This presentation covers both abdominal and pelvic masses, and general abdominal swelling. The patient may complain of a general increase in girth or of a discrete mass discovered accidentally; alternatively, the clinician might find the swelling while performing a physical examination.
Very few patients present with abnormal gait. It is more often noticed by the clinician, while the patient’s complaint is usually a manifestation of the gait (e.g. unsteadiness in Parkinson’s disease) or of its cause (e.g. pain in arthritis). Congenital causes are not considered here as patients are most unlikely to present such problems to primary care.
This is an infrequent cause for attendance – though the public is becoming increasingly aware of conditions such as restless legs syndrome (RLS) and Tourette’s, and their treatments. Obvious generalised seizures and tremors are not considered in this chapter but are covered elsewhere.
Women are far more likely to present with this symptom than men, often for cosmetic reasons. The likeliest queries relate to normal nails that break easily or are not smooth. Other abnormalities may be detected during physical examination rather than being volunteered by the patient, and may indicate significant pathology.
This symptom causes substantial anxiety in the sexually active woman: the first unexpectedly missed period suggests pregnancy; prolonged absence raises the concern that something is seriously amiss. In contrast, management is usually straightforward and helped by acknowledging the anxiety.
The sudden onset of severe abdominal pain represents a genuine emergency in general practice and is a common out-of-hours call. In the true acute abdomen, the patient is obviously ill, and as the clinical condition may deteriorate rapidly, ensure that you examine or refer the patient as soon as possible. NOTE: Upper and mid-abdominal pain are dealt with here. Lower abdominal pain is dealt with under ‘pelvic pain, acute’ and specifically epigastric-type pain is covered in more detail in the epigastric pain section.
This causes significant worry in parents, often about the possibility of appendicitis. Some of the causes listed here (such as infant colic and constipation) can cause recurrent or chronic pain – this is a less common presentation, but one which, in children, still has a tendency to be presented as an ‘acute’ problem, either because of a perceived deterioration or parental anxiety. If managing children is within your scope of professional practice, more details about recurrent childhood abdominal pain can be found in the section of the same name.
A pregnant woman who develops this symptom is very likely to be extremely concerned that there is a threat to her pregnancy. Anxiety levels may therefore be high in the patient and her partner. Acknowledge this emotional distress by an urgent and full assessment. Listed here are causes specific to pregnancy and conditions which may be exacerbated or altered by pregnancy and reinforce the need for appropriate referral as this is rarely within the nursing scope of professional practice.
There are many possible individual causes of confusion. Patients with acute confusion are usually elderly and often present out of hours via a call from an anxious relative or neighbour. The dementias constitute the chronic confusional states, which are not considered here.
This is nearly always seen in women rather than men. In its mildest form it is experienced universally at some time or other associated with periods, ovulation or sexual intercourse. In its severest form it is the commonest reason for urgent laparoscopic examination in the UK.
This is a terrifying symptom for the patient, and the subjective feeling of shortness of breath is not predictably related to the type or degree of pathology. This, combined with the fact that the cause is often organic, means that a careful and urgent assessment and appropriate referral is mandatory.
This is a very common problem in primary care. Usually, there are few physical signs, although occasionally a genuine monoarthritis with all the classical signs of inflammation will present. Overall, the most likely aetiological factor is trauma, though other conditions may already affect a joint. In the elderly, an exacerbation of osteoarthritis is common; this condition may also cause multiple joint pain. The knee is probably the single most frequently affected joint.
This is a common reason for an urgent surgery appointment. Any consultation should be undertaken in the surgery, where optimal examination conditions and equipment are to hand. Carefully examine to assess acuity, state of the cornea and pupillary reflexes if this falls within your scope of professional practice.
This presentation is one that is generally straightforward to deal with, and effective treatment can usually be offered immediately.
The temptation to make a diagnosis without examination should be resisted – some of the causes (such as perianal abscesses) require urgent attention and others may, rarely, provide something of a surprise (e.g. fistulae, carcinoma).
This is usually severe and distressing. Because of reflex sphincteric spasm, constipation very often follows and increases the pain and suffering further. Adequate examination is also difficult for the same reason and should not be undertaken unless within the practitioner’s scope of practice; a visual inspection does not yield the diagnosis, a rapid referral should be made.
Arm pain is a common presentation with a wide differential. Many generalised disorders, such as arthritis, neuropathy and polymyalgia, cause widespread symptoms, which may involve the arm – these are not considered here. Instead, this section concentrates on pain specific to the arm, or pain characteristically referred to the arm.
Ongoing backache is a familiar presentation to all clinicians, and acute back pain is one of the most common reasons for an emergency appointment in primary care. The average practice of 4 GPs can expect around 500 consultations for this problem each year. Eighty percent of the Western population suffer back pain at some stage in their lives: It is the largest single cause of lost working hours among both manual and sedentary workers; in the former it is an important cause of disability. Remember that many non-orthopaedic causes of back pain lie in wait, so be systematic and consider an early referral to a GP.
This common symptom is usually caused by poor dental hygiene. As a presenting complaint it is seen far more often by dentists than other clinicians. It may be detected when examining a patient for an unrelated complaint, and rarely but significantly can herald serious pathology.
The primary cause of this symptom is nearly always infection, usually because of poor dental hygiene: an endemic problem worldwide. Systemic problems may also cause gum pain or bleeding. While a dental referral is likely to be the end result, it is worth checking for general causes or easily remediable problems before directing the patient to the dentist.
Blisters are skin swellings containing free fluid. Up to 5mm they are called vesicles, larger than 5mm they are called bullae. The fluid can be lymph, serum, extracellular fluid or blood. Some conditions cause both kinds of blister, but others mainly one or other type. Pustules are dealt with elsewhere (see ‘Purpura and petechiae’).
This extremely common symptom is very familiar to all. The most frequent cause, the common cold, is not included here, since nasal obstruction in itself is not usually the presenting symptom. The majority of causes of nasal obstruction are benign, but care should be taken to consider referral in those few cases that do not respond promptly to simple treatment.
Bright red blood in the urine causes instant alarm in a patient, and usually generates an emergency appointment or an out-of hours call. Blood may also be picked up by dipstick testing or MSU during the assessment of some other problem or in a routine medical. This is often less frightening even when disclosed to the patient, but should prompt an immediate referral for a full investigation.
Swelling of the breast tissue in a male is an embarrassing symptom, often presented behind the facade of a ‘calling card’. The following differential diagnosis does not include other causes of breast swelling, which are referred to in the Top Tips at the end of this section. In true breast swelling, glandular tissue is palpable behind the areola and is usually bilateral.
The discovery of a lump in a woman’s breast will usually create a lot of anxiety. She will probably have found it herself and with the high public awareness of breast cancer, will want reassurance or rapid action. If within your scope of practice, a careful examination of both breasts and associated lymph nodes is mandatory. Otherwise make an immediate referral to a GP.
Breast pain has a variety of innocent causes: The commonest are puberty and pregnancy. It can be a troublesome recurrent problem for women with cyclical mastalgia. Cancer is very likely to be a major concern: this is an uncommon cause and pain is an unfortunately late sign of the disease.
Calf pain is usually innocent, except when accompanied by swelling. It is often caused by cramp, which is especially common in the elderly. In this group it can cause significant distress, through the havoc wreaked on sleep. Some of the less likely diagnoses, such as peripheral vascular disease, have important implications, so careful assessment is necessary.
Acute chest pain is a regular visitor to general practice: It may generate more adrenaline in the clinician than the patient. In spite of a constellation of causes, a good basic clinical approach within your scope of practice will determine your actions and appropriate referral in nearly all cases, long before any necessary investigations are complete.
Pelvic pain is defined as chronic if it has been present for three cycles or more. The difference between this and ‘normal’ period pain is one of intensity and duration. It is one of the commonest reasons for referral to a gynaecology clinic and for a woman to attend the practice in the first place.
Shortness of breath is defined as difficult, laboured breathing. Medical teaching, unlike nursing teaching, tends to focus on individual pathologies. however, in practice there is often some overlap between several contributory causes and sometimes the diagnosis can only be made after ongoing referral to a doctor and the subsequent therapeutic trials of treatment.
This problem may present in any age group. In young to middle-aged adults, the cause is very likely to be benign, but this alters with age. Malignancy should always be suspected in the elderly even though other causes are still commoner. A precise diagnosis sometimes remains elusive.
Constipation is defined as the infrequent or difficult evacuation of faeces. One study of a large normal working population showed variation in frequency from three times a day to three times a week. The average practice of 4 GPs will see about 80 presentations of constipation each year. In most cases, there is a combination of aetiological factors, and serious causes are rare.
This is a symptom that patients seem to fear or value – as a signifier of possible cancer or a justifier of antibiotics – far more than clinicians. Most coughs are simply viral URTIs, but the nurse should be aware of the various other possibilities, especially when the symptom is persistent.
This symptom can appear so trivial. If managing children is within your scope of professional practice, reassurance and explanation are often all that is required, and this can build a bond with parents and children. Take parents seriously and sympathetically: nocturnal cough is a destroyer of sleep and family peace.
Patients invariably view this relatively uncommon symptom as representing something serious – this is rarely the case in primary care. In practice, the origin of the blood may not be immediately obvious: quite often, blood from the nose or throat may be coughed out with saliva (spurious haemoptysis) and described as ‘coughing up blood’.
This is a very frequent reason for an out-of-hours call. A baby’s cry is almost impossible for parents to ignore. When crying continues unabated in spite of all that parents can do to settle an infant, parental distress sets in and they will turn to you for an answer and a solution.
Deafness is a frustrating symptom. In children it creates educational difficulties and parental worry. In adults, everyday life is fraught with difficulties, and there may be stigmatisation. Three million adults in the UK suffer some degree of persistent deafness. Congenital causes acquired in utero are not included here.
Diarrhoea is the passage of abnormally liquid and frequent stools. It is said to be chronic if it lasts more than 2 weeks. It is the fifth-commonest presenting symptom in general practice. Patients will use the term ‘diarrhoea’ when presenting, but they may just mean frequent stools.
This is a very common presentation and is usually caused by gastroenteritis or some other acute infection. Less common is the subacute or prolonged case, where the differential is wider and where a referral is required for more detailed analysis.
This symptom can mean several things, and a careful history is necessary to tease out the precise problem: Difficulty in initiating swallowing; a sensation of food sticking somewhere; painful swallowing; also included here is the sensation of ‘something in the throat’ even when not trying to swallow anything.
This common and vague symptom can mean different things to different people. It is treated here as being a sense of light-headedness without the illusion of movement characteristic of vertigo. This is a useful distinction in practice as the causes of true vertigo are different – see Vertigo section. Dizziness tends to be a heartsink symptom as it is so common, has so many diagnostic possibilities, is so often linked with anxiety and other symptoms – and very often the exact cause remains obscure.It generally requires referral.
Diplopia is nearly always binocular, with movement of one eye being limited for a number of possible reasons. Although relatively uncommon as a presenting symptom, the majority of causes are significant and therefore immediate referral is required as more detailed assessment is essential.
Dysuria is a very common symptom where the diagnosis and management are usually straightforward. It’s worth bearing in mind, though, that there are occasional causes other than ‘cystitis’, especially in recurrent or unresolving cases. Also, genuine repeated infections can sometimes be a sign of some underlying problem.
This is often seen in swimmers and returned tropical travellers. It is frequently a sequel to water trapped behind earwax in the ear canal, which swells and encourages stasis and subsequent infection. The vast majority of cases seen settle with simple treatment, but be wary of rarer serious causes.
This the commonest reason for an out-of-hours concern for a child. Parental distress is often as great as the child’s, and appropriate advice can do much to relieve this – even over the telephone. Causes in adults are far more varied than for children and can originate in the pinna, ear canal, middle ear and from neighbouring structures (referred pain).
Up to 40% of the adult population suffer this symptom in any one year. Only about one in ten seeks help, usually presenting with ‘indigestion’. The first step involves sorting out exactly what the patient means by this term. The second is to establish whether it is acute, chronic or acute-on-chronic. And the third revolves around management, which is often orientated towards a pragmatic, symptomatic approach rather than establishing a precise diagnosis.
The terminology in this area can be very confusing with words like ‘syncope’ and ‘faints’ being used imprecisely. Episodic loss of consciousness can occur in any age group, though it tends to be commoner in the elderly. It is a frightening experience for the patient, and it demands thorough examination, investigation and a low threshold for referral. For the clinician, the differential widens in the older the patient – and cardiac causes should not be overlooked in the elderly.
This is the partial or complete failure to achieve a satisfactory erection. The inability to ejaculate (ejaculatory erectile dysfunction) is not dealt with here. Erectile dysfunction presents increasingly frequently in primary care as new treatments are developed and publicised.
Erythema is a reddening of the skin due to persistent dilation of superficial blood vessels, and can be local or generalised. It is distinguished from flushing (see ‘Flushing’) by its permanence: flushing is transient.
This is defined as excess growth of terminal hair in women in male distribution sites (i.e. chin, cheeks, upper lip, lower abdomen and thighs). It presents as a cosmetic problem. Ethnic origin must be taken into account: Mediterraneans and Indians grow more than Nordics. Japanese, Chinese and American Indians grow the least. In the UK, according to surveys, up to 15% of women believe they have excess body hair, although only a minority present to the primary care.
Under normal conditions, 800mL of water is lost daily as insensible loss, mostly in sweat. Excessive sweating can at least double this figure. As a symptom, it is normally part of a package of other problems – it is unusual for the patient to present with excessive sweating in isolation.
Polyuria is a highly subjective symptom and one which presents rather less often than urinary frequency (which is dealt with separately, see 'Frequency'). Most of the causes of polyuria listed here are also, by implication, causes of polydipsia – the only causes of true polydipsia not included are those due to dehydration.
Because of their close proximity to the eye, and their occasional cosmetic effect, eyelid problems can be disproportionately distressing to the patient. The differential diagnosis is wide –so the clinician must be confident it is within their scope of practice or make an appropriate referral.
Pain in the face may either be due to local disease of any of the major structures of the face, or conditions affecting the innervation. The latter can occur anywhere between the posterior fossa and the ends of the trigeminal nerve. A good examination is not difficult but should be within the practitioners’s scope of professional practice.
Unlike most of the other ‘skin’ sections, this section is presented according to the rash distribution. This is because it is a common presentation, one with a wide differential and one which causes the patient significant concern, largely because of the cosmetic impact. Occasionally, it can be caused by, or represent, significant pathology. Individual facial spots – such as basal cell carcinoma – aren’t considered here.
This section looks at ‘internal’ causes of facial swelling rather than superficial skin conditions, which are dealt with in other sections. This problem is usually a major concern to the patient because of the disfigurement, which it is impossible to hide. The causal conditions are often very painful too.
Facial ulcers and blisters present much earlier than similar lesions elsewhere on the body because of the cosmetic disfigurement. Smaller lesions, especially basal cell carcinomas, are often picked up coincidentally by the clinician when the patient attends for some unrelated matter. (NB: For rashes confined, or largely confined, to the face, see 'Facial rash'.)
Many falls are genuine trips – so sorting out trip hazards is one of the most effective strategies to advise. Possible medical contributors are numerous and may combine in elderly patients with recurrent falls. NOTE: The term ‘drop attacks’ is inconsistently defined in the literature as ‘falls with no loss of consciousness’, ‘falls with loss of consciousness’ or may be regarded as a distinct diagnostic entity rather than a symptom. It is a term best left unused.
The patient complaining of feeling tense and anxious may induce similar feelings in the clinician – because there are many possible underlying and contributory causes, the consultation may be lengthy, and the patient may well present in a crisis. A calm, methodical approach, possibly stretching over more than one consultation, will pay dividends.
This symptom can be very difficult to fathom, not least because patients often find it nigh on impossible to describe exactly what they’ve experienced. Patience and a painstaking approach are essential – most of the clues are likely to be in the history rather than in the examination. This section does not cover double vision, gradual loss of vision or persistent sudden loss of vision, which are dealt with elsewhere.
This symptom presents more often in women than in men, not only because of its cosmetic importance, but also because the menopause accounts for the vast majority of presentations. It is different from emotional blushing in its context, severity, duration and extent.
Pain in the foot is difficult for patients to ignore and so will often present with a relatively short history. Local causes predominate, but clinicians should be mindful that spinal involvement with referral through S1 (lateral border of the foot) and L5 (dorsum of the foot to the big toe) nerve roots may occur. Ankle pain is not considered here.
This means an increased frequency of micturition, and is usually associated with the passage of small amounts of urine. It is not the same as increased production of urine (see ‘Excessive urination’). It is a commonly presented problem, affecting women far more often than men: The average practice of 4 GPs will deal with around 240 cases of cystitis (the main cause) each year.
The four major causes of gradual blindness in the world are cataract, onchocerciasis, vitamin A deficiency and trachoma. The latter three are very rare in the UK. Cataract occurs in 75% of over-65s, but only 20% of 45- to 65-year-olds. Most cases of gradual loss of vision encountered in primary care arrive via the optician, often with a letter outlining the problem and suggesting referral to an ophthalmologist.
Most causes of lumps in the groin are non-urgent. Many patients do not realise this, however the development of a groin swelling often heralds an urgent appointment, either because the patient fears sinister pathology, or because the patient knows the diagnosis but erroneously perceives it as an emergency. Diagnosis and disposal are usually straightforward.
This is an uncommon presentation – but one we may see increasingly frequently as men become less reticent about discussing such issues. As with any symptom involving leakage of blood, anxiety levels tend to run high but it is unusual for the symptom to have a sinister cause.
A distressing symptom for both genders: young men may fret about self-image, and women are horrified at the cosmetic disaster unfolding. The psychological significance of increased hairfall is all too easy to overlook in a typical busy surgery should be recognized and reassurance given that the problem is being taken seriously.
A hallucination is a sensory perception occurring without any external stimulus. This distinguishes it from an illusion, which is a distortion of a sensory perception. Hallucinations can occur in any sensory modality and may present in isolation or as part of a larger clinical problem (particularly an acute confusional state). A hallucination is often a very frightening experience for the sufferer.
The differential diagnosis is quite wide but ‘arthritis’ is often uppermost in the patient’s mind. A brief history and focused examination should provide the correct diagnosis quite rapidly in most cases.
The presentation of a hand or wrist swelling has a low chance of being anything sinister or time-consuming. That said, the differential is wide and a definite diagnosis can be difficult.
There are almost as many causes for headache as there are disorders. This universal symptom presents a challenge to because it is common, very often non-organic, but seriously pathological just often enough to merit a thorough and usually negative examination. The chance of a sinister hidden problem is always there, but the known vast majority of benign headaches can put the clinician off guard.
This is a common presenting complaint. The average practice of 4 GPs can expect about 400 women to consult each year for menstrual problems (female clinicians rather more) and many of these will be for menorrhagia. Normal menstrual blood loss is 20–80 ML. In practice, measurement is not feasible, so the definition rests on what the woman reports, although some efforts can be made to establish whether or not the bleeding is ‘excessive’.
Hoarseness may start suddenly and last a few days (acute), or arise gradually and continue for weeks or months (chronic). The history will clarify this and point the way forward in management. Acute hoarseness rarely causes any diagnostic problem or concern; the less common chronic case raises more worrying possibilities and usually requires referral.
Incontinence is involuntary micturition. It is not a common presenting symptom, embarrassment tending to inhibit patients, but it is often mentioned as a ‘while I’m here’ or noted by the clinician, typically because of the characteristic odour when visiting an elderly patient. It may present more frequently in the future as the problem receives more publicity and patients realise that help is available. The population prevalence in women is around 10%, but is probably much higher in older age groups.
About 80% of couples conceive within the first year of trying, and a further 5%–10% in the second. The actual definition of infertility is nowadays viewed as less about an arbitrary period of being unsuccessful at falling pregnant and more about when it might be appropriate to intervene – which, in turn, will depend on various factors such as age, any suggestion of an obvious underlying cause, patient wishes and so on. The most significant factor affecting investigation and referral is prevailing local and national protocols and guidelines.
This problem is commoner in women, and commonest in the elderly. Normal sleep requirement varies widely. A few people need only 3–4 h per night and the average amount of sleep needed declines with age. Self-reporting of time taken to get to sleep and hours slept are said to be inaccurate, but it is the change from the individual’s normal pattern that is significant in practice.
Irregular vaginal bleeding presents commonly in primary care – particularly to female GPs and nurses, as the patient will often anticipate a pelvic examination. This chapter covers all causes of this symptom throughout life including prepubertal, causes in early pregnancy and post-menopausal (causes in late pregnancy are not covered as they constitute a quite different clinical scenario). The key to appropriate management usually lies in a careful history
Itching is the commonest presenting dermatological symptom. It is frequently distressing, and may interfere with the patient’s quality of life – for example, by preventing normal sleep. Therefore, it should be taken seriously. A good history alone will reveal the diagnosis in the majority of cases. The remainder will yield to thorough examination and investigation. Dermatological referral need only be a last resort to achieve diagnosis.
This is a nuisance symptom which patients present with directly, or via their optician. It can be very difficult to ascertain whether the problem is arising from the eyelid or the eye itself. Often, the symptoms affect both and the causes overlap – which is why they’re considered together here.
This might appear a mundane symptom, but it can cause the patient significant distress. It’s usually a presentation, in which a brief examination can be performed at the same time as an equally brief history. But the clinician should be mindful that the problem can sometimes be more complicated than it might at first appear.
Patients rarely present with the complaint of ‘turning yellow’; more often – though still infrequently – the clinician notices jaundice during an examination of the patient. If it is within your scope of professional practice, a systematic clinical assessment together with relevant laboratory investigations will help pinpoint the cause. Otherwise, make an immediate urgent referral.
Chronic leg ulcer is a major problem in the UK. It is reckoned that nearly 1% of the population may be affected by leg ulceration at some time during their lives. Recurrence is common. The vast majority have a vascular underlying cause.
This is an infrequent but alarming presentation, as it may herald significant pathology and may be difficult to manage properly in an uncooperative toddler. If within your scope of professional practice, assessment should be methodical and patient, and referral or follow-up arranged unless the diagnosis is obvious at the outset.
Clinicians may disagree – with patients and among themselves – about where exactly the ‘loin’ is. For the purposes of this chapter, it is the area between the lower ribs and the pelvis, anteriorly or posteriorly. Loin pain is a common acute or subacute presentation, with patients tending to assume that the symptom inevitably represents a renal problem. Occasionally, they are correct. But a musculoskeletal aetiology is much more likely, and there are other possible causes to trip up the unwary.
Loss of sex-drive can be a daunting presentation. This universal problem spans adulthood in both sexes. Systematic enquiry and an appoproriate referral for examination is the key to successful management.
A macule is a flat, demarcated, abnormally coloured area of skin of any size. It may be red (e.g. drug eruption), dark red (e.g. purpura), brown (e.g. a flat mole) or white (e.g. pityriasis versicolor). Purpura is described elsewhere (see ‘Purpura and petechiae’). There is some crossover between erythema (see ‘Erythema’) and red macules.
Memory loss is a distressing and perilous symptom for both sufferers and caring relatives. It may be due to organic or non-organic causes. Memory is classified into immediate, short-term (or recent) and long-term (or remote) memory. The type of loss varies according to the cause. Memory loss is also a feature of any cause of acute confusion; this problem is covered in the 'Confusion, acute' section.
Mouth lumps and marks can be unfamiliar territory – partly because it is rarely an area of expertise for most clinicians, and partly because many mouth problems are picked up by, or presented to, dentists in the first place. A proportion of patients will choose primary care as the first port of call, so a working knowledge of the area is useful.
This common symptom generally has common causes which are simple to detect and treat, and it is clearly important to spot the occasional serious problem at an early stage. Examination is simple, and a dentist may well have a clearer idea if referral is necessary in more obscure cases.
The range of causes of multiple joint pain spans acute, chronic and chronic relapsing conditions. The difficulty for the primary care clinician is sifting through the wide differential and spotting early significant disease that requires prompt referral.
A lump in the neck usually means just one thing to a patient: cancer. This is rarely the cause in practice, and a careful examination and explanation can be most effective. Occasionally, further investigation is needed. For a more detailed analysis of ‘Swollen glands’, including cervical glands, see the ‘Swollen glands’ section.
Nipple discharge has a number of disparate causes, from the first outward sign of a previously unrecognised pregnancy, to a late sign of an advanced carcinoma. It can cause embarrassment and concern in equally large amounts. Compared with breast pain and lumps, it is a relatively rare presenting symptom. Take it seriously assess carefully and refer quickly – investigation will often be needed.
Nocturia may present in isolation or it may be a manifestation of other urinary disturbances such as polyuria or frequency. Surprisingly, in older age groups, it is as common in women as men. Occasional nocturia is, of course, quite normal – the symptom should only be viewed as pathological when it causes disruption or distress.
Skin nodules are larger than papules – more than 5mm diameter. However, their depth is more significant clinically than their width. Some are free within the dermis; others are fixed to skin above or subcutaneous tissue below. The causes are various; the patient is usually concerned about the cosmetic appearance or malignant potential.
This is commonest in the very young and the very old. It may present routinely as a recurrent problem, or in the acute situation when the patient cannot control the bleeding. The latter cases usually result in trivial haemorrhage by clinical standards, but may create a disproportionate amount of alarm. Occasionally, a prolonged nosebleed can cause significant hypovolaemia, especially in the elderly.
Paraesthesiae and numbness are taken here to mean sensations of tingling, pins-and-needles, subjective numbness, and feelings of cold and heat. They may appear spontaneously or be a result of touching the area of skin concerned. Patients are often alarmed and may make an immediate association with serious disease. The differential is huge but most cases in primary care involve anxiety, nerve entrapment or cerebrovascular disease.
This term is taken to apply to women. It causes much misery and may be embarrassing for a woman to discuss with anyone. As a result, it may be the ‘hidden agenda’, presenting as a nonexistent ‘discharge’ or vague ‘soreness down below’ for GP partners but for nurses this is a likely and possibly expected subject when undertaking cytology screening. Alternatively, it may be the underlying cause of a presentation of infertility or stress. Tact and sensitivity are the most valuable diagnostic and therapeutic tools in these situations.
This symptom has a multitude of causes. A careful history is required to distinguish between muscle and joint pain, and between muscle pain and weakness. In some of the underlying pathologies, these symptoms may coexist. Cramp, causing very transient muscle pain, is covered elsewhere (see the 'Calf pain' section).
Painful periods are extremely common: 50% of women in the UK complain of moderate pain, and 12% suffer severe, disabling pain. Primary dysmenorrhoea is pain with no organic pathology, usually starting when ovulatory cycles begin. Secondary dysmenorrhoea is associated with pelvic pathology, and appears later in life.
Pain in the tongue is usually caused by something immediately apparent on examination, but there are a few less obvious causes. This is something much more likely to be seen by a dentist, but is not strictly dental and therefore a working knowledge of the symptom is firmly within the remit of primary care.
Palpitations are presented fairly frequently in primary care, sometimes in isolation but more often immersed in other symptoms. Patients use the word ‘palpitations’ to describe a remarkable variety of sensations, and it is important to establish exactly what is meant. Cardiac causes are relatively rare; anxiety about a cardiac problem, and anxiety as a cause of the symptom, are common.
Papules are solid, circumscribed skin elevations up to 5 mm in diameter. If they are larger, they are called nodules – these are dealt with elsewhere (see ‘Nodules’). (Clearly, many nodules start life as a papule; to avoid confusion, if they are generally ‘nodular’ by the time they present , then they are dealt with in that section, and not repeated here.) They are usually round but the shape, and the colour, may vary. They may be transitional lesions, e.g. becoming vesicular, or about to ulcerate. NOTE: There are more causes of papules than can be listed here. This is a sensible selection.
Pain in the penis occurs not just as a result of local causes, but also by referral from remote lesions. It frequently generates embarrassment for the patient, who may also be frightened that he has a sexually transmitted disease. The diagnosis will often be clear after a carefully taken history and appropriate examination.
Presentation of this symptom is nearly always accompanied by fear of sexually transmitted disease, even in elderly or no longer sexually active men. There are a number of other causes, many of which are significant and require investigation.
Clinicians deal with fevers on a daily basis – the vast majority are caused by viruses and are self-limiting. This section deals with a different and much less common scenario: a temperature above normal for three weeks or more. It may be continuous or swinging. Many more causes exist than can be named here, but those likeliest in general practice are listed.
Purpura are reddish-purple lesions which do not blanch with pressure. When less than 1 cm in diameter, they are called petechiae; if larger, they are known as ecchymoses. The problem often presents as ‘bruising easily’ and is a common ‘while I’m here’ complaint in primary care. Most cases are normal, with causative minor trauma simply being forgotten or unnoticed.
Pustules are raised lesions less than 0.5 cm in diameter containing a yellow fluid. They signify infection to most people, and will often present in an urgent appointment, as they are likely to have appeared suddenly. Patients will often expect antibiotic treatment. This will not always be necessary, so be prepared to offer a clear explanation and an appropriate alternative.
This is a very common presenting complaint and creates a lot of anxiety in the patient. By far the likeliest causes are haemorrhoids or a fissure, but more sinister pathologies should be considered according to the clinical picture, especially in older patients.
Bleeding from anywhere tends to generate a great deal of anxiety. If that bleeding is from the rectum, and the patient is a child, then the stress levels inevitably multiply. So while this is a relatively unusual presentation, it will often present as an ‘urgent’ and typically require much reassurance. Any clinician will have to deal with their own anxiety too – of working within their scope of practice and not overlooking the rare serious cause
Recurrent abdominal pain in childhood can have a great number of causes. More than 85 have been listed, and as in most areas of general practice, the trick is to sift through the morass of information to find the keys to the diagnosis and open the way to effective management. The underlying cause in the most persistent cases is usually non-organic (90% of those referred to hospital).
Hip area pain is a common presentation in the middle-aged and elderly, and the patient will often attribute it to osteoarthritis. This diagnosis may well be correct, although the differential is wide – besides, the patient’s view of what actually constitutes the ‘hip’ may be at odds with the anatomical truth.
Recurrent knee pain is a very common presentation with a wide differential. Classification of causes isn’t helped by changing and confusing nomenclature. As ever in general practice, a careful history and examination will provide useful clues – but management will often be dictated more by degree of disability and the patient’s wishes than by making a precise diagnosis.
Retention is failure to empty the bladder completely. The acute form characteristically affects men, presents urgently and requires immediate catheterisation or hospitalisation. Chronic retention may produce few symptoms and may only be discovered during palpation of the abdomen.
Though not usually viewed as a significant symptom, this is very bothersome to those that suffer it. Many of the pathologies overlap with the causes of the ‘Blocked nose’ – please refer to this chapter too, as appropriate. The cause is rarely sinister, but referral for further assessment may be necessary if it persists in spite of treatment.
Skin scales represent an abnormally fast piling up of keratinised epithelium. Scales and plaques are common at all ages and have a variety of causes. The presentation will centre on cosmetic appearance, itching, fears about serious disease or a combination of these.
Scrotal swellings can occur at any age. They arise most commonly from the testicle and its coverings, the spermatic cord and the skin. Greater awareness of testicular cancer has resulted in increasing numbers of young men attending the general practice, usually with benign lumps.
Given that this type of rash affects inaccessible and uninviting nooks and crannies of the body, it may be dealt with in a cursory way. In most cases, that won’t be a problem, as the diagnosis may be clear. The differential is wider than many imagine, though, and the symptoms troublesome or painful enough to cause the patient real distress.
This presenting symptom is common – the average practice of 4 GPs will see about 500 cases each year – the most over-treated, the most controversial and usually the most mundane.
The most common causes of acute neck stiffness are benign and easily managed in general practice. However, this symptom causes disproportionate panic in parents of febrile children thanks to extensive media coverage of meningitis. This anxiety can spill over into adult illness behaviour, with the result that a troublesome but harmless symptom may be misinterpreted as the harbinger of serious pathology.
Acute stridor is a very frightening experience for both child and parents. The respiratory effort can lead to hyperventilation, making things worse. ‘Difficult’ or ‘noisy’ breathing in a child in the winter quite commonly elicits a 111 call and request for an out-of-hours visit. The usual cause is viral croup, producing mild, harmless stridor – but serious cases do occur. A calm exterior and a methodical approach are the keys to effective management.
Sudden loss of vision is a genuine emergency. Most causes require an urgent ophthalmological opinion as there is little that others can do. This particular symptom is not often encountered in general practice – a prompt appointment or visit and a careful examination are necessary to assess the situation and exclude the causes not requiring urgent specialist treatment. Blurring, such as that found in some cases of the acute red and painful eye, is not covered here.
This is one of the commonest presenting complaints in the elderly and, in this age group, may be linked to recurrent falls. As a result, it is frequently the reason for a home visit request. In younger age groups, it is much rarer, but much more likely to signify serious pathology.
Such has been the publicity about cramped airline flights that this presentation – and the closely related symptom, ‘calf pain’ (refer to that section) – has become quite common. The worry the patient has about a possible DVT matches the clinician’s anxiety not to miss this significant problem. In most cases, a careful history, backed up by appropriate examination, should reveal the true cause.
There are very many causes of swollen glands (lymphadenopathy), but in general it is possible to narrow the list of possible causes down to a manageable few by careful history and examination. Age, geography (or travel history) and distribution of enlarged glands have a considerable influence on the differential diagnosis.
This is an uncommon symptom in everyday general practice. Though commonest in the young adult, it can affect all age groups. In its acute form, it is excruciating and disabling. In the chronic form it is usually described as a dull ache or dragging sensation. It is the former which creates the most diagnostic difficulty and anxiety.
This symptom probably generates more general practice advice calls and parental anxiety than any other. It is nearly always caused by an infection of some kind. The list of culprits is so vast that we have concentrated on the common and occasional ones more likely to be seen in general practice in the UK.
The complaint of thirst rings alarm bells in clinicians and patient alike. Diabetes clearly needs to be excluded but the differential may need to be extended beyond this in the light of negative initial tests. Dry mouth tends to create less concern but can sometimes herald significant pathology and may be a serious nuisance to the patient.
This means noises heard (nearly always subjectively) in the ears or head. They are often described as being like a whistling kettle, an engine, or in time with the heartbeat. As a short-lived phenomenon, it is very common (often with URTIs) – such cases do not usually present to the general practice. More serious, persistent tinnitus occurs in up to 2% of the population. It is very distressing and can cause secondary depression and insomnia. Objective tinnitus is very rare.
Feeling tired all the time is such a common presenting symptom that ‘TATT’ has become a universal acronym. In around 85% of first consultations the cause is apparent by the end. Although the vast majority turn out to have a non-organic cause, it is clearly important not to get lulled into ignoring important physical illness. A structured approach makes for a successful consultation.
This is rhythmic movement of parts of the body. There are three clinical types: rest tremor (worst at rest), postural tremor (worst in a fixed posture, e.g outstretched arms) and intention tremor (worst during voluntary movement). Tremor may be noticed by the nurse or other clinician during an assessment for some other problem, or it may be the presenting symptom. In the latter case, the patient may be embarrassed by the lack of ‘self-control’, so a sympathetic approach is important.
Vaginal discharge is usually a symptom of the reproductive years, but can occur at any age. It can be influenced by the menstrual cycle, use of ‘the pill’, age, pregnancy and sexual activity. Treatment is often simple, but if it fails, or if there are risk factors for STDs, it is sensible to refer to a GUM clinic.
Vertigo is an illusion of movement of either the patient or his or her environment. This is both visual and positional. Associated nausea or vomiting are common and, in its acute form, it is a severe and completely disabling symptom. It must be distinguished from ‘light-headedness’ (see section on Dizziness).
Vomiting is one of the commonest reasons for a general practice call – especially for children. While most cases are self-limiting and benign, the possible causes are numerous and the symptoms can herald serious pathology. Careful assessment is required, together with a willingness to review and admit if the diagnosis remains unclear.
This presentation may vary from a few red streaks in gastric fluid to copious quantities of bright red blood. Blood static in the stomach for a few hours will change to look dark and granular, like coffee grounds. Always do a full urgent assessment, and be prepared for the sudden need for resuscitation.
This is not a simple problem for general practice as the differential is wide and encompasses some serious illnesses. Ongoing vomiting is less of an urgent worry, with a narrower range of possibilities.
Vulval irritation encompasses soreness and itch and is a very common presentation in primary care. Nurses maybe the first to be consulted in association with cytology screening or family planning clinics. Sometimes it is a veiled need to talk about than a psychosexual problem. With sensitivity, the real issues should emerge during the consultation.
Vulval swellings may originate in the vulva, or appear there after displacement from their origin. They often present as ‘a lump down below’ – an expression which belies the variety of possible causes. They generate a lot of anxiety but are rarely sinister.
This often unpleasant symptom is uncommon, but very important, as many causes are significant and require specialist investigation, treatment and follow-up. Patients often have difficulty visualising or describing these types of lesions, so adequate examination is vital in establishing the diagnosis.
By far the commonest cause of this problem is simple obesity. This is 50% commoner in women, who also present more often than men. Many obese patients have unrealistic expectations of what the general practice can directly achieve.
The significance of weight loss should not be underestimated: In about one-third of patients, there is no specific cause, but in the rest, a serious underlying pathology is found. The minority of these are psychiatric; 90% have organic illness. Thorough assessment from the start is the rule.