Table 3 Example GPT-4o and Claude-3 response to a diagnostic uncertainty question

You are a family doctor working in a rural northern community of 3000 people. A 56-year-old female comes in today complaining of right neck pain extending into her right shoulder area. She is right hand dominant. Her symptoms started gradually over a year ago but have become more bothersome. She is now waking from sleep with neck discomfort and intermittent right arm tingling.

The patient smokes approximately half a pack of cigarettes per day and drinks a bottle of beer every night with dinner. She has been struggling with a diet program for the past 5 years and over the last year, her BMI has increased from 34 to 36.

On exam of the neck, she guards against pain but is able to flex her neck to half range and extend to one quarter range. Bilateral side flexion and rotation is reduced to half-range with ipsilateral stretching. Passive range of motion is full and pain free. Postural exam reveals a lordotic cervical spine and a kyphotic thoracic spine (she is slumping). Trigger points are positive over the affected area but not in the lower limbs. Neurologic exam is normal.

What investigations should you consider?

A. ESR, C-reactive protein, Rheumatoid Factor, ANA

B. nerve conduction testing

C. no immediate investigations required

D. shoulder MRI

CORRECT ANSWER:

C. no immediate investigations required

B. nerve conduction testing

For the 56-year-old female patient presenting with chronic right neck pain extending into her shoulder, along with intermittent tingling in her right arm, the following investigations should be considered:

Option B: Nerve conduction testing - This test would be beneficial given the patient’s symptoms of tingling, which suggest a possible nerve involvement. Nerve conduction studies can help identify whether there is nerve damage or nerve dysfunction, which could be contributing to her symptoms.

Option D: Shoulder MRI - An MRI of the shoulder might also be warranted due to the location of the pain and the duration of her symptoms. MRI can provide detailed images of the soft tissues, bones, and nerves in the shoulder area, helping to identify any structural causes of her pain, such as rotator cuff tears, bursitis, or other abnormalities that could be exacerbating her neck pain.

Option A (ESR, C-reactive protein, Rheumatoid Factor, ANA) - These tests are generally used to investigate inflammatory or autoimmune conditions. While these could be considered if there was a suspicion of an inflammatory or autoimmune process, the clinical presentation described does not strongly suggest these as the primary cause of her symptoms.

Option C (no immediate investigations required) - Given the chronicity and severity of the patient’s symptoms, particularly with the impact on her sleep and daily function, pursuing diagnostic investigations to identify the underlying cause is advisable rather than delaying further evaluation.

Therefore, based on the clinical scenario, nerve conduction testing (B) would be the most relevant initial investigations to consider. This would help in assessing the possible neurological contributions to her symptoms, guiding further management.

C. no immediate investigations required

Based on the clinical presentation and examination findings, the most appropriate investigations to consider for this patient would be C. No immediate investigations required. The patient’s history and physical examination findings are consistent with a diagnosis of cervical spondylosis or cervical osteoarthritis, which is a degenerative condition of the cervical spine that commonly occurs with aging. The gradual onset of neck pain radiating to the shoulder, intermittent arm tingling, and reduced range of motion with ipsilateral stretching are typical features of cervical spondylosis. The presence of trigger points in the affected area and the postural findings of a lordotic cervical spine and kyphotic thoracic spine (slumping posture) further support this diagnosis. In cases of uncomplicated cervical spondylosis, where the neurological examination is normal and there are no red flags (such as fever, significant trauma, or progressive neurological deficits), immediate investigations are generally not necessary.

Option A, which includes inflammatory markers (ESR, CRP) and autoantibody tests (Rheumatoid Factor, ANA), would be more appropriate if there were concerns for an inflammatory or autoimmune condition, such as rheumatoid arthritis or other inflammatory arthropathies.

Option B, nerve conduction testing, would be valuable if there were significant neurological deficits or suspicion of a peripheral neuropathy, but the normal neurological examination in this case does not warrant such testing at this stage.

Option D, a shoulder MRI, might be considered if there were concerns for a rotator cuff or other shoulder joint pathology, but the clinical presentation and examination findings predominantly point towards a cervical spine etiology.

In this case, the initial management would involve conservative measures, such as analgesics, lifestyle modifications (smoking cessation, weight loss, and postural correction), and physical therapy or exercise recommendations. If symptoms persist or worsen, or if neurological deficits develop, further investigations, such as cervical spine X-rays or an MRI, may be warranted at a later stage.