Situations as Starting Points (SSPs)
This chapter provides a set of generic situations covering the common circumstances, symptoms, complaints and findings which the physician should be able to manage on day one of his or her residency.
In other words, he or should be able to assess a patient presenting with any of these situations in a well-structured way, establish a differential diagnosis, and propose diagnostic, therapeutic, social and preventive/counselling measures. The list encompasses most of the typical situations a young resident may face. The situations are listed under several subheadings to make their use easier, but in some instances, the classification is arbitrary. Items listed as “symptoms” may also be defined as “findings”, and vice-versa. A set of pre-defined criteria was used to design the list. The situations were selected:
- if they occur frequently
- if rapid and appropriate intervention may be crucial or even life-saving
- if they are a recognized cause of important emotional distress for the patient
abnormal perspiration
swelling, tumor, included enlarged lymph nodes (lymphadenopathy)
excessive thirst, excessive fluid intake (polydipsia)
fatigue, tiredness
feeling sick
fever, chills, hyperthermia
flushing
hypothermia
itching
pain of all types
sleep problems (insomnias, hyper-somnias/sleepiness, parasomnias)
oedema (diffuse or local)
unnatural death
unexpected or sudden death
weight gain, obesity
weight loss, loss of appetite
S1 Head and neck
diplopia, ptosis, abnormal eye movements
acute and gradual loss of vision (acute, slow, temporary, partial)
alteration of voice (hoarseness, aphonia, dysphonia)
asymmetric face, deformation
bleeding nose
blepharospasm
difficulty in swallowing, choking
discharge from ear(s)
dryness, pain, mass in mouth or throat, oral lesions
earache
facial, jaw or tooth pain, trismus
hearing impairment: hyper- and hypoacusis, deafness, whistling, tinnitus
micro- and macrocephaly
nasal discharge
nasal obstruction
neck stiffness and pain
painful, red, itchy eyes; eye discharge
snoring
sore throat
squint (strabismus)
swelling of face, lips, neck
swelling of the eyelid
visual disturbances, photophobia, light flashes, floating objects, diplopia, color blindness, blurred vision
S2 Chest
apnea, apnea with arousal
change of respiratory pattern
breast lump, breast discharge, changes of breast size
chest discomfort
chest pain
cough, expectoration, hemoptysis
dyspnea
heartburn (pyrosis)
impaired or painful passage of food, dysphagia, regurgitation
painful respiration, wheezing, stridor
palpitations
parietal chest pain
S3 Abdomen
abdominal pain
abdominal distension
abdominal mass
altered defecation pattern, anal incontinence
anal itching, anal pain, anal protrusion
hematemesis
constipation
diarrhea
anal bleeding, melena; fresh blood, mucus, pus in feces
nausea, vomiting
S4 Pelvis, urogenital system
variations in sexual development
anuria, pollakiuria, oliguria, polyuria
dysuria, pyuria, hematuria
issues related to conception, e.g. infertility and sterilization
menstrual symptoms: disorders of menstruation, painful menstruation, premenstrual symptoms
pelvic mass
pelvic pain
request for contraception, emergency contraception
scrotal pain, swelling or mass
sexual complaints and dysfunction
swelling, pain in groin
symptoms related to menopause
urethral discharge
urinary incontinence and enuresis
urinary retention
uterine prolapse, pelvic relaxation
vaginal bleeding
vaginal discharge
S5 Back and extremities
abnormal posture and back deformities
back pain
deformities of skeleton and joints
myalgia
pain, burning, cramp, numbness in the extremities
swollen or painful joints, morning stiffness, reduction of joint mobility
S6 Skin
changes in oral, genital or perianal mucosa
ecchymosis, hematoma, purpura
hyper- or hypopigmentation
infected wound, delayed wound healing, skin ulcers
jaundice (icterus)
lack or loss of hair, excessive hair growth
macules, papules, pustules, blisters, ulcers and abscesses, bullae, thickening, necroses, tumors of the skin
nail complaints
redness of the skin (localized or diffuse) and/or mucosa
S7 Nervous system
abnormal sense of balance, falls
abnormal gait
abnormal involuntary movements, tremor, tic, lack of coordination
disorders of speech or language
dizziness, vertigo
headache
cognitive impairment, including loss of concentration, memory disturbance, and trouble in understanding
paresis, paralysis
disturbances of sensation (hyper- or hypo-esthesias, paresthesias, hyper- or hypoalgesia)
twitches, fasciculations, convulsion, seizure and status epilepticus
S8 Injuries and trauma
abdominal injuries
burn, cold injury
contusion, soft tissue bruising
dislocation of a joint
drowning or near drowning
injury by foreign body
head and brain injuries and trauma
injuries of the extremities
laceration, closed or open wound, blood loss
spine injuries
thoracic injuries
vascular injuries
S9 Emotional and behavioral symptoms
anxiety and panic
attention deficit
change in behavior
change in eating behavior
change in mood
hyperactivity
irrational fear, fear of illness
irritability, aggressive and violent behavior
changes in mental status such as confusion, delirium, (auto-)aggressive behavior
obsessive and/or compulsive behavior
reactions to major stressful events
self-harm, including suicide
non-medical substance use (“misuse”), addiction e.g. tobacco, alcohol, illegal substances (“controlled medicines”), gambling and gaming
F1 Findings upon physical examination
abnormal blood pressure
variations in external genitalia (female, male, including intersex and transgender individuals): physiological or pathological, hormonal driven, post-surgical or after mutilation
abnormal findings upon auscultation
abnormal findings upon inspection
abnormal findings upon palpation
abnormal findings upon percussion
bradycardia, tachycardia, irregular pulse
cachexia and malnutrition
cognitive impairment
cyanosis
abnormal speech or speaking
exophthalmos (proptosis), myosis or mydriasis
halitosis (fetor oris)
gangrene
impairment or loss of consciousness, coma
oedema
pallor
pulseless patient, cardiorespiratory disturbances and arrest
transient loss of consciousness, syncope
F2 Findings upon additional examination
abnormal blood gas values
abnormal cardiac enzymes
abnormal coagulation profile
abnormal X-rays of abdomen, chest and skeleton
abnormal leukocyte count
abnormal ECG
abnormal electrolytes
abnormal fecal analyses, occult blood, parasites
abnormal glycaemia and markers of glycaemia homeostasis
abnormal histology, cytology and molecular genetic tests
abnormal liver enzymes
abnormal markers of kidney function
abnormal serum lipids
abnormal thyroid hormones
abnormal urine sediment
anemia
blood group incompatibility
effusion detected by ultrasound (abdomen, pleura)
elevated biomarkers of inflammation
low bone density
nutritional deficiencies
polycythemia
proteinemia, albuminemia
proteinuria
thrombopenia, thrombocytosis
O1 Situations related to pregnancy and motherhood
abnormal birth weight and prematurity
basic care during regular delivery and postpartum period
basic pre- and post-conception screening for genetic diseases and malformations
maternal problems during pregnancy such as fever, oedema, hypertension, irregular premature labour
problems related to delivery
problems related to lactation
basic care during conception and pregnancy
request for abortion
suspicion of pregnancy, unplanned pregnancy
O2 Situations related to childhood
abnormal growth and accelerated or retarded puberty, failure to thrive
behavioural issues in childhood and adolescence
child abuse and neglect
child immunization
developmental delay
feeding and eating issues during infancy, childhood and adolescence
fetal problems during pregnancy
infant death
irritable, crying infant
learning and school problems in childhood and adolescence
low muscle tone and hypotonia
well-baby visit, well-child visit, and well-adolescent visit
O3 Situations related to old age
elder abuse and neglect
functional impairment (cognition, sensory and motor)
malnutrition and sarcopenia
polymorbid, polymedicated patient
pressure ulcers
progressively dependent patient
urinary and fecal incontinence
O4 Issues linked with prevention and health promotion
consultation before engaging in sports activities or after a sport injury
immunization plan
promotion of a healthy lifestyle
request for and managing check-ups, health examinations, radiological and laboratory procedures
promotion of sexual health and fertility
shared assessment of risks and benefits of screening and treating asymptomatic conditions
shared assessment of risks and protective factors for frequent life-compromising diseases, such as cardiovascular, metabolic, oncological, and neurological diseases
O5 Palliative care
caregivers’ fatigue, loss of energy
change in treatment goals and end-of-life decisions
holistic care of the dying patient
management of refractory symptoms (pain, nausea)
need for psychosocial or other kind of support (e.g. spiritual)
O6 Psychosocial issues
absenteeism (school, work)
concern about appearance, body image
domestic violence, sexual abuse, rape
harassment, bullying, mobbing
issues regarding diversity of affective and sexual orientation and gender identity
issues related to family life such as divorce, single parenthood and reconstructed family
loss, death, grieving process, illness of someone close
mental or spiritual suffering
problems related to work conditions, burnout, unemployment, financial problems
O7 Various health care issues
consultation before or after a trip to a foreign (tropical) country
determination of incapacity to work or to attend class/educational lessons
dietary counselling including a healthy and sustainable nutrition
environmental and psychosocial aspects of chronic conditions
errors or misconduct of a co-worker or another healthcare professional
immunocompromised patient
issues related to food tolerance
medically unexplained symptoms
nosocomial infection
request for informed consent for a procedure
patient refusing treatment
patient with sexually transmitted/transmittable infection
patient with another cultural background, migration
physical and psychosocial inpatient and outpatient rehabilitation
poor adherence to treatment
pre-intervention and pre-operative assessment
request for certificate, attestation or expertise by patients and insurers
request for unnecessary investigations and treatment
request for information about gene therapy
request for information related to organ donation, transplantation
benefits and risks of complementary and integrative medicine
suspicion of drug intolerance or interaction (including herbal medicine and dietary supplements)
suspicion of a rare disease
vulnerable patients
request for genetic counselling
intoxication, poisoning