Symptom based consultation

Question 1

63 year old Mr Smith comes to see you. He has been getting more out of breath when walking up hills and stairs over a few months. It seemed to start relatively quickly but is now just a gradual decline. He is a smoker 20 a day. He gets some chest pain after eating which he describes as burning.

What are your differential diagnosis?
What conditions can we rule out based on the information provided?

Answer 1

1. COPD - emphysema
2. Angina
3. GERD

Rule out

• lung cancer: no persistent cough, no blood present, no chest pain worse on breathing deeply or coughing.
• pneumonia: no evidence of cough, no persistent breathlessness, no congestion.

Question 2

26 year old Miss Jones comes to see you complaining of stomach pain, she has looser stools and spasmodic pain relieved by defection. There has been no blood, she has lost a bit of weight recently. Her father died of bowel cancer and she is tearful when discussing it with you.

What can we rule out?
What are some differential diagnosis?

Answer 2

Rule out

• bowel cancer: no blood present, young female.
• diverticulitis: too young, more common in elderly and usually gets worse after going to the toilet, not better.

Likely diagnosis

• IBS: loose stools, relieves pressures on defeacation. Most commonly detected between 20/30 and women are twice as likely as men to have it.
• IBS: ulcerative colitis / chrons disease - stool sample to differentiate between IBS/IBD (calprotectin) and then doing colonoscopy
• Food poisoning: is there nausea too, can she relate it to eating out somewhere?
• Viral gastroenteritis: is thee nausea or vomiting and is she dehydrated?

Question 3

Why are negative symptoms important in consultation?

Answer 3

1. Absence of a symptom may be just as important as the presence of a symptom.
2. We also need to seek whether something is NOT there such as asking about weight loss to help rule out cancers. No tight chest pain that radiates, no change with position (orthopnoea), no ankle swelling? No cough?

Question 4

What is a red flag symptom? Name some red flags of headache as an example.

Answer 4

Red flags are specific attributes derived from a patient’s medical history and the clinical exam that are usually linked with a high risk of having a serious disorder.

Headache as example

• sudden explosive headache - subarachnoid haemorrhage
• temple tenderness - temporal arteritis
• 3rd trimester pregnancy - pre eclampsia
• new and increasing headache increased by straining - increased intracranial pressure
• migraine in elderly patient as migraines typically don’t start in the elderly

Question 5

Name some red flags for a cough.

Answer 5

• foreign travel (atypical pneumonia)
• weight loss - hoarse voice in smoker
• haemoptysis
• suspect inhaled foreign body in children no signs of infection
• unresponsive to treatment