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.
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 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.
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.
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.
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 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.
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.
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.
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.
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.
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.
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 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.
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.
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.