Making Sense of Acute Medicine: A Guide to Diagnosis PDF

Preface

This book is a guide to decision-making in Acute Medicine – a practical approach to the differential diagnosis of patients presenting as emergencies on the ‘medical intake'.

Remarkable technological advances have been made in diagnostic medicine during the last 30 years. Examples include the development of magnetic resonance imaging (MRI), positron emission tomography (PET), spiral computerized tomography (CT), cardiac troponins, biochemical tumour markers, and numerous endoscopic and interventional radiological procedures. However, the appropriate use and interpretation of these tests remains dependent on the clinical skills, decision-making and analytical capabilities of the doctors who request them. Clever tests are no substitute for sound clinical skills and may actually mislead practitioners who lack the ability to use them appropriately. To use a crude analogy, a bad driver will drive a car badly regardless of whether it is a battered old Ford or a brand new Ferrari – and neither will get him to his destination if he makes an error of judgement leading to an accident on the way.

Competent physicians have many skills that underpin their practice of medicine and fundamental to these is the ability to take an accurate, comprehensive history (quickly) and perform a competent and directed physical examination. This results in an informed differential diagnosis which, in turn, dictates the requesting of focused diagnostic tests in order to narrow the differential diagnosis and guide the clinical management plan. The reader might consider that this is blindingly obvious; but it is our experience that many medical students and junior doctors (and some more senior ones too) display poor clinical reasoning and decision-making skills and this results in their employing a ‘scatter-gun' approach to diagnosis, suggesting or requesting multiple tests in the hope that the diagnosis will ‘turn up' as a result. That is not good medicine. It exposes patients to unnecessary procedures and may uncover minor, irrelevant investigative abnormalities, which can result in additional unnecessary tests and may obscure the primary problem. The diagnostic art starts with excellent clinical skills.

Some new diagnostic techniques entail significant potential risk to patients. The obvious example is the risk posed by exposure to medical radiation as a result of the huge increase in radiological imaging that has occurred in recent years. Medical radiation is now the principal source of radiation exposure in the populations of developed countries. Given the wealth of increasingly complex technology now available to doctors, and the accompanying potential risks to patients, we believe that good reasoning and decision-making skills have never been more important in clinical medicine.

This book focuses on clinical decision-making as it applies to some major common presentations in acute medicine. Each chapter aims to analyse a medical presentation in a systematic way, and the reader is encouraged to apply logical thought at various stages particularly with regard to investigation and management.

This book is not intended to be a complete reference text for Acute Medicine. In particular, management is covered in outline only and not in detail as many other texts address management of acute medical problems. The topics covered relate to major common presentations to emergency medical services and not to specific diagnoses or physiological parameters (such as ‘hypotension'). After all, patients do not attend emergency departments stating their diagnosis or complaining that they are hypotensive. To get the most out of this book it will be necessary to have a degree of background knowledge of common medical conditions. Our intention is to aid the clinical reasoning skills of medical students and trainee doctors as they learn to make the transition from clerking the patient to rationalizing differential diagnosis, requesting sensible and focused investigations, and formulating appropriate management plans.