Chapter-4 COMMON SYMPTOM APPROACH, PPT.pptx

Approach to
Common Symptoms
Module-4

Learning objectives- Bleeding PR
At the end of the module non-specialist
medical officer must be able to:
 Enumerate the causes of rectal bleeding
 List the red flag signs
 Perform digital rectal examination
 Know criteria for referral to a higher
centre

BLEEDING PER RECTUM
 Rectal bleeding is a common symptom at all
ages, can present as an acute and
life-threatening event or as chronic bleeding,
which might manifest as iron-deficiency
anemia.
 The majority of patients with rectal bleeding
will have benign anal conditions such as
haemorrhoids or an anal fissure, but rectal
bleeding may also be a symptom of
inflammatory bowel disease or colorectal
cancer.
 It is significant in elderly as it may be the only
clue of underlying colon cancer.

Approach to a patient with rectal bleeding :
 Best practice in primary care will include careful
attention to history, presence or absence of perianal
symptoms, age of patient (in view of likely differential
diagnosis with each age group), family history of
colorectal malignancy and red flag symptoms including
weight loss, symptoms suggestive of anaemia, and
change in bowel habit.
 Rectal bleeding has a positive predictive value (PPV) for
colorectal malignancy of 8% in patients aged over 50
years of age
 Examination of the abdomen to exclude abdominal mass
and digital rectal examination (DRE) to examine for
fissure and exclude rectal cancer may be useful.

Investigations:
 Blood count to assess degree of anemia
 Renal and liver function test
 Fecal occult blood in unexplained anemia
especially in elderly males
 Ultrasound abdomen to look for mass.

Primary Care Management
 In low risk patients with rectal bleeding who are
not overly anxious, it is reasonable to manage
their symptoms with treatment and adopt a ‘watch
and wait’ policy.
 Minimally symptomatic haemorrhoids may be
safely observed. Patients with symptomatic
haemorrhoids should be given advice about
topical treatment, oral fluid intake,
Commissioning guide 2013 Rectal Bleeding high
fibre diet and fibre supplementation.
 Consideration should be given to referral to a
specialist community or secondary care provider
of colorectal services in case of red flag signs

Referral criteria
 Any patient with rectal bleeding who meets the
following criteria should be referred urgently
under the two week wait guidelines as
recommended by NICE Referral Guidelines for
Suspected Cancer:
1. aged ≥40 years with rectal bleeding and change
in bowel habit towards looser and/or more
frequent stools for 6 weeks or more
2. aged ≥60 years with rectal bleeding persisting for
6 weeks or more without change in bowel habit
and without anal symptoms
3. rectal bleeding and a palpable rectal mass

Learning objectives - Cough
Classify cough as acute, subacute and
chronic
Enumerate the causes of cough
Enumerate the red flag signs
Know criteria for referral to higher centre

COUGH
 ACUTE COUGH
 SUB ACUTE COUGH
 CHRONIC COUGH

History And Physical Examination
 Duration and character of cough.
 Smoking history and intake of drugs precipitating cough
( e.g. ACE inhibitor).
 History of contact with Tuberculosis should be sought
specifically.
 Red Flag signs: weight loss, associated with hemoptysis,
chronic smoking history, change in voice, persistent
cough
 At first, life threatening causes like pneumonia, asthma,
COPD, pulmonary embolism, bronchiectasis, lung
abscess, lung cancer, foreign body inhalation or
congestive cardiac failure have to be ruled out by
investigating symptoms, signs and laboratory
investigations.

Investigations
 Complete blood count to rule out infection
 chest x ray to look for pulmonary and cardiac
pathology
 pulmonary function tests in chronic obstructive
pulmonary disease
 sputum culture and sensitivity
Referral indications:
 Red flag signs, lung mass and cardiomegaly in
chest xray

Learning objectives - Dizziness
 At the end of the module non-specialist
 Enumerate the causes of dizziness
 Learn to take an appropriate history and
do clinical examination
 Know when to refer to higher centre

DIZZINESS
 This term is often vaguely used to describe
many conditions like light headedness, reeling
sensation, faintness and imbalance.
Causes
 Most dangerous being pre-syncopal dizziness
due to cardiac arrhythmia.
 orthostatic hypotension,
 medication effects,
 vertigo(vestibular causes),
 space occupying lesions,
 vascular causes like transient ischemic attacks,
migraine and arrhythmias.

History
 History plays a major role in delineating the cause for dizziness.
 Vertigo is an illusion of movement of one’s own self or the
surroundings.
 Patient should be enquired about the time of onset, nature, postural
variation, duration, frequency, associated features, provoking factors
and relieving factors. Based on the duration brief dizziness can be
attributed to orthostatic hypotension and benign paroxysmal positional
vertigo (BPPV). Vestibular migraine and meniere’s disease on the other
hand lasts for hours.
 Repeated attacks of dizziness should raise the suspicion of transient
ischemic attacks and migraine.
 Associated symptoms also help to assess the cause. Unilateral hearing
loss, tinnitus, ear fullness, ear pain point to a peripheral cause of vertigo
whereas unsteady gait, blurring of vision, diplopia, headache and
numbness suggest a central cause like a stroke or brainstem lesion.
 Postural variation leading to dizziness is commonly seen in benign
paroxysmal positional vertigo and orthostatic hypotension.

Examination
 As most of the causes point to a neurologic dysfunction special attention should
be given to this system in these patients. The most important step is to
differentiate a peripheral cause from a central one.
 Looking for eye movements and nystagmus and hearing is of prime importance.
The range of eye movements should be observed and both eyes should be
compared for any asymmetry.
 Pursuits and saccades should be checked. Poor pursuits or inaccurate saccades
generally point to a central disease.
 Nystagmus is mostly jerk type. Look for primary position nystagmus in light, if
present it indicates a central pathology. Even upbeat nystagmus and gaze
evoked nystagmus favour central disease.
 All patients with episodic dizziness with positional variation should be tested
with Dix-Hallpike maneuver, Testing for hearing abnormalities is done to rule
out meniere’s disease and acoustic schwannomas. Cerebellar functions
including gait have to be meticulously examined to look for cerebellar
pathology. An intentional tremor, past pointing and swaying while walking
favour a cerebellar disease.
 Investigations
 Routine blood investigations to rule out anemia , diabetes and renal failure
 Electrocardiogram to rule out arrhythmia
 Referral indications : focal neurological signs, arrhythmias

Learning objectives - Breathlessness
 Define breathlessness
 Enumerate the causes of breathlessness
 Do appropriate clinical examination
 Interpret chest radiograph and ECG in a
patient with breathlessness

BREATHLESSNESS ( DYSPNOEA )
 Breathlessness is defined as subjective experience of
breathing discomfort that consists of qualitatively
distinct sensations that vary in intensity.
 Dyspnea a symptom can be experienced only by the
person experiencing it and must be distinguished
from the signs of increased work of breathing
HISTORY
 Duration of dyspnea,
 progression ,
 changes with position,
 associated symptoms like cough, chest pain, smoking
history.

Physical Examination
 Respiratory rate and measure the pulsus paradoxus,
 signs of anaemia, cyanosis, cirrhosis (spider angiomata,
gynaecomastia)
 Examination of chest
 Percussion(dullness is indicative of pleural effusion and
hyperresonace is a sign of emphysema),
 Auscultation(wheeze, rhonchi, prolonged expiratory phase,
diminished breath sounds are clues to disorders of airway; rales
suggest interstitial edema, and fibrosis).
 Cardiac examination should focus on elevated JVP, left
ventricular dysfunction, and valvular disease.
 Clubbing of the digit may be an indication of interstitial
pulmonary fibrosis

Investigations
 Baseline blood investigations to look for
anemia, liver and renal failure
 Chest x-ray to look for cardiac and pulmonary
pathology
 Electrocardiogram to rule out cardiac pathology
Referral indications :-
 Acute dyspnea, increased respiratory rate,
decreased oxygen saturation, evidence for
cardiac or respiratory failure

Learning objectives - Fatigue
 Enumerate the causes of fatigue in the
elderly
 Take appropriate history and do relevant
clinical examination

FATIGUE
 Fatigue is a major disabling symptom of the old age which can be
related to a wide number of systemic, neurologic and psychiatric
conditions.
 It is an inherently subjective human experience of physical and mental
weariness, sluggishness, and exhaustion. Fatigue is practically defined
as difficulty in initiating or maintaining voluntary mental or physical
activity.
 Fatigue should be distinguished from muscle weakness, a reduction of
neuromuscular power, somnolence and dyspnea on exertion.
 Although fatigue can be a presenting feature of malnutrition, nutritional
status may also be an important comorbidity and contributor to fatigue
in other chronic illnesses, including cancer-associated fatigue. it can be
sometimes presenting feature of congestive cardiac failure,
cardiopulmonary disease.
 Most of the times the underlying cause couldn’t be made out and are
categorized under chronic fatigue syndrome. A detailed history,
examination may be required to avoid extensive workup and treatment

History
 A detailed history should be collected focusing on the onset, quality,
duration, diurnal variation, associated symptoms, aggravating and
relieving features. All these in total can give a clue to the syndrome,
that is to determine whether fatigue is primarily mental, physical or
both.
 History should be taken to differentiate fatigue from extensive daytime
sleepiness, dyspnea on exertion, exercise intolerance and muscle
weakness. any complaints of fever, chills, night sweats, or weight loss
should raise suspicion for an occult infection or malignancy.
 A careful personal history is taken to know the addictions. And in case
of alcoholics a proper detail of the type and amount consumed is noted.
 Treatment history should include antidepressants, antipsychotics,
anxiolytics, any drug withdrawl.
 Minimal neurological examination to be carried out to rule out objective
neurological weakness.
 Fatigable weakness is usually seen in neuromuscular disorders, but
doesnot have breakaway quality as seen in fatigue.

 A quick and thorough examination is done to
screen for any signs of cardiopulmonary
disease, malignancy, lymphadenopathy,
organomegaly, infection, liver failure, renal
failure, malnutrition and connective tissue
diseases
Referral indications :-
 Evidence of underlying organic pathology
 Depression
 Drug addictions

Learning objectives - Fever
 Define fever, hyperpyrexia, hyperthermia
and pyrexia of unknown origin
 Recognize varied presentation of fever in
the elderly

FEVER
 Fever the most common symptom of any infection or disease process is
defined as an A.M temperature of >37.2ºC(98.9ºF) or a P.M
temperature of >37.7ºC(99.9ºF).
 A fever of >41.5ºC(106.7ºF) is called hyperpyrexia. It occurs in patients
with severe infections but most commonly seen in CNS haemorrhages.
 Hyperthermia (heat stroke) is characterized by an uncontrolled increase
in body temperature that exceeds the body’s ability to loose heat.
Exogenous heat exposure and endogenous heat production are the two
mechanisms by which hyperthermia can result in dangerously high
internal temperatures. Hyperthermia is often diagnosed on the basis of
events immediately preceding the elevation of core body temperature.
Antipyretics do not reduce elevated temperature in hyperpyrexia.
 Fever that is undiagnosed after 3weeks of evaluation is called Fever of
Unknown Origin (FUO)
 Age related impairment in thermoregulation and decreased sweating
predisposes elderly to hyperthermia. Also elderly may fail to mount an
increase in temperature in response to infection so they may have
infection without fever

History
History regarding the onset of fever, duration, progression, grade of fever, diurinal
variation, number of episodes per day, association with chills and rigors, association
with skin rash, joint pains, convulsions, association with bleeding manifestations,
relief with medication is necessary.
.
 Eyes, ears, nose, oral cavity, lymphadenopathy, extremities, skin, examination
 Recording the pulse rate, respiratory rate, blood pressure, temperature play a
crucial role in clinical examination.
 Systemic examination includes respiratory, cardiovascular, gastrointestinal,
neurological, rheumatological systems.
 LABORATORY REPORTS
 COMPLETE BLOOD COUNT
 Urinalysis to exclude UTI
 Cultures
 Serology
 Abdominal Ultrasonography to look for mass and abscess
Referral indications
 Fever of unknown origin, associated with weight loss, with hemodynamic
instability

Learning objectives - Headache
 Enumerate the different types of primary
and secondary headache
 Recognize the red flag signs in a patient
with headache

HEADACHE
 Headache is being responsible for more disability than any other
neurological problem.
primary or secondary Headache
 Primary headaches are those in which headache and its associated
features are the disorder in itself. Primary headache often results in
considerable disability and a decrease in patients quality of life.
 whereas secondary headaches are those caused by exogenous disorders.
Mild secondary headaches ,such as that seen in association with upper
respiratory tract infections, is common but rarely worrisome.
 Life-threatening headache is relatively uncommon, but vigilance is
required in order to recognize and appropriately treat such patients.

Common causes of headache
Primary headache Secondary headache
Tension type Systemic infection
Migraine Head injury
Idiopathic stabbing Vascular disorders
Exertional Subarachnoid hemorrhage
Cluster Brain tumor

History and clinical evaluation
 Duration of headache, diurnal variations, localization, and any
associated symptoms like nausea, vomittings, photophobia, lacrimation,
rhinorrhea etc.
 The patient who presents with a new, severe headache has a differential
diagnosis that is quite different from the patient with recurrent
headaches over many years.
 In new-onset and severe headache, the probability of finding a
potentially serious cause is considerably greater than in recurrent
headaches.
 Serious causes to be considered include meningitis, subarachnoid
hemorrhage, epidural or subdural hematoma, glaucoma, tumor, and
purulent sinusitis.

Investigations
 Complete blood count to rule out infections and malignancy
 Blood chemistry
 CSF analysis in suspected case of meningitis
 Imaging studies of brain in suspected case of tumor and sub
arachnoid hemorrhage
 Red flag signs : sudden severe headache, associated with focal
neurological signs, aggravated with bending and coughing
 Temporal(giant cell) arteritis is an inflammatory disorder of
arteries that frequently involves the extracranial carotid
circulation. It’s a common disorder of elderly, affects above 50
age group and women account for 65% of cases.
Referral indications :
 presence of red flag signs and persistent headaches

Learning objectives: Insomnia
 Define insomnia
 Enumerate the types and consequences of
insomnia
 Counsel the patient regarding sleep
hygiene

INSOMNIA
 Insomnia is an experience of inadequate or poor-quality sleep
characterized by one or more of he following problems:
 difficulty falling asleep,
 difficulty maintaining sleep,
 waking up too early in the morning and sleep that is not refreshing.
 Insomnia also involves daytime consequences such as
 fatigue,
 lack of energy,
 difficulty concentrating and irritability.
 Chronic insomnia refers to sleep difficulty occurring at least three
nights per week for one month or more.
 The prevalence of insomnia increases with age and is more common in
women

Causes of Insomnia
 Acute insomnia
--an emotional or physical discomfort
 Chronic insomnia
--caused by many different factors acting singly or in
combination and often occurs in conjunction with other health
problems.
Consequences
 Acute insomnia
--sleepiness, negative mood and impairment of performance.
 Chronic insomnia
--complain of fatigue, mood changes (e.g., depression,
irritability), difficulty concentrating and impaired daytime
functioning

Assessment
 Assessment should include specific questions
concerning sleep onset, sleep maintenance, and
early-morning wakening as these will provide clues
to the causative agents and to management.
 Patients should be asked about previous sleep
problems, screened for depression and anxiety, and
asked about symptoms of thyroid disease. Caffeine
and alcohol are prominent causes of sleep problems,
and a careful history of the use of these substances
should be obtained.
 Both excessive use and withdrawal from alcohol can
be causes of sleep problems.

Interventions
 The mainstays of intervention include
improvement of sleep hygiene
(encouragement of regular time for sleep,
decreased nighttime distractions, elimination
of caffeine and other stimulants and alcohol),
intervention to treat anxiety and depression,
and treatment for the insomnia itself.
Referral indications :
 evidence of underlying organic disease,
failure of non pharmacological measures.

• Regular sleep/wake cycle
• Regular exercise morning/afternoon
• Increase exposure to bright light during day
• Avoid exposure to bright light during night
• Avoid heavy meals/ drinking <3 hrs of bedtime
• Enhance sleep environment
• Avoid caffeine, alcohol, nicotine
• Relaxing routine
• Warm bath/socks
Principles of Sleep Hygiene

Learning objectives : Pain
 Define pain
 Do pain assessment
 Do pain intensity meaurement

PAIN
 Pain is an unpleasant sensation localized to
a part of the body. It is often described in
terms of a penetrating or tissue-destructive
process (e.g., stabbing, burning, twisting,
tearing, squeezing) and/or of a bodily or
emotional reaction (e.g., terrifying,
nauseating, sickening).

Pain assessment and physical examination
 The treatment of pain begins with the assessment of what instigated the
pain, how it can be terminated, and what management modalities are
most effective for a particular patient.
 When a patient presents with pain we should ask for the site, character
of the pain, onset, progression, duration, radiation, diurnal variations,
aggravating and relieving factors.
 Clinical manifestations of persistent pain are often complex and
multifactorial in the older population
 the elderly patient's condition is often complicated by depression,
psychosocial concerns, denial, poor health, and poor memory.

Pain Intensity Measurement
The visual analogy scale (VAS),
Verbal descriptor scale
Numerical rating scale
The McGill Pain Questionnaire

Visual Analogue Scale (VAS)-for-assessment of pain.

After assessing the intensity of pain, one should
perform a thorough examination
.
 Complete history and physical examination, with focus on most
pressing pain issues
 Review of location of pain, intensity, exacerbating and/or
alleviating factors, and impact on mood and sleep
 A screen for cognitive impairment such as the Folstein
minimental examination
 A screen for depression
 A review of the patient's ADLs (bathing, dressing, toileting,
transfers, feeding, and continence) and instrumental ADLs (use
of phone, travel, shopping, food preparation, housework, laundry,
taking medicine, handling finances)
 Assessment of gait and balance
 A screen for sensory depression to examine basic visual and
auditory function

Pain management modalities in the elderly
 Treatment modalities for pain in the elderly
may be categorized into the following areas
1) Pharmacotherapy (most commonly
employed)
2) Psychological support
3) Physical rehabilitation
4) Interventional procedures

Learning objectives: Pruritis
 Define pruritis
 Enumerate the causes of pruritis
 Give symptomatic treatment

PRURITUS
 Pruritus is defined as an unpleasant sensation that
provokes the desire to scratch. It is a common
symptom, rather than a specific disease entity, that
occurs in a diverse range of skin diseases and may
appear as a prominent feature of extracutaneous
disorders such as systemic, neurologic, and
psychiatric diseases.
 Pruritus is a subjective sensation; therefore, the
diagnosis is based solely on the patient's symptoms
 Most common cause of pruritis in elderly is age
related alteration in skin structure and xerosis
which can be managed with emollients and
reassurance.

History:
 Disease history typically reveals the onset of pruritus, its
intensity, and sleep disturbances related to it.
Physical examination
Itch can be divided into pruritoceptive, neurogenic, neuropathic,
psychogenic. Dermatological pruritus is diagnosed in patients with
primary skin lesions that can be linked with itch sensation.
Investigations:
If a condition cannot be diagnosed based on the clinical findings
alone, further investigation is warranted
 atopic dermatitis or urticaria,
 A skin biopsy
 Microscopy of skin scrapings
 Stool microscopy
Treatment:
 Antihistaminics, steroids, treatment of underlying cause

Learning objectives: Seizure
 Define seizure
 Classify seizures
 Take appropriate history and do physical
examination
 Give first aid and refer to higher centre

SEIZURE
 Seizure is a paroxysmal event that occurs due
to abnormal excessive or synchronous neuronal
activity in the brain. Highest incidence of
seizures is seen in early childhood and oldage.
 Seizure and epilepsy are two different entities.
 Any single episode of seizure or recurrent
episodes of seizures due to correctable
conditions does not imply that the patient has
epilepsy. Before approaching a patient with
seizures it is essential to classify the seizure
activity.

Classification of seizure
 Focal seizures can be motor, sensory, autonomic and cognitive.
 Generalized seizures on the other hand can be absence tonic
clonic, tonic, atonic and myoclonic.
History
 Details of episode to be elicited from patient / care giver, rule out
common causes (CVA, hypoglycemia, electrolyte imbalances).
 Determine risk factor & precipitating events.
 Exclude Syncope, TIA, Migraine etc.
Examination
 head to toe examination, Signs of head trauma
 Skin should be searched for neurocutaneous markers
 signs of renal failure or liver failure.
 all peripheral pulses and auscultation of heart and carotid vessels
 a complete neurological examination

Investigations:
 A routine blood work up is done to rule out
metabolic derangements.
 Investigations at higher centre include EEG,
Brain imaging
Treatment:
 Antiepileptics
 Correction of underlying metabolic
abnormalities
 Treatment of underlying cause

Learning objectives: Vomiting
 Enumerate the causes of vomiting
 Give symptomatic treatment
 Know when to refer tom higher centre

VOMITING
 Vomiting (emesis) is the oral expulsion of
gastrointestinal contents due to
contraction of gut and thoracoabdominal
wall musculature
Causes of emesis
nausea and vomiting are caused by
conditions within and outside the gut as well
as by drugs and circulating toxins

History and physical examination
 the history helps define the etiology of nausea, vomiting. Drugs,
toxins, and infections often cause acute symptoms, whereas
established illnesses evoke chronic complaints.
 Gastroparesis and pyloric obstruction elicit vomiting within an
hour of eating.
Diagnosis :
 Routine blood investigations to rule out infections and organ
failure
 Imaging of chest and abdomen to rule out bowel obstruction.
 Referral indications: Hematemesis, evidence of bowel
obstruction, chronic vomiting associated with weight loss
Treatment:
 Identify and correct the fluid and electrolyte imbalances
 Treat the underlying cause
 Anitemetics

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