Junior doctors often struggle to develop a management plan when assessing patients with a convoluted history or an unrecognisable constellation of symptoms and signs.
It is particularly complicated when patients possess a number of co-morbidities or active problems with overlapping clinical features. This is becoming an increasing problem in all areas of medicine due to our growing elderly population.
It is important to find a means of separating out the problems. This typically requires getting a clear chronological order of events. Without this it is difficult to glean how symptoms cluster or develop with time. Consequently, it is easy to confuse oneself by grouping the problems in the wrong way. The typical mistake that doctors make is to view history taking and diagnosis as a process of symptom gathering rather than a sequential evolution of a pathological process. The chronological progression is as equally important as the list of clinical features in forming a diagnosis.
It much easier to identify patterns if one can distinguish hyper-acute, acute, sub-acute and chronic problems and try to relate them to pre-existing pathology, potential complications or new issues.
- Determine which symptoms are typically chronic, recurrent, persistent or unchanging (‘What are you like when you are usually relative well? What tends to bring them on? What treatment do you take and how do you respond?’)
- Determine if those chronic symptoms have become more acute (‘Have there been a change to your usual symptoms? When did that happen? When did you think you took a turn for the worse? Are they worse, more frequent, more persistent? Have you noticed anything else? Has there been a different response to treatment?’)
- Determine which new symptoms have become more recent (‘When did you think you got worse? What did you notice first when they started? How did things change over time?
- Determine which symptoms eventually prompted the acute presentation (‘What concerned you to eventually bring you here today? Compared to say earlier this week?)
As you try to define distinct entities and symptom clusters, try to confirm they are indeed unique and separate:
- Try to find temporal patterns between triggers/insults and the clusters of symptoms that define and distinguish unique pathology g. exertion, food, activity, time-of-day, environmental exposures – dust, chemicals, smoke, radiation, sun; biological exposures – sick contacts, contaminated water, medications
- Try to relate predisposing conditions/risk factors that may much later lead to the development of disease/complications that the patient may have not yet been diagnosed g. hypertension, diabetes, hyperlipidaemia, smoking, carcinogens, family history of cancer, drug side effects
- Obtain clues about previous health encounters for previous symptoms, provisional diagnoses reached, investigation outcomes and responses to treatments that help either confirm or exclude different possibilities (e.g. CT abdomen and colonoscopy normal, no response to dietary modification)
- Note particular features that things have changed or a new problem has developed by identifying if there are a change in the nature, character or location of symptoms, the typical triggers that lead to it or a lack of response to the usual treatment (e.g. ‘worse headache ever different from my usual migraine and not better with Imigran’)
- Always compare current investigations with recent ones to see if a new pathology has developed or if it represents a stable chronic issue g. Abnormal labs, xrays or ECG
- Finally it is important to see if there are connections between the various problems and if possible draw a clear narrative that links them (e.g. new exertional angina due to sub-acute upper GI blood loss from recent NSAID used for treatment of progressive debilitating osteoarthritis)
Following this analysis, the priorities then become:
- Stabilise and treat the acute problem g. transfuse, GTN prn
- Withdrawal offending agents/triggers/insults g. bed rest until Hb adequate, stop NSAIDS
- Treat and investigate the underlying pathology, monitor response g. PPI, H.Pylori testing +/- eradication +/- endocopy
- Optimise underlying pathology or issues g. physiotherapy, home supports, referral for consideration of joint replacement, exercise stress test for occult coronary artery disease
Each disease process has a story.
Each patient may have many stories.