The 10-Minute Clinical Assessment

Knut Schroeder

• Publisher: Wiley-Blackwell
• Year: 2016
• Print ISBN:
  9781119106340
• eBook ISBN:
  9781119106357
• Edition: 2
• Topic: Medicine
• Subtopic: Clinical Medicine

THE 10-MINUTE CLINICAL ASSESSMENT

Clinical assessment is at the heart of medicine. Health professionals working in busy clinical settings, such as general practitioners, nurse practitioners and hospital doctors on-call, often have to assess patients under considerable time constraints. This book teaches the reader how to gather clinical information effectively, accurately and safely even when time is at a premium. Using a focused and evidence-based approach, it provides step-by-step assessment strategies for common and important clinical scenarios, particularly those that require 'lateral'and holistic thinking, such as falls in the elderly, weight loss, 'tired all the time'and assessment of diabetic or homeless people.

This second edition of The 10-Minute Clinical Assessment is fully updated in line with the latest guidelines and includes brand new general chapters on focused clinical assessment, red flags, and useful consultation tools. It covers a wide range of common and important topics, including cardiovascular, respiratory, haematology, musculoskeletal, neurology, mental health, gynaecology, obstetrics, urology, ophthalmology and ear, nose and throat. This new edition also includes sectionson undifferentiated and miscellaneous presentations, on paediatrics and adolescent health; and on problems in older people. Each of the individual disease sections is uniformly structured to provide rapid reference, including:

• Key features of the history, including questions relevant to patientsand important for making a diagnosis
• Common patient ideas, concerns and expectations
• The 'value' of present or absent symptoms for diagnosis and prognosis
• What should be examined, and why
• A summary of 'red flags' – issues that must be assessed
• Important differential diagnoses and their clinical features
• Useful tips, tricks and hints for effective patient assessment

Written by an experienced medical educator and practicing GP, in consultation with a multidisciplinary team of medical students, GPs, PG trainees, hospital doctors and nurses, this title specifically covers the clinical skills assessment (CSA) part of the Membership of the Royal College of General Practitioners (RCGP) examination.

New to this edition is a refreshed approach to the methodology employed inclinical assessment, to reflect recent trends in the teaching of clinical assessment. This edition also includes the latest evidence-based recommendations (including the latest NICE guidelines) and recent developments in order to provide the reader with a concise yet comprehensive resource for clinical reference.

Paediatrics and adolescent health

The sick and/or feverish child

Key thoughts

Practical points

• Diagnosis. Feverish illness is commonly caused by acute viral infections. It is important not to miss serious conditions, such as meningococcal septicaemia or pneumonia, as symptoms and signs may be nonspecific in the early stages. Sick children can be worrying for both parents and health professionals.
• Severity. Assess and record temperature, conscious level, respiration rate, heart rate, capillary refill time and the state of hydration in every child that is unwell.
• Management. Thorough assessment will help decide whether a child needs to be admitted to hospital or if they can safely be managed in the community.

Possible causes

• Infection. Nonspecific viral illness, acute upper respiratory tract infection, gastroenteritis, otitis media, pneumonia, urinary tract infection or, rarely, meningitis, meningococcal septicaemia, septic arthritis or Kawasaki disease.
• Toxic. Accidental poisoning.
• Allergy. Food allergies (e.g. nuts), insect bites.
• Trauma. Accidental general trauma, head injury, non-accidental injury and child abuse.
• Metabolic (rare). Diabetic ketoacidosis, hypoglycaemia or an exacerbation of an inborn error of metabolism.
• Shock (rare). Septicaemia, hypovolaemia.

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RED FLAGS

• Reduced level of alertness
• High fever unresponsive to antipyretic medication and lasting for longer than 5 days
• Petechial or purpuric rash
• Severe diarrhoea and vomiting
• Dehydration
• Increased capillary refill time >3 seconds
• Neck stiffness
• Bulging fontanelle
• Pale, mottled or ashen skin
• Blue lips or tongue
• Tachypnoea with chest indrawing
• Focal neurological signs

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History

Ideas, concerns and expectations

• Ideas. What do the parents/guardian believe to be the cause of the underlying illness?
• Concerns. Worries about meningitis and meningococcal septicaemia are common.
• Expectations. Parents may want to be reassured that there is no underlying serious illness. They may also expect a prescription for antibiotics, further investigation or hospital admission.

History of presenting complaint

• Context. Ask open questions and listen attentively to the child (if possible) and to what the parents have to say about their child's illness: they are the experts on their child, and may give important clues about possible underlying diagnoses.
• Age. Children under 3 months are at higher risk of serious bacterial infection.
• Main symptoms. In most cases, symptoms will point to a specific source of infection (e.g. cough, ear ache, sore throat, joint pains, urinary symptoms) or another cause of illness. Has there been any change in symptoms? Have new symptoms emerged? Urinary tract infections often present in a nonspecific way in young children. Poor feeding, lethargy, irritability, abdominal pain, urinary symptoms and offensive or bloodstained urine all point towards urinary tract infection.
• Alertness. Has the child been alert and responsive? Lethargy and drowsiness may indicate serious illness requiring hospital admission. If a child is semi- or unconscious, move straight on to assessing airway, breathing and circulation (ABC). A child that still plays and interacts with the environment is unlikely to be seriously ill.
• Breathing. Respiratory distress is likely if the child finds it hard to breathe due to chest infection or another cause. If the onset of shortness of breath is sudden and there is no fever or other pointer to infection, consider foreign-body aspiration. Stridor occurs in upper airway obstruction, which may occasionally be caused by laryngo-tracheobronchitis, croup, foreign body or acute epiglottitis (rare).
• Fever. Fever indicates infection, such as acute viral illness, gastroenteritis, otitis media, pneumonia, appendicitis, urinary tract infection or, rarely, meningitis, septic arthritis or epiglottitis. Any prolonged fever lasting for more than 5 days will usually require more detailed assessment and investigation and indicates an intermediate risk of serious infection. Has anything been tried to bring the fever down? Did the parents give antipyretics in adequate doses?
• Rash. Any non-blanching rash should raise suspicions of meningococcal septicaemia, particularly if the child is ill, if individual lesions are >2 mm in diameter, if the...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Foreword
• Preface to 1st edition
• Preface to 2nd edition
• About the author
• Acknowledgements
• Selected useful resources
• The focused consultation
• Undifferentiated and miscellaneous presentations
• Paediatrics and adolescent health
• Cardiovascular
• Respiratory
• Endocrine and metabolic
• Gastrointestinal
• Infectious diseases
• Haematology
• Musculoskeletal
• Neurology
• Gynaecology
• Obstetrics
• Urology and renal medicine
• Mental health
• Skin
• Ophthalmology
• Ear, nose and throat
• Problems in older people
• Index
• Eula