, and Clinical Presentation Mapping Sue Greenhalgh Consultant Physiotherapist NHS Bolton
Be Aware!
Clinical Reasoning Recognition of serious pathology early depends on awareness, vigilance and suspicion rather than rules (Grieve, 1994)
Early Presentation May not have lost weight May not have constant pain May not have night pain May respond to treatment for a short time May attribute the pain to a cause MAY have an undiagnosed non symptomatic primary tumour (e.g.breast)
Deyo, Rainville,, & Kent (1992) The subjective examination The provides clinicians with clearer indications of serious pathology than the objective examination
Herrings Any misleading biomedical or psychosocial factors that will deflect the course of accurate clinical reasoning
Misattribution by Herrings Patient Referring doctor or allied health professional Treating physiotherapist Inappropriate overt illness behaviour Other conditions which complicate the clinical scenario Biomedical Masqueraders
The chronological presentation Date Clinical Presentation Mapping Reflection
Clinical Presentation Mapping Date Document known dates and profession of clinician e.g. G.p., Physio Document known red flags and significant clinical findings at each consultation Reflection Populate above, including Herrings THEN REFLECT
Clinical Presentation Mapping case 1 Date Reflection 27/08/08 GP No 1 New onset left sided low back pain Thought to be gallstones New pain not previously suffered Age 52 years 29/08/08 GP NO 2 LBP severe, Sent to A&E Admitted In-Patient until 11/09/08 Lumbar spine x-ray Abdominal ultrasound Abdominal x-ray ALL REPORTED AS NORMAL CAUTION; Do not be reassured by previous investigations being reported as normal. Were they investigating the correct aspect or area?
Date 15/09/08 GP No 3 No specifically documented in GP notes Thought to be musculoskeletal Advice given Clinical Presentation Mapping 26/09/08 GP No 4 LBP severe, Referred to Physiotherapy No again documented 09/10/08 Physio appointment and GP No 5 Patient had started to walk with a stick as legs felt weaker Weight loss Stopped work and describes feeling depressed reported feeling some improvement Reflection CAUTION; Serious pathology appears to respond to physiotherapy in the early stages
Clinical Presentation Mapping Date 23/10/08 Physio review 27/10/08 Gp No 5 03/ 11//08 Gp No 6 Gait re-education Discussed paced exs approach Goal to wean off walking aid and return to work No red Documented Medication adjusted Patient reported feeling hot with increased frequency Gp suspected UTI Reflection Good knowledge of essential
Clinical Presentation Mapping Date 10/11/08 Gp No 4 home visit 13/11/08 DNA Physio appointment 14/ 11//08 Gp No 4 & 6 Home visit requested due to pain Patient reported severe abdominal pain and PV bleeding 2/52 cancer pathway to gyaenocology Reflection Seen by general surgeons MRI lumbar spine organised Discharged back to Gp for Ortho referral
Clinical Presentation Mapping Date 16/12/08 Gp No 6 Oromorph prescribed and Orthopaedic referral carried out 2/01/09 CATS AOP (Access time around 2 days) Documented significant weight loss Non segmental neurology Band like pain Severe restriction of lumbar flexion Poor balance and mobility Saddle anaesthesia and retention Drunken feeling Fuzzy feeling in legs Legs not my own Dragging leg Reflection MRI WHOLE spine expedited
Clinical Presentation Mapping Date 6/01/09 Multiple spinal metastases 9/01/09 RBH Primary Breast Cancer Reflection 7 Gp s 1 physio 1 AOP Approx 5 month patient journey
Clinical Presentation Mapping Date 27/08/08 GP No 1 New pain not previously suffered Age 52 years 15/09/08 GP No 2 New pain not previously suffered Age 52 years Band-like pain 09/10/08 Physio New pain not previously suffered Age 52 years Band-like pain Weight loss Sudden change in Mobility (began walking with a stick) Herrings Negative investigations for abdo pain as in patient Normal bloods and lumbar x-ray report 2/52 inpatient stay Back pain improving Sleep ok, no night pain Previous tests including CRP & Myeloma tests negative Possible emergence of yellow flags
Clinical Presentation Mapping Date 03/11/08 GP New pain not previously suffered Age 52 years Band-like pain Weight loss Sudden change in Mobility (began walking with a stick) Fever & chills New pain not previously suffered Age 52 years Band-like pain Weight loss Sudden change in Mobility (began walking with a stick) Fever & chills 02/01/09 CATS AOP Non segmental neurology Severe restriction of lumbar flexion Poor balance and mobility Saddle anaesthesia and retention Drunken feeling Fuzzy feeling in legs Legs not my own Dragging leg
Key Messages Good knowledge of essential to aid diagnosis early in disease process Extent of inconsistent Gp contributed to delay in diagnosis Symptom progression not linear. Improving presentation not unusual in early stages and not necessarily reassuring Previous normal investigation reports need to be appropriate to be reassuring
Theoretical Case Cost Savings 4 GP 164 3 GP home visits 369 spinal x-ray 22 Abdominal x-ray 22 Ultrasound scan 55 Elective inpatient stay with diagnostic procedure 1633 2 OP attendances for General Surgeon 292 Urine test 5 6 Blood tests 30 3 MSK appointments 129 Total 2721
Date 12/7/09 GP OOH 01.30 am Clinical Presentation Mapping Case 2 19/7/09 A&E No 1 04.00 am Reflection/ Herrings Worsening low back pain < 72 hours after twisting Radiating into stomach Shooting pain, P&N and numbness right leg Age 37yrs Severe Pain/Night pain Not relieved by simple analgesia Band-like pain Telephone Triage Alogorithm No other red flag Questions asked Non-dermatomal right leg pain above knee No neurology B&B normal Given Crutches Analgesia advice (taking inappropriately) add NSAID Severe Pain/Night pain IVDU Weight Loss 2/12 Unkempt 12 A&E attendances in 6/12 Normal Lumbar Spine XR Stopped opioid use GI problems under surgeons Intermittent 13 year history of LBP Asleep in Dept
Clinical Presentation Mapping Date 20/7/09 A&E no 2 06.31 am Heroin 1/52 ago Sciatica right leg Sensory loss L3/4/5 left leg Feels unwell Fever Worsening pain Abdominal tenderness Poor Appetite WCC 29.7 CRP 331.3 Severe Pain/Night pain IVDU Weight Loss 2/12 Unkempt Band like pain Reflection CAUTION; Do not be reassured by previous investigations being reported as normal. Were they investigating the correct aspect or area?
Date 20/07/09 Ortho 10.40 Clinical Presentation Mapping 20/07/09 Ortho admission Back Pain Lethargy? Discitis Feels Unwell Poor appetite/ Weight loss Urinary incontinence Drug abuser Severe pain MRI lumbar spine organised Large Para spinal abcess Reflection Time of attendance night crying Unkempt Fever Malaise Lethargy Band-like pain
Key Messages Good knowledge of essential to aid diagnosis early in disease process Previous normal investigation reports need to be appropriate to be reassuring (XR Lx) Always look for infection in IVDU (even if deny recent use) Fever/malaise/lethargy/poor appetite may be signs of systemic infection (Greenhalgh & Selfe, 2009)
Clinical Presentation Mapping Reflective tool Learning process Safety Produce new knowledge-recognise early warning signs Use regularly to understand cases-clinicians clinicians thought processes, symptom presentation, patient history Improve patient care
Thank You Sue Greenhalgh Consultant Physiotherapist NHS Bolton susan.greenhalgh@bolton.nhs.uk