Making Sense of Acute Medicine: A Guide to Diagnosis (Hodder Arnold Publication)

321 Pages·2010·3.25 MB·English

by  Paul F. Jenkins

MAKING SENSE
ACUTE
of
MEDICINE
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MAKING SENSE
ACUTE
of
MEDICINE
A GUIDE TO
DIAGNOSIS
Paul F Jenkins
MA MB BChir FRCP FRCPE FRACP
Winthrop Professor of Medicine,
Faculty of Medicine, Dentistry and Health
Sciences, University of Western Australia,
Royal Perth Hospital and Joondalup Health
Campus, Perth, Australia
Paula H Johnson
MBChB DM FRCP
Associate Professor of Medicine, University
of Western Australia and Consultant General
and Respiratory Physician, Fremantle
Hospital, Fremantle, Australia
First published in Great Britain in 2010 by
Hodder Arnold, an imprint of Hodder Education, an Hachette UK company,
338 Euston Road, London NW1 3BH
http://www.hodderarnold.com
© 2010 Paul F Jenkins and Paula H Johnson
All rights reserved. Apart from any use permitted under UK copyright law, this
publication may only be reproduced, stored or transmitted, in any form, or by any
means with prior permission in writing of the publishers or in the case of reprographic
production in accordance with the terms of licences issued by the Copyright Licensing
Agency. In the United Kingdom such licences are issued by the Copyright Licensing
Agency: Saffron House, 6-10 Kirby Street, London EC1N 8TS.
Whilst the advice and information in this book are believed to be true and accurate
at the date of going to press, neither the authors nor the publisher can accept any
legal responsibility or liability for any errors or omissions that may be made. In
particular (but without limiting the generality of the preceding disclaimer) every
effort has been made to check drug dosages; however it is still possible that errors
have been missed. Furthermore, dosage schedules are constantly being revised and
new side-effects recognized. For these reasons the reader is strongly urged to
consult the drug companies’ printed instructions before administering any of the
drugs recommended in this book.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book is available from the Library of Congress
ISBN-13 978-0-340-98425-3
1 2 3 4 5 6 7 8 9 10
Commissioning Editor: Joanna Koster
Project Editor: Sarah Penny and Jane Tod
Production Controller: Kate Harris
Cover Design: Amina Dudhia
Indexer: Lisa Footitt
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Contents
Preface vi
Acknowledgements ix
List of abbreviations x
1 The shocked patient 2
2 The comatose patient 14
3 Chest pain 32
4 Breathlessness 48
5 Palpitation 72
6 Syncope 84
7 Seizures 94
8 Dizziness 108
9 Acute confusion 126
10 Acute headache 138
11 Weakness 156
12 Abdominal pain 174
13 Haematemesis and melaena 188
14 Diarrhoea and vomiting 198
15 Jaundice 212
16 Th e patient with a fever 224
17 Joint problems 238
18 Skin rashes 252
19 Back pain 270
20 Leg swelling 282
Index 294
v
Preface
This book is a guide to decision-making in Acute Medicine – a
practical approach to the differential diagnosis of patients
presenting as emergencies on the ‘medical intake’.
Remarkable technological advances have been made in
diagnostic medicine during the last 30 years. Examples include
the development of magnetic resonance imaging (MRI),
positron emission tomography (PET), spiral computerized
tomography (CT), cardiac troponins, biochemical tumour
markers, and numerous endoscopic and interventional
radiological procedures. However, the appropriate use and
interpretation of these tests remains dependent on the clinical
skills, decision-making and analytical capabilities of the
doctors who request them. Clever tests are no substitute for
sound clinical skills and may actually mislead practitioners
who lack the ability to use them appropriately. To use a crude
analogy, a bad driver will drive a car badly regardless of
whether it is a battered old Ford or a brand new Ferrari – and
neither will get him to his destination if he makes an error of
judgement leading to an accident on the way.

Competent physicians have many skills that underpin their
practice of medicine and fundamental to these is the ability to
take an accurate, comprehensive history (quickly) and perform
a competent and directed physical examination. This results
in an informed differential diagnosis which, in turn, dictates
the requesting of focused diagnostic tests in order to narrow
the differential diagnosis and guide the clinical management
plan. The reader might consider that this is blindingly obvious;
vi
but it is our experience that many medical students and junior E
C
doctors (and some more senior ones too) display poor clinical A
F
reasoning and decision-making skills and this results in their E
R
employing a ‘scatter-gun’ approach to diagnosis, suggesting or P
requesting multiple tests in the hope that the diagnosis will
‘turn up’ as a result. That is not good medicine. It exposes
patients to unnecessary procedures and may uncover minor,
irrelevant investigative abnormalities, which can result in
additional unnecessary tests and may obscure the primary
problem. The diagnostic art starts with excellent clinical skills.
Some new diagnostic techniques entail significant potential
risk to patients. The obvious example is the risk posed by
exposure to medical radiation as a result of the huge increase
in radiological imaging that has occurred in recent years.
Medical radiation is now the principal source of radiation
exposure in the populations of developed countries. Given the
wealth of increasingly complex technology now available to
doctors, and the accompanying potential risks to patients, we
believe that good reasoning and decision-making skills have
never been more important in clinical medicine.
This book focuses on clinical decision-making as it applies to
some major common presentations in acute medicine. Each
chapter aims to analyse a medical presentation in a systematic
way, and the reader is encouraged to apply logical thought at
various stages particularly with regard to investigation and
management.
This book is no t intended to be a complete reference text for
Acute Medicine. In particular, management is covered in
outline only and not in detail as many other texts address
management of acute medical problems. The topics covered
relate to major common presentations to emergency medical
services and not to specific diagnoses or physiological
parameters (such as ‘hypotension’). After all, patients do not
attend emergency departments stating their diagnosis or
complaining that they are hypotensive. To get the most out of
vii
E this book it will be necessary to have a degree of background
C
A knowledge of common medical conditions. Our intention is
F
E to aid the clinical reasoning skills of medical students and
R
P trainee doctors as they learn to make the transition from
clerking the patient to rationalizing differential diagnosis,
requesting sensible and focused investigations, and formu-
lating appropriate management plans.

viii
Acknowledgements
The authors wish to thank Dr Peter Kendall and Dr Lena Thin
for help in finding x-ray images for reproduction here.

ix