to various common symptoms

Published on 24/06/2015 by admin

Filed under Internal Medicine

Last modified 24/06/2015

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It is useful to have a ‘ready-to-use’ aid in the form of a checklist for approaching the various symptoms a candidate might encounter in the long case. Below are discussed the commonly encountered symptoms, together with the relevant issues that need to be investigated. When encountering each problem, ask for details as described.


Back pain

Back pain is very common. In addition to the following salient clinical features, it is important to enquire into the occupational and functional difficulties associated with the symptom. Clinical features to concentrate on include:

Acute disc prolapse

Acute disc prolapse is a particularly common disorder, and so it is important to be able to identify features that suggest this diagnosis. The onset of pain is usually associated with such activities as lifting. The patient presents with lower back pain, muscular spasms and at times lancinating pain, paraesthesias and weakness of the lower limbs due to neurological involvement.
Basic steps in management include bed rest during the acute stage when the pain is excruciating, analgesia according to the pain ladder concept, and muscle relaxants. The patient should be advised to mobilise as pain permits. If pain persists unabated beyond 6–10 weeks, or there is significant neurological deficit, neurosurgical review is indicated. Surgical therapy involves microdiscectomy or hemilaminectomy. If there is bladder or bowel involvement, it should be considered a neurosurgical emergency and acted on promptly.
Spinal canal stenosis presents with spinal claudication—that is, pain and paraesthesias, particularly in the buttocks, on walking and relieved by rest. The management should essentially include a neurosurgical review.

Chest pain

This is a very common presentation and can indicate a medical emergency. It is therefore important to distinguish the more serious, time-critical and potentially life-threatening differential diagnoses from those that are not so serious. The precise location of the pain, associated other symptoms, its severity, haemodynamic stability and oxygenation as well as the patient’s background history (age, coronary risk factor profile etc) may provide vital clues to the seriousness of the current presentation.