American College of Physicians: Internal Medicine — Doctors for Adults ®


Evaluation and treatment of common symptoms

By Lola Butcher

A 37-year-old man presents with a six-month history of nonproductive cough. He has tried many over-the-counter cough suppressants without benefit. A non-smoker with no significant past medical history, he has a normal physical exam and a normal chest X-ray.

Meanwhile, a 26-year-old woman complains about dry coughing for a month. The problem started with an upper respiratory infection, but the nasal congestion and throat pain went away two weeks ago.

Would omeprazole be worth trying for either patient? Does either patient need an antihistamine?

Douglas S. Paauw, FACP, a general internist and professor of medicine at the University of Washington School of Medicine, said the evaluation and treatment of common symptoms—cough, fatigue, headache, dizziness and back pain—often represent the most challenging aspect of primary care medicine.

“We don’t have patients coming in, saying ‘I have lupus,’” he said. “What we get is a whole bushel of symptoms and we have to sort through them. How do we work them up? What is serious and what is not? Then how do we treat?”

Dr. Paauw, who holds the Rathmann Family Foundation Endowed Chair for Patient-Centered Clinical Education, will reprise a session from Internal Medicine 2006 that is based upon a board review course he has conducted many times.

For each of the five symptoms, Dr. Paauw will discuss how the symptom can lead to a diagnosis. In what circumstances is a physical exam helpful? When is a test necessary? When will recognition of a certain symptom complex in addition to the original symptom point to a specific diagnosis?

For example, many patients present with their self-diagnosis of a tension headache or sinus headache. In many cases, the true culprit is migraine.

“There is a remarkable under-diagnosis of migraine headache,” Dr. Paauw said. A study of nearly 3,000 women who believed they had been suffering sinus headaches found that 88% of them actually had migraines. [Arch Intern Med 2004;164 (16): 1769-1772]

“We’ll be looking at different clinical features that help us think of one headache type vs. another,” he said. “Doctors are good at treating headache if they figure out which type of headache they are seeing.”

Patients with chronic headache are frequently and unnecessarily sent for diagnostic imaging, he said. A review of more than 400 CT scans performed on patients with chronic headache found only four scans were significant and only one revealed an abnormality that could be treated. [CMAJ 1994;151(10):1447-1452] Another study of nearly 900 scans of patients with diagnosed migraine headaches found only four scans (0.4%) identified a treatable condition. [Report of the Quality Standards Subcommittee American Academy of Neurology.]

The bottom line: The routine use of neuroimaging is inappropriate for patients with recurrent headaches defined as migraine but no recent change in pattern, seizures or focal neurologic signs or symptoms.

Meanwhile, fatigue—a complaint of 20% of outpatients—requires equal skill in parsing out symptoms to determine whether the problem is primarily physical or psychological. One clue is duration of the symptoms. The longer the patient has suffered fatigue, the more likely that a psychological issue is the root cause.

Sleepiness caused by sleep apnea can masquerade as fatigue, Dr. Paauw said. His presentation will review indications pointing to apnea and a list of diagnostic tests appropriate for chronic fatigue patients. Many common laboratory tests are not useful for clarifying a fatigue-related diagnosis, and certain tests should not be ordered.

“It’s what people see all day,” he said. “It’s the stuff practitioners scratch their heads over and say ‘I wish I knew a little more about this because I see it all the time.’”


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