Evidence-based tips for common illnesses
From the July ACP Internist, copyright © 2008 by the American College of Physicians
By Jessica Berthold
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Most internists have seen it hundreds of times: the Middle-Aged Patient Who Can't Stop Coughing. He's otherwise healthy and doesn't smoke; his chest X-ray and physical exam are normal.
About 70% of internists would prescribe a trial of omeprazole for the patient, if the audience at an Internal Medicine 2008 session is any indication. But they would be wrong, according to Douglas Paauw, FACP, who led a talk—and quiz—on evaluating and treating common symptoms.
"For 'professional coughers,' it's best to start off with a combination of antihistamine and decongestant," Dr. Paauw said, detailing the results of a 1993 Annals of Internal Medicine study on the subject. "And you must pick a drying antihistamine that makes them sleepy."
It was just one of the evidence-based tidbits the expert tossed at the audience during his session, which covered the bread-and-butter symptoms of the general internist: headache, cough, fatigue and dizziness. Attendees did fairly well on certain quiz items, like evaluating chronic fatigue syndrome, and less impressively on others, like discerning different kinds of headache.
Coughing up the right answer
Three separate studies in the 1990s showed that chronic cough can have different causes, with postnasal drip, asthma and gastroesophageal reflux disease (GERD) the most common culprits, Dr. Paauw said.
"Persistent cough may also have more than one cause in the same patient," Dr. Paauw noted.
The 1993 Annals study found that, for patients who had been coughing for a mean of 140 weeks, 55% saw a big improvement in cough during the first week of taking a sedating antihistamine/decongestant combination. Those who didn't improve and still had postnasal drip symptoms followed an algorithm: First add nasal corticosteroids to the combination treatment, then evaluate and treat for asthma, then evaluate and treat for GERD.
"Almost all of the patients in the study got better when this algorithm was used," Dr. Paauw said.
A separate 2003 study in Chest found that 79% of patients with GERD responded to daily treatment with proton pump inhibitors, with or without promotility agents, after one month. Half of them took more than two weeks to improve, however.
"So the lesson is, don't give up after one to two weeks on treatment for GERD. Tell your patients to be patient and stick with the treatment, and bring them back to your office in a month," Dr. Paauw said.
For patients with a shorter-term, productive cough—say three weeks—the diagnosis is usually acute bronchitis caused by a virus. Antibiotics, beta agonists and cough suppressants don't tend to do much good … but a spoonful of honey might.
A single dose of buckwheat honey before bedtime significantly resolves symptoms of upper respiratory tract infections, while honey-flavored cough medicine doesn't, a 2007 study in the Archives of Pediatric Adolescent Medicine found.
"I'd say, if you're going to prescribe something for bronchitis, you might as well prescribe something that's totally safe," said Dr. Paauw.
Pertussis—a growing problem in the U.S.—usually just presents as a nagging, persistent cough, though cough-induced vomiting and subconjunctival hemorrhage/petechiae can occur. Erythromycin and trimethoprim/sulfadiazine can be effective treatments, but only if given within eight days of symptom onset.
"Usually patients come in after that time window, so it may not help to prescribe anything after a week," Dr. Paauw said.
Getting a handle on headache
Another quiz item about headache that Dr. Paauw presented to the audience yielded a lackluster response: 46% chose the right answer when asked what their next step should be. The item dealt with a 46-year-old man who had developed a severe headache in the morning at work. He also had nausea, shoulder and neck stiffness, and one episode of emesis. He reported no history of migraines or similar headaches.
One should suspect a potential subarachnoid hemorrhage, so a computed tomography (CT) scan without contrast would be the next step. This is the best test when looking for blood, Dr. Paauw said.
"Doctors often miss this diagnosis," Dr. Paauw said. "They think it is a pulled neck muscle … then the patient comes to have a subarachnoid hemorrhage."
Subarachnoid hemorrhage can be recognized by:
- sudden onset of "the worst headache of my life,"
- average age of 46,
- neck pain, and
- nausea and vomiting in about 20% of cases
Migraines are another common cause of visits to the general internist, Dr. Paauw said. In fact, a 2004 study in the Archives of Internal Medicine showed that many of the headaches that patients and doctors believe are sinus headaches are actually migraines. These patients reported sinus pressure, sinus pain and nasal congestion—but upon further questioning, also had symptoms of migraines.
"Sinus headaches usually come with fever and purulent drainage, and they are not chronic," Dr. Paauw said. "If you go beyond the sinus symptoms and keep asking questions, you'll often discover a so-called sinus headache is actually a migraine."
Muscle or "tension" headaches usually aren't severe enough to bring a patient to the doctor's office, so they are an unlikely cause, he added. Cluster headaches have a fairly unique profile—10-20 minutes of intense pain, followed by a lull for several hours, then another 10-20 minute episode. Ninety percent of the time, cluster headaches occur in men—usually men who smoke.
The POUNDing pneumonic is a way to remember the classic symptoms of migraine, Dr. Paauw said. The more symptoms a patient has, the higher likelihood the headache is a migraine. The pneumonic is:
- Pulsating
- 4-72 hOurs duration
- Unilateral
- Nausea
- Disabling
Migraines also tend to get worse with activity, and are more common in people with a family history and who get motion sickness easily. Neuroimaging isn't warranted with patients who have recurrent migraine headaches, he added.
"Duration is a big sign with migraines. Not many other kinds of headaches last so long," Dr. Paauw said.
Ferreting out fatigue's cause
Fatigue is the seventh most common symptom in primary care: it occurs in about 20% of outpatients, and is the specific reason for 3% to 4% of visits, Dr. Paauw said. Fatigue is also a tricky symptom, because it is often confused with sleepiness, and takes some detective work to determine if the cause is primarily physical or psychological.
Key signs that the cause is psychological are that the fatigue is chronic and its progression fluctuates; its onset followed a problem or conflict; it is present in the morning and improves during the day; and it is unaffected by sleep. Physical causes, on the other hand, tend to increase as the day progresses and get worse over a period of time. Sleep usually provides some relief—with patients feeling their best in the morning.
"A person with an overwhelming physical illness usually feels better after she rests, then gets pooped later on," Dr. Paauw said. "A depressed person is tired in the morning, becomes activated as the day goes on, then gets tired at the end of the day."
When describing symptoms, patients often have trouble differentiating between sleepiness (falling asleep at inappropriate times) and fatigue (lack of energy). Sleepiness may indicate sleep apnea, signs of which include snoring, daytime napping, morning headaches, hypertension and trouble losing or maintaining one's weight, he said.
Research indicates the following tests are useful in diagnosing chronic fatigue syndrome: Alanine transaminase (ALT), renal function/electrolytes/glucose, sedimentation rate, thryoid stimulating hormone (TSH) and HIV if risk factors are present. Other tests, however, have not been shown to be useful, such as: Epstein-Barr virus serologies and other viral serologies, electrocardiogram (unless the patient has high risk or signs of cardiac disease), and chest X-ray (unless the patient smokes), Dr. Paauw said.
Dealing with dizziness
Taking a thorough patient history is always important—and that's especially so when determining the cause of dizziness.
Douglas Paauw, FACP: "History is your best tool in sorting out dizziness."
"History is your best tool in sorting out dizziness," Dr. Paauw said.
If you have an older patient who gets dizzy when she stands up and tries to walk, ask her if she feels better when she touches a wall or leans on another person. If so, the diagnosis is probably multiple sensory deficits—a combination of poor vision, poor hearing and orthopedic deformities that make her feel off balance. The solution is a cane or a walker, and some education—especially about her risk of falls.
Meanwhile, a patient who, upon describing the dizziness, has trouble being specific is a likely candidate for an anxiety or panic disorder.
"This is the patient that drives you crazy when you try to get an explanation. She'll say her head feels like it's floating," said Dr. Paauw. "The telltale sign (of anxiety/panic disorder) is that the sensation is present at all times. Have her hyperventilate to see if it brings symptoms. If so, educating her on the condition can bring a lot of relief."
Benign paroxysmal positional vertigo (BPPV) is marked by nighttime episodes of dizziness which last about 15-30 seconds, and usually occur when the patient rolls over in bed, Dr. Paauw said. The patient will often describe the sensation as the room spinning around him. The Epley maneuver is a good first treatment, with research showing that half of patients see their symptoms resolve by 10 days after the treatment.
"Drugs aren't very useful due to the brevity of the attacks. They should be considered only in patients who don't respond to Epley and who have very frequent attacks," Dr. Paauw said.
The vertigo associated with brainstem ischemia also produces a spinning sensation, but the feeling is constant and has an acute onset. Other key signs are vertical nystagmus and an increased feeling of vertigo when the Dix-Hallpike maneuver is performed.
"If the vertigo is still happening after three times doing the Dix-Hallpike maneuver, this means something," Dr. Paauw said. "Most central vertigo patients are older and have atherosclerosis, as well as other brainstem or cerebellar symptoms."
For more on particle repositioning maneuvers, see the PIER module on BPPV at http://pier.acponline.org/physicians/diseases/d310/d310.html
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Test yourself on common symptoms
The following cases were presented during Dr. Paauw’s talk on “Evaluation and Treatment of Common Symptoms” at Internal Medicine 2008. Answers are at the end.
1. A 26-year-old woman presents with a three-week history of cough. The cough began at the time of an upper respiratory tract infection with nasal congestion and sore throat. The nasal congestion and throat pain resolved two weeks ago, but a productive cough has persisted. Her physical exam is unremarkable. At this point, what would you recommend?
A. Azithromycin for 5 days
B. Doxycycline for 7 days
C. Amoxicillin for 7 days
D. Chest X-ray
E. Omeprazole 20 mg po qd
F. None of the above
2. A 29-year-old woman reports having headaches about twice a month. She feels pain behind her right eye and, frequently, pain on her forehead. Her headaches often get better with 550 mg of Naprosyn. She has never had visual problems or nausea with her headaches. The headaches are worse with exercise. About once a month the headache is bad enough to force her to leave work early. What is the most likely type of headache she’s having?
A. Migraine
B. Cluster
C. Muscle tension
D. Nitrate headache
E. None of the above
3. A 29-year-old woman reports she has had frequent headaches over the past 12 months that include pressure pain on her forehead, under her eyes and over her cheeks. She usually has nasal congestion as well. She has not had any fevers or purulent nasal discharge. What is the most likely problem?
A. Cluster headaches
B. Migraine headaches
C. Sinus headaches
D. Tension headaches
4. A 34-year-old woman reports she has had severe fatigue for the past eight months. It began suddenly following a flu-like illness last winter. This illness was characterized by 10 days of high fever, myalgias and tender adenopathy. Since then she has had to cut back to 50% time at work, goes to bed at 7 p.m. every night and wakes up unrested. Exercise makes her fatigue much worse. Outside tests include a normal CBC, ESR, TSH, SMA 20, Monospot test, and negative HIV test. Her physical exam is normal. What is the next step in evaluation?
A. EBV serologies
B. Mammogram
C. Abdominal CT scan
D. Blood cultures
E. None of the above
5. A 22-year-old woman has had headaches for the past six months, occurring four to five times a month. The headaches are of great intensity, involving the right side of her head, with the maximum intensity of pain occurring behind her right eye. Symptoms worsen with exertion. The headaches last three to six hours, are sometimes associated with nausea, and on two occasions have been preceded by a scotoma in the right eye. Neurologic exam is unremarkable. What would you recommend next?
A. CT scan without contrast
B. CT scan with contrast
C. MRI
D. MRA
E. No imaging
6. A 31-year-old construction worker reports feeling tired all the time. She has trouble getting through the workday and worries that she may have a serious illness. Her fatigue has worsened since she was recently promoted to foreman, a job that requires longer work hours and a higher stress level. Which of the following symptoms are concerning for a physical rather than a psychological cause of her fatigue?
A. Symptoms relieved by sleep
B. Symptoms increased during periods of stress
C. Symptoms better later in the day
D. Symptoms for the last 10 months
E. Symptoms that began at the time her father died
7. A 37-year-old woman reports onset of “migraine” headaches at age 20. She had two to three a month until about 18 months ago, when the frequency increased to six to eight headaches a month. Over the past six months she has had headaches almost every day. Her physical exam included a normal neuro exam. What is the most appropriate recommendation for this patient?
A. Stop all headache medications
B. Begin Amitriptyline
C. Begin daily triptan
D. Begin SSRI
E. Obtain MRI
8. An 83-year-old woman comes in with concerns about worsening dizziness. She has had an increase in disequilibrium recently, and a recent fall. She has no history of CAD or seizure disorder. Her symptoms begin when she stands up and starts to walk. They are improved when she stops for a minute and touches the wall. Her medications include sertraline, nizatidine, calcium carbonate and estrogen. What is the most likely diagnosis?
A. Benign positional vertigo
B. Vestibular neuronitis
C. Orthostatic hypotension
D. Panic attacks
E. Multiple sensory deficits
Answer key:
1: F. An X-ray is defensible, but there is a lot of data showing antibiotics don’t really change the course of acute bronchitis.
2. A. This is the most common version of the migraine in the U.S.
3. B. Migraines are often misdiagnosed as sinus headaches. The absence of fever or purulent drainage, as well as the chronicity, indicates this is not a sinus headache.
4. E. The patient has chronic fatigue syndrome, for which there isn’t a need for EBV serologies or the other tests.
5. E. There is no evidence that neuroimaging is warranted for patients with migraines.
6. A. Feeling better after sleep is a sign of physical illness, while being tired in the morning is a sign of psychological illness.
7. A. This looks like a transformed headache, caused by overuse of analgesics.
8. E. The patient’s age, her disequilibrium, and the fact that the dizziness subsides when she touches a wall, all indicate multiple sensory deficits.
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