Symptomatology in clinical practice

Dr. B. K. Iyer

Cardicare

Symptomatology terms

SymptomatologySymptomatology

Symptomatology is the clinical picture of all the patient's

symptoms and signs

Any deviation from health that can only

be perceived or felt by the patient

When a symptom has a

physical manifestation that can be detected by

others

Set of symptoms &

signs associated with & characteristic

of any one particular disease.

SymptomSymptom

SignSignSyndromeSyndrome

Symptomatology types

SymptomatologySymptomatology

AcuteAcute

SubacuteSubacuteChronicChronic

Symptomatology outcomesSudden worsening in

the severity of the symptoms / signs

OutcomeOutcome

Abnormal condition or

complication due to the original disease and remains after

original disease has resolved

Temporary improvement in the symptoms and signs of a disease without the underlying disease being cured

Return of the original

symptoms and signs of the

disease

ExacerbationExacerbation

SequelaSequela

RemissionRemission

RelapseRelapse

Symptomatology association

To fully understand

the symptoms, history is vital and thereafter

only a physical

examination

CurrentCurrent

Past Past medical / medical / surgicalsurgical

FamilyFamilySocialSocial

Drug Drug allergyallergy

HistoryHistory

A diagnosis is a

determination as to the

cause of the patient's

symptoms and signs

Symptomatology - significance

Attention to symptomatology is very important when it comes to -

HIV

Fever

Pain abdomen

Symptomatology - significance

Why so?

In HIV, misleading symptomatology is seen Due to diminished immunity Due to multiple opportunistic infections

Fever symptomatology of may be misleading Due to multiple causes Due to probability of rapid condition worsening

Misleading symptomatology in PUO

Check yourself up and tick the right answer:

The commonest cause of PUO is:1. A rare disease presenting in atypical way.

2. A common disease presenting typically.

3. A rare disease presenting typically.

4. A common disease presenting in atypical way.

Misleading symptomatology in PUO

The right answer:

The commonest cause of PUO is:4. A common disease presenting in atypical

way.Categories of Illness Causing PUO

Infections 30 - 40 %

Malignancies 20 – 25 %

Collagen Vascular Disease 10 – 20 %

Miscellaneous 15 – 20 %

Undiagnosed 10 – 15 %

Changes in terminology in PUO

Old Definition: Fever higher than 38.3oC on several occasions. Duration of fever – 3 weeks Uncertain diagnosis after 1 week of study in

hospital New definition:

Eliminated the in-hospital evaluation requirements → 3 outpatient visits, or 3 days in hospital. … Ambulatory as well as in hospital.

Classification in PUO

Classical PUO Nosocomial PUO

Immune related

Diseases to remember after initial inconclusive investigation reports:• DVT/PE, C diff, drugs

•Neutropenic PUO•HIV-Associated•Transplant

1) Neoplasm2) Sero-ve Collagen Vascular

Disease3) Increasing Tuberculosis4) Elderly with Endocarditis5) HIV with or without infection or

malignancy6) Implanted prosthetic devices7) Travel … New Exposure

Aetiologies of PUO

Infection: 3 major causes

1. Abscess .. especially occult ..

2. Intracellular organisms. (salmonella mycobacterium, brucella)

3. Intravascular … SBE

Sero –ve collagen vascula diseases, need to recognize the syndrome otherwise no diagnosis

1) Still’s disease(young / adult)2) Giant cell arteritis3) Polymyalgia Rheumatica4) Behcet’s Disease5) Relapsing polychondritis

15% of PUO

Remember not to forget travel, animal exposure.

Symptomatology changes in PUO

Failure to have quick response → does not mean wrong diagnosis: Endocarditis Pelvic Inflammatory Disease Typhoid Fever

Antimicrobial Therapy is expected to suppress, but not cure an infectious process such as abscess → may have false feeling of response.

Clues to aetiologies of PUO

Hyperthyroidism1. Occasionally cause

PUO → most frequently diagnosed clinically.

2. Often accompanied by weight loss.

Any drug can cause fever

Clues to aetiologies of PUO

Localizing Symptoms may indicate the source of fever

Back Pain TB Spondylitis / Bone Metastasis

Headache Chronic Meningitis/GCA

RUQ Pain Liver Abscess

LUQ Pain Splenic Abscess

Oral & Genital Ulcer Behcet’s Disease

Jaw Claudication Temporal Arteritis

Subtle changes in behavior Granulomatous Meningitis

Diagnostic delay has adverse effect in:

Intra Abdominal Infection

Miliary Tuberculosis

Recurrent Pulmonary Emboli

Disseminated Fungal Infection

Temporal Arteritis

Arnow PM. Fever of Unknown Origin. Lancet, 1997; 350:575-580

PUO in HIV patients

PUO in HIV patients

Diagnostic approach to PUO

Minimal Diagnostic tests for PUO

History+Physical exam. CBC & Diff Blood Cultures x 3 Chemistry Microscopy as needed LFTs

USG and Urine culture Chest X-ray Hepatitis serologies (if

abnormal LFTs)

Other Basic Tests for PUO

ESR/CRP ANA Rheumatoid Factor HIV testing IgM Mantoux

Invasive Procedures in PUO

Lumbar Puncture Biopsy

Liver Temporal Artery Bone Marrow Lymph Node

Surgical Exploration of the Abdomen

Imaging in PUO

CT Abdomen Chest

Nuclear Imaging Lower Extremity Dopplers Echocardiography

Clues to diagnostic tests of PUO

ESR & CRP is elevated in: Bacterial Infection Neoplasm Immunological-mediated

inflammatory states Tissue infarction

Bone marrow1) Granuloma±Tubercle Bacilli→TB

2) Aplastic Cells → Leukemia

3) Leishmania Bodies → Kala-Azar

4) Atypical Cells → Lymphoma

5) Atypical Plasma Cells M.myeloma

Arnow PM. Fever of Unknown Origin. Lancet, 1997; 350:575-580