Data gathering and interpretation 🧐
Descriptors and examples for the RCGP Trainee
This capability area is about the gathering, interpretation, and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations.
💭 Example Reflection
A Curious Case of Joint Pain 🦴
Description
I was on the paeds assessment area in A&E and my next patient was a young girl who had come in with her mother with an interesting history. She had a background of multiple episodes of tonsillitis every year, including strep tonsillitis. She had been seen by ENT but they had not deemed it necessary to remove her tonsils just yet. On this admission she had had again a sore throat but had developed chest pain, then joint pains in her small joints and then elbows and knees. She had also been having some jerky movements of her right hand. On seeing her I was immediately worried she might meet the major criteria for rheumatic fever. On detailed examination she had effusion in 2 of her joints but arthralgia alone in many others. Her tonsils were large and scarred but not inflamed at this present time. Her chest pain could have been cardiac but I was unsure, and all this was worrying me even more that she might have rheumatic fever.
I had a chat with the patient and her family about this and discussed my suspicions. They were alarmed, understandably, at the provisional diagnosis but I explained to them that acute rheumatic fever (ARF) was quite rare in this country but was extremely important to start prophylactic antibiotics for. They were worried needless antibiotics might cause harm if our diagnosis was wrong, but we talked about pros vs cons and came to the shared conclusion that in this case we absolutely needed to start medications. We also briefly discussed possible differential diagnoses but decided we needed more information to be certain what it was.
I then discussed her case with a registrar. I wanted to send off an ASO titre and other bloods to rule in/out my provisional diagnosis, start treatment with penicillins, and consider admission. My registrar advised starting her the penicillin and discharging her home after sending off the bloods. I did this and made sure to extensively safety net. I also directed them to patient.info for further information and reassured them that even though we were treating for rheumatic fever, we could not be sure it was that until we had the blood results back.
A couple of days later, this patient was readmitted with increasing joint pains. We kept her on regular NSAIDs, which helped greatly with the pain — this is another feature of rheumatic fever arthralgias. Her bloods all came back negative however, except the ASOT which disappeared from the lab but was not repeated due to the normal CRP and ESR. A provisional diagnosis of reactive arthritis was made and the consultants were quite happy with my management of this patient.
Reflection: What will I improve, maintain, or stop?
Weird and wonderful cases present very often in paediatrics, and hoofbeats can be zebras as often as they are horses. This patient was a typical example of the interesting cases we see every day on paediatrics. I am happy with my initial management of the patient; I managed to take a detailed history, elicit the clinical signs that pointed me towards the most important diagnosis to rule out, started therapy to reduce risk to the patient and made plans for investigations and follow-up.
I have developed a system for myself that I stick to when taking paediatric histories and that way I ensure I do not miss anything major. I will continue to refine it over time.
Learning needs identified from this event
I determined my knowledge of rheumatic fever was not as good as it could be. I will need to read more about this topic and perhaps present it next time I am due for departmental teaching.
Data Gathering And Interpretation
Trainee: This was a case I was involved in for quite a few days. At initial presentation, a systematic enquiry enabled me to notice red flags in the history for possible ARF. I examined accordingly and used my clinical exam findings to inform the investigations I requested. I then kept the family abreast of the blood results and changed management accordingly, ie stopping penicillins as it became clear from the bloods and the rheumatology consult that it was unlikely to be ARF.Trainer: Good evidence of a thorough history taking including past infections and non-throat symptoms
Making A Diagnosis/Decisions
Trainee: I used the history to make a list of possible differentials and started treating for the likeliest one. As more information came in from the bloods and specialist input, I revised my initial hypothesis. I took ownership of my decision to start penicillins early but also stopped them when it was clear my initial diagnosis had been wrong.Trainer: I like the fact that you didn't forget about rare diagnoses like rheumatic fever. But looking back would you have discussed your concerns with a senior colleague quickly first before using the term rheumatic fever to the family? How did that conversation go? Anything you would do differently next time? What were the features against rheumatic fever in the end? Hoofbeats are usually horses but don't forget about the zebras, especially if early diagnosis is important.Trainee: I discussed my concerns with 3 separate seniors, who all agreed with my provisional diagnosis. It was only after that that I had a discussion with the patient and the family. They had already been suspecting the same diagnosis so it was not much of a shock to them, though I did emphasize it was a rare diagnosis and was only one of the differentials. In the end, all of the patient's bloods were normal, including CRP, ESR, and rheumatology bloods. We had a discussion with paediatric rheumatology who thought it was reactive arthritis. The chest pain had disappeared soon and the ECGs were all normal. The arm jerking was observed and was muscle fasciculations, not Sydenham's chorea as we had initially thought. I was quite relieved to have been proven wrong!
Supervisor comment
Super, interesting case.
