Approach to hypercalcemia

Hypercalcemia is a presentation commonly encountered in the clinical setting. Due to its vast differential diagnosis, a systematic approach is necessary when approaching patients with hypercalcemia. This article presents a simple, yet thorough approach to help clinicians determine the etiology of their patient's hypercalcemia. The main components of history taking, physical examination, and laboratory investigations for patients with hypercalcemia are highlighted. Emphasis is put on the importance of determining whether the hypercalcemia is associated with elevated or inappropriately normal parathyroid hormone (PTH) or not. The main etiologies of PTH-dependent hypercalcemia and PTH-independent hypercalcemia are explored. Primary hyperparathyroidism and hypercalcemia secondary to malignancy are highlighted as together, they make up 90% of hypercalcemia cases. A presentation of the management principles of hypercalcemia is also provided.

A Crohn’s Disease Patient with Extraintestinal Manifestations: A Case Report

Crohn’s disease (CD) is a chronic debilitating inflammatory disease which mostly affect gastrointestinal tract, but due to its unique features, CD enables to affect extraintestinal organs. Pathophysiology of extraintestinal manifestations is still debatable as many experts propose immune-related hypotheses. It is still unpredictable which manifestation precedes another as studies ongoing. Diagnosing CD is difficult since no gold standards available, therefore clinicians must combine history taking, diagnostic modalities, and a good clinical judgement to diagnose CD. Treatment for CD is not only to treat disease activity, but also to prevent complications to preserve patients’ quality of life.

Assessment and examination of the respiratory system

Respiratory complaints are seen regularly in general practice. Eleanor Squires looks at the importance of advanced practitioners carrying out a systematic assessment and examination of a patient with respiratory symptoms The aim of this article is to explore the importance of carrying out a systematic assessment and examination of a patient with respiratory complaints. History taking using recommended acronyms will be discussed, along with a focus on the most common presentations. Finally, it will discuss a systematic examination of the patient.

Diagnostic statements: a linguistic analysis of how clinicians communicate diagnosis

Objectives To investigate from a linguistic perspective how clinicians deliver diagnosis to patients, and how these statements relate to diagnostic accuracy. Methods To identify temporal and discursive features in diagnostic statements, we analysed 16 video-recorded interactions collected during a practice high-stakes exam for internationally trained clinicians (25% female, n=4) to gain accreditation to practice in Australia. We recorded time spent on history-taking, examination, diagnosis and management. We extracted and deductively analysed types of diagnostic statements informed by literature. Results Half of the participants arrived at the correct diagnosis, while the other half misdiagnosed the patient. On average, clinicians who made a diagnostic error took 30 s less in history-taking and 30 s more in providing diagnosis than clinicians with correct diagnosis. The majority of diagnostic statements were evidentialised (describing specific observations (n=24) or alluding to diagnostic processes (n=7)), personal knowledge or judgement (n=8), generalisations (n=6) and assertions (n=4). Clinicians who misdiagnosed provided more specific observations (n=14) than those who diagnosed correctly (n=9). Conclusions Interactions where there is a diagnostic error, had shorter history-taking periods, longer diagnostic statements and featured more evidence. Time spent on history-taking and diagnosis, and use of evidentialised diagnostic statements may be indicators for diagnostic accuracy.

AN OBSERVATIONAL STUDY TO ASSESS THE PARENTAL DOSHA PRAKRITI OF AUTISTIC CHILDREN

Prakriti refers to the genetically determined physical and mental constitution of an individual. Autism is a lifelong disability identified by impaired communication, social interaction and repetitive behaviours. The genetic, envi- ronmental and immunological factors play an important role in generating autism. Genetic factors are more pre- dominant in autism pathogenesis than the environmental factors that would modulate the phenotype. Until now, no interventions have proven widely effective in providing complete relief to autism. Therefore, the prevention of autism needs supreme attention. To a greater extent, prakriti of an individual can determine proneness to particu- lar diseases. To assess the prakriti of both parents of 30 diagnosed cases of autistic children attending the OPD and IPD of Govt. Ayurveda College, Kannur were randomly selected. They are subjected to detailed history taking based on specially prepared proforma and assessments were recorded. Their prakriti assessment was done using a validated computer-assisted questionnaire software Ayusoft developed by C-DAC Pune. The data was statistically analysed. In this study, Vata pitta prakriti was significantly seen in mothers of autistic children. Keywords: Prakriti, Autism

AN AYURVEDA CONCEPTUAL STUDY ON EIGHT DOMAINS IN THE ASSESSMENT OF MIND

History taking, clinical examinations play a major role in confirming the diagnosis and predicting the prognosis of the illness. This is applicable in psychiatric as well as psychosomatic disorders. Sometimes organic diseases may simulate the presentation of psychiatric disorders and vice versa. Many types of examination techniques are ex- plained in Ayurveda which help directly or indirectly to elicit and diagnose psychiatry disorders. Astavibhrama, impairment in eight domains of mental faculties - thinking process (Mano vibhrama), intellect (Buddhi vibhrama), consciousness and orientation (Sanjnajnana vibhrama), memory (smriti vibhrama), desire or interest (Bhakti vibhrama), temperaments (sheela vibhrama), behaviour (chesta vibhrama), conduct (achara vibhrama); a concept adopted for the diagnosis of unmada (insanity). These eight domains can be generalised for eliciting the mental status of an individual. Keywords: Astavibhrama, Mental status examination, Psychiatric disorder

Critical thinking and diagnostic reasoning when advanced practitioners assess and treat skin conditions

Advanced clinical practitioner (ACP) roles require a broad range of knowledge of both medical and surgical medicine and the ability to work autonomously in a variety of settings. Despite around half of the UK adult population presenting with a skin condition requiring attention, this is something many ACPs feel unprepared to be consulted on. However, due to the complexity and large number of potential diagnoses, it is imperative that ACPs develop their confidence and knowledge to diagnosis, request investigations and initiate treatment for a patient with a skin complaint. In the first part of this clinical review the authors presented the key elements of history taking, consultation and assessment of the skin. This second clinical review discusses the main differential diagnoses, mimics, common investigations and treatments. This article is designed to support novice ACPs from acute hospital settings to primary care to develop a foundation of understanding in the main diagnosis and treatment options that should be considered following a clinical assessment of patients’ skin outside the dermatology setting.