General Practice Cases at a Glance

Carol Cooper, Martin Block

• Publisher: Wiley-Blackwell
• Year: 2016
• ISBN:
  9781119043829
• Edition: 1
• Topic: Medicina
• Subtopic: Formazione medica

General Practice Cases at a Glance is a workbook of clinical scenarios, ideal for those working in general practice, on their GP rotations, or looking to improve their history-taking, diagnostic and management planning skills. Written by practising teaching GPs, it provides an accessible overview of the richness and complexity of general practice.

With 50 engaging consultations, covering all age ranges and a broad spread of clinical areas, each symptom-based chapter begins with the clinical presentation of a patient, before going on to uncover the full history and examination. As you work through each true-to-life case, there are red flag symptoms, useful charts and tables, and further resources to deepen your knowledge.

General Practice Cases at a Glance:

• Is suitable for clinical students, Foundation doctors, and those preparing for the MRCGP's CSA
• Includes 50 case scenarios from across the medical spectrum, from mental health and paediatrics to musculoskeletal and ENT medicine
• Is comprehensively illustrated
• Features current clinical guidelines, and charts and tables to accompany each case
• Is the companion volume to General Practice at a Glance, ISBN 978-0-470-65551-1, (Awarded First Prize in the Primary health care category at the 2013 BMA Medical Book Awards) but is also a stand-alone resource

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.

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Open and closed questions

Open questions are useful at the beginning of your history taking. They give the patient space to give you important information. You can also use them to ask about how the symptoms are affecting your patient’s life, what his mood is like and so on.

Closed questions are useful when you need to be clear about a specific detail. In general this is useful later in your history taking. For instance you might want to clarify a particular diagnosis (e.g. ‘Is it worse when you breathe in?’) or exclude a red flag (e.g. ‘Have you seen any blood in your stool?’).

Using mostly open questions, and then moving to a handful of appropriate closed questions helps GPs gain lots of information in a time-efficient way.

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Tip

When you are next sitting in with a GP look out for when he or she asks open and closed questions.

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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.

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?’...

Table of contents

• Cover
• Title page
• Copyright
• Preface
• Part 1 Introduction
• Part 2 Cases
• List of abbreviations
• Index of cases by speciality
• Index
• EULA