SYMPTOMS ASSESSMENT
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.
PAIN
Ascertain:
1. The nature of the onset and the events surrounding the onset (gradual or sudden). If the pain was of sudden onset, what was the patient doing at the time?
2. Precipitating factors
3. Exact location and radiation
4. Severity and character
5. Factors that exacerbate or relieve the pain
6. Duration, diurnal pattern, temporal pattern, progression
7. What the patient has done so far in addressing the pain (e.g. doctors involved, medication taken), including non-pharmacological means that have been tried, such as acupuncture, chiropractic and physiotherapy.
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:
The differential diagnoses that need to be considered can be grouped under six broad subheadings for ease of comprehension and memorising:
• Traumatic injury
• Mechanical—muscular, postural, spondylosis (prolapse of the vertebral disc), spinal stenosis, diffuse idiopathic skeletal hyperostosis (DISH), spondylolisthesis, fibromyalgia
• Inflammatory—ankylosing spondylitis, sacroiliitis due to any seronegative arthropathy, septic arthritis of the sacroiliac joint (more common in the young male adult)
• Metabolic—osteoporosis-associated pathological fracture, osteomalacia, Paget’s disease of bone, renal osteodystrophy
• Neoplasia—metastatic cancer, multiple myeloma, primary bone tumour
• Referred pain
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.
Headache
Vital elements of the clinical assessment include:
1. The factors listed above, under ‘Pain’
2. Associated other symptoms, such as:
• neck stiffness and photophobia—suggesting meningitis
• gastrointestinal symptoms, transient neurological deficit—suggesting migraine
• jaw claudication—suggesting temporal arteritis
• purulent nasal discharge and facial tenderness—suggesting chronic sinusitis
• eye irritation—suggesting cluster headache
• early-morning exacerbation—could suggest increased intracranial pressure, chronic renal failure with azotaemia or obstructive sleep apnoea.
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.
