing (eg, monitoring the anion gap in a patient with diabetic ketoacidosis). The clinician must be prepared to know what to do if the patient does not respond as expected. Is the next step to treat again, to reassess the diagnosis, or to follow up with another more specific test?
The fifth step in clinical problem-solving is to monitor treatment response or efficacy. This may be measured in different ways—symptomatically or based on physical examination or other testing. For the emergency physician, the vital signs, oxygenation, urine output, and mental status are the key parameters.
The clinical problem-oriented approach to reading is different from the classic “systematic” research of a disease. Patients rarely present with a clear diagnosis; hence, the student must become skilled in applying textbook information to the clinical scenario. Because reading with a purpose improves the retention of information, the student should read with the goal of answering specific questions. There are seven fundamental questions that facilitate clinical thinking.
What is the most likely diagnosis?
How would you confirm the diagnosis?
What should be your next step?
What is the most likely mechanism for this process?
What are the risk factors for this condition?
What are the complications associated with the disease process?
What is the best therapy?
Reading with the purpose of answering the seven fundamental clinical questions improves retention of information and facilitates the application of “book knowledge” to “clinical knowledge.”
The method of establishing the diagnosis was covered in the previous section. One way of attacking this problem is to develop standard “approaches” to common clinical problems. It is helpful to understand the most common causes of various presentations, such as “the worst headache of the patient’s life is worrisome for a subarachnoid hemorrhage.” (See the Clinical Pearls at end of each case.)
The clinical scenario would be something such as: “A 38-year-old woman is noted to have a 2-day history of a unilateral, throbbing headache and photophobia. What is the most likely diagnosis?”
With no other information to go on, the student would note that this woman has a unilateral headache and photophobia. Using the “most common cause” information, the student would make an educated guess that the patient has a migraine headache. If instead the patient is noted to have “the worst headache of her life,” the student would use the Clinical Pearl: “The worst headache of the patient’s life is worrisome for a subarachnoid hemorrhage.”
The more common cause of a unilateral, throbbing headache with photophobia is a migraine, but the main concern is subarachnoid hemorrhage. If the patient describes this as “the worst headache of her life,” the concern for a subarachnoid bleed is increased.
In the aforementioned scenario, the woman with “the worst headache” is suspected of having a subarachnoid hemorrhage. This diagnosis could be confirmed by a CT scan of the head and/or lumbar puncture. The student should learn the limitations of various diagnostic tests, especially when used early in a disease process. The lumbar puncture showing xanthochromia (red blood cells) is the “gold standard” test for diagnosing subarachnoid hemorrhage, but it may be negative early in the disease course.
This question is difficult because the next step has many possibilities; the answer may be to obtain more diagnostic information, stage the illness, or introduce therapy. It is often a more challenging question than “What is the most likely diagnosis?” because there may be insufficient information to make a diagnosis, and the next step may be to pursue more diagnostic information. Another possibility is that there is enough information for a probable diagnosis, and the next step is to stage the disease. Finally, the most appropriate answer may be to treat. Hence, from clinical data, a judgment needs to be rendered regarding how far along one is on the road of:
Frequently, the student is taught “to regurgitate” the same information that someone has written about a particular disease, but is not skilled at identifying the next step. This talent is learned optimally at the bedside, in a supportive environment, with freedom to take educated guesses, and with constructive feedback. A sample scenario might describe a student’s thought process as follows:
Make the diagnosis: “Based on the information I have, I believe that Mr. Smith has a small-bowel obstruction from adhesive disease because he presents with nausea and vomiting, abdominal distension, high-pitched hyperactive bowel sounds, and has dilated loops of small bowel on x-ray.”
Stage the disease: “I don’t believe that this is severe disease because he does not have fever, evidence of sepsis, intractable pain, peritoneal signs, or leukocytosis.”
Treat based on stage: “Therefore, my next step is to treat with nothing per mouth, NG (nasogastric) tube drainage, IV fluids, and observation.”
Follow the response: “I want to follow the treatment by assessing his pain (I will ask him to rate the pain on a scale of 1-10 every day), his bowel function (I will ask whether he has had nausea or vomiting, or passed flatus), his temperature, abdominal examination, serum bicarbonate (for metabolic acidemia), and white blood cell count, and I will reassess him in 48 hours.”
In a similar patient, when the clinical presentation is unclear, perhaps the best “next step” may be diagnostic, such as an oral contrast radiological study to assess for bowel obstruction.
Usually, the vague query, “What is your next step?” is the most difficult question because the answer may be diagnostic, staging, or therapeutic.
This question goes further than making the diagnosis, but also requires the student to understand the underlying mechanism for the process. For example, a clinical scenario may describe a 68-year-old man who notes urinary hesitancy and retention, and has a nontender large hard mass in his left supraclavicular region. This patient has bladder neck obstruction either as a consequence of benign prostatic hypertrophy or prostatic cancer. However, the indurated mass in the left neck area is suspicious for cancer. The mechanism is metastasis occurs in the area of the thoracic duct, because the malignant cells flow in the lymph fluid, which drains into the left subclavian vein. The student is advised to learn the mechanisms for each disease process, and not merely memorize a constellation of symptoms. Furthermore, in emergency medicine, it is crucial for the student to understand anatomy, physiology, and ways that would correct the problem.
Understanding the risk factors helps the practitioner to establish a diagnosis and to determine how to interpret tests. For example, understanding risk factor analysis may help in the management of a 55-year-old woman with anemia. If the patient has risk factors for endometrial cancer (such as diabetes, hypertension, anovulation) and complains of postmenopausal bleeding, she likely has endometrial carcinoma and should have an endometrial biopsy. Otherwise, occult colonic bleeding is a common etiology. If she takes NSAIDs or aspirin, then peptic ulcer disease is the most likely cause.
Being able to assess risk factors helps to guide testing and develop the differential diagnosis.
Clinicians must be cognizant of the complications of a disease so that they will understand how to follow and monitor the patient. Sometimes the student will have to make the diagnosis from clinical clues and then apply his or her knowledge of the consequences of the pathological process. For example, “a 26-year-old man complains of right-lower-extremity swelling and pain after a trans-Atlantic flight” and his Doppler ultrasound reveals a deep vein thrombosis. Complications of this process include pulmonary embolism (PE). Understanding the types of consequences also helps the clinician to be aware of the dangers to a patient. If the patient has any symptoms consistent with a PE, CT angiographic imaging of the chest may be necessary.
To answer this question, not only does the clinician need to reach the correct diagnosis and assess the severity of the condition, but the clinician must also weigh the situation to determine the appropriate intervention. For the student, knowing exact dosages is not as important as understanding the best medication, route of delivery, mechanism of action, and possible complications. It is important for the student to be able to verbalize the diagnosis and the rationale for the therapy.
Therapy should be logical and based on the severity of disease and the specific diagnosis. An exception to this rule is in an emergent situation such as respiratory failure or shock when the patient needs treatment even as the etiology is being investigated.
The first and foremost priority in addressing the emergency patient is stabilization, then assessing and treating the ABCs (airway, breathing, circulation).
There is no replacement for a meticulous history and physical examination.
There are five steps in the clinical approach to the emergency patient: addressing life-threatening conditions, making the diagnosis, assessing severity, treating based on severity, and following response.
There are seven questions that help to bridge the gap between the textbook and the clinical arena.