As the patient engagement juggernaut gathers pace, the National eHealth Collaborative has recently weighed in with a Patient Engagement Framework
This is set out in a very simple and useful tabular format and highlights the symptom checker as key tool to engage the patient. Significantly, it includes the tool under the "Engage Me" column supporting “engage and attract” and “retain and interact” activities.
This really shows how the movement has matured from believing that the patient could be informed by just providing a depositary of information but no real means of making sense of it. Now, the proponents of patient engagement realize that an engaged patient must also be an informed and empowered patient and tools must be provided to the patient to help them make sense of the information. Personally, I have always believed that helping the patient to research their own diagnosis with tools, like a powerful symptom checker, elevates the whole patient engagement movement another few notches. It really is crossing the Rubicon as it encourages patients to engage in the crucial but rarefied domain of formulating a differential diagnosis and clinical reasoning.
Since the patient is an expert on their symptoms, why shouldn’t they be encouraged to do this?
As the Framework also states, the provision of a symptom checker is aligned with Stage 1 of Meaningful Use.
In addition, the Bipartisan Policy Center’s recent report, Improving Quality and Reducing Costs in Health Care: Engaging Consumers Using Electronic Tools found that engaging consumers more fully in their own health and healthcare not only improves the experience of care for patients and their families, but also improves the quality and cost effectiveness of care. The new Accountable Care Organisations and those participating in Patient Centered Medical Home would be well advised to read these documents and make sure that they are offering these tools to their patients.
Lastly some fascinating results from the latest Pew Research survey. They now call those who search online for health information “online diagnosers”.
“When asked if the information found online led them to think they needed the attention of a medical professional, 46% of online diagnosers say that was the case. Thirty‐eight percent of online diagnosers say it was something they could take care of at home and 11% say it was both or in‐between.
When we asked respondents about the accuracy of their initial diagnosis, they reported:
- 41% of online diagnosers say a medical professional confirmed their diagnosis. An additional 2% say a medical professional partially confirmed it.
- 35% say they did not visit a clinician to get a professional opinion.
- 18% say they consulted a medical professional and the clinician either did not agree or offered a different opinion about the condition.
- 1% say their conversation with a clinician was inconclusive.”
It seems that patients are using tools like the symptom checker sensibly and going to see their doctor in almost half the occasions that they do search. Also very impressive is their accuracy rate of 41%-not bad for totally untrained lay people!
It seems increasingly obvious that the patients are a vast, untapped resource for healthcare professionals. Provided with the appropriate tools, like a symptom checker, the patients could be doing a lot of useful work before they even arrive at the consultation. Rather than complaining about patients coming in with lists or print outs, doctors should be channeling their patients' energy and motivation into saving them time and making the consultation more productive and, therefore, satisfying.
The USA today covered the Pew Research and asked their readers whether they “turn to the internet for medical diagnoses”. 85% answered yes!
Symptom:
Vomiting blood (Other names: bloody vomit, hematemesis, haematemesis).
General Description:
Vomiting blood is regurgitation of the blood from somewhere in the upper gastrointestinal tract which includes the mouth, pharynx, esophagus, stomach or small intestine. It should be differentiated from coughing up blood (hemoptysis). Vomiting blood usually refers to significant amounts of blood in the vomit. Blood in vomit may be bright red or it may appear as black or dark brown like coffee grounds. Vomiting blood may be caused by swallowing blood which has resulted from a nosebleed or from forceful coughing but it normally is caused by something more serious and medical attention should be sought immediately.
Causes:
Some causes of vomiting blood are:
- Peptic ulcer disease: This is the most common cause of upper gastrointestinal bleeding.
- Gastritis: This is inflammation of the stomach lining and can erode the lining (erosive gastritis). The most common cause is prolonged use of nonsteroidal anti-inflammatory drugs (NSAID’s). The most common symptoms of nonerosive gastritis include upper abdominal discomfort or pain and nausea and vomiting. Erosive gastritis may have other symptoms of bloody vomit, black or tarry stools or bloody stools.
- Esophagitis: This is inflammation, irritation or swelling of the esophagus (food pipe). Esophagitis is often caused by fluid that contains acid flowing back from the stomach to the esophagus which is commonly called gastroesophageal reflux. Other symptoms can include cough, difficulty swallowing, heartburn, painful swallowing, hoarseness or sore throat.
- Esophageal tear/esophageal perforation: This is a hole in the esophagus (food pipe) which allows the contents of the esophagus to pass into the mediastinum which is the area surrounding the chest and can result in an infection of this area called mediastinitis. This can be caused by surgical procedures or trauma.
- Dieulafoy’s lesion: This is caused by a large stomach arteriole ( a small blood vessel that branches out from an artery leading to the smaller capillaries in the blood circulation) that erodes and bleeds. This can lead to a bleed in the stomach but is an uncommon condition.
- Gastric varices: These are dilated submucosal (layer of stomach lining) veins in the stomach. They are commonly found in patients with portal hypertension which can be a complication of cirrhosis (liver scarring due to liver damage). Other symptoms include passing black, tarry stools or frank blood (which is bright red and highly visible) in the stool. Many patients can present with shock due to the profound blood loss.
Risk factors:
Hematemesis risk factors include use of Nonsteroidal Anti-Inflammatory Drugs (NSAID’s), aspirin, chronic alcohol use or those with chronic renal failure.
When is it an emergency?
Vomiting blood is a medical emergency and you should see a doctor immediately. It's important to identify quickly the cause of the bleeding and prevent more severe blood loss or complications. Call the emergency service if vomiting blood causes dizziness after standing, rapid shallow breathing or displaying signs of shock (pallor, fast weak pulse, low blood pressure, feeling faint or cold clammy skin).
How you can help your doctor:
Provide your doctor with as much information as you can, it may help you to think about the answer to these questions you may be asked:
- When did the vomiting begin?
- Have you ever vomited blood before?
- How much blood was in the vomit?
- What color was the blood (did it look bright red or like coffee grounds?)
- Have you had any recent nosebleeds, surgery, severe coughing, dental work or stomach problems?
- Do you have any other symptoms?
- What medicines do you take?
- Do you drink alcohol or smoke?
Seeking early medical attention will mean diagnosis and treatment is initiated earlier to detect where the bleeding is orginating from and to stop the bleeding.
Symptom:
Painful periods (Other names: dysmenorrhea, dysmenorrhoea)
General Description:
Most women will experience some degree of pain during their regular menstrual periods.This is normal and should be expected. The womb (uterus) is a large muscle and contracts continually but these are mild contractions and not usually felt. Around the time of the period (menstruation) the contractions become stronger as the blood supply is temporarily cut off during the contractions and this is what causes the pain. The purpose of the contractions is to enable the womb to shed its lining each month and this is lost as a bleed (menstrual period). This is an essential part of female fertility and the period pain caused by it is a side effect. Occasionally, in some women, the period pain can be extremely intense and the cause should investigated so that treatment can be determined or self-help mechanisms put in place.
Causes:
If you have experienced severe painful periods (dysmenorrhea) since you began menstruating, then it is unlikely that a cause will be found and it may be just a part of your normal fertility cycle. There are certain things, like stress, which can aggravate the condition. You should speak with your doctor as this could be primary dysmenorrhea and they will be able to recommend lifestyle changes such as swimming or gentle exercise, using medication if necessary, or a trial of a TENS (transcutaneous electronic nerve stimulation) machine to ease the pain.
More serious causes of painful periods (also termed secondary dysmenorrhea) include:
- Endometriosis – this is caused by the cells lining the womb growing in the fallopian tubes or ovaries. When these cells shed and fall away they cause intense pain.
- Uterine fibroids – non-cancerous tumors grow in the womb and can cause heavy and painful periods.
- Pelvic inflammatory disease – the womb, fallopian tubes and ovaries become infected with a bacteria which leads to inflammation. Other symptoms include fever and vaginal discharge.
- Adenomyosis – tissue lining the womb starts to grow within the muscular wall of the womb. This extra tissue causes painful periods.
- Intrauterine device (IUD) – An IUD is a form of contraception, if you have had an IUD recently fitted then this can cause some pain in the first three months.
Period pain is rarely a sign of disease but, as a general rule, you should consult with your doctor if the pain interferes with your life and prevents you from working, or carrying out your normal daily tasks. Also, if you experience any unusual vaginal discharge or pain as a result of sexual intercourse.
Isabel symptom checker showing possible causes of the symptom painful periods
How you can help your doctor:
Before your consultation with you doctor, think about the following questions they may ask you.
- Describe your period pain.
- Do you get pain only around the time of your monthly period or does the pain occur at other times. If so, how frequently?
- Does anything relieve the pain you experience?
- Do you have any other symptoms like fever, vaginal discharge or pain after sexual intercourse?
- Have you recently had an intrauterine device fitted?
When is it an emergency?
You should call you doctor right away if you experience any of the following symptoms:
- Increased or foul-smelling vaginal discharge
- Fever and pelvic pain
- Sudden severe pain especially if your period is more than a week late and you have been sexually active since your last period.
- You pass blood clots or have other symptoms in addition to the pain
You should also make contact with you doctor if you have any of these longer term problems:
- You have experienced pain with your period for three monthly cycles and the treatments do not control the pain.
- You have pain and had an IUD fitted longer than three months ago.
- Your pain occurs at other times besides during your monthly menstrual period.
Symptom:
Sore throat (Other names: Pharyngitis, inflammation of the pharynx, raw throat, pharyngeal inflammation, throat pain).
General Description:
A sore throat is pain, scratchiness or irritation of the throat. It is associated with the various parts of the throat and named for the specific area affected i.e. the pharyngitis, tonsillitis, laryngitis and the less common but very serious epiglottitis.
Causes:
Some causes of a sore throat are:
- Viral infections – Most common. Viral illnesses that cause a sore throat include, common cold, flu (influenza), mononucleosis (mono), measles, chickenpox, croup.
- Bacterial infections – less common. Bacterial infections that can cause a sore throat include, strep throat (from Streptococcus pyogenes, or group A streptococcus), Whooping cough, diphtheria.
- Allergies - Allergies to pets, molds, dust or pollen.
- Postnasal drip - This can irritate and inflame the throat.
- Dryness - Dry indoor air, especially in winter. This can be worsened by breathing through your mouth due nasal congestion.
- Irritants - Air pollution, tobacco smoke or chemicals.
- Muscle strain - Yelling or speaking for extended periods of time without rest.
- Gastroesophageal reflux disease (GERD) - A digestive system disorder in which stomach acids back up in the food pipe.
- Tumors - Cancerous tumors of the throat and larynx.
Risk factors:
Age - Children and teens are more vulnerable. Tobacco - Smoking and secondhand smoke is irritating to the throat. Allergies - Allergies or ongoing allergic reactions to dust, molds or pet dander can make you more prone to develop a sore throat than are people who don't have allergies. Exposure to chemical irritants - The air from the burning of fossil fuels or common household chemicals and cleaners can cause throat irritation. Chronic or frequent sinus infections - Sinus infections increase the risk of sore throat due to the irritation caused by drainage from the nose. Close quarters - Living and working in small space especially in winter when more time is spent inside and less fresh air is available. Areas such as child care centers, classrooms, offices, prisons and military installations are examples. Lowered immunity - You are more susceptible to a sore throat when you have HIV, diabetes, are taking steroids or chemotherapy drugs, are under stress, fatigued, and/or have a poor diet.
How you can help your doctor:
- Prepare a list of medication that you take. Be sure to include bout the OTC (over the counter) as well a prescription drugs.
- Document what symptoms you have besides a sore throat.
- Identify when the symptoms began.
- Did the symptoms begin quickly or gradually?
- Is there, or was there fever associated with the sore throat?
- If yes, what was the temperature and how long did it last?
- Has there been any difficulty breathing?
- How have you treated the sore throat in order to lessen the symptoms?
- Can you associate any action that makes the sore throat worse, such as swallowing?
- Is a sore throat a recurring problem?
- Have you identified any other symptoms or problems that seem unrelated to your sore throat but occur at the same time?
- Are you a smoker?
- Are you regularly exposed to second hand smoke?
- Do you have any food allergies?
- Do you have any drug allergies?
- Do you have any environmental allergies?
- Do you take allergy medication?
When to make an appointment with your doctor
You should see a doctor when you have a sore throat for more than a week or is associated with difficulty swallowing or breathing, difficulty opening your mouth, joint pain, earache, rash, fever over 101 F (38.3 C), blood in saliva or phlegm, have frequently recurring sore throats, a lump in your neck or hoarseness lasting more than two weeks.
When is it an emergency?
If you experience a sore throat with difficulty breathing, drooling, leaning forward to breathe, taking rapid shallow breaths, "pulling in" of muscles in the neck or between the ribs with breathing, high-pitched whistling sound when breathing, and/or have trouble speaking you should seek emergency help. This could be epiglottitis which is the inflammation of the epiglottis (this the tall semi tubular structure at the back of the throat). This type of sore throat is rare and is an emergency as the airway can close or block.
Symptom:
Nocturia or night-time urination frequency. (Other names: night-time urination, excessive urination at night, night frequency, micturition night).
General Description:
Nocturia is the need to wake up and pass urine more than once at night. This is different to nocturnal enuresis where urine is passed unintentionally during sleep. One episode of nocturia a night is considered normal. It is a common symptom in men and women and can have a significant impact on quality of sleep and therefore quality of life as you can feel tired and irritable during waking hours. As you get older the incidence of waking at night to pass urine increases, in under 60 year olds the incidence overall is 28%, in over 60 year olds this rises to 41%.
Causes:
Some causes of nocturia include:
- Producing a lot of urine/polyuria: If you produce more than 2 litres of urine a day this is called polyuria.
- Nocturnal polyuria: Your body produces a lot of urine whilst you sleep.
- Poor sleep: You wake often at night and will frequently go to the bathroom at night when awake. This is normally a habit and not because you actually need to pass urine.
- Excessive drinking before bedtime: If you experience nocturia it can be due to drinking too much in the evening before going to bed. Excessive caffeine and alcohol consumption can also cause the nocturia symptoms to be exacerbated.
- Low nocturnal bladder capacity: You produce more urine at night than your body is able to hold.
- Benign prostatic hyperplasia/BPH: This is a common condition in men over 50 which results in nocturia due to obstruction of the urethra (the tube that connects the urinary bladder to the genitals so the urine can be removed from the body. Other symptoms of this include changes in urine stream, low back pain, fatigue and fever.
- Diabetes insipidus and diabetes mellitus: Other symptoms include excessive urination day and night, weight loss, weakness, excessive thirst.
- Urinary tract infection: This can cause you to wake at night and pass urine several times during the day; you will also experience some other symptoms which may include fever, pain when passing urine or strong smelling urine.
- Medications: Some medications used in treatment of heart conditions called diuretics can cause nocturia as well as some medications used in the treatment of dementia.
Risk factors:
Factors that may increase your chances of developing nocturia include advanced age, if you are on certain medications, or if you have urinary tract problems or cardiac disease, obesity or sleep apnea.
How you can help your doctor:
Before your consultation with you doctor, think about the following questions they may ask you.
- How long have you been experiencing the symptom of nocturia?
- On average how many times a night do you wake up and pass urine?
- Do you drink large volumes of fluid before you go to sleep? It's a good idea to keep a fluid intake diary where you record what type of fluid and how much you drink every day and at what time. Keep the diary for 7 days and take to your appointment.
- Have you changed your medications recently?
- Have you also had any pain or burning whilst passing urine or any other symptoms like stomach pain and stomach tenderness?
Nocturia is a symptom which, for many older people, adversely affects their quality of life and has been linked to increased morbidity problems due to the elderly falling more often especially when tired but, with help from your doctor and understanding what the cause of your nocturia is, then it can often easily be rectified.
Symptom:
Dizziness and Vertigo (Other names: disequilibrium, faintness, giddiness, light-headedness, unsteadiness, vertigo, wooziness).
General Description:
Dizziness is a feeling that you are spinning, tilting or about to fall. The sensation of dizziness can also make you feel lightheaded which may make you feel faint. It can also cause you to feel giddy or to have difficulty walking straight. Many people who feel dizzy have vertigo which is a specific type of dizziness. Vertigo causes a sense of spinning, dizziness, swaying or tilting. You may feel that you or objects around you are moving. Vertigo can also be caused by inner ear or brain problems.
Causes:
Some causes of dizziness and vertigo are:
- Drop in blood pressure (orthostatic hypotension): This is caused by your blood pressure falling when you stand up or rise from sitting suddenly. The fall in blood pressure is only for a short time as it quickly readjusts and this problem tends to occur as you get older.
- Medications: Dizziness can be a complication of taking some medications. Take a look at the patient leaflet in the medication under side effects to see if dizziness, vertigo or light-headed is a known side-effect. Do not stop the medication but see your doctor.
- Anxiety disorders: Those experiencing anxiety with panic attacks may feel dizzy or light-headed. This can worsen if you over-breathe (hypoventilate).
- Low blood sugar (hypoglycaemia): commonly occurs in Diabetics who are insulin dependent. Dizziness may occur with sweating and confusion.
- Benign paroxysmal positional vertigo: Sudden episodes of vertigo that can last seconds or minutes. The episode occurs when you move your head a certain way. A common example is when you get up in the morning or turn over in bed and an episode occurs. The vertigo occurs due to the sensitive hairs in the labyrinth being stimulated by a solid piece of material when you move your head. This sends wrong messages to your brain about your head position resulting in vertigo.
- Labyrinthitis / inner ear inflammation: There are various causes and is most commonly caused by a viral infection. Other symptoms beside vertigo include feeling sick, hearing loss, flu-like symptoms.
- Meniere’s disease: This condition includes symptoms of vertigo, hearing loss, buzzing or ringing in your ears (tinnitus). Episodes can range from minutes to hours and can eventually result in hearing loss and permanent tinnitus. It occurs due to fluid building up in the ear causing the labyrinth to swell and the symptoms to occur.
- Acoustic neuroma: Is a benign (non cancerous) tumor that grows on the acoustic nerve. Symptoms include vertigo, hearing loss and tinnitus. The symptoms worsen as the condition progresses.
Risk factors:
Factors that may increase your chances of feeling dizzy for people aged over 65 years are those taking certain medications such as blood pressure lowering medications, seizure medications, sedatives and tranquilizers. Past episode of dizziness could lead to more dizziness episodes.
How you can help your doctor:
Before your consultation with you doctor, think about the following questions they may ask you:
- Describe your dizziness.
- When you have an episode of dizziness do you feel like the room is spinning or you may faint?
- Has the dizziness occurred as a one off episode or have you had several episodes?
- Does it occur at a certain time of day or when you are carrying out a certain activity?
- Do you have any other symptoms like loss of balance or vomiting when the dizziness occurs?
When is it an emergency?
Most causes of dizziness and vertigo are not serious and quickly get better on their own but some causes are life threatening. Generally, if you have unexplained dizziness, feel dizzy regularly or have severe dizziness and you do not know why then you should be seen by a doctor to have it checked out.
If you experience dizziness or vertigo with any of the following symptoms then you should seek medical attention immediately:
- Severe headaches which differ to ones you normally get
- Hearing problems
- Visual loss
- Speech problems
- Weakness of legs or arms
- Difficulty walking
- Collapse or unconsciousness
- Numbness
- Chest pain
- Irregular pulse, fast or slow pulse
- Any other symptom that cannot be explained
These symptoms could indicate other disorders like a stroke or heart attack which is why you shouldn’t delay seeking medical treatment via the emergency services.
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The Case Record 12 (2012) of the Massachusetts General Hospital in the New England Journal of Medicine details a 10 month old girl presenting to the emergency department due to vomiting and unresponsiveness which had begun 7 hours earlier. The baby became more somnolent, and after further work up and tests, she was diagnosed with Ileocolonic intussusception associated with syncope (neurologic intussusception).
Intussusception is a major cause of intestinal obstruction in young children, and it occurs when a portion of bowel slides into the next part of the bowel (like a telescope) which creates a bowel blockage which leads to swelling, inflammation and decreased blood flow to the intestinal parts involved. It is a medical emergency which should be treated quickly, and it is therefore important to ensure that Intussusception is appropriately considered when constructing a differential for a baby presenting between age 3 months to 3 years with any of the key symptoms such as abdominal pain, vomiting, lethargy, irritability, blood per rectum, pallor or palpable abdominal mass and tests should be performed to rule in or rule out this diagnosis.
The peak age of incidence is 7 months, and 75% of cases are diagnosed in children under a year. Boys are more commonly affected than girls at a ratio of 3:2. The baby tends to have colicky abdominal pain lasting for 1 to 3 minutes and in between these episodes the baby behaves normally.
Vomiting can be nonbilious or bilious, lethargy or irritability can sometimes be the only presenting complaint. Other late symptoms or indicators of severe disease which take longer than 24 hours to develop are occult blood per rectum or frank blood and mucus resembling currant jelly, intractable vomiting, abdominal distention or hypovolemic shock. Therefore identifying Intussusception early is the key to a good prognosis.
It may be possible to feel a palpable abdominal mass (sausage shaped mass) in the right upper quadrant or epigastrium. Guaiac-positive stools may be found and occasionally a rectal mass may be palpable or a prolapse through the anus may be seen. Other less common symptoms which the baby may present with include diarrhea or poor feeding.
Other conditions to rule out are appendicitis (rectal bleeding is not present, intussusception is more colicky abdominal pain than the abdominal pain seen in appendicitis), gastroenteritis, UTI (this can be easily confused with Intussusception) and pyloric stenosis (typically appears between 2 and 12 weeks and presents with projectile nonbilious vomiting after feeding).
To confirm Intussusception in a baby with any of the symptoms mentioned, an abdominal plain x-ray should be carried out which may appear normal but could show an abdominal mass, abnormal gas pattern, air-fluid levels, dilated bowel loops, empty right lower quadrant, “Target sign”, free intra-abdominal air. Other tests to consider are ultrasound and diagnostic enema.
Once diagnosed then treatment should begin immediately to prevent the condition worsening with appropriate fluid resuscitation. Depending on how clinically stable the baby is, then contrast enema reduction or immediate surgical reduction should be carried out.
A key way to support the early diagnosis of Intussusception is to use a diagnosis checklist tool for the symptoms the child presents with to remind medical practitioners that these are key symptoms that occur in this condition and any young child meeting the criteria for age (under 3 years) and symptom(s) mentioned earlier should be acted upon quickly. The condition ruled out as early diagnosis is the key to improved outcome. See the diagnosis tool applied to this condition below in the graphic:
In the Case Record 12 (2012) of the Massachusetts General Hospital, using the Isabel diagnosis system (graphic above) with the symptoms the baby presented with, Intussusception is on the list of likely diagnoses and is red flagged indicating the seriousness of the condition and that further appropriate tests carried out to rule it in or out immediately.
The typical appearance of an intussusception in a patient with Peutz-Jeghers-Syndrome (intestinal polyposis) after contrast enema: the so-called coil-spring appearance and cupping in the head of barium.
Fluoroscopy image during air enema demonstrating a large soft tissue mass in the region of the caecum representing the intussusception (the patient is lying prone hence the caecum lies on the right side of the image).
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