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Sexually transmitted infections

Introduction The following chapter covers the history, examination and investigation of the patient who presents with genital symptoms and outlines the common sexually transmitted infections (STI) and non-infective conditions encountered in the sexual health clinic. A fundamental principle in the treatment of the patient with genital symptoms is recognition of the stigma associated with the condition and the shame he may feel in presenting himself to…

Renal and urology system

Introduction Many patients with renal disease have few or non-specific symptoms, whereas disease within the urinary tract usually does have symptoms, many of which are reasonably specific for the disease processes involved. As the kidney and urinary tract are clearly and closely linked, this chapter combines kidney and urinary tract problems in a coherent whole. The diagnostic process in nephrology and urology The clinical syndromes associated…

Nervous system

Introduction In recent years impressive advances have been made throughout the field of neurology—in delineating disease entities and understanding their aetiology and pathogenesis; in diagnostic methods, particularly imaging and genetic testing; and in treatment and management. However, despite advances in investigations, careful clinical assessment remains of central importance. The fundamental importance of the clinical history and examination cannot be overemphasized. In the diagnosis of neurological disease,…

Locomotor system

Introduction Musculoskeletal symptoms are a major cause of pain and disability, accounting for a quarter of all general practitioner consultations in the United Kingdom (UK), with significant economic consequences. Common musculoskeletal conditions, such as back pain and osteoarthritis, are the dominant causes of chronic pain, disability and work loss in the UK and many other countries, consuming considerable health and social service resources. In addition, inflammatory…

Gastrointestinal system

General principles A key requirement of being a good doctor is the ability to make a robust diagnosis. Making a diagnosis requires identifying departure from normal and involves answering two key questions: 1. Where is the problem (i.e. the anatomical site)? 2. What is the problem (i.e. nature of disease)? A good history and a focused examination are the keys to making a diagnosis/differential diagnoses, and…

Cardiovascular system

Introduction Recent decades have seen major changes in patterns of cardiovascular disease. In the developed world, syphilitic and tuberculous involvement of the cardiovascular system has become rare, and the incidence of rheumatic disease has declined considerably. Myocardial and conducting tissue diseases are diagnosed with increasing frequency and the importance of arterial hypertension has become recognized. Coronary artery disease has emerged as the major cardiovascular disorder of…

Respiratory system

Introduction Diseases of the respiratory system account for up to a third of deaths in most countries and for a major proportion of visits to the doctor and time away from work or school. As with every aspect of diagnosis in medicine, the key to success is a clear and carefully recorded history; symptoms may be trivial or extremely distressing, but either may indicate serious and…

Patients in pain

Introduction Pain is a familiar phenomenon that is part of our everyday life and is a feature of various diseases. It most commonly accompanies an injury, where it serves its most important purpose, namely, to protect us, alert us and make us remove ourselves from danger. It can possibly trigger a spinal withdrawal reflex ( Fig. 11.1 ). Both congenital insensitivity to pain and extreme sensitivity…

Patients with a fever

Introduction Fever is one of the most common presenting features in the practice of any doctor who sees patients with acute illness. It is the hallmark of the body’s response to infection or inflammation. Before looking at the causes of fevers it is important to understand what we mean by that term and how the reaction to it is generated in the body. Fever is an…

Patients presenting as emergencies

Introduction A medical emergency requires swift recognition and prompt action. Recognition of urgency does not necessarily require a precise diagnosis; the fact that the patient is dangerously unwell is usually obvious owing to an abnormality revealed by the internationally recognized assessment system for critically ill people of Airway, Breathing, Circulation, Disability and Exposure of the patient (ABCD and E). When an abnormality is found it should…

Psychiatric assessment

Introduction Psychiatry is the ultimate clinical speciality. At one level, it is about one unique organ—the brain. Unlike other organs, our brains can argue, change jobs, vote and perform many other things. However, the practice of psychiatry is concerned with more than the brain, or even the mind; when the ways we think/feel/behave/interact go wrong, clinical psychiatry interrogates, formulates and treats. We rely on what people…

Older people

Introduction ‘In the end, it’s not the years in your life that count. It’s the life in your years.’ Abraham Lincoln At the turn of the twentieth century, there were 65000 people in the UK aged 85 or older. By 2050, it is projected there will be more than 3 million. Many people still associate old age with frailty, disability and loss of independence. The positive…

Children and adolescents

Introduction The skill of clinical examination is the true art of medicine and nowhere more so than in the examination of children. Children are not small adults and, as such, the approach to their examination differs. The examiner needs to be flexible, opportunistic and able to tailor the examination to the individual infant, child or young person. In order to maximize the success of the examination,…

Women

Introduction All medical history taking, examination, investigation and management plans are intensely personal matters for patients. In obstetric and gynaecological practice, intimate details must be elicited; this requires tact, discretion, consideration and the maintenance of proper confidentiality. Women may have particular expectations of their doctors and complying with these may not be easy. A gentle manner and a genuine interest in the patient help to develop…

Ethical considerations

Introduction The cornerstone of a good relationship between doctor and patient is trust. In primary care, this relationship (often in the context of caring for the whole family) may be built up over several years, but in hospital practice or in an emergency, the patient and the doctor may be meeting for the first time. Patients expect a high standard of behaviour and care when they…

The next steps: Differential diagnosis and initial management

Introduction The term ‘Differential Diagnosis’ used to be very widely used by doctors, but it now seems to be used less, and is less well understood. It might be better termed as ‘Differential Diagnoses’, because the process of preparing it is to formulate a list of possible diagnoses that cover the presenting clinical situation, usually written in the descending order of likelihood. It is a very…

General patient examination and differential diagnosis

Introduction The separation of the history from the examination is artificial because the latter starts with the first greeting and ends when the patient departs. Some physical findings may prompt further questioning; do not be concerned that your history taking was inadequate, but revisit these areas at the conclusion of the examination or during it. From the outset, the clinician is assimilating potentially relevant information from…

Doctor and patient: General principles of history taking

Introduction If asked why they entered medicine, most doctors would say that they wish to relieve human suffering and disease. To achieve this aim for every patient, it is essential to understand what has gone wrong with normal human physiology in that individual and how the patient’s personality, beliefs and environment are interacting with the disease process. History taking and clinical examination are initial, but crucial,…

Primary Disorders of Connective Tissue

Introduction Many primary connective tissue disorders alter the radiographic appearance of the skeleton and are referred to as skeletal dysplasias (see Chapter 49 ). A smaller number of disorders produce connective tissue laxity syndromes, such as the Ehlers–Danlos syndrome, in which the major impact is on the structure and function of soft tissues such as ligaments, tendons, vessels, and skin. Others are characterized by limitation of…

Pain Amplification Syndromes

Pediatric rheumatologists encounter children with a wide variety of musculoskeletal pains, including those with acute and chronic pain that appears disproportional or amplified, with a degree of pain subsequently suffered. In some cases, there is no clear trigger. Chronic musculoskeletal pain, regardless of its trigger, can bring persistent and recurrent distress, disability, and widespread family disruption. Early recognition, limiting investigations, and multidisciplinary rehabilitation optimizes both child…