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Part 1 Approach to the Patient
Part 2 Approach to the Trauma Patient
Part 3 Approach to Clinical Problem Solving
Part 4 Approach to Reading
The transition of learning from a textbook or journal article to applying the information in a specific clinical situation is one of the most challenging tasks in medicine. It requires retention of information, organization of the facts, and recall of myriad data with precise application to the patient. The purpose of this text is to facilitate this process. The first step is gathering information, also known as establishing the database. This includes recording the patient’s history; performing the physical examination; and obtaining selective laboratory examinations, special evaluations, and/or imaging tests. Of these, the historical examination is the most important and useful. Sensitivity and respect should always be exercised when interviewing patients.
The history is usually the single most important tool in reaching a diagnosis. The art of obtaining this information in a nonjudgmental, sensitive, and thorough manner cannot be overemphasized.
Age: Some conditions are more common at certain ages; for instance, age is one of the most important risk factors for the development of breast cancer.
Gender: Some disorders are more common in or found exclusively in men; examples include prostatic hypertrophy and cancer. In contrast, women more commonly have problems such as breast cancer and thyroid nodules. 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 colorectal cancer in Black individuals and diabetes mellitus in the Hispanic population).
The possibility of pregnancy must be entertained in any woman of childbearing age.
Cultural awareness and sensitivity should be exercised when communicating with patients, particularly those with less access to health care.
Chief complaint: What is it that brought the patient into the hospital or office? Is it a scheduled appointment or an unexpected symptom, such as abdominal pain or hematemesis? The duration and character of the complaint, associated symptoms, and exacerbating and/or 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 surgical presentation should include age, gender, and chief complaint (severity & duration). Example: A 32-year-old man complains of lower abdominal pain over an 8-hour duration.
Past medical history:
Major illnesses such as hypertension, diabetes, reactive airway disease, heart failure, and angina should be detailed and should include the following information.
Age of onset, severity, or end-organ involvement.
Medications taken for a particular illness, including any recent change in medications and the reason for the change.
Last evaluation of the condition (eg, when was the last echocardiogram performed in a patient with heart failure?).
Name of the provider or clinic following the patient for the disorder.
Minor illnesses, such as a recent upper respiratory tract infection, may impact the scheduling of an elective surgery.
Hospitalizations, no matter how trivial, should be detailed.
Past surgical history: Date, types, indications, and outcomes of procedures should be elicited. Laparoscopy versus laparotomy should be distinguished, since numerous abdominal surgeries (especially laparotomies) can lead to adhesive disease that requires more extensive surgical planning. Surgeon, hospital name, and location should be listed. This information should be correlated with the surgical scars on the patient’s body. Any complications should be delineated, including anesthetic complications, difficult intubations, and so on.
Allergies: Reactions to medications should be recorded, including severity and temporal relationship to administration of medication. Immediate hypersensitivity should be distinguished from an adverse reaction.
Medications: A list of medications including dosage, route of administration and frequency, and duration of use should be developed. Prescription, over-the-counter, and herbal remedies are all relevant. Corticosteroids can impede wound healing.
Social history: Marital status; family support; alcohol use, use or abuse of illicit drugs, and tobacco use; and tendencies toward depression or anxiety are important.
Family history: Major medical problems, genetically transmitted disorders such as breast cancer, and important reactions to anesthetic medications such as malignant hyperthermia (an autosomal dominant disorder) should be explored.
Review of systems: A system review should be performed, focusing on the more common diseases. For example, in a young man with a testicular mass, trauma to the area, weight loss, neck masses, and lymphadenopathy are important. In an elderly woman, symptoms suggestive of cardiac disease should be elicited, such as chest pain, shortness of breath, fatigue, weaknesses, and palpitations.
Malignant hyperthermia is a rare condition inherited in an autosomal dominant fashion. It is associated with a rapid rise in temperature up to 40.6 °C (105 °F), usually on induction by general anesthetic agents such as succinylcholine and halogenated inhalant gases. Prevention is the best treatment.
General appearance: Note whether the patient is cachectic versus well nourished, anxious versus calm, alert versus obtunded.
Vital signs: Record the temperature, blood pressure, heart rate, and respiratory rate. Oxygen saturation, height, and weight (and body mass index [BMI]) are often included here. For trauma patients, the Glasgow Coma Scale (GCS) is important (some clinicians will record in neuro exam instead of vital signs).
Head and neck examination: Evidence of trauma, tumors, facial edema, goiter and thyroid nodules, and carotid bruits should be sought. With a closed-head injury, pupillary reflexes and unequal pupil sizes are important. Cervical and supraclavicular nodes should be palpated.
Breast examination: Perform an inspection for symmetry and for skin or nipple retraction with the patient’s hands on her hips (to accentuate the pectoral muscles) and with her arms raised. With the patient supine, the breasts should be palpated systematically to assess for masses. The nipples should be assessed for discharge, and the axillary and supraclavicular regions should be examined for adenopathy.
Cardiac examination: The point of maximal impulse should be ascertained, and the heart should be auscultated at the apex as well as at the base. Heart sounds, murmurs, and clicks should be characterized.
Pulmonary examination: The lung fields should be examined systematically and thoroughly. Wheezes, rales, rhonchi, and bronchial breath sounds should be recorded.
Abdominal examination: The abdomen should be inspected for scars, distention, masses or organomegaly (ie, spleen or liver), and discoloration. For instance, the Grey Turner sign of discoloration on the flank areas may indicate an intra-abdominal or retroperitoneal hemorrhage. Auscultation should be performed to identify normal versus high-pitched, and hyperactive versus hypoactive bowel sounds. The abdomen should be percussed for the presence of shifting dullness (indicating ascites). Careful palpation should begin initially away from the area of pain, involving one hand on top of the other, to assess for masses, tenderness, and peritoneal signs. Tenderness should be recorded on a scale (eg, 1-4, where 4 is the most severe pain; or mild/moderate/severe). 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 are particularly important in assessing for pain on percussion that may indicate renal disease.
Female: The external genitalia should be inspected and the speculum then 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 infection. The scrotum should be palpated for masses, and if present, transillumination should be used to distinguish between solid and cystic masses. The groin region should be carefully palpated for bulging (hernias) on rest and on provocation (coughing). This procedure should optimally be repeated with the patient in different positions.
Rectal examination: A rectal examination can reveal masses in the posterior pelvis and may identify 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 and skin: The presence of joint effusions, incisions, tenderness, skin edema, and cyanosis should be recorded. Any wounds should be evaluated for redness, swelling, and discharge.
Neurologic examination: Patients who present with neurologic complaints usually require thorough assessments, including evaluation of the cranial nerves, strength, sensation, and reflexes.
A thorough understanding of anatomy is important to optimally interpret the physical examination findings.
Laboratory assessment depends on the circumstances.
A complete blood count: To assess for anemia, leukocytosis (infection), and thrombocytopenia.
Urine culture or urinalysis: To assess for infection or hematuria when ureteral stones, renal carcinoma, or trauma is suspected.
Tumor markers: For example, in testicular cancer, beta-human chorionic gonadotropin, alpha-fetoprotein, and lactate dehydrogenase values are often elevated.
Complete metabolic panel: Serum creatinine and blood urea nitrogen (BUN) to assess renal function; aspartate aminotransferase (AST) and alanine aminotransferase (ALT) values to assess liver function; electrolytes such as sodium and potassium are also important to obtain.
An ultrasound examination is the most commonly used imaging procedure. For example, it can distinguish a pelvic process in female patients, identify gallstones and measure the caliber of the common bile duct, and help discern solid versus cystic masses.
Computed tomography (CT) is extremely useful in assessing fluid and abscess collections in the abdomen and pelvis. It can also help determine the size of lymph nodes.
Magnetic resonance imaging (MRI) identifies soft tissue planes and may assist in assessing prolapsed lumbar nucleus pulposus and various orthopedic injuries.
Intravenous pyelography (IVP) is much less often performed now. It uses dye to assess the concentrating ability of the kidneys, the patency of the ureters, and the integrity of the bladder. It is also useful in detecting hydronephrosis, ureteral stones, and ureteral obstructions.
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), perisplenic view, subxiphoid pericardial window, and perisplenic window (Douglas pouch). In the extended FAST (E-FAST) examination, the bilateral hemithoraces and upper anterior chest wall are also visualized.
In caring for the potentially unstable patient, the trauma surgeon goes through a primary and secondary survey. The primary survey is based on ABCDE assessment (airway, breathing, circulation, disability [neurologic status including GCS score], and exposure [hypothermia, hemorrhage]), which should only take 5 minutes. Rapid interventions include securing the airway, oxygen and ventilatory support, intravenous access, fluid and blood component transfusion, and identification and treatment of life-threatening conditions (eg, tension pneumothorax, cardiac tamponade).
A secondary survey includes a focused history and an efficient head-to-toe physical examination, key laboratory and imaging studies, and assessment/prioritization of injuries and conditions. A useful mnemonic for the history is AMPLE: allergies, medications, past medical/surgical history or pregnancy, last meal, and events surrounding injury or environment.
There are typically four distinct steps that a clinician takes to systematically solve most clinical problems:
Making the diagnosis
Assessing the severity or stage of the disease
Proposing a treatment based on the stage of the disease
Following the patient’s response to the treatment
A diagnosis is made by a careful evaluation of the database, analyzing the information, assessing the risk factors, and developing the list of possibilities (the differential diagnosis). Experience and knowledge help the clinician “key in” on the most important possibilities. A good clinician also knows how to ask the same question in several different ways and use different terminology. For example, a patient may deny having been treated for “cholelithiasis” but answer affirmatively when asked if he has been hospitalized for “gallstones.” Reaching a diagnosis may be achieved by systematically reading about each possible cause and disease.
Usually, a long list of possible diagnoses can be pared down to two or three that are the most likely, based on selective laboratory or imaging tests. For example, a patient who complains of upper abdominal pain and 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 localizing to the right lower quadrant may have acute appendicitis.
The first 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, describing “how bad” a disease is. With malignancy, this is done formally by staging the cancer. Most cancers are categorized from stage I (least severe) to stage IV (most severe). With some diseases, such as with head trauma, there is a formal scale (the GCS) based on the patient’s eye-opening response, verbal response, and motor response.
The second step in clinical problem solving is to establish the severity or stage of the disease. There is usually prognostic or treatment significance based on the stage.
Many illnesses are stratified according to severity because the prognosis and treatment often vary based on the severity. If neither the prognosis nor the treatment is affected by the stage of the disease process, there would be no reason to subcategorize the illness as mild or severe. For example, obesity is subcategorized as moderate (BMI 35-40 kg/m2) or severe (BMI greater than 40 kg/m2), with different prognoses and recommended interventions. Surgical procedures for obesity, such as gastric bypass, are only generally considered when a patient has severe obesity and/or significant comorbidities such as sleep apnea.
The third step in clinical problem solving is, in most cases, tailoring the treatment to the extent or stage of the disease.
The final step in the approach to a disease is to follow the patient’s response to the therapy. The “measure” of response should be recorded and monitored. Some responses are clinical, such as improvement (or lack of improvement) in a patient’s abdominal pain, temperature, or pulmonary examination. Other responses can be followed by imaging tests, such as a CT scan to determine the size of a retroperitoneal mass in a patient receiving chemotherapy, or with a tumor marker, such as the level of prostate-specific antigen in a male receiving chemotherapy for prostatic cancer. For a closed-head injury, the GCS is used. The student must be prepared to know what to do if the measured marker does not respond according to what is expected. Is the next step to treat again, to reassess the diagnosis, to pursue a metastatic workup, or to follow up with another more specific test?
The fourth step in clinical problem solving is to monitor treatment response or efficacy, which can be measured in different ways. It may be symptomatic (the patient feels better) or based on a physical examination (fever), a laboratory test (prostate-specific antigen level), or an imaging test (size of a retroperitoneal lymph node on a CT scan).
The clinical problem-oriented approach to reading is different from the classic “systematic” research of a disease. A patient’s presentation rarely provides a clear diagnosis; hence, the student must become skilled in applying textbook information to the clinical setting. Furthermore, one retains more information when one reads with a purpose. In other words, the student should read with the goal of answering specific questions. There are several fundamental questions that facilitate clinical thinking:
What is the most likely diagnosis?
How can you confirm the diagnosis?
What should be your next step?
What is the most likely mechanism for this disease process?
What are the risk factors for this disease process?
What are the complications associated with this 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 has been 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 most common cause of serosanguineous nipple discharge is an intraductal papilloma.”
The clinical scenario might be: “A 38-year-old woman is noted to have a 2-month history of spontaneous blood-tinged right nipple discharge. What is the most likely diagnosis?” With no other information to go on, the student notes that this woman has a unilateral blood-tinged nipple discharge. Using the “most common cause” information, the student makes an educated guess that the patient has an intraductal papilloma. If instead the patient is found to have a discharge from more than one duct and a right-sided breast mass is palpated, it is noted: “The bloody discharge is expressed from multiple ducts. A 1.5-cm mass is palpated in the lower outer quadrant of the right breast.” Then the student uses the clinical pearl: “The most common cause of serosanguineous breast discharge in the presence of a breast mass is breast cancer.”
The most common cause of serosanguineous unilateral breast discharge is intraductal papilloma, but the main concern is breast cancer. Thus, the first step in evaluating the patient’s condition is careful palpation to determine the number of ducts involved, an examination to detect breast masses, and mammography. If more than one duct is involved or a breast mass is palpated, the most likely cause is breast cancer.
In the preceding scenario, it is suspected that the woman with the bloody nipple discharge has an intraductal papilloma, or possibly cancer. Ductal surgical exploration with biopsy would be a confirmatory procedure. Similarly, an individual may present with acute dyspnea following a radical prostatectomy for prostate cancer. The suspected process is pulmonary embolism, and a confirmatory test would be CT angiography or possibly a ventilation/perfusion scan. The student should strive to know the limitations of various diagnostic tests, especially when they are used early in a diagnostic process.
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 obtain more data. Another possibility is that there is enough information for a probable diagnosis and that the next step is staging the disease. Finally, the most appropriate answer may be to begin treatment. Hence, based on the clinical data, a judgment needs to be rendered regarding how far along one is in the following sequence.
Frequently, students are taught to “regurgitate” information that they have read about a particular disease but are not adept at identifying the next step. This skill is learned optimally at the bedside in a supportive environment with the freedom to make educated guesses and receive constructive feedback. A sample scenario might describe a student’s thought process as follows:
Make a 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, vomiting, and abdominal distention and has dilated loops of bowel on radiography.”
Stage the disease: “I do not believe that this is severe disease because he does not have fever, evidence of sepsis, intractable pain, leukocytosis, or peritoneal signs.”
Treat based on stage: “Therefore, my next step is to treat with nothing per mouth, nasogastric tube drainage, and observation.”
Follow the response: “I want to follow the treatment by assessing his pain (asking him to rate the pain on a scale of 0-10 every day), recording his temperature, performing an abdominal examination, obtaining a serum bicarbonate level (to detect metabolic acidemia) and a leukocyte count, and reassessing his condition in 24 hours.”
In a similar patient, when the clinical presentation is unclear, perhaps the best next step is a diagnostic one, such as performing an oral contrast radiologic study to assess for bowel obstruction.
The vague question “What is your next step?” is often the most difficult one because the answer may be diagnostic, staging, or therapeutic.
This question goes further than making the diagnosis and requires the student to understand the underlying mechanism of the process. For example, a clinical scenario may describe a 68-year-old man who notes urinary hesitancy and retention and has a large, hard, nontender mass in his left supraclavicular region. This patient has bladder neck obstruction due to benign prostatic hypertrophy or prostatic cancer. However, the indurated mass in the left neck area is suggestive of cancer. The mechanism is metastasis in the area of the thoracic duct, which drains lymph fluid into the left subclavian vein. The student is advised to learn the mechanisms of each disease process and not merely to memorize a constellation of symptoms. Furthermore, in general surgery, it is crucial for students to understand anatomy, physiology, and how a surgical procedure will correct a problem.
Understanding the risk factors helps the practitioner establish a diagnosis and determine how to interpret test results. For example, understanding the risk factor analysis may help in the treatment of a 55-year-old woman with weight loss and anemia. If the patient has risk factors for colon cancer (eg, familial adenomatous polyposis, prior ovarian cancer, ulceratve colitis) and complains of melanotic stool or changes in stool caliper, she likely has colorectal carcinoma and should undergo colonoscopy. Otherwise, occult benign gastrointestinal bleeding is a common etiology. If she takes nonsteroidal anti-inflammatory drugs or aspirin, peptic ulcer disease is the most likely cause.
A knowledge of the risk factors can be a useful guide in testing and in developing the differential diagnosis.
Clinicians must be cognizant of the complications of a disease so that they can understand how to follow and monitor the patient. Sometimes, the student has to make a diagnosis from clinical clues and then apply his or her knowledge of the consequences of the pathologic process. For example, a 26-year-old man complains of a 7-year history of intermittent diarrhea, lower abdominal pain, bloody stools, and tenesmus and is first diagnosed with probable ulcerative colitis. The long-term complications of this process include colon cancer. Understanding the types of consequences also helps the clinician to become aware of the dangers to the patient. Surveillance with colonoscopy is important in attempting to identify a colonic malignancy.
To answer this question, the clinician not only needs to reach the correct diagnosis and assess the severity of the condition, but also must 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. Students should focus on the indications for surgery and be able to succinctly and clearly verbalize these. For example, in peptic ulcer disease, the student should know that the primary therapy is nonsurgical, and the indications for surgery include acute bleeding that does not stop using nonoperative means, perforation, suspected cancer, and intractable symptoms despite medical therapy.
Students should know the primary treatment for various conditions and the indications for surgical management.
In an emergency situation, the priorities are ABCDE (primary survey), followed by a secondary survey.
There is no replacement for a meticulous history and physical examination.
There are four steps in the clinical approach to the patient: making the diagnosis, assessing the severity of the disease, treating based on severity, and following the patient’s response.
There are seven questions that help bridge the gap between the textbook and the clinical arena.
Students should be aware of the primary therapies for various medical conditions and the indications for surgical management.