“Patient suffers from disease but presents with symptoms”-Dr.Sarker.

When a patient comes to chamber of a physician or hospital, we as a doctor listen to him or her. Patient tells the main problems which we call chief complaints. The doctor should construct a list of differential diagnosis in mind and allow the patient to tell his story freely. Then the doctor would be clear about the history by asking undirected (open) questions (e.g. tell me more about abdominal pain) and directed questions (e.g. is it colicky?) about the relevant facts-past history, family history, drug history and social history. A careful history will narrow down the differential diagnosis. In primary and secondary level there is a little scope to do the extensive investigations and get specialist opinion, there is no alternative to careful history taking and proper physical examination, even if facility of investigation is available.

At the end of history and examination the physician should have to reach a provisional diagnosis that is usually confirmed by investigations. But in primary level in our country there is little scope to do full investigation because of unavailability, so the physicians have to rely on clinical diagnosis.

 

A patient with fever

Fever is a common presentation to the general practitioners. Fever is a usual presentation of infection but may be due to other diseases like lymphoma, connective tissue disease. There is a wide range of differential diagnosis for fever but careful history (e.g. duration, pattern of fever) will narrow down the list and clinical examination and proper investigation will lead to reach the diagnosis. Most of fever are trivial and due to viral causes and self-limiting and needs no treatment.

History regarding fever–

Symptoms of common respiratory infections– sore throat, nasal discharge, sneezing and sinus pain.

Symptoms of lower respiratory tract infection (cough, sputum, wheeze or breathlessness).

Genitourinary symptoms-Ask specifically about frequency of micturition, dysuria, loin pain, and vaginal or urethral discharge (urinary tract infection, pelvic inflammatory disease and sexually transmitted infection (STI)).

Also enquire about sexual contacts with or without protective contraception (STI, blood-borne viruses).

Abdominal symptoms-Ask about diarrhoea, with or without blood, weight loss and abdominal pain (gastroenteritis, intra-abdominal sepsis, inflammatory bowel disease, malignancy).

Joint symptoms– Active arthritis is suggested by joint pain, swelling or limitation of movement.

Rash– Enquire about appearance and distribution.

Travel history– Always ask about foreign travel. If the patient has been in an endemic area, malaria must be excluded, whatever the presenting symptoms.

Drug history– Drug fever is uncommon and therefore easily missed. The culprits include penicillins and cephalosporins, sulphonamides, antituberculous agents, anticonvulsants (particularly phenytoin), methyldopa and quinidine.

Alcohol consumption-Alcoholic hepatitis, cirrhosis and hepatocellular carcinoma are all recognised causes of fever.

 

1. A patient with fever and running nose

A 25 years gentle man presents with 3 days fever with running nose.

What would you consider as differential diagnosis?

Common cold (Acute coryza)

Allergic rhinitis

 

What key questions would you ask?

Single attack- common cold, (it may recur by years)

Recurrent or persistent attacks- Allergic rhinitis

Rapid onset, Sneezing, Sore throat, Watery nasal discharge which becomes mucopurulent or purulent after 24 to 48 hours and Cough- common cold.

Same features but nasal discharge remains watery all along-allergic rhinitis. Positive family

History/ history of asthma and eczema.

Fever-prominent in common cold, feverish in allergic rhinitis.

 

What will you examine?

Nasal inspection- erythematous congested mucosa- common cold

Pale shiny mucosa- allergic rhinitis

Mucopurulant discharge- bacterial rhinosinusitis –complication of common cold.

Auscultation of lungs- rhonchi- acute bronchitis- complication of common cold.

Atopic asthma-association of allergic rhinitis

Initial investigations- Diagnosis is clinical. May do blood test for TC, DC, Hb% and ESR.

Eosinophilia (>6%) in allergic rhinitis.

Provisional diagnosis- Common cold (Acute coryza)

Treatment- no specific treatment.

Paracetamol 0.5-1 g 4-6-hourly.

Nasal decongestant.

Antibiotics not necessary if uncomplicated.

 

What are the complications of common cold?

Sinusitis

Bronchitis

Pneumonia.

Hearing impairment, otitis media due to blockage of Eustachian tubes.