Approaches to symptoms of disease

Authors : NIGEL FONG
Edition :
Year : 2016
Description :

Patients present with symptoms and not named diseases.
Faced with a clinical problem, it is insufficient to know individual diseases; rather, being able to work forward from symptoms to diagnosis is key. Memorized lists of differentials are burdensome and unhelpful; it is far better to have well-reasoned algorithms that not only lists differentials, but also identifies what are likely vs what is unlikely but critical to exclude, and how to distinguish each differential from the other in a particular patient.These notes attempt to suggest a thought process that
leads towards diagnosis, incorporating history, physical exam, and initial investigations. I emphasize clinical utility over theoretical beauty, favouring clinical differentiators over pathological classifications as branch points in the schemas. Diseases predominantly managed by different
specialties are discussed simultaneously – the dichotomy between ‘medical’ and ‘surgical’ disease is false anyway.


Some cautions are in order. First, clinical reasoning needs to be fluid and flexible, and not a ‘checklist’. Do not memorize an approach, rather, make sense of it and work it out. My aim is to describe the thought process, rather than provide a protocol to follow. A useful exercise would be to read the suggested approach, set it aside, and without referring, attempt to draw out the approach in
flowchart form from first principles, as well as logically deduce appropriate initial investigations. Then look again at the suggested approach and note what you have missed out.
Secondly, this is neither a replacement for your textbook,nor a substitute for solid clinical reasoning. It is written to be concise, hence –
• Knowledge of basic content, history taking, and clinical examination skills are assumed.
• As the focus is on differential diagnosis and initial workup, detailed investigation and management of individual diseases is not discussed. Use approaches as a roadmap to read up on individual diseases.
• Images are omitted for the sake of brevity and to sidestep copyright issues, do look up relevant
photos and radiographs.
• Rare diseases are usually excluded.


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