No 16 - How many different types of patients walk through your ED or GP front door?
tldr
How many different ways can patients present?
The ICD-10 lists 68,000 disease codes and this will be impossible to learn for anyone but the best and more freakishly good at memorising. So, I have produced a list of 10 groups of 56 presentations that I believe summarises almost all of the patients you will see turn up in ED or GP.
Once again, I have spent a few days thinking about what I am doing day to day, the patients that I am seeing and treating and what I was taught at medical school almost a decade ago.
As someone who is pretty simple, I like to try and bring things back to first principles. I want to be the best doctor that I can be and so I want to learn as much useful medicine as I can. The problem that I feel that I have is that you could argue that all of medicine is theoretical useful and therefore picking a place to start learning becomes a time-wasting challenge.
I thought I would take a radical step back and prioritise my learning by what is commonly seen by doctors on the medical front line. The front line being the Emergency Department and the GP surgery.
Who do you see on the Medical Front Line?
The Medical Front Line is where the undifferentiated patients first consult a medical professional for help with their problems. And almost immediately, I ran into a problem when I was thinking about this and reading around the subject.
The problem is this; in “classical” medical education (#MedEd), healthcare professionals are taught the “epidemiology of disease” i.e. These are the top 10 diseases that patients (people) die from, or we are taught the prevalence of a disease, syndrome, condition or gene allele. Even “The Symptom Sorter” by Dr Keith Hopcroft is divided into anatomical or “organ systems” chapters, rather than chapters based around the “symptoms” themselves.
The Process
The patients’ present with “problems”, healthcare professionals then ask them about their “symptoms” and then we try to piece these symptomatic jigsaw puzzles together into a “differential list” and eventually a “diagnosis” of a “disease”.
In effect then, “classical” MedEd is teaching the process backwards from how it works on the frontline.
So, how many ways are there for patients to present?
The “classical” MedEd answer is:
• There are 11 Organ systems – Skin, Skeletal, Muscular, Nervous, Cardiovascular, Endocrine, Respiratory, Lymphatic, Digestive, Urinary, Reproductive,
• Roughly 30 different medical and surgical specialities
• ? >100,000 different human illnesses
• 68,000 ICD-10 Codes (International Classification of Disease, WHO)
• 13,000 ICD-9 Codes (1979-2015)
• 157 disorders DSM-V
So to give an exact answer, there are between 13,000 and 68,000 different ways of diseases presenting… as long as all of those diseases present in the same way. However, we know that not all patients with the same anatomical, pathophysiological disease present in exactly the same way and therefore there must be 68,000*n different ways to present.
That is a very big and scary number. It is also not a useful number, because there is absolutely no way that I will be able to prioritise and learn >68,000 different presentations.
So, there must be a better way?
The alternative approach is not to look at how diseases present but to flip the process and look at how patients present?
There is only a limited number of possible symptoms a patient could present with and this makes the list much more manageable. I did a bit of an ad hoc literature review on PubMed and found a few useful papers, which can be used to make a more useful list.
https://www.definitivehc.com/blog/top-20-most-common-er-diagnoses
https://dorsetgpcentre.com/f2-foundation/essential-clinical-cases-for-f2-gp-trainees/
Armon K, Stephenson T, Gabriel V, et al. Determining the common medical presenting problems to an accident and emergency department. Archives of Disease in Childhood 2001;84:390-392. https://adc.bmj.com/content/archdischild/84/5/390.full.pdf
Kuster T, Nickel CH, Jenny MA, Blaschke LL, Bingisser R. Combinations of Symptoms in Emergency Presentations: Prevalence and Outcome. J Clin Med. 2019;8(3):345. Published 2019 Mar 12. doi:10.3390/jcm8030345 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6462968/
Armon et al published the following list based on nearly 4000 children presenting to a UK ED in 2001:
1. Breathing difficulty 1164 (31%)
2. Febrile illness 764 (20%)
3. Diarrhoea +/− vomiting 617 (16%)
4. Abdominal pain 239 (6%)
5. Seizure 178 (5%)
6. Rash 190 (5%)
7. Other 650 (17%)
Kuster et al used a qualitative method to produce the following list of 35 predefined symptoms which they then used to assess patients presenting to a German ED:
Feeling feverish, rash, headache, dizziness, acute visual disorder, acute hearing disorder, nasal discharge, sore throat, cough, expectoration, dyspnoea, chest pain, abdominal pain, nausea, vomiting, diarrhoea, constipation, flank pain, dysuria, neck pain, back pain, arm pain, leg pain, joint pain, joint swelling, leg swelling, altered state of mind, dysesthesia, palsy, gait disorder, speech disorder, fatigue, weakness, loss of appetite, and feeling sleepy.
They reported that only 8.5% of patients presented with a symptom that wasn’t on this list.
The Summary List
I have then taken the above reports and tried to apply my own simplistic, systematic thinking to the lists and produced the following 10 groups of 56 common presentations:
1. Non-specific symptoms (7): frail, generally unwell, malaise, fatigue/lethargy, loss of appetite, drowsy/reduced GCS, altered state of mind/ confused/ delirium,
2. Fever
3. Pain (10): chest pain, abdominal pain, headache, dental pain, flank pain, neck pain, back pain, arm pain, leg pain, joint pain,
4. Trauma (4) – wounds, bruises, amputations, deformity
5. Neurological (12): syncope, palsy, gait disorder, speech disorder, weakness, numbness, acute visual disorder, acute hearing disorder, dizziness, vertigo, loss of smell/taste
6. Breathing (5): SOB/ dyspnoea, cough/expectoration, phlegm, nasal discharge, sore throat,
7. GU (8): nausea, vomiting, diarrhoea, constipation, dysuria, incontinence, LUTS, retention
8. Rash, joint swelling, leg swelling,
9. Gynae (5): PV discharge, HMB, no/irregular periods, pregnancy, infertility
10. Mental health (4): low mood/depression, mania, psychosis, suicidal
56 ways for a patient to present does not sound like a short list, but it is far more manageable than 68,000. This list of 10 groups of symptoms is by no means an authoritative total overview of the entire of medicine, and it is just my opinion, but I think it is probably adequate for most people’s needs. The act of producing this list has certainly felt like a worthwhile use of time for myself just to ground myself in what is the real world of medicine and what I need to know about.
I intend to use this list to guide my own future study and produce some more articles branching off from here.
If you think this article has been useful then please feel free to share it. If you would like to let me know your thoughts on this topic then please use the comment section below, especially if you think that I have missed out something obvious. I look forward to hearing your thoughts.
As always, thanks for reading and good luck with your own medical education.