Correctly diagnosing symptoms can be a tricky task


Doctors, being fallible, sometimes get it wrong, the more culpably so when dismissing their patients’ symptoms as being “all in the mind”. My first, never to be forgotten, introduction to the serious consequences of this was as a medical student attending the outpatient clinic of The London Hospital’s senior cardiologist Wallace Brigden. He interrupted proceedings to tell us something about the next patient on the list – a former naval officer now in his late thirties. Five years earlier he had become increasingly breathless when climbing the steps to the bridge to take the watch. The medical officer examining him could find nothing amiss with his heart and lungs, a verdict subsequently confirmed by a cardiac specialist. 

He was duly dismissed from the service on psychiatric grounds at which point he fell belatedly under Dr Brigden’s care. The cause of his breathlessness, it turned out, was real enough – a thrombus in his calf veins throwing off scores of minuscule blood clots that had silted up his lungs. The Navy did the decent thing in giving him an honourable discharge, but by then this brave man had endured the terrible humiliation of being judged a malingerer and the damage to his lungs was irreparable. 

To be sure some symptoms are psychosomatic – though they are much less common than is often alleged. But the cautionary tale of this naval officer illuminates the considerable dangers in the recently reiterated claim that “many” reported side effects of drugs are illusory. This is the “nocebo effect”, the supposition that those commonly reported muscular aches and pains, bowel disturbances, general decrepitude etc, are not true side effects, but rather the psychosomatic expression of a misguided belief that drugs can be harmful in this way. 

The implication that doctors should dispute the validity of their patients’ symptoms could scarcely be more unfortunate. 

On the contrary over the past two decades, the numbers in whom those side effects are serious enough to warrant emergency admission to hospital has increased dramatically – almost doubling to just under 100,000 a year. This is a profoundly non-trivial matter. 

Cold intolerance cures

The gentleman, recently featured in this column, increasingly intolerant of the cold (“in summer when all are in shirt sleeves, I am wearing a pullover”) has prompted others to report likewise. The general view would seem to be this is an age-related disturbance of the thermoregulatory system. Still, a couple of more remediable causes merit consideration. 

Cold intolerance is a classic symptom of an underactive thyroid- along with lethargy, weight gain and constipation. This is usually readily diagnosed by the finding of a raised TSH level (Thyroid-Stimulating Hormone) on a routine blood test. The result can however sometimes be misleadingly within the normal range, a retired family doctor points out, and thus the opportunity for appropriate treatment with thyroxine is overlooked. The further possibility, mentioned by a couple of readers, is low blood pressure. “I was always very cold until I stopped taking my Amlodipine blood pressure pills,” writes a woman in her eighties. Two years on her readings, previously low, are now normal for her age without the need for medication and gratifyingly she no longer has to wear a jumper on sunny days. 

Red wine benefits

Finally, the merits of red wine for those with prostate problems or an irritable bladder have been independently confirmed by several readers. “My night trips to the bathroom are markedly fewer on the (usually three) evenings of the week when I indulge in a glass of red,” writes one gentleman. Nor is that all for, as reported in this paper last month, a study, admittedly not yet peer-reviewed, involving 300,000 people has found that those who regularly drink two glasses of wine (red or white) with their evening meal markedly reduce their risk of subsequently developing type 2 diabetes by more than a fifth.


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