Life would be much simpler for GPs if patients presented with diagnoses. Unfortunately, they do not: they present with symptoms, which are frequently vague, sometimes multiple and occasionally obscure. It is up to the GP to create some order from this chaos. However, the vast majority of clinical texts adopt a diagnosis, rather than symptom-based, approach and the few which do reflect the reality of patient presentations are inevitably orientated towards hospital medicine and so are irrelevant to GPs.
This book, originally serialised, in a different form, in Doctor magazine, aims to redress the balance. It analyses a multitude of symptoms commonly seen in primary care and, for each, presents differentials, distinguishing features, possible investigations and key points. The only omissions are presentations for which there are so few differentials that diagnosis is really quite simple (e.g. ‘lump on elbow’); those which rarely present in isolation (e.g. nausea, anorexia); and those which are so rare that the reader would be sure to require specialist advice (our personal favourite being ‘pilimiction’).
Written by two full-time GP principals, its perspective is very much grass roots primary care – though informed by the latest evidence and guidance where possible or appropriate – and its appeal is therefore wide. GP registrars and young principals, relatively unfamiliar with the protean presentations possible in general practice, will be able to check their diagnostic hypotheses against the information in the book; the more experienced GP might use it as a refresher or as a pointer to a more exotic diagnosis in an unusual case; and the nurse practitioner, taking increasing responsibility as a first port of call in primary care for many patients, will find the contents unique and essential.
The popularity of the first edition and the need for second, third, fourth and fifth editions emphasises the fact that, while general practice may experience multiple reorganisations and restructurings, the bread and butter business of making sense of symptoms remains. This new edition adds a number of extra chapters and significant updates of existing chapters.
Each symptom is analysed in a uniform, accessible way, as follows.
This defines the symptom and its key characteristics, and gives some idea of the frequency of presentation.
This lists the likely diagnoses, subdivided ‘Common’, ‘Occasional’ and ‘Rare’. (It should be noted that these headings are relative to the symptom in question. For example, some of the ‘common’ causes of delayed puberty will be rarer than some of the ‘occasional’ causes of acute abdominal pain – for the simple reason that abdominal pain is much commoner than delayed puberty as a presenting symptom.) Restrictions of space and imagination mean that such a differential can never claim to be exhaustive, and a lack of accurate prevalence data renders the allocation of the diagnoses to these subdivisions somewhat arbitrary, based on our experience rather than hard evidence. These are minor limitations, however; this section will invariably provide clear guidance as to the likely cause of any symptom.
This provides a quick guide to the key distinguishing features of the five most likely diagnoses listed in the preceding section.
This section outlines those investigations likely to assist the reader in making a diagnosis. The emphasis is upon tests performed in primary care or usually arranged by the GP. Where appropriate, more complex, hospital-initiated investigations are outlined – partly because GPs may wish to let their patients know the type of tests they might anticipate after referral and also because GP access to traditionally hospital-organised investigation is increasing. All investigations discussed are categorised according to the likelihood that they will be performed, the three categories being, ‘Likely’, ‘Possible’ and ‘Small print’.
This provides a potpourri of management nuggets appropriate to each symptom, which the authors have accumulated over the years. Such hints from experience are difficult to analyse or quantify and so most are unashamedly anecdotal rather than evidence based – this should not detract from their usefulness or occasional elegance. Some might appear to stretch the scope of the book in that they cross the boundary between symptom assessment and symptom management – but the reader should bear in mind that the diagnostic process, particularly in primary care, involves hypothesis testing, and so these boundaries are, in reality, blurred.
Most symptoms presented in primary care are benign, minor and self-limiting. This can occasionally lull the unwary into a false sense of security: for each presentation there exist pointers which should set alarm bells ringing. ‘Red flags’ highlights aspects of symptoms which suggest significant pathology and which therefore should not be missed or neglected.
This Symptom Sorter is designed to act as a rapid reference. It has deliberately been written in a note and list format so that, unlike weightier tomes, it is quick and easy to use. For the sake of brevity, common and well-recognised abbreviations have been used whenever possible. Its consistent style will soon breed familiarity and allow the reader to know where and how to retrieve information painlessly. To help achieve this, the symptoms are arranged in sections, each section corresponding to a system or anatomical region. In these sections, the symptoms are arranged alphabetically and, for the most part, are labelled in patient, rather than doctor, vernacular (e.g. shortness of breath rather than dyspnoea) – the exceptions being where there is no acceptable or concise ‘patientspeak’ version. However, as many symptoms can have a variety of descriptions (e.g. shortness of breath, dyspnoea, breathlessness, wheeziness, difficulty breathing and so on) the index is deliberately expansive and cross-referenced, and will quickly guide the reader to the appropriate pages.
The categorisation of symptoms and their arrangement in sections is a complex task which can be approached in a number of ways – for example, rashes might be divided according to distribution, size of lesion, morphology, itch and so on. Throughout, we have chosen the approach which seems most logical to us and which, whenever possible, avoids unnecessary omission or repetition; again, the index should rapidly point the reader in the right direction. Assigning symptoms to certain sections may sometimes seem arbitrary, especially when they can have such disparate causes, but this approach provides the book with a clear, understandable structure.
As GPs, we are aware that patients often present polysymptomatically. Our book, neatly dividing complaints into individual symptoms, might therefore be criticised for not accurately reflecting real primary care life. In fact, such presentations can usually be distilled down to one or two predominant symptoms; more minor symptoms often act as pointers to the actual diagnosis, a fact our ‘Ready reckoners’ in each chapter exploits. In the truly polysymptomatic, the book may help to define a common thread among the symptoms, thereby revealing the real diagnosis – usually, in such cases, anxiety or depression.
The book should be kept to hand for use during surgery to confirm the likelihood of a certain diagnosis or raise the possibility of others. Being comprehensive, relevant and accessible, retrieval of information will be speedy and helpful during the consultation itself (you may wish to wait until the patient is undressing behind the curtain: there should be time).
The book may be used in other ways. GP trainers could use the analysis of a certain symptom provided in the text as the basis for a tutorial. Indeed, the book could itself form part of the GP registrar’s curriculum. By ‘sorting’ two or three symptoms a week, using the text as a guide, the registrar could, over the course of his or her practice year, cover the vast majority of presentations seen in primary care. Trainers of undergraduates, too, will find that the contents provide useful material for teaching sessions.
Others might simply like to browse, refreshing or refining their diagnostic skills and mulling over the Red flags and Top tips.
Feedback received by the authors indicates that previous editions are now included in many undergraduate curricula as recommended reading, and the book is proving very popular among primary care nurses and nurse practitioners.
However the reader uses this book, we are convinced that it will prove an essential resource. Making sense of symptoms is the essence of general practice, and any tool designed by and for GPs which contributes to this art is likely to benefit doctors and patients alike.
Keith Hopcroft
Vincent Forte
August 2014
