It’s all in the history

 

80% of diagnoses are made from the history. Every medical student is told this at some point. House mentions it a few times…

The history is the mainstay of your diagnostic process. Nobody knows your patient like the patient himself, where it hurst, whether it’s normal for him – ask! By the end of the history you should have an idea of the two or three things that it’s most likely to be.

You should only examine once you know what you’re looking for, to confirm the findings that you anticipate from the history. Equally you should only conduct further tests to confirm what you think you’ve found.

 

You come first

I have received a lot of good advice from a variety of people within the world of medicine, so I thought I’d post it here so it doesn’t get forgotten, and maybe it will help someone else too!

1. Look after yourself, then you can look after others

You’re a human, I hate to break it to you, but you’re not perfect. Tired, disheartened doctors make mistakes and aren’t going to give the best care that they can. Eat right, sleep well, do things that make you happy. This will make you the best doctor you can be. 

 

Headache differential

“Doctor I have a headache – am I going to die?”


“Well… eventually…”

As a doctor you have to try and give useful answers to fairly important questions, like, better than this.

 

Differential diagnoses are one of the most useful tools when it comes to diagnosing symptoms and it’s important to ensure you’ve thought of as many of the potential causes as possible. Here’s a weird way to remember the key causes of a headache in an emergency situation.

Typical Day in A&E

You are on duty in the emergency department and you’re feeling incredibly tense, as someone has just fired off a cluster grenade somewhere in the hospital. You’ve just been called in to see a patient who has a very bad headache, who says he has a history of migraines


As you enter the room, you notice he’s holding a cricket bat and smoking a huge joint. Next to him a washing machine is spinning out of control, pouring smoke all over the room.


You notice a weird tingling stiffness in your neck, when suddenly his head catches fire.


The man stands up and says “To Be Honest mate I’m just gonna go home”, but his head begins to expand and he starts grinding his jaw


You don’t see what happens next because you go blind and pass out.

  • Tension headache
  • Cluster headache
  • Migraine
  • Subarachnoid (feels like being hit with a bat)
  • Drugs
  • CO poisoning 
  • Meningitis
  • Encephalitis
  • TBH – Tumour, TB, Haematoma
  • Temporal arteritis
  • Glaucoma

Step 1: Take a history


RED FLAGS:

  • First and worst headache ever
  • Sudden onset and really bad
  • Unilateral with eye pain
  • Worse on coughing
  • Scalp tenderness
  • Decrease in GCS

– Any trauma?

– Any neck pain?

– Any fever?

– Any loss of consciousness?

– Any decrease in consciousness?

– Any warning signs?

– Any fitting/biting of tongue?

– Any other medical conditions?

– Any changes in vision?

– Any drugs?

– Sudden or gradual onset?

– How severe?

Two crucial questions:

– “Have you been away?”

– “Could you be pregnant?”

Step 2: Do a neuro exam

Step 3: Look in their eyes

Step 4: Get thinking

DDx:

No signs on examination:

Tension headache

– Migraine

– Cluster

– Post-trauma

– Drugs – particularly nitrates and calcium channel blockers

– CO poisoning


Signs of meningism:

– Meningitis

– Subarachnoid haemorrhage


Decreased consciousness:

– Encephalitis

– Meningitis

– Stroke

– Cerebral abscess

– Subarachnoid haemorrage

– Tumour

– Haematoma

– TB meningitis


Papilloedema:

– Tumour

– Malignant hypertension

– Benign intracranial hypertension

– CNS infection of >2weeks


Painful jaw/temple:

– Temporal arteritis


Changes in vision:

– Glaucoma


Other:

– Paget’s disease

– Sinusitis

– Altitude sickness

– Cervical spondylosis

– Venous sinus occlusion

– Vertebral artery dissection

All of the above information is from the Oxford Handbook of Clinical Medicine 7th Edition

How to examine the hands

OSCEs are interesting beasts. They’re designed to measure one’s clinical prowess, although end up being a very artificial process that requires specific attention to learn, rather than just clinical experience. As a result, examinations in particular end up becoming a rehearsed routine that can be rattled off under intense pressure, without much actual thought as to what one is looking for in the first place. What I’ve tried to do here is write the ‘script’ but also give an idea of what to be thinking along the way, to help answer examiner questions and also to help be an actual doctor (which I’m hoping is the ultimate goal). Of course everyone will have their own style, and this is simply my own, but hopefully it might provide a useful framework. In particular I find it much easier to demonstrate movements rather than trying to describe them, and it helps build rapport between you and the patient if they’re playing a game of copying you #psychologywin.

The Dance

Introduction

*Student enters cubicle, washes hands and smiles*

“Good morning, my name is Will Sloper, I’m one of the fourth year medical students, I’ve been asked to do a quick examination of your hands, would that be alright?”

*Patient says yes*

“Thank you, may I ask your name? And how old are you if you don’t mind me asking”

(please could I ask you to roll up your sleeves?/remove your jumper?/put the cat down?)

“Before I begin, are you in any pain at the moment?”

*Patient says no/a little/yes my hand hurts*

“Great/Okay well I’ll be quick and do my best not to cause you any (more) pain. Is there anywhere that’s really sore to touch?”

*patient points at specific point*

“Alright, I’ll avoid that finger/bruise/bleeding open fracture as much as I can”

*Student offers cushion to patient. Patient places hands palms down on cushion on lap or table*

LOOK

“Firstly I’ll have a look at your wrists…”

*Student looks intently at wrists*

“…your hands…”

*ditto*

“…your fingers, and nails.”

*Student dwells on nails slightly to ensure examiner knows they have been thoroughly inspected*

“Lovely, please could you turn your hands over?”

*smiles*

*Patient turns hands over, while student watches patient’s face*

“Was there any pain while turning your hands over?”

*no*

“I’ll have a quick look at your palms…”

*Student looks intently at palms*

“…and wrists…”

*again*



FEEL

Now if it’s alright I’ll feel your wrists and palms”

*Student feels pulses, then the thenar and hypothenar eminences and then the palm*

“Lovely, thank you, can you please close your eyes for a moment and say ‘yes’ if you can feel me touch your hand?”

*Student lightly touches both eminences and index and little finger tips*

*yes, yes, yes, yes…*


“Does this make your fingers tingle?”

*Student lightly taps skin over carpal tunnel*

*no*

“Great, put your palms down again please and I’ll do the same on the back”

*Patient turns hands over, student watches face again*

“Close your eyes again and say yes if you can feel this”

*Student lightly touches first dorsal interosseous*

*yes*

“Thank you”

*Student places backs of hands on forearm for 2 seconds, wrist, then over the mcp joints*

“Let me know if this is at all tender” (if patient has identified tender area, address the fact that you do have to touch it, but will be as careful as possible)

*Student lightly squeezes the mcp joints while watching the patient’s face*


“I’ll now have a quick feel of each joint in turn”

*Student bimanually palpates each joint in turn, comparing each group with the other hand, and watching the patient’s face the whole time*

“Thank you, I’ll just do the same on your wrists”

*Student bimanually palpates wrists, guess what, while watching the patient’s face*

“Lovely, now I will just feel your forearms”

*Student runs hand up ulnar aspect of forearm while holding wrist with other hand*

MOVE

“Right, we’re almost there!” *smiles*

“Lastly I need you to do some movements for me if that’s alright, could I ask you to straighten your fingers as much as you can”

*Student then passively extends patient’s fingers gently, while watching the patient’s face*

“Thank you, next can you make a fist for me?”

*Student passively flexes patient’s fingers gently, again… FACE*

“Now could you do this?” *Student extends own wrists and places them together in prayer position in friendly and personable style*

*Patient copies student, #facialsurveillance*

“And now this?” *Student flexes own wrists and places together in equally nonthreatening manner*

*Patient copies student, #facialsurveillance*

Squeeze my fingers as hard as you can?”

“Finally could you spread your fingers as far as you can, and then do this?…”

*Student opposes thumb to each finger in turn, and patient does the same*

“…and could you pick this up for me with your index finger and thumb?”

*Student produces coin/magic bean/small rodent*


Conclusion


“Well thank you very much, I’ve finished my examination, do you have any questions for me?”

*Patient says no*


“Thanks again”

*Student smiles, washes hands and turns to examiner*



Presentation

“I performed an examination of the hands and wrists on Mrs Phalange who reported tenderness in her left wrist and upon inspection, noted the presence of a longitudinal scar/slight bruise on the dorsum of the right hand. The rest of the examination was normal, with sensation of the median, ulnar and radial nerves intact and good movement and function of all joints”

(Obviously this bit is going to vary hugely – practice making up a bunch of different presentations and you might find that in the exam, you can adapt one you’ve already made to fit your current patient)

“To complete my examination, I would like to:

  • take a full history
  • do a regional musculoskeletal exam of the elbow
  • do a neurological and peripheral vascular exam of the upper limbs

Why do the exam?

The main purpose of the hand exam is to elicit whether the patient has any:

  • pain
  • stiffness
  • reduction of function
  • evidence of previous disease/surgery

And as with all musculoskeletal examinations, it’s a good idea to follow a structure of:

  • look
  • listen
  • feel
  • move

And always, always, always…

  • ask about pain
  • compare the two sides

The things to look out for in the hand exam are as follows:

  • Looking
    • swelling
    • muscle wasting
    • deformity
    • skin changes
      • bruising
      • thinning
      • rashes
    • scars
    • nail changes
      • onycholysis
      • pitting
      • vasculitis of nail folds
  • Feeling
    • pulses
      • vascular impairment?
    • muscle wasting
      • may suggest nervous injury or carpal tunnel syndrome
    • tendon thickening
    • sensation
      • carpal tunnel, peripheral neuropathy
    • temperature
      • inflammation is hot
      • Raynaud’s is cold
    • nodules
      • Heberden’s nodes in osteoarthritis
      • gouty tophi
      • rheumatoid nodules
    • squeezing
      • tenderness is early sign of inflammation
    • joint palpation
      • warm, rubbery swollen joints are suggestive of active synovitis
    • Tinel’s test
      • special test for carpal tunnel syndrome
    • Phalen’s test
      • same idea
  • Moving
    • failure of movement could be:
      • muscular
      • neurological
      • tendinous
      • articular
    • Passive extension may help determine which
    • Picking up a coin/small rodent gives an idea of function

Write lists

 

I’ve always been moderately proficient at managing several concomitant tasks, but when I reached my limit, I would suddenly slam into a wall of stubborn hopelessness, liberally marinaded in doubt and despair. So I started writing things down, on paper, on my phone, anywhere that I could see the thoughts in front of me. Usually the list would be a lot shorter than it felt in my head, and immediately much more manageable. I would write down how I would tackle each thing, and when, and the weight would gradually start to lift from my shoulders. Checklists are great when you get to tick the items off at the end of the day, but lists of abstract things were also therapeutic. Just writing down ‘I am pissed off at […] because they […]’ felt like my grievances were being recognised, and I didn’t need to worry about them anymore because they’d been accepted. Every so often I would look back up my list and see that the scribblings of yesterday, or even this morning, seemed flippant and often plain irrelevant. I had moved on, and because of the list, I could see that I had, and these troubles could be lost to the ether. It works pretty well.

This blog is the latest list-based self-therapy to have a positive influence on my life. I mentioned at the beginning that I’ve found my concentration waning as this indolent self-doubt wormed its way around my head, yet for the first time in years I have sat down at a computer for over an hour and a half and persistently worked on something without even looking up from the screen. I’ve needed the toilet for the past half an hour at least and I’m painfully hungry, but no way am I breaking this chain of thought…

Predict your way happy

To be honest I thought I was pretty tragic when I started doing this, but after a while it made complete sense and my only regret is that I didn’t start doing it sooner. It runs in the same vein as the money=success section previously, but is much more versatile and applies to all aspects of life. It’s also a great boredom-killer on the tube…

How it works : by ‘predicting’ something bad, you’re pleasantly surprised when it goes well.

What it’s not : Giving up on life and assuming everything is going to be shit.

What it is : squeezing enjoyment out of everyday things for free!

Here’s how it works: At any time of day, whatever I’m doing, wherever I am, I think to myself about my current situation. I then think to myself that a specific negative thing is going to happen, and then see if my prediction was right. For example: While waiting for a bus or a train, I’ll say something to myself such as, “I bet the train’s going to be late“.

Scenario 1: The train is on time – I’m pleasantly surprised and my day just got a bit better


Scenario 2: The train is late – I’m right (arguably more important)


The idea is to be as specific as possible, for events that are out of your control. If the event is too vague, such as ‘I’m going to have a shitty day today‘ then you’ll probably spend a large amount of time being sad before you get your ‘I was right’ moment, by which time the novelty has probably worn off. The reason it needs to be out of your control is because then you cannot blame yourself for the outcome. If you say ‘I’m going to screw this up‘ and you do, you end up in a very negative cycle of self-deprecation. If, however, someone else is responsible, such as the train being late, you get the childish satisfaction of ‘Waheeey you messed up‘, which people may deny that they feel, but everyone does – schadenfreude.

I found that even when the bus or train was really really late, I was still ‘net’ happy, because I’d accurately predicted the outcome. So I started doing it with everything – It’s going to rain today, and I’m going to get soaked on the walk to work – is a good way to get yourself smiling during a downpour. That guy is going to look at me funny – I’ve only got this right once, and it totally took away the anxiety that I usually feel when I think someone’s looking at me weirdly.

After doing this for a while, I stumbled across this awesome article on lifehacker

…which basically says everything I just did, but also goes into some of the science behind it. Essentially, the ‘pleasure’ you feel from being right happens because you’re using your dopamine prediction pathways, the same one’s you use to learn about the world around you, and ‘cheating’ it into thinking it’s enjoying itself.

Awesome.

Why I stopped using Facebook

 

Facebook is toxic. It’s an incredible tool, an ingenious creating, allowing potentially unlimited communication between anyone with internet access, but psychologically it is an absolute nightmare. When I’m feeling crap, and I go on Facebook to distract myself, I invariably feel more crap after five minutes of scrolling. Why? Because I’m warmly greeting by a glistening barrage of how wonderfully blissful everyone else’s life is in comparison to my own. Jack got a new car, Amy got married, Simon managed to drink two entire boxes of red wine at that incredibly exclusive party and Anastasia continues to discover new filters to emphasise her perfect body. Nobody posts the bad stuff because we don’t like to show it off, and so our feed is simply a continued reminder of others’ successes. To compensate, we put our own super-hot selfies and achievement-photos up to demonstrate that we, too, are surviving in this world of cloying perfection, and to lap up the modern day heroin that is the Facebook ‘like’.

I stopped going on facebook. It made me so happy. I spent time thinking about my own plans and the friends that I genuinely enjoyed the company of, feeling no need for validation from the strangers that I knew deep down, at least in part, resented me for any achievement that I plastered across my wall. And why wouldn’t they? If I walked around Trafalgar Square with an A1 poster with my own face on it, shouting ‘This is me on my super-expensive holiday!’ passers-by would probably be want to tell me exactly where to shove it, or have a go themselves.

I lie… I didn’t stop completely. It’s a really good way to organise events and share photos, and occasionally link ridiculous cat videos to equally bored colleagues. Equally, I’ll totally admit that I get a warm buzz inside when someone likes a post or photo of mine, but it feels so much better when I know I put it there so my mum could see it while she was away, rather than to see how many likes I could rack up.

Redefine Success

 

The obvious social markers of ‘success’ are usually money and popularity. A big house in a sought-after neighbourhood and nice clothes that demonstrate your lack of concern for financial minutiae.

I tried to stop caring about money. I couldn’t completely not care because sometimes it would be nice not to have to think about whether I could afford that coffee in the morning, and sure if you offered me a stack of free cash I’m not exactly going to turn it down (I might question your source first). But I’m not obsessing about money.

I used to see people with loads of spare cash and assume that they were happier than me. Sure money brings freedom, nicer possessions and the ability to partake in enjoyable experinces more often, but there are two critical things I force myself to remember when I find myself envying that nice watch on the tube :


– I don’t know what that person sacrificed to get that money

– the human brain is the most remarkable learning machine on the planet

Why the second point? Notice how quickly you get used to stuff when you practice a lot? Like driving or using your phone? Your brain adapts to its environment extremely quickly – it’s a very useful survival skill. However it also very quickly starts searching for more – another great way to survive.

I’ve found that whenever I’ve changed something in my routine, such as buying nicer food or getting a new phone, within a few weeks or months I’ve quickly forgotten how much of a luxury it is, and it has become the new normality. My baseline assumption of what I expect my life to include has simply absorbed this new, expensive addition, and business continues as normal. However when I deliberately avoid incorporating something nice that I probably could just about afford into my life, I look forward with a childish eagerness to the one day per week/month/year that I allowed myself to indulge. It’s such a treat to go out for dinner once a month. I get so excited about buying Tesco finest aberdeen angus burgers. It sounds tragic, but it’s the opposite. I get a massive hit of enjoyment off a tiny increase in expenditure, far more than anyone who’s used to that lifestyle everyday, and like an unshakeable addiction, greater and greater doses of glamour and expense are needed to bring such a rush.

What’s my point? By not having lots of nice stuff all the time, I get more enjoyment out of simple everyday things that other people wouldn’t grant a second thought. As a result, buy not having as much money, I’m more happy. Weird.

I just saw a man in an Armani suit walk on the train with his Ipad blasting through his £300 headphones. Poor soul.

Measure you against you

 

What makes me happy is progress. I don’t care what that progress is, as long as I am getting better at something, or someone else is getting happier, I’m happy. It says so right there in the big five. So it makes absolutely no sense to use other people as a mark of your own achievement. They’ll have their own goals, their own achievements and problems, and their own motivational tools. Chances are if they’re out in public, they’re hiding what’s bothering them and putting on their best ‘everything’s going great’ face, which is only going to make you feel worse. I’d be lying if I said I totally didn’t care what other people think of me, because it’s natural to want to be liked – evolutionarily it improves your chances of survival if you’re accepted into a group – but I have always inflated the importance of other people’s opinions in my own mind, as if they had some great insight into what was expected, or sociably acceptable, and it was tiresome trying to compete with an apparently insurmountable level of expectation. Interestingly what I discovered when I stopped putting so much effort into pleasing other people, and started to focus on just doing what I enjoyed, other people started to show more interest in what I was doing, and what I thought. I was always caring what other people would think. My only regret is that I hadn’t realised that it couldn’t matter less at an earlier age.

Stop trying to achieve

 

The single most sinister element that’s hampered me all along the way, which I assume runs rife within our westernised population, thriving on an infusion of instant technological and financial gratification, is the fear of failure. The fear of regret, the fear that this project will flop, as will the next one, and the fear that the amount of energy and time that I’ve put into it will never be retrievable, so surely my time is better spent doing something else?

As a medical student there is increasingly little time available for anything other than academic and clinical advancement, so I found myself constantly questioning whether those precious morsels of time could be more effectively spent, and it made me so sad. I was never in the moment, enjoying the activity for the simple pleasure of doing something that made me feel good – everything had to be ‘productive’ or set me up in someway for my career to progress in the direction that it should. I don’t even know what ‘should’ means. Did I even want a career? I’d always assumed I had, but it recently struck me that I had spent so much time thinking about what I should do that I hadn’t stopped to think what I wanted. In truth, I have no idea. All I know is that it is going to fulfil the big five, and that’s what I’m going to spend my time doing.

The Red One

  • Banana                                 1
  • Greek yogurt                       3 tbsp
  • Frozen summer fruits     to taste (like, 1/3 of the blender)
  • Pine nuts                             2 tbsp
  • Flax seeds                            2 tbsp
  • Spinach                                1 frozen blob
  • Kale                                       1 frozen blob
  • Rice milk                             to volume/texture

Meany Greenie Smoothie

love this smoothie. It tastes mainly of pineapple, it’s thick, and it’s filling.

  • Spinach                1 frozen blob
  • Kale                       1 frozen blob
  • Chlorella              1tsp
  • Spirulina              1tsp
  • Pumpkin seeds  3tbsp
  • Chia seeds           1tbsp
  • Flax seeds            3tbsp
  • Sunflower seeds 3tbsp
  • Maca powder       1tsp
  • Coconut oil          2tsp
  • Pineapple             1/2 can
  • Greek yogurt       3tbsp
  • Rice milk              to volume/texture preference
  • Banana                  1
  • Lemon juice        1/2 lemon
  • Whey protein     1 scoop
  • Ice

 

This shit is the BOMB, yo…” – Jesse Pinkman

 

Why this smoothie makes me feel good:

  • niacin
  • zinc
  • protein
  • fibre
  • vitamins A, C, E and K
  • vitamin B6
  • folate
  • calcium
  • iron
  • magnesium
  • potassium
  • ?protects against oxidative DNA damage
  • ?reduces inflammatory markers
  • ?improves HDL/LDL ratio