The key points to determine the clinical history and examination

Published: 2019-10-07 07:00:00
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A conclusive valid diagnosis to made clinical history and medical examination are the core points of consideration. The case history and medical examination are termed as clinician-intensive elements of patience since the information is acquired in the examination rather than the non-clinician intensive laboratory tests and supplementary studies not obtained examination room. A prescriptive history and medical examination should entail presenting complaint, history of the presenting complaint, family history, past medical history, drug history, social history, and systemic review (Peterson 1992).

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Flushing is the redness of the skin associated with burning and sweating sensation it may be depicted in the face, neck or chest and it is caused by dilation of blood vessels underneath the skin . The fundamental points of consideration in this history should be the duration of the symptoms, intensity, associated symptoms and the environmental predisposition. Flushing is associated with sweating indicates autonomic mediated cause and it distinguishes it from direct vasodilation cause. It is imperative to advise the patient to keep a record of flushing reactions for duration of a fortnight. This entails recording associations with emotional stress, bronchospasm, food or medication intake, diarrhea, exertion and urticaria. Most systemic disorders have flushing as a symptoms and other related symptoms are used for differential. Lack of adequate diagnosis from history and physical examination calls for evaluation of other specific systemic disorders associated with flushing such as mastocytosis, carcinoid and pheochromocytomas. Carcinoid this may be wide spread rush with bright red or reddish brown color developing to telangiectasia and bluish coloration of the face. Mastocytosis particularly Cutaneous Mastocytosis causes urticaria pigmentosa. Pheochromocytomas there are no particular findings. MTC is shown by telangiectasia face and arms, protracted flushing, a thyroid nodule and persistent discoloration. VIPoma there is no concrete results. Abdominal mass shows renal cell carcinoma.

Differential diagnosis for flushing for a lady age of 59

Use of certain substances such as spicy food and hot beverages or food may cause flushing in individuals occurring as auriculotemporal flushing, gustatory flushing and dumping syndrome. Dumping syndrome begins after gastric surgery and is accelerated after ingestion of hot meals or drinks causing a racing heart, weakness, stomach upset, sweating and dizziness. This condition usually worsens after menopause. Auriculotemporal flushing is one sided flushing associate with parotid surgery while gustatory flushing is both sided flushing caused by chewing pepper for more than 5 minutes and not related to parotid surgery.

Alcohol-related flushing if the lady had a defective in enzyme acetaldehyde dehydrogenase that causes a buildup of acetaldehyde also tyramine or histamine found in fermented alcoholic beverage may cause flushing. Also, a combination of drugs such as disulfiram, ketoconazole, and metronidazole may cause flushing.

Carcinoid syndrome is one of the cases associated with flushing mainly cutaneous flushing which is caused by carcinoid tumors. The carcinoid tumor secrets vasoactive substances such as histamine, polypeptide hormones, serotonin, prostaglandins and bradykinin directly into systemic circulation causing dilation of blood vessel thus flushing. The common symptoms are flushing and telangiectasias, tachycardia, bronchospasm, pellagra, hypotension, right sided heart disease or failure and diarrhea .

Mastocytosis is characterized by overproduction of mast cells. It can occur in two forms systemic and cutaneous, systemic happens when the mast cells accumulate in the body tissues such as small intestine, liver, and spleen. The cutaneous mastocytosis commonly referred as urticaria pigmentosa is the one mostly depicted by infiltration of mast cells in the skin. Mast cells play a significant role in immune systems, and they release histamine and cytokines that cause dilation of blood vessels consequently leading to flushing.

Medullary thyroid carcinoma (MTC) this is thyroid cancer originating from the C cells that produce Calcitonin. The elevated level of calcitonin causes flushing as well as diarrhea.

Pheochromocytoma is a rare cancerous tumor that develops in chromaffin cells of the adrenal glands releasing epinephrine and norepinephrine hormones that cause episodic high blood pressure. These hormones cause increased blood pressure, heart rate and metabolisms that lead to increased sweating, pale skin, and headache.

Pancreatic tumor especially VIPoma, which occurs when cancer grows at islets cells causing cells to secret high level of a vasoactive intestinal peptide hormone. The hormone increases secretion of intestinal hormones and relaxation of smooth muscle of gastrointestinal. It is characterized by flushing, weight loss, nausea, diarrhea and abdominal pain.

Serotonin syndrome is caused by increased in the serotonin levels in the blood due to high intake of drugs, or food supplements contain it. Serotonin is a chemical compound produced by the body essential for the proper functioning of nerve cells and brain. The symptoms of the syndrome include flushed skin, heavy sweating, headache, confusion, high fever and irregular heartbeat.

Renal cell carcinoma is a kidney cancer that affects the kidney tubules caused by high smoking, misuse of particular medication, genetic factors. Some of the features are pale skin, abdominal pain, weight loss, vision problems and high blood pressure. Most people suffering from this cancer are older people of the age of 50 to 70 years.

Investigations to be done to help elicit the underlying diagnosis

Complete blood count that will determine the blood chemistry and check the components present in blood if they high or lower than normal and the possible disease associated with it. The vital elements to be looked at are red blood cells, platelets, hemoglobin, white blood cells hematocrit and this may help diagnosis infection, inflammation, anemia, leukemia and bleeding cancer.

Liver function tests are tests performed to assess the function of the liver by checking the presence and the amount of enzymes released by the liver. The enzymes are found in hepatocytes, and when damaged or injured they spill into the blood. Some of the liver function tests include aspartate aminotransferase, alkaline phosphatase, alanine aminotransferase and gamma-glutamyl transpeptidase

Catecholamines tests are used to check for the presence or absence and the concentration of catecholamine in the urine or blood such as epinephrine, norepinephrine and dopamine. The test is ordered when there is evidence of some symptoms since there are increased cases of false positive results.

24-hour urine 5-HIAA for carcinoid syndrome is an analysis performed to identify serotonin metabolite 5-HIAA in urine. 24 hours are preferred since the levels of metabolite vary within the day. The results can be biased when the patient has been taking serotonin reach food such as bananas, walnuts, and plums also certain drugs such as guaifenesin, phenothiazines, and methocarbamol. The regular excretion level of 5-HIAA is < 10 mg/day while in patients carcinoid syndrome the excretion is > 50mg/day.

Histamine and prostaglandin D2 for systemic mastocytosis tests are taken to measure the overproduction of histamine and prostaglandins in cases attributed mastocytosis. The elevated levels will be an indication of mastocytosis. This is a general marker for all types of mastocytosis.

Metanephrines biochemical tests for pheochromocytomas by measuring free metanephrines present in plasma or urine. Pheochromocytomas causes increased levels of metanephrines since its produced by metabolism of catecholamine mainly epinephrine and norepinephrine. This test is very sensitive, and cases of false positive are high, and it may be affected by smoking, stress, drugs and certain foods.

Serum tryptase for systemic mastocytosis is a test conducted to check for the presence of tryptase in serum which is released due mast cell degranulation which is released concurrently with histamine . This test is discriminative since the total tryptase level in plasma correlates to the density of mast cells in systemic mastocytosis while patients with cutaneous mastocytosis have a healthy level of tryptase in serum.

The aspect of urine collection that can be considered to be the Cause of the issue

The standard level of 5-HIAA excretion ranges from 10 to 42 umol/day. Patients with coracoid syndrome have an elevation with some having values of urinary 5-HIAA excretion above 523 umol/day. A study conducted showed, 5-HIAA excretion in patients who had carcinoid syndrome ranged 518 to 10826 umol/day. Patients should probably avoid intake of tryptophan- and serotonin-rich foods as well as medicines that may cause a false-positive urinary 5-HIAA at least 24 hours before and during the 24-hour urine collection. A false positive result may occur due to association with certain serotonin-rich food type and drugs hence this should be three days prior to urine collection.

The radiological investigation to be requested and the features to be looked for

The central imaging modalities for identification metastatic carcinoid tumors are Magnetic resonance imaging (MRI), Computed tomography (CT) and somatostatin receptor scintigraphy (SRS, OctreoScans). Computed tomography can be used to check carcinoid tumors originating in the ileum usually producing mesenteric masses having immense desmoplastic fibrosis because of extension of primary tumors into the mesentery or mesenteric lymph node metastases (Crocetti 2003).

CT scans are suitable for identification of carcinoid tumors, which are mostly located in the center of the mesentery depicted by a circumferential pattern of fibrosis which surrounds small bowel.

Liver metastases are effectively detected by the use MRI. This was highlighted by a study conducted on 64 patients with metastatic gastrointestinal neuroendocrine tumors with multiphasic MRI detecting a large number hepatic lesions than depicted by CT or somatostatin receptor scintigraphy.

Additional investigation that can be requited at the same time

Other tests that can be performed to improve the credibility of the diagnosis are somatostatin-receptor scintigraphy (OctreoScans), functional PET imaging techniques. Also, endoscopy can be conducted both Upper and lower (and an exceptional view to terminal ileum) for evaluation of unknown primary site of metastatic carcinoid.

Description of the available treatment for the condition

Surgery as the patient has a metastasis to the liver with primary tumor in the midgut. May be she would benefit from de-bulking the tumor and even increase the chance for here subsequent non-surgical therapy (depend on tumor size and how it been affected by pressuring surrounding organs).

Somatostatin analogues (Octreotide) using short acting subcutaneous tds reduce the level of biochemical tumor marker and improve the symptoms. Hepatic embolization is not needed as the patient doesnt suffer from pressure effect on the liver. External mean radiotherapy is not required also as there is no feature for bone involvement or spinal cord compression. Alpha-interferon combination with octreotide showed to improve a total of 70% of patients. Also, will help decrease tumor size.

Radioactive isotope both radiolabelled somatostatin analogue as (SOM230-Pasireotide) under evaluation and radiolabelled MIBG related to adrenalin and would concentrate in carcinoid tumor. Future treatment: to work on preventing tumor growth, Antiangiogenic (AntiVEGF) currently under evaluation.

Bibliography

Boyer, Edward W.,...

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