Thursday, June 23, 2016

Structured format of history and clinical images and radiology for the online record

Summary title:

A 40 years old man with abdominal pain since 3 years 


This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here early winter 2015 after collecting informed patient consent (form downloadable here ) by LNMCH research assistant and patient-information-communication-executive for a discussion (scroll to the bottom) initiated by patient's primary care physician in-charge: 
RECORD MANAGED BY: KULDEEP GUPTA (research assistant and patient-information-communication-executive LNMCH)

Narrative history in patient's voice: 

Structured system review: 

Check list for Systems Review 

GENERAL Fatigue/malaise, Fever/rigors/night sweats, Weight/appetite, Skin: rashes/bruising Sleep disturbance 

CARDIOVASCULAR Chest pain/angina Shortness of breath (including on exercise) Orthopnoea Paroxysmal nocturnal dyspnoea Palpitations Ankle swelling 

RESPIRATORY Chest pain, Shortness of breath/wheeze, Cough/sputum/haemoptysis, Exercise tolerance 

GASTROINTESTINAL Appetite/weight loss Dysphagia Nausea/vomiting/haematemesis Indigestion/heart burn Jaundice Abdominal pain Bowels: change/constipation/diarrhoea/ description of stool/blood/mucus/flatus 

MUSCULOSKELETAL Pain/swelling/stiffness – muscles/joints/ back Restriction of movement or function Power Able to wash and dress without difficulty Able to climb up and down stairs 

GENITO-URINARY Frequency/dysuria/nocturia/polyuria/oliguria Haematuria Incontinence/urgency Prostatic symptoms Impotence Menstruation (if appropriate): menarche (age at onset) duration of bleeding, periodicity menorrhagia (blood loss) dysmenorrhoea, dyspareunia menopause, post-menopausal bleeding 

CENTRAL NERVOUS SYSTEM Headaches Fits/faints/loss of consciousness Dizziness Vision – acuity, diplopia Hearing Weakness Numbness/tingling Loss of memory/personality change Anxiety/depression 

ENDOCRINE Menstrual abnormalities Hirsutism/alopecia Abnormal secondary sexual features Polyuria/polydipsia Amount of sweating Quality of hair 

SKIN Rash Pruritus Acne 

(reference for above and below: Originally by Kate Chatten, Mary Howe, Gillian Marks, Tom Smith and Dr Lorraine Noble. Edited and updated by Henry Tufton, Dr Alison Sturrock and Dr Deborah Gill © Division of Medical Education 2012


Respiratory History 

• Record the date and time the history was taken. • Name, Age, Occupation(s) Presenting Problem/Complaint 

There are seven main respiratory symptoms to ask about: 
1. Cough (character) 
2. Sputum (colour, amount) 
3. Haemoptysis (colour, amount) 
4. Wheeze (diurnal variation?) 
5. Chest Pain (site, radiation, character) 
6. Shortness of breath (exercise tolerance, orthopnoea) 
7. Systematic symptoms e.g. night sweats and weight loss 

For each symptom describe: 

• Onset • Duration • Course • Severity • Precipitating Factors • Relieving factors • Associated features • Previous episodes Past Medical History e.g. Tuberculosis, atopy Drug History Allergies, inhalers, nebuliser, home oxygen Social History Smoking history-measured in pack years Contact with animals/pets Presence of stairs in or leading into flat/house Hobbies Who/how is shopping done? Family history e.g. asthma/hayfever 
Systemic Review

Cardiovascular History • 

Record the date and time the history was taken. • Name, Age, Occupation(s) Presenting Problem/ Complaint

Remember the 8 questions you need to ask about each symptom?

There are 4 main cardiovascular symptoms:

1. Chest pain (character, radiation)

2. Shortness of breath (exercise tolerance, orthopnoea, paroxysmal nocturnal dyspnoea)

3. Presence and extent of oedema (ankle, leg or sacral)

4. Palpitations (tap out rhythm, any dizziness or blackouts)

During the history consider (and ask about) the main risk factors for Ischaemic Heart Disease: 1. Smoking 2. Hypertension 3. Diabetes mellitus 4. Hyperlipidaemia 5. Family history

Past Medical History (may ask under presenting complaint) e.g. angina, myocardial infarction, bypass operation, rheumatic fever, stroke, intermittent claudication

Social History Smoking (pack years), alcohol,

Family History At what age did the relative have illness?

Drug History Allergies

Originally by Kate Chatten, Mary Howe, Gillian Marks, Tom Smith and Dr Lorraine Noble. Edited and updated by Henry Tufton, Dr Alison Sturrock and Dr Deborah Gill © Division of Medical Education 2012

Locomotor History 

Main points to enquire about are:

1. Evolution of condition • Acute or chronic? • Associated events • Response to treatment

2. Current symptoms • Pain • Stiffness • Swelling • Pattern of joint involvement

3. Involvement of other symptoms • Skin, lung, eye or kidney symptoms • Malaise, weight loss, fevers or night sweats?

4. Impact of lifestyle • Patient’s needs/ aspirations • Ability to adapt with functional loss Pain History

If the presenting complaint is pain (most types of pain e.g. chest, abdominal etc) the main points to elicit can easily be remembered using the mnemonic ‘SOCRATES’.

All of these should be documented in the HPC.

• S -site • O -onset • C -character • R -radiation • A - associations • T -timing • E -exacerbating & relieving factors • S -severity Remember to ask about use of medication for pain relief.

Clinical Images:

Investigation images:

new investigation report images 10/12/15:

Clinical conversational decision support:

मोनिका पठानिया राठौर General blood picture, any comments on ivc? Malignancy, kala azar can be possibilities.
Rakesh Biswas Kuldeep, The age is mentioned wrong or the report above is of someone else?
Rakesh Biswas Looks like 'cirrhosis with large liver.' Will try to get his liver biopsy done tomorrow. Any particular points to look for in liver biopsy particularly for the potential differentials of 'cirrhosis with large liver.'
Yashdeep Das Rakesh Biswas sir, can this be a case of portal hypertension but, there are no mention of anorectal varices or oesophageal varices
Yashdeep Das Rakesh Biswas sir, this is just a guess and a long shot.....but Lupus is also possible.
Rakesh Biswas Thanks Yashdeep for taking this shot as this should also benefit those who are learning in the audience. smile emoticon
Rakesh Biswas Please search for Lupus criteria and let us know how many common criteria this patient may fit into. Let us see if he fits into at least 4 out of the 12 common criteria. Do let us know.
Rakesh Biswas
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Yashdeep Das The patient has problem in liver, spleen and also kidneys as investigation shows albuminuria and increased serum urea..... Lupus attacks all the above mentioned organs. Rakesh Biswas sir..
Yashdeep Das portal hypertension can be due to the liver cirrhosis which can also occur due to autoimmune hepatitis
Yashdeep Das the person is anemic and leukopenic which can be caused by lupus as well
Yashdeep Das lupus also causes nasal ulcer which can lead to nasal bleeding
Rakesh Biswas Yashdeep there are many other causes of Leucopenia. Can you see if this patient has any of them? Can a large spleen also cause leucopenia Trisha?
Trisha Rana Definitely, an enlarged spleen can be responsible for leucopenia keeping in mind the other causes as well.The detailed answer of your question is as follows:
The effects on your spleen may be only temporary, depending on how well your treatment works. ...See More

Trisha Rana Among the many causes of leucopenia Bone marrow diseases, bone marrow damage or suppression are very prevalent. In these conditions the bone marrow does not produce sufficient WBCs or selectively produces excess of one type of WBCs leading to a lack of other types. The causes include myelodysplastic syndrome, leukemia, myeloproliferative syndrome, myelofibrosis (bone marrow replaced by fibrous tissues)
Rakesh Biswas Thanks Trisha, So the first part of your answer was perhaps taken from here (or a similar site):
Rakesh Biswas It would be a good idea to always share the link from where your information content is taken?
Trisha Rana We can opt for checking levels of vitamin B12 and folate deficiency as it also plays a key role in leucocyte count maintenance.
Rakesh Biswas Also when you share a large amount of content your actual answer tends to get drowned in that? smile emoticon For example in response to the question "Can a large spleen also cause leucopenia?" it would have been easier to have just said yes and quoted a journal article where a possible mechanism to large spleen causing leucopenia may have been studied and described. Please do continue to share your thoughts and queries. smile emoticon
Trisha Rana I'll keep that in mind Sir smile emoticon
Rakesh Biswas Any luck with the emergency handouts? smile emoticon
Rakesh Biswas
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Trisha Rana's photo.
Rakesh Biswas Trisha can you copy paste the translation here?
Rakesh Biswas TrishaYashdeep, I guess some of you needed to be showed how to palpate his organs as Prof Seema was telling me today that some of you were palpating it from outside his clothes. She will discuss this case in detail tomorrow but meanwhile and even after please feel free to share your thoughts here on what you have gathered till now from your offline interaction with this patient in the wards.
Bhavik Shah Having gone through only a limited amount of information through the thread present here, how about primary myelofibrosis? The history says that the patient has been feeling weak for quite some time. His counts are low. Hepatosplenomegaly with symptoms...See More
Rakesh Biswas Thanks Bhavik, Now we shall need to decide as to which one to go for first. Bone marrow biopsy or liver biopsy. smile emoticon Dr Chandra Mouliany comments?
Chandra Mouli CBC n bloodfilm would be helpful to narrow down the differentials. Tear drop poikilocytes n platelet dysmorphology will be prominent of he has MF. Especially if we are thinking of MF given the duration of the complaints n spleen size. Hepatomegaly is usually not that prominent in MF unless splenectomy had been performed. As BM biopsy is easier may be go for it first.
Rakesh Biswas Thanks Dr Chandra MouliKuldeep please upload his peripheral smear report.
Rakesh Biswas
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Rakesh Biswas Dr Sagar can we send him to you for his bone marrow biopsy?
Rakesh Biswas Dr Ajay, Can you ask any faculty of pathology there in AIIMS if they would be able to perform his bone marrow biopsy? Getting a bone-marrow biopsy needle in Bhopal can be very difficult. Most of the needles here are sternal puncture needles and one can only do aspiration with those. Dr Ratan would you be able to do it?
Rakesh Biswas Prof Seema, Talked to Dr Rajneesh, HOD, AIIMS, Bhopal today and they can do the bone marrow biopsy (they have the needle). I shall send him the details of this patient on email.
Bhavik Shah Can they provide the microscopic picture of the slide? This much of information seems inadequate I think!
Rakesh Biswas Unfortunately all peripheral smear slides are discarded immediately after reporting as a rule here (perhaps in all places in Bhopal? DrIshan?). I wonder if the same happens in BJMC? smile emoticon
Rakesh Biswas To capture these images even as they are reported we need interns like you here. smile emoticon
Bhavik Shah Umm, I don't know if they discard the slides here or not, but reporting is always in depth for PS like tear cells, parasites, entire morphology of blood cells is covered in reporting. So, at least that makes it a bit easier.
Rakesh Biswas

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Rakesh Biswas His CT abdomen shows hypodense areas in the spleen suggestive of venous infarcts:
Rakesh Biswas We deferred his bone marrow biopsy as his current CBC is suggestive of near normal WBC and platelet counts. The offline consensus in the unit weighs in heavily in favor of cirrhosis or Non cirrhotic portal fibrosis. Perhaps we can just tackle his spleen and reduce its size using a radiological intervention that Dr Agamya does here routinely and perhaps he can also help to get a intra-portal biopsy?


  1. General blood picture? Any Comment on ivc? Malignancy, kale agar need to be ruled out
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