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…
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…
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…
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…
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…
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…
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,…
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…
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…
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…
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…
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,…
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…
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…
Many nonrheumatic systemic disorders cause musculoskeletal signs or symptoms, most commonly arthralgia, arthritis, myalgia, or bone pain. They can mimic rheumatic diseases, and it is therefore important to be aware of these conditions to avoid delay in the correct diagnosis. This chapter outlines some systemic disorders that may present in the guise of a rheumatic disease, and we aim to highlight features to suggest the conditions.…
Definition and Classification Inflammatory bowel disease (IBD) denotes a group of related and heterogeneous disorders characterized by chronic intestinal inflammation and generally classified into Crohn disease (CD) and ulcerative colitis (UC). When there are features of both UC and CD, as can occur in the setting of predominantly colonic IBD, the term IBD-unclassified (IBD-U) is applied. Some children initially considered to have IBD-U will over time…
Musculoskeletal pain of noninflammatory origin is common in childhood and is a frequent cause of referral to pediatric rheumatologists, orthopedic surgeons, sports medicine specialists, and primary care physicians. Noninflammatory causes of pain are more common than inflammatory ones, and early identification and differentiation from other causes of musculoskeletal pain, such as infection or malignancy, are essential to the institution of appropriate therapy and avoidance of inappropriate…
Introduction Skeletal dysplasias are disorders characterized by developmental abnormalities of the skeleton. They form a large heterogeneous group and range in severity from precocious osteoarthropathy to perinatal lethality. , Disproportionate short stature is the most frequent clinical complication but is not uniformly present. There are more than 400 recognized forms of skeletal dysplasia, which can make determining a specific diagnosis difficult. This process is further complicated…
Normal Skeletal Composition The complex structure and composition of bone is directly related to the two primary functions of the skeleton: to support the tissues of the body in order to permit locomotion and to provide a reservoir of ions critical to metabolic functions. , Bone is composed of 70% mineral and 30% organic constituents. Hydroxyapatite, consisting primarily of calcium and phosphorus, accounts for 95% of…
Introduction One of the challenges of pediatric rheumatology is the broad spectrum of conditions ranging from the benign to the potentially life-limiting childhood malignancies that may present with relatively nonspecific musculoskeletal symptoms and signs. The importance of careful history taking, thorough physical examination, and appropriate use of investigations to arrive at the correct diagnosis cannot be over emphasized. When assessing a child with an arthritis or…