Symptom Sorter - 6th Edition
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© 2020 Keith Hopcroft and Vincent Forte
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Library of Congress Cataloging-in-Publication Data
Names: Hopcroft, Keith, author. | Forte, Vincent (General practitioner), author.
Title: Symptom sorter / Keith Hopcroft and Vincent Forte.
Description: Sixth edition. | Boca Raton : CRC Press/Taylor & Francis Group, [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2019056048 | ISBN 9780367468095 (paperback) |
ISBN 9780367468101 (hardback) | ISBN 9781003032106 (ebook)
Subjects: MESH: Signs and Symptoms | Diagnosis | Diagnosis, Differential |
Diagnostic Techniques and Procedures | Handbook
Classification: LCC RC69 | NLM WB 39 | DDC 616/.047--dc23
LC record available at https://lccn.loc.gov/2019056048
ISBN: 9780367468101 (hbk)
ISBN: 9780367468095 (pbk)
ISBN: 9781003032106 (ebk)
Typeset in Garamond Premr Pro
by Nova Techset Private Limited, Bengaluru & Chennai, India
To Ali D, my rock
—VF
To D, H and W: Thank you for sorting out all the symptoms
I developed writing this book
—KH
CONTENTS
Abbreviations ix
Introduction 1
Abdomen 5
Anorectal 49
Breast 65
Cerebral 79
Chest 105
Ear127
Eye141
Face163
General physical 177
Genital 243
Hair and Nails 275
Limbs 287
Neck 331
Nose 349
Oral359
Pelvic 375
Periods 385
Skin399
Urinary 425
Index 447
vii
ABBREVIATIONS
A&E accident and emergency CT computed tomography
ABPI ankle brachial pressure index CVA cerebrovascular accident
ACE angiotensin-converting enzyme CXR chest X-ray
ACR albumin creatinine ratio D&C dilatation and curettage
ACTH adrenocorticotrophic hormone DIC disseminated intravascular
ADH antidiuretic hormone coagulation
AF atrial fibrillation DKA diabetic ketoacidosis
AFP α fetoprotein DM diabetes mellitus
ALT alanine-amino transferase DU duodenal ulcer
anti-CCP anti-cyclic citrullinated peptide DUB dysfunctional uterine bleeding
ANUG acute necrotising ulcerative DVT deep vein thrombosis
gingivitis DXA dual energy X-ray
ARC AIDS-related complex absorptiometry
ASO antistreptolysin EAM external auditory meatus
AST aspartate-amino transferase EBV Epstein–Barr virus
BCC basal cell carcinoma ECG electrocardiogram
BNP B type natriuretic peptide EEG electroencephalogram
BP blood pressure ELISA enzyme-linked immunosorbent
BPH benign prostatic hypertrophy assay
BTB breakthrough bleeding EMG electromyography
BV bacterial vaginosis EMU early morning urine (sample)
BXO balanitis xerotica obliterans ENT ear, nose and throat
CA-125 cancer antigen 125 EO epididymo-orchitis
CCF congestive cardiac failure ERCP endoscopic retrograde
CKD chronic kidney disease cholangiopancreaticogram
CMPI cow’s milk protein intolerance ESR erythrocyte sedimentation rate
CNS central nervous system ET Eustachian tube
COPD chronic obstructive pulmonary FBC full blood count
disease FIT faecal immunochemical test
CPK creatine phosphokinase FSH follicle-stimulating hormone
CREST calcinosis/Raynaud’s γGT gamma glutamyl transpeptidase
phenomenon/oesophagealdys GAD generalised anxiety disorder
motility/sclerodactyly/ GF glandular fever
telangiectasia GI gastrointestinal
CRP C-reactive protein GI granuloma inguinale
CSF cerebrospinal fluid GnRH gonadotrophin-releasing
CT carpal tunnel hormone
ix
x Abbreviations
GORD gastro-oesophageal reflux NSAID non-steroidal anti-inflammatory
disease drug
GUM genito-urinary medicine OA osteoarthritis
Hb haemoglobin OE otitis externa
HCG human chorionic gonadotrophin O/E on examination
5HIAA 5-hydroxy-indole-acetic acid OG onychogryphosis
HIV human immunodeficiency virus OGD oesophago-gastro duodenoscopy
HLA human leucocyte antigen OM otitis media
HRT hormone-replacement therapy OTC over the counter
HSV herpes simplex virus PAN polyarteritis nodosa
HVS high vaginal swab PCOS polycystic ovary syndrome
IBD inflammatory bowel disease PCR protein creatinine ratio
IBS irritable bowel syndrome PCV packed cell volume
IC intermittent claudication PE pulmonary embolism
IGTN ingrowing toenail PEFR peak expiratory flow rate
IHD ischaemic heart disease PF proctalgia fugax
INR international normalised ratio PID pelvic inflammatory disease
ITP idiopathic thrombocytopenia PMR polymyalgia rheumatica
purpura PMT pre-menstrual tension
IUCD intrauterine contraceptive PR per rectum
device PRIST paper radioimmunosorbent disc
IVP intravenous pyelogram test
IVU intravenous urogram PSA prostate-specific antigen
JCA juvenile chronic arthritis PTH parathyroid hormone
LFT liver function tests PU peptic ulcer
LGV lymphogranuloma venereum PUO pyrexia of unknown origin
LH luteinising hormone PV per vagina
LMP last menstrual period PVE per vaginal examination
LN lymph node PVD peripheral vascular disease
LRTI lower respiratory tract infection RA rheumatoid arthritis
LSD lysergic acid diethylamide RAST radioallergosorbent test
LUTS lower urinary tract symptoms RAU recurrent aphthous ulceration
LVF left ventricular failure RLS restless legs syndrome
MAOI monoamine oxidase inhibitor RUQ right upper quadrant
MC&S microscopy, culture and SA septic arthritis
sensitivity SCC squamous cell carcinoma
MCV mean cell volume SHBG serum hormone binding
MI myocardial infarction globulin
MMR measles, mumps, rubella SLE systemic lupus erythematosus
MRI magnetic resonance imaging SOB shortness of breath
MS multiple sclerosis STD sexually transmitted disease
MSU mid-stream urine (sample) SVT supraventricular tachycardia
NAI non-accidental injury TAH total abdominal hysterectomy
NICE National Institute for Health TATT ‘tired all the time’
and Care Excellence TB tuberculosis
Abbreviations xi
TCA tricyclic antidepressant U&E urea and electrolytes
TFT thyroid function tests URTI upper respiratory tract infection
TIA transient ischaemic attack UTI urinary tract infection
TMJ temporomandibular joint UV ultraviolet
TN trigeminal neuralgia VMA vanillyl-mandelic acid
TSH thyroid-stimulating hormone VT ventricular tachycardia
TURP transurethral resection of WCC white cell count
prostate WRULD work-related upper limb
TV trichomonal vaginosis disorder
INTRODUCTION
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 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 multiple subsequent editions emphasises
the fact that, while general practice may experience many 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.
The GP overview
This defines the symptom and its key characteristics, and gives some idea of the frequency of
presentation.
Differential diagnosis
This lists the likely diagnoses, subdivided ‘Common’, ‘Occasional’ and ‘Rare’. (It should be
noted that these headings are relative to the symptom in question.) Restrictions of space and
1
2 Symptom Sorter
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.
Ready reckoner
This provides a quick guide to the key distinguishing features of the five most likely diagnoses
listed in the preceding section.
Possible investigations
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’.
TOP TIPS
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’ highlight aspects of symptoms which
suggest significant pathology and which therefore should not be missed or neglected.
Introduction 3
How to use this book
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 time in practice, 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’.
4 Symptom Sorter
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
October 2019
ABDOMEN
Abdominal swelling 6
Acute abdominal pain in adults 9
Acute abdominal pain in children 12
Acute abdominal pain in pregnancy 15
Chronic/recurrent abdominal pain in adults 18
Constipation21
Diarrhoea in adults 24
Diarrhoea in children 27
Epigastric pain 30
Loin pain 33
Recurrent childhood abdominal pain 36
Vomiting39
Vomiting blood 42
Vomiting in infants 45
For ‘Difficulty swallowing’, see ‘Neck’ chapter
5
ABDOMINAL SWELLING
The GP overview
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 GP might find the swelling while performing a physical examination.
Differential diagnosis
COMMON
◩◩ pregnancy
◩◩ irritable bowel syndrome (IBS)
◩◩ constipation
◩◩ fibroid uterus
◩◩ enlarged bladder
OCCASIONAL
◩◩ coeliac disease
◩◩ ascites (itself has many causes)
◩◩ intestinal obstruction
◩◩ ovarian mass (cyst or malignant tumour)
◩◩ carcinoma of stomach or colon
◩◩ hepatomegaly (various causes)
RARE
◩◩ splenomegaly (various causes)
◩◩ pancreatic carcinoma
◩◩ aortic aneurysm
◩◩ massive para-aortic lymphadenopathy
◩◩ hydronephrosis, renal cysts and renal malignancy
6
Abdominal swelling 7
Ready reckoner
Pregnancy IBS Constipation Fibroid uterus Bladder
Size varies No Yes Possible No Possible
Amenorrhoea Yes No No No No
Poor urinary stream No No No No Yes
Diarrhoea No Yes Possible No No
Cannot get below Yes No Possible Yes Yes
Possible investigations
LIKELY: Pregnancy test, ultrasound.
POSSIBLE:Urinalysis, FBC, U&E, LFT, CA-125, anti-endomysial and anti-gliadin antibodies,
plain abdomen X-ray.
SMALL PRINT: Hospital-based lower GI investigations, paracentesis, CT scan.
◩◩ Pregnancy test essential in amenorrhoeic women.
◩◩ Urinalysis may reveal microscopic haematuria in renal or bladder tumours.
◩◩ Abdominal ultrasound is the quickest and most efficient way to define the source of most
abdominal swellings or masses. Ultrasound of pelvis/abdomen may also be indicated
according to an elevated CA-125 (see below).
◩◩ Full blood count (FBC): Anaemia likely in malignancy, possible in fibroids with menorrhagia;
also will reveal blood dyscrasias.
◩◩ Urea and electrolytes (U&E) may be deranged in gross renal disease. Liver function tests
(LFTs) may give a clue to alcoholic hepatomegaly or malignancy. Low albumin in ascites.
◩◩ CA-125: May be indicated in women, especially those aged 50 or more, to help exclude
ovarian cancer.
◩◩ Anti-endomysial and anti-gliadin antibodies: For possible coeliac disease.
◩◩ Hospital-based lower GI investigations: Useful to confirm or exclude colonic disease.
◩◩ Plain abdominal X-ray: May show constipation or obstruction (in the latter case, likely to be
arranged after admission).
◩◩ Other tests are likely to be arranged after specialist referral, e.g. paracentesis (to investigate
and relieve ascites), CT scanning (to establish nature of mass and its effects on surrounding
structures).
TOP TIPS
◩◩ Take care in the history to distinguish between intermittent or variable swelling, and
progressive swelling. The former will probably not be caused by serious pathology, whereas
the latter may well be.
◩◩ Pregnancy can catch out the unwary, particularly when dealing with perimenopausal women
or teenage girls. Do not accept the claim that ‘I can’t be pregnant’.
8 Symptom Sorter
◩◩ Some ‘swellings’ turn out, on examination, to be impalpable or to represent normal anatomy.
The physical examination may have a therapeutic effect. If not, explore the patient’s concerns
more fully and consider anxiety, depression or other psychological problems if symptoms
persist.
◩◩ Weight loss in conjunction with abdominal swelling should immediately suggest malignancy.
◩◩ Acute onset of swelling with abdominal pain suggests obstruction, requiring urgent surgical
attention.
◩◩ Obesity presents difficulties in examination and can be difficult to distinguish from ascites.
If in doubt, arrange an ultrasound.
◩◩ Resonance on percussion does not rule out a solid mass: Retroperitoneal masses will push
bowel anteriorly and may be apparently tympanic.
NOTES:
ACUTE ABDOMINAL
PAIN IN ADULTS
The GP overview
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 the patient as soon
as possible.
NOTE: Upper and mid-abdominal pain are dealt with here. Lower abdominal pain is dealt with
under ‘acute pelvic pain’ and specifically epigastric-type pain is covered in more detail in the
epigastric pain section.
Differential diagnosis
COMMON
◩◩ peptic ulcer
◩◩ biliary colic
◩◩ appendicitis
◩◩ gastroenteritis
◩◩ renal colic
OCCASIONAL
◩◩ cholecystitis (may follow biliary colic, but pain is constant and fever present)
◩◩ diverticulitis
◩◩ acute or subacute bowel obstruction (adhesions, carcinoma, strangulated hernia, volvulus)
◩◩ pyelonephritis
◩◩ muscular wall pain
◩◩ pancreatitis
◩◩ Meckel’s diverticulum
RARE
◩◩ perforation (e.g. duodenal ulcer [DU], carcinoma) resulting in peritonitis
◩◩ hepatitis
◩◩ Crohn’s and ulcerative colitis
◩◩ ischaemic bowel
