The masquerades

It is important to utilise a type of fail-safe mechanism to avoid missing the diagnosis of these disorders. Some practitioners refer to consultations that make their 'head spin' in confusion and bewilderment, with patients presenting with a 'shopping list' of problems. It is in these patients that a checklist is useful. Consider the apparently neurotic patient who presents with headache, lethargy, tiredness, constipation, anorexia, indigestion, shortness of breath on exertion, pruritus, flatulence, sore tongue and backache. In such a patient we must consider a diagnosis that links all these symptoms, especially if the physical examination is inconclusive; this includes iron deficiency anaemia, depression, diabetes mellitus, hypothyroidism and drug abuse.

A century ago it was important to consider diseases such as syphilis and tuberculosis as the great common masquerades, but these infections have been replaced by iatrogenesis, malignant disease, alcoholism, endocrine disorders and the various manifestations of atherosclerosis, particularly coronary insufficiency and cerebrovascular insufficiency.

If the patient has pain anywhere it is possible that it could originate from the spine; so the possibility of spinal pain (radicular or referred) should be considered as the cause for various pain syndromes such as headache, arm pain, leg pain, chest pain, pelvic pain and even abdominal pain. The author's experience is that spondylogenic pain is one of the most under diagnosed problems in general practice. A checklist that has been divided into two groups of seven disorders is presented (Tables 15.4 and 15.5). The first list, 'the seven primary masquerades', represents the more common disorders encountered in general practice; the second list includes less common masquerades although some, such as Epstein-Barr mononucleosis, can be very common masquerades in general practice.

Table 15.4 The seven primary masquerades

1. Depression

2. Diabetes mellitus

3. Drugs

• iatrogenic

4. Anaemia

5. Thyroid and other endocrine disorders

• hyperthyroidism

• hypothyroidism

6. Spinal dysfunction

7. Urinary infection

Neoplasia, especially malignancy of the so-called 'silent areas', can be an elusive diagnostic problem. Typical examples are carcinoma of the nasopharynx and sinuses, ovary, caecum, kidney and lymphoietic tissue. Sarcoidosis is another disease that can be a real masquerade (click here for further reference).

As a practical diagnostic ploy, the author has both lists strategically placed on the surgery wall immediately behind the patient. The lists are rapidly perused for inspiration should the diagnosis for a particular patient prove elusive.

Table 15.5 The seven other masquerades

1. Chronic renal failure

2. Malignant disease

• multiple myeloma

• metastasis

3. HIV infection/AIDS

4. Baffling bacterial infections

• tuberculosis

• infective endocarditis

chlamydia infections

• atypical pneumonias e.g. Legionnaires

5. Baffling viral (and protozoal) infections

• Epstein-Barr mononucleosis

• TORCH organisms, e.g. cytomegalovirus

• mosquito-borne infections

— Ross River fever

6. Neurological dilemmas

Parkinson's disease

• Guillain-Barre syndrome

• seizure disorders

multiple sclerosis

myasthenia gravis

• space-occupying lesion of skull

migraine and its variants

7. Connective tissue disorders and the vasculitides

• Connective tissue disorders

— systemic sclerosis

— dermatomyositis

— overlap syndrome

• Vasculitides

— polyarteritis nodosa

— giant cell arteritis/polymyalgia rheumatica

— granulomatous disorders

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