CHI456 Lecture Notes I PDF

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CHI456 Differential DiagnosisLecture 1 Clinical Reasoning (Goodman Ch 1&2)Diagnosis The process of determining by examination the nature and circumstances of a diseased condition (medical) o The decision reached from such an examination A determining or analysis of the cause or nature of a p...

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CHI456 Differential Diagnosis Lecture 1 Clinical Reasoning (Goodman Ch 1&2) Diagnosis -

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The process of determining by examination the nature and circumstances of a diseased condition (medical) o The decision reached from such an examination A determining or analysis of the cause or nature of a problem or situation An answer or solution to a problematic situation

Origin -

Late 17th century: modern Latin, from Greek - Diagignoskein ‘distinguish or discern’ - Dia ‘apart’ gignoskein ‘recognise or know’ Oxford – Diagnose - Identify the nature of (an illness or other problem) by examination of the symptoms - Identify the nature of a medical condition

Holistic Approach to Management A whole-person diagnosis is based on two components: 1. The disease-centred diagnosis a. History, examination and special investigations, with the emphasis on making a diagnosis and treating the disease b. Does not focus significantly on the feelings of the person suffering from the disease

Why do we diagnose? - To identify/rule out life threatening conditions - To ascertain whether or not you are able to treat the Pt - To ensure that nothing that may affect the Pt’s wellbeing is overlooked - To recommend the most appropriate treatment for the Pt - To put the Pt’s mind at ease - To cover your own gluteal region!

A whole-person diagnosis 2. The patient-centred diagnosis a. Takes into account the diagnosed disease, its management and also psychosocial characteristics of the patient, including details about: i. The patient as a person ii. Emotional reactions to the illness iii. The family iv. The effect on relationships v. Work and leisure vi. Lifestyle vii. The environment

Big Picture History/Health Interview - PC (presenting complaint)/CC or MC - what are they presenting with? - HPI (History of PC- SOCRATES or OPQRSTU) o Medications/Allergies - PMHx (Past Medial History) - P&SHx (Personal and social History) - FHx (Family History) - RoS (Review of System) Create Differentials List - VINDICATE (also PROMPT, VITAMIN C) - What procedures will you include in your physical examination to either rule in or rule out your differentials? - Does the patient/client require immediate referral? History/Interview/Subjective Examination Provides the basis for and also directs the Physical Collect and interpret information about the Pt’s symptoms Examination (PE) - What is the main problem from their point of view? - How severe is the condition? - How may this influence their quality of life? - Should an exam even be performed? Example where o Activity limitations/participation restrictions - What do they expect from treatment, what beliefs you shouldn’t? Cervical fx - How irritable are they? do they hold, what are their preferences or goals? - Any precautions for PE or management - Patient rapport – 1st impressions count - Begin to generate hypothesis - Comparable signs (subjective & objective examination that differentiate b/w dx) Comparable Signs Medicolegal Guidelines for Examinations Those parts of both the Subjective Ex and Objective Ex that - Carefully explain the nature and purpose of the provide diagnostic information physical examination before you start - They are what helps differentiate this presentation - Indicate when an examination may be uncomfortable from others and directs your diagnoses and ask the patient to advise if you are causing pain - Those signs and/or symptoms that can be placed on - If a patient is required to disrobe, explain to what a problem list to, extent undressing is required and why o Help you formulate diagnosis, prognosis and - A patient’s modesty should be preserved when

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goals You are likely to compare or reassess them at a later stage to detect changes following your management

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undressing and dressing before and after a PE If the patient requests the presence of a chaperone or a friend, this should be respected The setting should allow the patient confidence to terminate the consultation at any time if he or she is uncomfortable

Physical Examination (Objective Examination) - Perform those tests and procedures necessary to challenge the differentials list - Mostly a structured approach o Though can add or remove procedures depending on the presentation - Identify source of pain – what hurts, where? - Identify functional impairments – why does it hurt? o Determine if disorder is mechanical in nature - Identify consistent patterns of movement that provoke symptoms or correlate with functional limitations - Identify clinical signs that correlate with symptoms o Motion palpation, neural tension tests, muscle palpation - Identify and note comparable signs for reassessment - Exclude red flags or determine presence of contraindications or precautions - Aim to correlate SE, OE and imaging findings Working Diagnosis - Problem List Management Plan - Goals - Intervention/Modalities - Frequency of care - Risks Discharge Plan Diagnosis Differential Diagnosis Diagnosis is based on probability!! - Determination of which one of two or more diseases - Symptom X = 15 conditions with similar symptoms is the one from which the - Symptom X and Y = 7 conditions patient is suffering. Also called differentiation. - Symptom X, Y and Z = 3 conditions - A list of the most probable causes of the person’s Example presenting complaint - Dizziness = motion sickness, tumour, raised - How many diagnoses are appropriate? intracranial pressure, cervical biomechanical lesion, - You should be able to justify each diagnosis that you Meniere’s Disease, Benign Positional Vertigo, have in your differential list Labrynthitis, Vestibular Neuritis, Migraine, TIA, Anxiety - You should have a suitable list of differential diagnoses - Dizziness and vomiting = motion sickness, tumour, from the patient history raised intracranial pressure, cervical biomechanical - The examination is guided by this list lesion, Meniere’s Disease, Benign Positional Vertigo, Labrynthitis, Vestibular Neuritis, Migraine, TIA, Anxiety - Dizziness, vomiting and tinnitus = motion sickness, tumour, raised intracranial pressure, cervical biomechanical lesion, Meniere’s Disease, Migraine General Approach to Diagnosis John Murtagh suggests that the practitioner should ask themselves 5 questions 1. What is the probability diagnosis? 2. What serious disorders must not be missed? 3. Could this patient have one of the masquerades in medical practice? 4. What conditions are often missed (pitfalls)? 5. Is the patient trying to tell me something else? P – Probability R – Red flag O – Often missed M – Masquerades P – Patient wants to T – Tell me something The probability diagnosis is based on - Practitioner’s experience - Epidemiological information - It is more common to see a rare presentation of a common disease than it is to see a rare disease! The serious disorders not to be missed M2I2

- Malignancies - Metabolic - Infarction - Infections Diagnosis – Common Masquerades - Depression - Diabetes Mellitus - Drugs o Iatrogenic o Self-abuse  Alcohol  Narcotics  Nicotine - Anaemia - Thyroid and other endocrine disorders - Spinal Dysfunction - Urinary tract infection (present in elderly person differently e.g. fatigue) - Malignancies

Mnemonics VINDICATE - Vascular - Infectious/Inflammatory - Neoplastic - Degenerative - Idiopathic/iatrogenic - Congenital - Autoimmune/Allergic - Trauma - Endocrine & metabolic VITAMIN C - Vascular - Infectious - Trauma - Autoimmune - Metabolic - Idiopathic/iatrogenic - Neoplastic - Congenital

Musculoskeletal Diagnosis Acute Trauma - Rule out o Fracture (including complications) o Dislocation o Gross instability Non-Traumatic Pain - Rule out o Tumours o Inflammatory arthritis o Infections o Visceral referral When assessing the musculoskeletal system, you have to have an excellent knowledge of: 1. Anatomy 2. Biomechanics 3. Normal ranges 4. Rehabilitation 5. Properties of tissues i.e. the healing rates 6. Epidemiology

Two main errors: A. Thinking all joints are distinctly different a. This leads to over-specialisation b. The practitioner may be unwilling to investigate fully B. Thinking that joints operate independently of each other a. This leads to possible exclusion of relevant information (kinematic chain) b. Knee pains are often caused by knee, hip or foot problems When assessing the musculoskeletal system, you have to think about the following: 1. Bone 2. Soft tissue a. Muscle b. Tendon c. Ligament d. Bursa e. Fascia f. Nerve 3. Joint

When taking a history for a musculoskeletal complaint you need to know - Mode of onset - Type of complaint o Pain, numbness, stiffness etc. - Locality - Mechanism of injury o Traumatic – fall, impact etc. o Non-traumatic – overuse o Insidious - Factors that affect the complaint o Aggravating/relieving factors o Time of day/night - Past history or diagnosis of complaint - Any symptoms that might be related - The rest of the Pt’s Hx especially PMHx, P&SHx, and FHx If you have taken a good history the correct/working diagnosis will usually be in your list of DDx The examination of your patient will be guided by your DDx - Your working diagnosis is the most probable one based on the information that you have acquired Management General Diagnostic Tips This is a very widely debated topic - A formal process for diagnosis is necessary - How much is too much? - The process needs to be both efficient and flexible - What is the best technique? o For a process to be efficient and flexible it - When should I refer? needs to incorporate several patterns of - Are they a pain or prevention patient? diagnostic thinking: - What goals should I set?  Hypothetico-deductive (backward - What measurements are best at determining a reasoning)  Model and pattern recognition change? (forward reasoning) - Is the change from your treatment better than the natural history?  Small worlds hypothesis - When should I re-evaluate?  The Guess Who game Basic template: - Acute care/pain management - Correct the problem that causes the pain/injury - Prevention of re-injury and minimisation of further injury Need to consider frequency - References for each section will include guidelines There are many guidelines that have been formulated by governments, associations, research etc. - You will develop your own management strategy through research and experience Tips to Assist in Making a Diagnosis - Take a closer look if the signs and symptoms don’t make sense! - It all depends on your perspective - What do you see? - Know what the normal is and the abnormal stands out - Know your limits; but never stop trying to exceed them! - Learn from your mistakes - When the answer is not clear, follow the rules - Sometimes things are beyond our understanding

Visceral Pain

Systemic vs. Musculoskeletal Pain Patterns Systemic Pain Onset - Recent, sudden - Does not present as observed for years without progression of symptoms

Description

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Intensity

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Duration

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Knife-like quality of stabbing from the inside out, boring, deep aching Cutting, gnawing Throbbing Bone pain Unilateral or bilateral Related to degree of noxious stimuli; usually unrelated to presence of anxiety Mild to severe Dull to severe Constant, no change, awakens the person at night

Musculoskeletal Pain May be sudden or gradual, depending on hx - Sudden: usually associated with acute overload stress, traumatic event, repetitive motion; can occur as a side effect of some medications (e.g. statins) - Gradual: secondary to chronic overload of the affected part; may be present off and on for years - Usually unilateral (except LBP radiating) - May be stiff after prolonged rest, but pain level decreases - Achy, cramping pain - Local tenderness to pressure is present -

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Pattern

Aggravating Factors

Relieving Factors

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Although constant, may come in waves Gradually progressive, cyclical Night pain Location: chest/shoulder Accompanied by SOB, wheezing Eating alters symptoms Sitting up relieves symptoms (decreases venous return to heart; possible pulmonary or CVS cause) - Symptoms unrelieved by rest or change in position - Migratory arthralgias: Pain/symptoms last for 1 week in one joint, then resolve and appear in another joint - Cannot alter, provoke, alleviate, eliminate, aggravate the symptoms Organ dependent (examples): - Oesophagus, eating or swallowing affects symptoms - Heat, cold, exertion, stress, heavy meal (esp. when combined) bring on symptoms - GI – peristalsis (eating) affects symptoms Organ dependent (examples): - Gallbladder, leaning forward may reduce

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May be mild to severe May depend on person’s anxiety level, the level of pain may increase in a client fearful of a “serious” condition Duration can be modified by rest or change in position May be constant but it more likely to be intermittent depending on the activity or position Restriction of active/passive/accessory movement(s) observed One or more particular movements “catch” the client and aggravate the pain

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Affected by movement: pain may become worse with movement or some myalgia decreases with movement

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Symptoms reduced or relived by rest or change in position

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Assoc. Signs & Symptoms Remote Pain

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symptoms Kidney, leaning to affected side may reduce symptoms Pancreas, sitting upright or leaning forward may reduce symptoms Variety of S&S

Medications - Many unusual signs and symptoms are adverse effects of medications and/or drug combinations - When appropriate, compile a list of medications currently being taken by the patient and consult with a pharmacist regarding possible side effects - Compare current symptoms with side effects - Report any suspicious clinical presentation to the physician During the Interview Watch for red flags of systemic illnesses: - Gradual onset with no known cause - Gradual, progressive, cyclical onset - Constant - Intense - Symptoms unrelieved by rest or change in position - Bilateral - Constitutional symptoms Constitutional Symptoms - Fever - Night sweats/Diaphoresis - Fatigue/weakness - Weight changes (specifically loss) - Dizziness/syncope - Pallor Screening in 3 to 5 Minutes The idea behind screening is to know what to look for so that when it appears in the clinical presentation (or when the patient reports certain red flag histories, risk factors, or symptoms) you will recognize it immediately and respond appropriately. The screening process: - Take vital signs - Review the pain body chart - Review medications and their potential side effects

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Muscle pain is relieved by short periods of rest without resulting stiffness, except in case of fibromyalgia; stiffness may be present in older adults Stretching Heat, cold Usually none, although stimulation of trigger points may cause sweating, nausea, blanching

Remember Screening for referral is based on - Presenting signs and symptoms → What you asked about - Clinical features → What you observed and identified - PMH → What they told you

Bilateral Symptoms - Pigmentation changes - Oedema - Rash - Clubbing/nail bed changes - Weakness - Numbness/tingling - Burning Other Associated S&Sx - Headache - Visual changes - Changes in bowel/bladder habit - Unusual vital signs - Warning signs of cancer - Dyspnea - Orthostatic hypotension Vital Signs If you only have time for one thing - Take the vital signs...they are called vital for a reason! Red Flag Vital Signs - Always take temperature with back pain of unknown cause - Always take BP when problem is o Neck o Upper quadrant o Thoracic outlet syndrome (TOS) Correlate unusual vital signs with other signs and symptoms

against current signs and symptoms Watch for red flags, risk factors, and associated signs and symptoms - Always ask a broad, open-ended question Blood Pressure -

Palpitations: Referral Required - Lasting for hours; - More than six episodes per minute - Accompanied by SOB, chest pain, dizziness, lightheadedness - Family history of sudden cardiac death - Personal history of heart disease

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Pallor Perspiration Fatigue Palpitations Normal variation (systolic, side to side) o Arms: male) o Beware the deconditioned, menopausal female with CHD o Requires careful monitoring - Remember orthostatic hypotension o Check pressure lying to sitting or o Sitting to standing Other Causes of Palpitations - Overactive thyroid - Caffeine (sensitivity), nicotine, alcohol - Side effects of some meds - Anxiety - Menopause (Decreased estrogen)

Lecture 2 – Head, Face & Neck Pain (Goodman Ch 14) Head, Face & Neck Pain- Common Red Flags - Severe trauma - Direct head trauma with loss of consciousness - Nuchal rigidity - Associated dysphasia - Associated cranial nerves or CNS S&S - Associated bladder dysfunction (cervical myelopathy) - Constitutional symptoms - Pre-existing conditions: cancer, RA, drug abuse - Failure to improve with conservative care (4-6 weeks duration) Concussion Acute - LOC - Light-headedness, headache - Vertigo/dizziness - Delayed motor/verbal responses - Memory or cognitive dysfunction - Balance/coordination problems - Concentration difficulties - Blurred vision/photophobia - Tinnitus - Nausea/vomiting - Slurred or incoherent speech

Systemic vs. Mechanical Pain Systemic - Awakens at night - Deep aching, throbbing - Reduced by pressure - Constant or waves/spasm - Cyclical, progressive symptoms

Mechanical - Sharp -  with rest -  by change in position -  when stressful action is stopped -  of A/PROM -  accessory motions

Late (Delayed) - Persistent low-grade headache - Easy fatigable - Sleep irregularities - Inability to perform ADLs - Depression/anxiety - Lethargy - Memory dysfunction - Light-headedness - Personality changes - Low frustration tolerance/irritability - Intolerance to bright lights and/or loud sounds

Facial Pain Probable Dx

Pitfalls: consider these if patient not responding and serious

conditions have already been ruled out: - Dental pain - TMJ dysfunction - Maxillary sinusitis - Migraine - Cranial nerve neuralgias - Trigeminal, glossopharyngeal & occipital - Eye disorders e.g. glaucoma - Trigger points - Chronic dental problems Serious disorders – rule these out! (M2I2) - Parotid gland - Cardiovascular referral - Malignancy/Metastases - Metabolic - Infections Dental Disorders Management Dental Caries Presentation - Refer to dentist - Pain usually aggravated by - Pain will not cross the midline - Usually specific to tooth Sinusitis Acute - Facial pain and tenderness over sinuses - Headache/Toothache - Nasal/Postnasal discharge - Cough be worse at night - Prolonged fever Chronic - Vague facial pain - Nasal obstruction - Toothache - Halitosis - Malaise Management - Sinus drainage techniques (massage, nasal bidet) - Over the counter medication - Referral to GP o FESS (functional endoscopic sinus surgery) for chronic sinusitis Trigeminal Neuralgia Presentation Examination - Middle aged or older patient - Some patients may limit their examination for fear of stimulating these points - Characteristically a severe, paroxysmal, and - Neurological examination findings are normal lancinating pain - Facial sensation, masseter bulk and strength, and o Crescendos in less than 20 seconds to an corneal reflexes should be intact excruciating discomfort felt deep in the o No sensory loss is found unless checked face, often contorting the patient's immediately after a burst of pain; any expression - Starts with a sensation of electrical shocks in the permanent area of numbness excludes the diagnosis affected area Management - A typical attack may consist of 2 to 3 stabbing pains over a min - Referral to GP for management - Episodes may become more frequent with time with - Medical therapy is often sufficient and effective spontaneous remission for weeks or months - Percutaneous procedures, sur...