Cover Page

General Practice Cases
at a Glance

Carol Cooper

Honorary Teaching Fellow
Department of Primary Care and Public Health
Imperial College London
General Practitioner
London, UK



Martin Block

Programme Director
Imperial GP Specialty Training
Department of Primary Care and Public Health
Imperial College London
GP Partner, Clapham Park Group Practice
London, UK







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Preface

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:

  • the history, including a brief PMH and current medication
  • questions for you to answer as you go along
  • red flag symptoms and signs which mustn’t be missed (marked inline)
  • useful info, charts and graphics
  • further resources, mostly online, to deepen your knowledge.

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:

  • reflect the richness of general practice
  • challenge students to think on their feet
  • make them commit their thoughts
  • enable them get the most from their general practice attachment
  • give them tools to become good doctors.

We hope you enjoy this book and wish you success and fulfillment in your career.

Carol Cooper
Martin Block

Disclaimer

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.

Acknowledgements

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.

Part 1
Introduction

  1. 1 The consultation
  2. 2 Clinical reasoning to reach a diagnosis

1
The consultation

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.

Focused history-taking vs. traditional history-taking

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.

How to take a focused history

  • Open with a general question like, ‘What can I do for you today?’ and then listen attentively.
  • Use the ‘golden minute’: give your patient time to open up about the problem without firing questions.
  • Use active listening.
  • Begin with open questions, followed by closed questions.

Clarify what your patient tells you.

  • ‘What do you mean by locking?’ Patients may also misuse medical terms, such as pernicious anaemia, and misquote the names of drugs they have taken.
  • Be curious in your probing, but don’t take statements for granted. ‘I don’t smoke,’ may mean your patient stopped two weeks ago, fearing he has lung cancer.

Find out more about the symptoms.

  • ‘How often do you get up at night to pass water?’
  • If there’s pain, get the details. You could use SOCRATES (Site, Onset, Character, Radiation, Associated factors, Timing, Exacerbating/relieving factors, Severity on a scale of 0–10) (Figure 1.1).
  • You can avoid an interrogative style by appropriate body language (e.g. smiling, nodding) to show a genuine interest in your patient.
Image described by surrounding text.

Figure 1.1 Using SOCRATES as a guide to taking a history.

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?’

Explore your patient’s ideas, concerns and expectations (ICE)

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.

Cartoon diagram shows call outs from patient saying do you think it’s serious, doctor?, he obviously thinks it’s serious; from doctor saying probably not, why is he still sitting there?.

Figure 1.2 Ideas, concerns and expectations.

Use sign-posting

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.

Examining the patient

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.

Think on your feet

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.

People skills

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.

Resources and references

Books

  1. Booton P, Cooper C, Easton G and Harper M. General Practice at a Glance. London: Wiley-Blackwell, 2013.
  2. Douglas G, Nicol F and Robertson C. (eds.) Macleod’s Clinical Examination. London: Elsevier, 2005.
  3. Stephenson A. (ed.) A Textbook of General Practice. London: Hodder Arnold, 2004.
  4. Fraser RC. (ed) Clinical Method: a General Practice approach. London: Butterworth Heinemann, 1999.
  5. Neighbour R. The Inner Consultation. 2nd edn. Oxford: Radcliffe Publishing, 2004.
  6. Silverman J, Kurtz S and Draper J. Skills for Communicating with Patients. Oxford: Radcliffe Medical Press, 2004.
  7. Very comprehensive and reviews all the supporting research evidence.
  8. Tate P. The Doctor’s Communication Handbook. 5th edn. Oxford: Radcliffe Medical Press, 2006.

Articles

  1. Almond S, Mant D and Thomson M. Diagnostic safety-netting. Br J Gen Pract. 2009; 59(568): 872–874. http://bjgp.org/content/59/568/872
  2. Henegan C. Diagnostic strategies used in primary care. BMJ. 2009; 338: 1003–1008. http://www.bmj.com/content/338/bmj.b946

2
Clinical reasoning to reach a diagnosis

Flowchart shows initiation of diagnostic hypotheses leading to refinement to collect more information to refine hypothesis to definition to share your reasoning and conclusions.

Figure 2.1 Clinical reasoning stages.

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:

  • initiation of a diagnostic hypothesis (or several)
  • refinement of these
  • definition of the final diagnosis.

This is called the hypothetico-deductive model.

Initiation stage

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.

Refinement stage

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.

Reflect at every stage

  • Is there anything you can’t explain? Patients do sometimes have symptoms that don’t conform to the textbook description, but beware of shoe-horning the facts to fit your preferred diagnosis.
  • Consider too what the patient thinks, and their ICE (see Chapter 1 on the consultation).
  • Don’t discard the other possibilities or pigeon-hole your patient’s problem too soon. Errors of bias can be serious.

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.

Part 2
Cases

  1. 1 My baby is burning up
  2. 2 I need something for hay fever
  3. 3 I can’t seem to shift this cough
  4. 4 My knee is very bad
  5. 5 I have migraine
  6. 6 I’ve come for my flu jab
  7. 7 He’s a little terror
  8. 8 I’ve got a problem with my shoulder
  9. 9 I can’t believe how much weight I’ve put on
  10. 10 It’s my back passage
  11. 11 I am pregnant again
  12. 12 My baby has an upset tummy
  13. 13 My ear really hurts
  14. 14 I’m worried about my drinking
  15. 15 She cries all the time
  16. 16 I need something to help me sleep
  17. 17 My eye hurts
  18. 18 I think I should get this prostate test, doctor
  19. 19 I can’t live with this pain much longer
  20. 20 I’ve got a red eye
  21. 21 I’m fed up with my spots
  22. 22 I’ve come for the results of my blood tests
  23. 23 I’d like to talk to you about HRT
  24. 24 I’ve got a bit of a discharge
  25. 25 I’m feeling tired and woozy
  26. 26 I think I need to get my blood pressure checked
  27. 27 Well, I’m pregnant
  28. 28 I’ve been feeling short of breath
  29. 29 She’s coughing non-stop
  30. 30 I’m worried about my memory
  31. 31 I’ve got this pain in my chest, doctor
  32. 32 I’ve been having terrible stomach cramps
  33. 33 I’m concerned this mole has been growing
  34. 34 I seem to have lost weight
  35. 35 I’m worried about my erection
  36. 36 I think the cancer has got me
  37. 37 I’m all over the place these days
  38. 38 She’s had tummy ache for two days
  39. 39 I don’t want to have my period when I am on holiday
  40. 40 It’s my leg
  41. 41 I’m having terrible diarrhoea
  42. 42 The nurse did my diabetes check last week. I’m here for the results
  43. 43 My skin is really itchy
  44. 44 Doctor, I’m just feeling really down
  45. 45 I’ve got a really bad burning in my stomach
  46. 46 I want to talk about my risk of breast cancer
  47. 47 I’ve got a terrible back ache
  48. 48 I’d like antibiotics please
  49. 49 I’m tired all the time
  50. 50 I’m worried about this lump, doctor

CASE 1
My baby is burning up

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.

What do you do now?

  • Take a full history of the current episode.
  • Has the temperature in fact been taken, and if so how (a forehead strip is inaccurate), and what was it? Have the parents tried giving him anything so far?
  • Ask questions to establish how ill this child is: is he playing, socializing, smiling? Is he more drowsy than usual? Children with a fever may be a bit subdued but they should be alert. Is there evidence of dehydration? Ask the mother if his nappies have been drier than usual.
  • Ask about other symptoms such as cough, hoarse voice and rashes. You already know his appetite is affected, so enquire about diarrhoea and vomiting.
  • Establish his immunization status. This should be in the medical records (see Table 1.1).
  • Ask about contact with anyone ill, and about foreign travel.
Chart shows diagram of naked child with rashes on body. URTI, flu, viral exanthems, otitis media, tonsillitis, septic arthritis, meningitis, sepsis, et cetera written beside.

Figure 1.1 Causes of fever.

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.

Do you examine this child?

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.

List at least six important signs you should look for in determining how ill a child is.

The traffic light system can be useful for assessing febrile children (see Resources), but it is easier to remember red flags such as:

  • inline Fever >38 °C in baby under 3 months or fever >39 °C in baby 3–6 months.
  • inline Won’t interact or socialize.
  • inline Difficult to rouse.
  • inline Pale or mottled skin.
  • inline Dry mucous membranes.
  • inline Reduced skin turgor.
  • inline Capillary refill time greater than 3 seconds.
  • inline Respiratory rate:
    • >60/min if under 6 months
    • >50/min if between 6 and 12 months
    • >40/min for children over 12 months.
  • inline Indrawing of intercostal spaces.
  • inline Grunting.
  • inline Tachycardia:
    • >160/min if under 12 months
    • >150/min if 12–24 months old
    • >140/min if 2–5 years old.
  • inline Non-blanching rash.
  • inline Inability to move a limb.
  • inline Bulging fontanelle.
  • inline Focal neurological signs.
  • inline High-pitched cry.
  • inline Low oxygen sats

Table 1.1 Chart of routine childhood immunizations.

Can you now reassure the mother that it is only a virus?

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.

Bar graph has time 1-7 days on horizontal axis. Ten horizontal bars for chickenpox, hand-foot-and-mouth, scarlet fever, roseola, measles, rubella, mumps, typhus, dengue, typhoid.

Figure 1.2 Usual prodromal phases of some infections, during which there may be fever and malaise.

What one test do you consider doing now?

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.

Ms Evans looks at you expectantly. What do you advise her to do?

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 inlinedrowsiness, inlineclammy skin and inlinerapid breathing. Many parents fixate on the presence or absence of a inlinenon-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.

What are the main features of Kawasaki disease?

  • High fever, often abrupt in onset, with irritability.
  • Inflammation and irritation of the lips, mouth and/or tongue.
  • Erythema, oedema and/or desquamation of the extremities.
  • Bilateral dry conjunctivitis.
  • Widespread non-vesicular rash.
  • Cervical lymphadenopathy >1.5 cm in size.

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.

Resources

  • NICE Feverish illness in children: Assessment and initial management in children younger than 5 years. http://www.nice.org.uk/guidance/CG160
  • http://pathways.nice.org.uk/pathways/feverish-illness-in-children#content=view-node%3Anodes-use-the-traffic-light-system-to-assess-risk-of-serious-illness
  • NICE Urinary tract infection in children: Diagnosis, treatment and long-term management. http://www.nice.org.uk/Guidance/CG54
  • Kawasaki disease Patient UK. http://www.patient.co.uk/doctor/kawasaki-disease-pro

CASE 2
I need something for hay fever

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.

What are your thoughts?

  • She may be naturally slim.
  • She may have an eating disorder, in which case it’s your duty to assess her and initiate treatment.
  • She may have lost weight unintentionally, which is your duty to investigate.

What three or four initial questions could you ask to sort out these three possibilities?

  • ‘How’s your general health?’
  • ‘Has your weight changed over the last few months?’
  • ‘What are your periods like?’ Amenorrhoea is common in anorexia nervosa, as well as bulimia even when the weight is normal.
  • ‘Do you feel the cold?’ This isn’t specific to eating disorders but can help distinguish hyperthyroidism (prefers the cold) from anorexia (often feels cold).

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.