Learning to be an Excellent Diagnostician

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  • Learn to take a detailed history of the presenting complaint i.e. site, character, location, radiation [Reference: Talley & O’Connor]
  • Learn to establish the chronology of a patient’s history in correct order and relate that to a plausible disease process e.g. underlying problems/risk factors > acute precipitating events > development and recurrence of symptoms > progression of symptoms > clinical encounters, tests, treatments and outcomes (don’t record the events in a random mish-mash. This is particularly important in complicated problems or when there are multiple co-existing acute and chronic issues that confound the narrative)

  • Learn how to consult properly and get observed feedback on your technique i.e.   using the right balance of both open-ended and close-ended questions to obtain the required information for diagnosis and treatment planning. [Reference: Talley & O’Connor, basic textbook on Clinical communication or Clinical Interview]

  • Learn how to do a proper review of systems. This is your main clinical tool for identifying, confirming or excluding the culprit organ system. [Reference: Talley & O’Connor]
  • Understand the patho-physiological mechanism behind each symptom elicited in the review of systems e.g. dyspnoea, chest pain, speech difficulties. Understand the different routes by which the pathology of different diseases can present as the same symptom. Use this as a means of generating a differential diagnosis [[Reference: Harrison’s Principles of Medicine – Cardinal Manifestations of Disease]

  • Learn to take a screening psycho-social history including core psychiatric symptoms, social supports, social dependents and social stressors (including interpersonal conflict, financial pressure, and legal proceedings) [Reference: Talley & O’Connor, Any basic undergraduate psychiatric text]
  • Learn the correct vocabulary to describe key features of the Mental State Examination e.g. withdrawn, guarded, teary, agitated, pressured, disorganised, incoherent, hypervigilant etc. [Reference: Talley & O’Connor, Any basic undergraduate psychiatric text]
  • Know how major psychiatric conditions manifest and the key diagnostic criteria that differentiate them from personality disorders e.g. psychosis, depression, mania, anxiety, panic attacks. [Reference: Any basic undergraduate psychiatric text]
  • Know the important features of organic brain syndromes that distinguish them from psychiatric conditions. [Reference: Oxford Handbook of Clinical Medicine, Any basic undergraduate psychiatric text]
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  • Learn to take a proper functional history. Try to relate how much do the current symptoms actually impact daily life and independence e.g. ADLs, occupation, hobbies, sleep quality, mobility, sexual function, socialisation etc

  • Understand the generic pathological processes that underlie all diseases e.g. infective, neoplastic, vascular, autoimmune etc and the broad principles of their causes and risk factors, by which they develop, clinically manifest themselves, investigated and are treated. [Reference: Any basic undergraduate pathology text in combination with a basic internal medicine or surgical text]

  • Understand the causes, patho-physiology and clinical manifestations of how different organs become diseased and progressively fail e.g. heart failure, respiratory failure, liver failure, renal failure, brain failure [Reference: Any basic undergraduate pathology text, Oxford Handbook of Clinical Medicine, Te Oh. The ICU Manual]

  • Understand the common causes, clinical features, pathophysiology and complications of common surgical diseases e.g. ulcers, hernias, soft tissue/pleural/pericardial fluid accumulations etc  [Reference: Any basic undergraduate pathology text, Browse A System of Surgical Signs]

  • Understand the process and complications of wound and fracture healing and relate this to the evaluation of a patient with recent or previous trauma and surgical trauma. [Reference: Any basic undergraduate pathology text, Browse A System of Surgical Signs, Apley. A Concise System of Orthopaedics]

  • Learn how to describe the nature and distribution of a rash properly before trying to diagnose it e.g. macular, popular, vesicular, localised, generalised, flexural, symmetrical, centri-petal [Reference: Any basic undergraduate dermatology text]

 

  • Know how to semi-quantify the severity of organ dysfunction and failure e.g. heart failure – exercise tolerance, ejection fracture, renal failure – serum creatinine, hyperakalaemia, acidosis, fluid overload [Reference: Oxford Handbook of Clinical Medicine, Te Oh. The ICU Manual]

  • Be aware of the common or serious conditions afflicting pregnant and labouring patients e.g. early pregnancy bleeding, pre-eclampsia, placental abruption, post-partum haemorrhage. Understand the patho-physiology, clinical manifestations, diagnostic criteria, investigation and treatment. Understand some of the issues of how the diagnosis or treatment of common medical or surgical conditions is influenced by pregnancy. [Reference: Oxyford Handbook of Obstetrics]

  • Know the mechanism of action of the major drug classes e.g. steroids, beta-adrenergic antagonists, diuretics.  Relate this to its different clinical uses and how it modifies the patho-physiology of different diseases. Relate drug mechanism to side effects, contraindications and precautions. [Reference: Australian Therapeutic Guidelines, Any undergraduate pharmacology textbook]
  • Understand the broad antibiotic classes and their spectra and typical clinical uses [Reference: Australian Therapeutic Guidelines – Antibiotic guidelines]
  • Know how to take a proper medication history including prescribed, over-the-counter, alternative and recreational. Take particular note of adequacy of responses, dose changes, adverse events and recent cessation. (Medication side effects/iatrogenesis are an important differential cause for any presenting problem. Knowing current or previous failed treatments can help guide further treatment of unresponsive or refractory disease)

  • Know the early and late complications of common surgical interventions e.g bleeding, infection, damage to proximal structures, wound breakdown fibrosis/scarring and how they manifest clinically or should be investigated and treated. [[Reference: Oxford Handbook of Clinical Surgery]
  • Learn how to perform a systematic physical examination of an organ system. [Reference: Talley & O’Connor, Browse. A System of Surgical Signs]
  • Understand the patho-physiological mechanism behind each abnormal physical sign elicited in the physicial exam. Understand the different routes by which the pathology of different diseases can present with the same sign. Use this as a means of generating a differential diagnosis. [Reference: Talley & O’Connor; Harrison’s Principles of Medicine – Cardinal Manifestations of Disease]

  • Learn how to interpret common laboratory tests and the differential diagnosis of abnormalities and the ongoing diagnostic approach e.g. hyponatraemia, abnormal liver enzymes, leucocytosis, positive urine protein on dipstick [Reference: Oxford Handbook Of Clinical Medicine]
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  • Learn how to interpret common ECG abnormalities and the differential diagnosis of abnormalities e.g. wide QRS, tachyarrythmias, bradyarrythmias, ST/T segments changes (you must be able to at least correctly diagnosis a STEMI, VT and Complete Heart Block) [Reference: The ECG made Easy]

  • Revise basic anatomy with common radiological images e.g. CXR/AXR. Learn to identify the key structures and normal appearances prior to learning pathological appearances. [Reference: Raby, Accident and Emergency Radiology; Any undergraduate anatomy text]
  • Learn basic anatomy of the extremities with common radiological trauma images e.g. ankle xray. Learn to identify the key structures and normal appearances prior to learning pathological appearances. [Reference: Raby, Accident and Emergency Radiology; Any undergraduate anatomy text]
  • When learning radio-diagnosis, understand common differentials for different radiological appearances and the ancillary data (clinical and radiological) by which you would distinguish them e.g. lung opacities, fluid levels, dilated bowel loops [Reference: Raby, Accident and Emergency Radiology]

  • Understand how age (paediatric/geriatric) or pregnancy (obstetric) alters the diagnostic approach or treatment of different medical and surgical diseases. [Reference: Compare and contrast information from Oxford Handbook of Clinical Medicine, Clinical Surgery, Paediatrics, Obstetrics and Geriatrics]

CORE CLINICAL REFERENCES (to always have in your library)

  • Talley & O’Connor. Clinical Examination
  • A System of Surgical Signs
  • Oxford Handbook of Clinical Medicine (+ various)
  • A Concise System of Orthopaedics
  • ECG made Easy
  • Accident and Emergency Radiology
  • Australian Therapeutic Guidelines
  • Te Oh. The ICU Manual

(+ additional undergraduate texts in anatomy, physiology, pharmacology and pathology)

Finally….. The best of way of consolidating knowledge is to build your reading around the cases you see each day rather than embarking on a systematic study of each reference.

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