The 10-Minute Clinical Assessment - Knut Schroeder - ebook

The 10-Minute Clinical Assessment ebook

Knut Schroeder

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Opis

Clinical assessment is at the heart of medicine. Health professionals working in busy clinical settings, such as general practitioners, nurse practitioners and hospital doctors on-call, often have to assess patients under considerable time constraints. This book teaches the reader how to gather clinical information effectively, accurately and safely even when time is at a premium. * Provides a systematic method of collecting and assessing relevant clinical information by suggesting step-by-step examination routines, including important patient-centred questions * Focuses on common symptoms and presentations * Treatment reflects the latest in evidence based practice (including latest NICE Guidelines) * Specifically covers the clinical skills assessment (CSA) part of the Membership of the Royal College of General Practitioners (RCGP) examination * Written by an experienced medical educator and practicing GP, in consultation with a multidisciplinary team of medical students, GPs, PG trainees, hospital doctors and nurses

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The 10-MinuteClinical Assessment

Second Edition

 

Knut Schroeder

MSc PhD DCH DRCOG DGM MRCP FRCGP CertMedEdHonorary Senior Clinical Lecturer in General PracticeCentre for Academic Primary CareUniversity of BristolGeneral Practitioner, Bristol

 

 

 

 

 

 

This edition first published 2017, © [2010, 2017] by John Wiley & Sons Ltd.

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Library of Congress Cataloging-in-Publication Data applied for.

9781119106340 (Paperback)

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: © Daniel Entenza / © EyeEm / GettyimagesCover design by Andy Meaden.

Set in 8/11pt FrutigerLTStd by Aptara Inc., New Delhi, India

1 2017

 

 

 

 

For Kiran and Rohan

Table of contents

Foreword

Preface to 1st edition

Preface to 2nd edition

About the author

Acknowledgements

Selected useful resources

The focused consultation

Focused clinical assessment

Useful consultation tools

Red flags in general practice

Undifferentiated and miscellaneous presentations

Suspected cancer

Weight loss

Tiredness

Dizziness

Chronic pain

Sudden collapse and syncope

Frequent attenders

Medication review and polypharmacy

Medically unexplained symptoms

Insomnia

Irritability and ‘stress’

Domestic violence

Homelessness

Paediatrics and adolescent health

The sick and/or feverish child

Suspected meningococcal meningitis and septicaemia

Neonatal jaundice

Faltering growth

Headache and migraine in children

Head injury in children

Suspected cancer in children and adolescents

Abdominal pain in children

Hearing loss in children

Childhood cough

Childhood wheeze

Constipation in children

Childhood obesity

Suspected child abuse and neglect

Nocturnal enuresis

Knee problems in children

Hip problems in children

Adolescent health problems

Self-harm in teenagers

Eating disorders

Autism-spectrum disorder

Cardiovascular

Chest pain

Palpitations

Cardiovascular risk assessment

Hypertension

Atrial fibrillation

Heart failure

Peripheral vascular disease

Respiratory

Shortness of breath

Haemoptysis

Suspected lung cancer

Asthma

Chronic obstructive pulmonary disease

Suspected pneumonia

Pleural effusion

Pulmonary embolism

Endocrine and metabolic

Diabetes review

Obesity

Hirsutism in women

Hypothyroidism

Hyperthyroidism

Hyponatraemia

Hypernatraemia

Hypokalaemia

Hyperkalaemia

Hypocalcaemia

Hypercalcaemia

Gastrointestinal

Nausea and vomiting

Dysphagia

Dyspepsia and reflux

Upper gastrointestinal bleeding and melaena

Abdominal pain

Constipation

Diarrhoea

Rectal bleeding and suspected bowel cancer

Abnormal liver function tests

Irritable bowel syndrome

Inflammatory bowel disease

Coeliac disease

Infectious diseases

Fever of unknown origin

Fever and illness in the returning traveller

HIV infection and AIDS

Tuberculosis

Rheumatic fever

Haematology

Iron-deficiency anaemia

Macrocytic anaemia (B12 and folate deficiency)

Bleeding disorders

Myeloma

Musculoskeletal

Soft-tissue injury

Acute hot and swollen joint

Chronic musculoskeletal pain

Polyarthralgia

Neck pain

Back pain

Shoulder and arm problems

Elbow problems

Hand problems

Hip pain

Groin problems

Leg pain and/or swelling

Knee pain

Foot and ankle problems

Gout

Osteoporosis

Neurology

Headache

Transient ischaemic attack and stroke

Head injury in adults

Suspected or confirmed brain tumour

Tremor

Motor neurone disease

Peripheral neuropathy

Multiple sclerosis

Gynaecology

Combined oral contraception

Menorrhagia

Amenorrhoea

Breast lumps

Loss of libido

Polycystic ovary syndrome

Suspected ovarian cancer

Obstetrics

Routine antenatal care

Bleeding in early pregnancy

Abdominal pain in pregnancy

Pre-eclampsia

Urology and renal medicine

Suspected urinary tract infection in women

Lower urinary tract symptoms in men

Urinary incontinence

Urethral discharge in men

Scrotal and testicular problems

Erectile dysfunction

Renal or ureteric colic (kidney stones)

Haematuria

Chronic kidney disease

Mental health

Depression

Self-harm and harm to others

Anxiety, phobias and panic disorder

Alcohol screening

Alcohol dependence

Illicit drug misuse

Obsessive–compulsive disorder

Mania

Schizophrenia

Skin

Moles and malignant melanoma

Pressure ulcers

Ophthalmology

Eye injuries

The acute red eye

Gradual painless visual disturbance

Sudden painless visual disturbance

Eye problems in older people

Ear, nose and throat

Neck swelling

Sore throat

Ear pain

Hearing loss in adults

Tinnitus

Sinusitis and facial pain

Problems in older people

General health assessment in older people

Cognitive problems and dementia

Falls in older people

Delirium and acute confusional state

Depression in older people

Palliative and end-of-life care

Parkinson's disease

Index

EULA

Guide

Cover

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Foreword

Being a GP is hugely rewarding but also incredibly complex. Patients can and do present themselves with a bewildering array of problems, and they expect their doctor to have the answer to everything straight away.

This variety is what makes general practice both satisfying and challenging, but it can be daunting for a recent graduate who is competent – but perhaps not completely confident.

Therefore, a guide like this is extremely valuable. It covers 154 selected clinical presentations from all the major clinical specialties that can be particularly challenging for people new to general practice. It contains references to the latest evidence and guidelines and tries to maintain a patient-centred approach throughout.

The target audience for this book is senior medical students and doctors starting their career in general practice, who may find the transition from full history and examination to the focused approach that we adopt in general practice difficult. It should also be helpful for candidates preparing for the CSA part of the MRCGP examination.

Even for experienced health professionals, this book will be extremely useful as a quick reference to have handy in the surgery. Because it is impossible to cover everything during a brief clinical assessment, the book tries to point out those areas that should be considered when faced with important and potentially tricky clinical presentations.

This guide is a highly valuable tool to use alongside the RCGP curriculum. It reflects a desire to improve patient care and the quality of general practice, a goal which should be applauded.

As someone who is passionate about general practice and GP education, I'm proud to recommend this book by Knut Schroeder as an excellent contribution to the genre.

Professor Steve Field FRCGP Chairman, Royal College of General Practitioners

Preface to the 1st edition

Those of us who work in busy clinical settings often have to assess patients under considerable time constraints. This can be a challenge, particularly when faced with undifferentiated presentations such as ‘headache’, ‘chest pain’, ‘weight loss’ or ‘dizziness’. The 10‐Minute Clinical Assessment provides suggestions for a focused approach in such situations and covers a selection of important and frequently demanding or difficult clinical presentations – symptoms as well as conditions – from all the major clinical specialties.

Medical students, nurses and even doctors undergoing postgraduate training often get surprisingly little teaching and training on what to include in a focused history and examination. This book bridges the gap by highlighting important differential diagnoses, ‘red flags’ and key aspects to consider during clinical assessment, while also giving some indication as to why these might be relevant. Important clinical presentations are covered with reference to the latest evidence and guidelines, and traditional practice is challenged in areas where new evidence has emerged. The book takes a holistic approach and also emphasises issues that are important for patients, including their ideas, concerns, expectations and issues around quality of life.

This book aims to be an aide memoire for general practitioners, trainees in general practice, medical students, nurses and paramedics working in primary care settings. Hospital doctors might also find the book useful when patients under their care develop clinical problems that are outside their specialty interest or when working in the Accident & Emergency department. It has been designed to allow quick reference during busy clinical sessions and in exam preparation. Information is presented in a structured, condensed and hopefully easily accessible way.

The 10‐Minute Clinical Assessment is based on experience gained from clinical practice, student teaching and examination, backed up by an extensive literature search and consultation with experts. Sections of the book have been ‘field‐tested’ among general practitioners, trainee doctors, medical students and nurses. In addition, every section has been reviewed by expert readers from primary and secondary care, whose comments have been invaluable and have led to numerous improvements and alterations. Some of the chapters on chronic diseases and cancer have also been looked at by ‘expert’ patients.

The book is not meant to be prescriptive – clinical assessment is not a tick‐box exercise! Each clinical encounter is different, has its own dynamic and needs to be tailored to the individual – taking a patient‐centred and caring approach. Because it is impossible to cover everything during a brief clinical assessment, the book points out those areas that should be considered when faced with important and potentially tricky clinical presentations. It offers some of the ‘essential pieces of a jigsaw puzzle’ that can help with recognising the whole picture.

The book covers clinical assessment only and deliberately does not include investigation and management, which for symptom‐based presentations will often depend on the outcome of the assessment. The 10‐Minute Clinical Assessmenttherefore needs to be read in conjunction with larger textbooks, as well as books on consultation skills, physical examination and clinical diagnosis – assuming that readers will have had the relevant clinical teaching at the bedside.

It was tempting to include pictures, case studies and diagrams, but this would have made the book too bulky for use in day‐to‐day practice. There is some unavoidable overlap and repetition between some of the topics, but these are kept to a minimum and allow each chapter to be read alone and independently.

I hope that the book will give you a better understanding of:

The issues that are important for patients.

Which questions to ask and what to examine (and why!) during focused clinical assessment, especially when under time pressure.

How to recognise ‘red flags’ and important disease patterns.

The main differential diagnoses and risk factors for each presentation.

How to exclude major and serious diagnoses quickly.

How to reduce the potential for misdiagnosis.

Which areas to explore in order to make informed decisions about patient management.

What information to consider for inclusion in referral letters to specialists.

Which clinical details are relevant when presenting history and examination findings to other colleagues.

Which essential issues to cover when assessing patients during undergraduate finals or postgraduate clinical examinations.

I sincerely hope that you will find the format of the book and the information provided useful. Please feel free to contact me ([email protected]) if you spot any errors or have suggestions for further improvements.

Knut Schroeder Bristol

Preface to 2nd edition

This new 2nd edition of The 10-Minute Clinical Assessment continues to give you all the information you need to carry out an effective and focused clinical assessment in general practice.

We have fully revised all the chapters using the latest key references, including the latest guidance from the National Institute for Health and Care Excellence (NICE).

Based on feedback and suggestions, especially from medical students and general practitioners in training, we have also added the following three new chapters on topics that are right at the heart of general practice:

Focused Clinical Assessment.

Discover how to become more patient-centred, learn some useful tricks of the trade and explore how you can save time in the consultation without compromising on quality.

Useful Consultation Tools.

Find better ways of asking questions and – more importantly – getting patients to talk. Uncovering how you can become a more effective listener and explore sensitive topics under time constraints, this chapter is packed with tips for conducting more effective consultations.

Red Flags in General Practice.

Learn how to spot important warning signs of serious disease and how to make sense of red flags, and find useful advice on avoiding serious medical errors.

I hope not only that this book will help you provide excellent care for your patients, but also that it supports you in becoming a more effective, better and happier doctor.

Wishing you all the best for your career,

Knut Schroeder Bristol June 2016

About the author

Knut Schroeder is a practising NHS GP with over 20 years' experience (10 of these as a GP Principal) and Honorary Senior Clinical Lecturer in General Practice at the University of Bristol. He is passionate about teaching consultation skills to new generations of GPs, particularly around ‘focused clinical assessment’ and ‘red flags’.

During his time as a full-time Consultant Senior Lecturer, he co-developed and delivered undergraduate and postgraduate courses on clinical diagnosis and evidence-based medicine. He was also responsible for the general practice part of the final-year examination for medical students at the University of Bristol for 2 years. He was a GP Trainer for 8 years and continues to teach medical students.

Knut has authored four books and co-written a number of book chapters, including Sustainable Healthcare, Diagnosing Your Health Symptoms for Dummies and two chapters of the Oxford Textbook of Primary Medical Care. He has written papers and articles published in international peer-reviewed journals and the GP press. Knut was Deputy Co-ordinating Editor for the Cochrane Heart Group for 4 years and has experience in writing and assessing systematic reviews of clinical literature.

Acknowledgements

I would like to thank Dr Gill Jenkins (part‐time GP in Bristol, medical writer and broadcaster) for contributing to chapters in the obstetric, gynaecology and endocrine sections and for commenting on earlier versions of the manuscript.

Very special thanks go to Mary Banks, Simone Heaton and everyone else at Wiley‐Blackwell for their tremendously kind support, encouragement, patience and professionalism.

Many thanks also to the doctors and nurses at the Stokes Medical Centre in Little Stoke, Bristol, for their comments and suggestions. I enjoyed the discussions!

Many general practitioners, hospital specialists, medical students, nurses, emergency care practitioners, paramedics and ‘expert’ patients have very kindly given up their time to read and comment on individual chapters or whole sections, or have contributed in other ways. I am particularly grateful to the following people (in alphabetical order) for their constructive criticisms and helpful suggestions, some of which have led to substantive changes:

Dr Andreas Baumbach, Dr Andrew Blythe, Dr Kate Boyd, Dr Simon Bradley, Dr Peter Brindle, Dr David Cahill, Dr Shane Clarke, Dr Mike Cohen, Dr Michelle Cooper, Mike Cox, Prof Paul Dieppe, Dr Lindsey Dow, Dr Ian Ensum, Dr Stuart Glover, Dr William Hamilton, Dr Michael Harris, Dr John Harvey, Dr Gayani Herath, Dr Rachel Hilton, Dr Rhian Johns, Dr James Jones, Dr David Kessler, Dr Tina LeCoyte, Prof Andy Levy, Dr Anne Lingford‐Hughes, Dr Elaine Lunts, Dr Paul Main, Dr Kate Mather, Dr David Memel, Lionel Nel, Mr Desmond Nunez, Dr Jess O'Riordan, Dr Lucy Pocock, Dr Robert Przemioslo, Dr Jon Rees, Dr Rebecca Reynolds, Dr Hayley Richards, Dr Ginny Royston, Dr Trevor Thompson, Mr Derek Tole, Dr Antje Walker, Dr Jane Watkins, Dr Alastair Wilkins, Dr Philip Williams and Dr Wolfram Woltersdorf.

Finally, I would like to thank my wife, Dr Sharmila Choudhury, for her understanding, kind support and constructive comments during this project.

Selected useful resources

The following is a selection of resources that have been useful reference points during the preparation of this book and which provide excellent sources for further information:

The 10-Minute Consultation series in the

British Medical Journal

. Available from:

http://www.bmj.com/specialties/10-minute-consultation

(last accessed 29 April 2016).

Clinical Knowledge Summaries.

cks.nice.org.uk.

National Institute for Health and Care Excellence (NICE).

www.nice.org.uk

.

PatientPlus articles.

www.patient.co.uk

.

People's Experiences at healthtalk.org. Available from:

http://www.healthtalk.org/peoples-experiences

(last accessed 29 April 2016).

The Rational Clinical Examination series in

JAMA

. Available from:

http://jama.jamanetwork.com/collection.aspx?categoryid=6257

(last accessed 29 April 2016).

Scottish Intercollegiate Guidelines Network (SIGN).

www.sign.ac.uk

.

The focused consultation

Focused clinical assessment

Key issues

Practical points

Effective practice.

Conducting a focused clinical assessment provides a good basis for safe and effective clinical practice.

Time constraints.

Students and doctors working in general practice can find it difficult to perform an effective clinical assessment within short (e.g. 10–15 minutes) overall consultation times, which will often also include discussing a management plan, issuing prescriptions, ordering tests and writing case notes.

Strategies.

Various strategies exist to help assess patients in a focused yet patient-centred way.

Structuring the consultation

Preparation

Key thoughts.

Think about the key issues from the start of the consultation – or even before, if you know the reason for the patient's attendance. This will help you decide which issues to focus on during the consultation.

Practical points.

At the beginning of the consultation, make a mental list of the main points to bear in mind, such as red flags (ruling in and ruling out disease), possible differential diagnoses and diagnoses you do not want to miss.

Demographic variables.

Combine your medical knowledge with the likely prevalence of conditions in your work setting.

Risk factors.

Consider possible risk factors, such as alcohol, smoking and unhealthy diet(s).

Red flags.

Think about relevant alarm symptoms and signs that you might need to explore for a particular clinical presentation.

Stocking the room.

Make sure your consulting room is well stocked with essentials for the consultation (e.g. sampling bottles, stationery, thermometer covers, etc.), because having to leave your room to get these can waste valuable time.

History

Ideas, concerns and expectations.

Explore the patient's health beliefs, worries and understanding of their symptom(s) and condition(s), and what impact these have on their day-to-day life. Try to phrase your questions naturally (you can find useful phrases in the chapter on Useful Consultation Tools).

History of presenting complaint.

Focus initially on exploring issues around the presenting complaint and use relevant questions to rule in and rule out important diagnoses.

Past and current medical problems.

Identify any comorbidities that might influence your diagnosis and management.

Medication.

Consider all medication, but especially any drugs that might be particularly relevant, such as oral anticoagulants (e.g. bleeding), nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g. gastric problems) and steroids (e.g. immunosuppression).

Family history.

Does the patient have a significant family history that may be relevant?

Social history.

How does the clinical presentation fit into the patient's social context, including work, home life and social situation?

Review of previous investigations.

Check the results of any previous relevant investigations, because they may influence your assessment.

Examination

Ask permission.

Always ask patients' permission before you perform a physical examination, and offer a chaperone for intimate examinations, if appropriate. During the clinical assessment, stay sensitive to the patient's feelings, and be alert to nonverbal cues.

General assessment.

Quickly look for any obvious clues. Does the patient look unwell? Are there any obvious physical signs at first glance?

Vital signs.

Record important vital signs (e.g. pulse, blood pressure, temperature, respiratory rate, oxygen saturation in the periphery) to help in assessing the severity of the illness. Taking vital signs is also useful as a baseline for ongoing monitoring and for medicolegal reasons.

Focused physical examination.

Adopt a focused and selective approach, tailored to the findings from the history. Inspect, palpate, auscultate and check the function of relevant body areas and systems, as appropriate. You are looking for evidence that confirms or refutes your working diagnosis. Be curious and be prepared to reconsider your diagnosis when the findings are at odds with the history (e.g. hearing fine crackles in a patient with chronic obstructive pulmonary disease (COPD)).

The diagnostic process

Consider ‘early triggers’ in the consultation

Spot the diagnosis.

You may be able to recognise nonverbal patterns, such as skin conditions (e.g. atopic eczema) or a ‘barking’ cough (whooping cough), based on your previous experience or clinical knowledge.

Explore patients' self-labelling.

Patients may come with a self-diagnosis (which may or may not be correct), which can direct the diagnostic process.

Consider the presenting complaint.

The patient's initial statement (e.g. ‘I have tummy pain’ or ‘I have a headache’) can be used to direct your assessment.

Establish your working hypothesis.

Elements in both the history and the examination may trigger your working hypothesis. For example, thirst, feeling unwell and looking tired in a young person may suggest the possibility of type 1 diabetes.

Strategies for narrowing down the possibilities

Rule out diagnoses.

Shortlist and rule out serious diagnoses based on what you consider to be likely causes of the presenting problem. This can also help to prevent clinical errors.

Assess in a stepwise fashion.

Assess patients based on the anatomical location of their problem or the suspected underlying pathological process. Clarify exactly where the problem is located, for example by asking them to point to the relevant body area.

Consider likelihood.

Use symptoms, signs and diagnostic tests to rule in or rule out likely and unlikely diagnoses. This requires you to know the degree to which a positive or negative result from your history, examination and bedside tests adjusts the probability of a given disease.

Recognise patterns.

Compare symptoms and signs with patterns you have seen in previous patients and cases you have read about – a common approach in general practice. This process relies on your memory of known patterns of disease. Remember that some conditions, such as myocardial infarction, brain tumour and depression, can present in various ways. Over time, you will build up a repertoire of these patterns and their variants.

Use clinical prediction rules.

Validated clinical prediction rules (e.g. the Ottawa ankle rules) represent a more formal version of pattern recognition.

Consider other strategies

Known diagnosis.

You can often rule out serious disease without further testing if a diagnosis is sufficiently certain (e.g. viral upper respiratory tract infection, viral wart, acne vulgaris).

Point-of-care tests.

Use appropriate point-of-care (bedside) tests to rule in or rule out a disease (e.g. blood glucose strip test, urine dipstick, oxygen saturation in the periphery). This can be useful in the presence of red flags and when a presentation or diagnosis does not fit any obvious pattern of disease.

Tests of treatment.

Use the response to treatment to refute or confirm a diagnosis (e.g. inhalers in nocturnal cough).

Tests of time.

Use the natural course of a disease to predict when the patient should improve (the ‘wait and see’ approach) (e.g. in suspected viral gastroenteritis or the common cold).

No label applied.

When you cannot arrive at a diagnosis, consider sharing your uncertainty with the patient and establish a ‘safety net’ by arranging appropriate clinical review, appropriate diagnostic tests or referral, as required.

Writing useful case notes

Concision.

Write concise yet comprehensive case notes and consider taking a structured approach (e.g. history, examination, impression and working diagnosis, management).

Thought process.

In addition to providing clinical details, give the reader a ‘feel’ for your thought processes and for how the consultation went.

History.

Record information relevant to the presenting complaint and underlying condition, including important positive and negative answers to direct questions.

Examination.

Include important positive and negative findings, in particular your general impression, the results of objective measurements (e.g. vital signs, size of skin lesions) and relevant ‘system’ findings (e.g. respiratory, cardiovascular or neurological findings).

Impression and diagnosis.

With the support of your findings, state your general impression and working diagnosis in clear and unambiguous terms. If you are uncertain about the diagnosis, say so, and mention any steps that you have taken to rule out serious disease.

Management.

Include any tests that you have arranged, what you have told the patient (including risks and benefits of any treatments), consent (including discussions around any procedures) (if applicable), treatment (including drug doses, prescription details and any other treatment), follow-up arrangements for tests and appointments and progress so far.

Summary of main principles

Apply focus.

Try to integrate your clinical and communication skills so that you can understand your patients' symptoms, physical signs and other important factors. Such factors include the impact of medical problems on patients' lives, their health beliefs and worries and their expectations about treatment.

Tailor your approach.

Remember that when serious illness is unlikely (absence of red flags, normal examination), you do not need to perform an exhaustive ‘full’ history and examination; it is preferable to tailor your approach to the clinical presentation (the clinical chapters in this book highlight the important aspects to consider for each clinical presentation).

Acknowledge problems.

Directly acknowledge and respond to patients' concerns.

Take a holistic approach.

Take a holistic and structured approach when gathering information. Apply your understanding of human diseases, while staying person-centred.

Gather data systematically.

Take a well-organised history and gather data methodically to create a solid foundation upon which to base your physical examination and from which to make clinical judgements.

Prioritise.

Try to establish early on in the consultation whether a patient has multiple problems they wish to talk about, so that you can prioritise accordingly.

Make use of consultation models.

Learn about the various consultation models that exist to help you structure and manage your consultation (you can find some useful summaries and starting points at the Bradford Vocational Training Scheme website,

www.bradfordvts.co.uk

).

Key references and further reading

Fahey T, van der Lei J. Producing and using clinical prediction rules. In:

The Evidence Base of Clinical Diagnosis: Theory and Methods of Diagnostic Research

(2nd edition). Knottnerus JA, Buntinx F (eds). Wiley-Blackwell BMJ Publishing, Hoboken, NJ; 2008.

Heneghan C, Glasziou P, Thompson M et al. Diagnostic strategies used in primary care.

BMJ

2009;338:b946.

Schroeder K, Chan W-S, Fahey TP. Focused clinical assessment.

InnovAiT

2011;4(1):41–48.

Useful consultation tools

Key thoughts

Practical points

Focused assessment.

Various consultation and communication techniques can help you perform a concise yet comprehensive clinical assessment in primary care.

Question types.

Open questions, especially at the beginning of the consultation, are useful in getting an overview of a clinical problem. Direct questioning can help establish further details.

Body language.

Be aware of your conscious and unconscious movements and postures, which convey your attitudes and feelings, beyond what you express with words.

History-taking

Introducing yourself

Initial contact.

Stand up, gently smile, establish good eye contact (without staring) and consider shaking hands with your patient, if you feel it is appropriate.

Greeting.

Greet and welcome the patient, using their name and language appropriate to the context (e.g. ‘Good morning, Mrs Gupta, nice to meet you’ or ‘Hello, Mr Jones’.

Introduction.

Unless the patient knows you, clearly introduce yourself using your professional title and surname (e.g. ‘Hello, my name is…’). Some people think that calling yourself ‘Dr’ emphasises hierarchy, while introducing yourself with your first and second names suggests equality and partnership. In any case, make it clear to the patient what your professional role is.

Acknowledging others.

Greet anyone who accompanies the patient, and establish their relationship to the patient, if it is unclear. Avoid making assumptions.

Opening the consultation

Listening.

You can start the consultation by saying nothing and actively listening, adopting an interested and welcoming posture. Many patients will start talking spontaneously and tell you why they have come to see you.

Open questions.

Starting with open questions can help find the main reason for the patient's attendance. Examples are, ‘What would you like to talk about today?’ and ‘What brought you here today?’.

Probing questions.

A second open (probing) question or ‘soft command’, such as, ‘Can you tell me a bit more about this, please?’ or ‘Is there anything else that you’d like to tell me?', will help explore the nature of the presenting problem and the patient's agenda.

Story.

The ‘story’ of the patient's complaint can be established by asking questions like, ‘Could you tell me how it all started?’, ‘When were you last well?’, ‘How long has this been going on for?’ and ‘Tell me more about….’. Keep the flow going by asking, ‘And what happened then?’, ‘What did you do when…?’ and ‘This is interesting. Can you explain it to me in a bit more detail?’.

The golden minute.

For the first minute or two (the ‘golden minute’), allow the patient to tell their story in their own words, without interrupting them unnecessarily. Make sure you listen attentively, because patients will often direct you to the correct diagnosis!

Patient agenda.

Try to pick up cues about the patient's agenda (which may not initially be obvious), as well as their worries and emotions. It is easy to underestimate the significance of seemingly trivial or simple reasons for consultation.

Observation.

Be alert to any body signals the patient sends out (e.g. tone of voice, raised eyebrows, blushing, fidgeting).

Encouragement.

Encourage patients to keep talking by maintaining appropriate eye contact, leaning slightly forward, giving them your full attention and saying ‘Mmh’, ‘Yes’ or ‘Sure’ every now and then.

Concerns.

Patients often worry about the possibility of a serious underlying condition, such as cancer. Explore whether there are particular reasons why the patient is concerned (e.g. reading a newspaper article, diagnosis of cancer in a friend or relative, the presence of risk factors such as smoking).

Avoidance of leading questions.

Try not to use leading questions, such as, ‘You haven't passed any black tarry stools, have you?’.

History of the presenting complaint

Closed questions.

Closed questions are useful for collating and clarifying further details about the patient's problem (e.g. ‘Where exactly does it hurt?’, ‘When exactly did you first notice your symptoms?’, ‘What were you doing when your pain started?’).

Selective questioning.

Let further questions, following possible diagnostic lines, be guided by the probabilities of underlying conditions.

Effect on life.

Explore how symptoms have affected the patient's life (e.g. ‘How has this pain affected your daily life?’, ‘Is there anything that you can't do because of your symptoms?’, ‘How are things at home?’).

Open-mindedness.

Avoid making immediate assumptions and having pre-conceived ideas about the problem and possible underlying diagnoses.

Patient cues.

Avoid changing the topic when a patient presents important information that needs further exploration (e.g. Patient: ‘Yesterday, I bled so much that I stained my sofa, which was very embarrassing.’ Doctor: ‘So, tell me: have you lost any weight?’).

Patient-centredness.

Continue to be led by what the patient wants to talk about, and show flexibility. Strive to let the consultation progress fluently and logically.

Natural manner.

Avoid interrogating the patient by using formulaic phrases or questions that sound unnatural. Being natural will allow them to speak openly.

Ideas, concerns and expectations

Important health beliefs.

Make sure you explore the patient's health beliefs, preferences and understanding – their ‘ideas, concerns and expectations’ (ICE). Try to avoid formulaic questions or questions that sound ‘scripted’, such as, ‘What worries you?’. Sometimes, stating what other people have felt in the patient's situation can help (e.g. ‘When my friend John was diagnosed with depression, he…’).

Ideas.

Explore the patient's ideas with questions like, ‘Have you had any thoughts about what might be causing your symptoms?’, ‘Have you had any ideas about what might be going on?’ or ‘What do you think may be happening with you?’.

Concerns.

Ask about the patient's worries and concerns (e.g. ‘Is there anything in particular about your symptoms that's worrying you?’, ‘What do you think is the worst thing that your symptoms might mean?’).

Expectations.

Find out what the patient expects from the consultation (e.g. ‘Have you had any thoughts about what we might be able to achieve today?’).

Dealing with ICE.

Make sure you pick up and deal with the patient's ICE later in the consultation, to demonstrate that you take them seriously and that you will take them into account when considering management options.

Asking direct or sensitive questions

Explain your questions.

Consider warning the patient before you ask a series of closed questions (e.g. ‘Would it be OK if I asked you a few specific questions about your symptoms now?’, ‘Just so that I can get a better idea of what might be going on and to rule out a serious problem, I’d like to ask you some more questions. Would that be OK?', ‘Is it OK if I asked you a more sensitive/personal/private question now?’).

Clarify details.

Ask the patient to explain any ‘jargon’ (e.g. ‘What do you mean by diarrhoea/dizziness/constipation?’). Go back if necessary, by saying, ‘Is it OK if, just to clarify things, we go back a little and talk about…again?’.

Show empathy.

Consider making reflective statements when it is appropriate (e.g. ‘This must be very difficult for you’, ‘You seem quite anxious/angry/upset about this’, ‘You seem to find it quite hard to talk about this’, ‘This must be a very difficult situation for you’).

Ask the patient.

Ask the patient what question they would like you to ask next, then ask it. Or, after summarising your findings, ask, ‘Is there anything important that you think I’ve missed out?'. Such questions can help reveal issues that are particularly important to your patient.

Frame the consultation.

Try to reframe the consultation by using the patient's own language before you move on to discuss the management plan.

Key references and further reading

Kenny D. Some key suggested phrases for consultations. Available from:

http://damiankenny.co.uk/listofphrases.doc

(last accessed 29 April 2016).

Khan I.

Focused Clinical Assessment in 10 Minutes for MRCGP.

Radcliffe Publishing, London; 2012.

Schroeder K, Chan W-S, Fahey TP. Focused clinical assessment.

InnovAiT

2011;4(1):41–48.

Red flags in general practice

Key thoughts

Practical points

Definition.

Red flags are alarm or warning symptoms, signs and diagnostic test results that suggest a potentially serious underlying disease.

Diagnosis.

Being able to spot red flags can help with ruling in and ruling out serious diagnoses, such as cancer, myocardial infarction or stroke.

Test.

Red flags can be regarded as ‘diagnostic tests’, in that their presence or absence can help adjust the probability of serious diagnoses.

Call to action.

In primary care, further investigation or referral is often required when red flags are present.

Red flags in context

Duration.

Symptoms that are usually harmless and are often caused by self-limiting illnesses, such as cough, tiredness or diarrhoea, can develop into red flags when they last longer than expected (approximately 4–6 weeks) (e.g. in patients with cancer). Be suspicious when symptoms are progressive (e.g. worsening breathlessness or abdominal pain).

Associated features.

Interpret red flags in the context of the history, because their significance depends on the circumstances in which they develop.

Demographics.

Take demographic characteristics such as age into account when interpreting red flags, because some diagnoses (e.g. certain cancers, myocardial infarction) are more common in later life.

Clinical signs.

The presence or absence of additional clinical features provides important contextual information when considering serious underlying conditions and associated red flags. Checking and monitoring vital signs, such as pulse rate, respiratory rate, blood pressure, temperature and oxygen saturation in the periphery, can often yield useful clues.

Spotting and interpreting red flags

The role of red flags

Clinical practice.

Identifying and interpreting red flags is an important part of clinical practice.

Over-interpretation.

Wrongly over-interpreting the significance of a red flag can lead to over-referral and may increase patient anxiety.

Missing red flags.

Not spotting or ignoring red flags may result in missed diagnoses or, in the worst case, death.

Referral.

The presence or absence of red flags can help decide whether a referral needs to be immediate, urgent (within 2 weeks) or routine.

Early disease.

In the early stages of conditions such as cancer, symptoms can be nonspecific and difficult to spot. Be vigilant to the early warning signs, such as loss of appetite, weight loss, malaise, lethargy, fever or sweats, generalised itching, shortness of breath, bone pain and lymphadenopathy.

Reasons for missing red flags

Lack of attention.

Beware of paying too much attention to other findings and ruling out a serious diagnosis prematurely. This can happen easily if a patient presents with two or more different problems at the same time.

Lack of knowledge.

It is easy to miss red flags when you are unaware of their significance for the underlying diagnosis.

Not listening.

Avoid missing clues by listening carefully to the patient's story. Do not rush. Avoid suppressing evidence that does not seem to fit.

Follow-up.

Make sure you reassess a patient if the working diagnosis does not fit. A useful rule of thumb is to perform a full review (perhaps together with a colleague), arrange further investigation or refer to a specialist if the patient's symptoms persists after two alternative diagnoses have been considered.

Useful techniques for identifying red flags

Open questions.

Use open questions and start generally (e.g. ‘What can I do for you?’), before engaging in further open probing (e.g. ‘Can you tell me more about your symptoms and how they started?’, ‘Is there anything else that you think may be important?’, ‘What happened then?’).

Reasons for consulting.

Establish the reason why the patient has come, then explore all their presenting symptoms in detail.

Vigilance.

Be vigilant to the presence of red flags at all times, and actively search for important ‘hidden’ red flags: in defiance of their name, red flags are not always obvious!

Symptom combinations.

Be aware of important symptom combinations that may suggest serious underlying disease (e.g. older age AND tiredness AND weight loss AND rectal bleeding may suggest bowel cancer).

Key references and further reading

Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients.

Br J Cancer

2009;101:580–586.

Hamilton W, Peters TJ.

Cancer Diagnosis in Primary Care.

Churchill Livingstone Elsevier, Oxford; 2007.

National Institute for Health and Care Excellence (NICE). Suspected cancer: recognition and referral. NICE guidelines [NG12]. June 2015. Available from:

http://www.nice.org.uk/guidance/ng12

(last accessed 29 April 2016).

Schroeder K, Chan W-S, Fahey TP. Recognising red flags in general practice.

InnovAiT

2011;4(3):171–176.

Undifferentiated and miscellaneous presentations

Suspected cancer

Key thoughts

Practical points

Diagnosis.

Diagnosing cancer early on clinical grounds alone can be difficult. It is important to think about the possibility of cancer if symptoms are unusual or persistent. A number of cancers may present with typical features.

Referral.

Early diagnosis of cancer will in many cases improve the prognosis. Symptoms and signs of cancer should prompt urgent referral for further investigation and management.

RED FLAGS

Unusual symptom patterns

No improvement of symptoms over time

New-onset alarm symptoms (e.g. haematuria, haemoptysis, dysphagia or rectal bleeding)

Three or more consultations for the same problem

History

Ideas, concerns and expectations

Ideas.

Explore the patient's knowledge and beliefs about cancer – there are many myths about the disease.

Concerns.

Patients often worry about the possibility of cancer. Explore any particular reasons why the patient is concerned (e.g. reading a newspaper article, diagnosis of cancer in a friend or relative, the presence of risk factors such as smoking).

Expectations.

What does the patient expect in terms of investigation and treatment?

History of presenting complaint

Onset.

Symptoms of cancer usually start gradually and develop over weeks and months.

Progression.

Aggressive tumours may grow and spread rapidly.

Severity and quality of life.

How severe are the symptoms and how far do they affect the quality of life? Are there any activities that the patient cannot do anymore?

Context.

How do the symptoms fit into the context of the patient's life?

Nonspecific symptoms

Weight and appetite.

Progressive, unintentional and unexplained weight loss with or without reduced appetite may indicate cancer, particularly if there is no other obvious physical or psychological cause.

Nausea and vomiting.

These are particularly common with upper gastrointestinal cancers.

Tiredness.

Fatigue is a common nonspecific symptom of many cancers (especially haematological ones), but may also be due to iron-deficiency anaemia caused by, for example, gastrointestinal tumours.

Fever and night sweats.

Particularly common with haematological cancers.

Lymphadenopathy.

Swollen lymph nodes are commonly due to infection, but may also be caused by lymphoma or metastatic disease.

Infections.

Cancer may affect the immune system, which increases the risk of concomitant and recurrent infections.

Risk factors for cancer

Smoking.

Smoking is linked to various cancers, particularly lung, bladder and cervix cancer.

Age.

Many cancers become more common with age.

Toxins.

Ask about drug use, as well as industrial and occupational exposures. Certain chemicals are risk factors for bladder cancer. Alcohol and chronic hepatitis may lead to liver cancer. Asbestos exposure may cause lung cancer.

Previous cancer.

Always ask about a past history of cancer, as this increases the risk of recurrence.

Lung cancer

Cough.

A chronic, persistent and treatment-resistant cough is a common presenting symptom.

Haemoptysis.

This is an important symptom in smokers or ex-smokers over the age of 40.

Hoarseness.

This may occur if the recurrent laryngeal nerve is affected.

Other chest symptoms.

Ask about chest pain, shortness of breath and shoulder and arm pain (Pancoast tumour).

Underlying respiratory problem.

Ask about any unexplained changes in existing symptoms if there is an underlying chronic respiratory problem such as asthma or chronic obstructive pulmonary disease (COPD).

Upper gastrointestinal cancer

Gastrointestinal symptoms.

Important symptoms are unexplained upper abdominal pain in conjunction with weight loss (with or without back pain), chronic gastrointestinal bleeding, dyspepsia, dysphagia and persistent vomiting.

Jaundice.

The presence of jaundice should raise concern, particularly if it is associated with other gastrointestinal symptoms.

Anaemia.

Unexplained iron-deficiency anaemia suggests possible upper or lower gastrointestinal cancer.

Lower gastrointestinal cancer

Rectal bleeding.

Fresh blood dripping into the toilet pan is common with haemorrhoids. Rectal bleeding raises the possibility of cancer if it is associated with a change in bowel habit to looser stools (without anal symptoms), as well as in patients aged over 40. Any rectal bleeding in patients over the age of 60 is suspicious. Blood mixed with stool is suggestive of a higher lesion.

Change in bowel habit.

Looser stools and/or increased stool frequency persisting for 6 weeks or more and without anal symptoms are suggestive of malignancy, particularly in patients over the age of 40 and/or if associated with rectal bleeding.

Breast cancer

Breast lump.

Consider breast cancer if a lump persists after the next period, presents after the menopause or enlarges.

Family history.

There may be a positive family history.

Past history.

Ask about a past history of breast cancer.

Skin changes.

Ask about nipple distortion, nipple discharge (particularly if blood is present) and unilateral eczematous skin changes that do not respond to topical treatment.

Gynaecological cancer

Post-menopausal bleeding.

This should raise suspicions if the woman is not on hormone replacement therapy, continues to bleed 6 weeks after stopping therapy or is taking tamoxifen.

Vaginal discharge.

Women with vaginal discharge should be offered a full pelvic examination, including visual assessment of the cervix.

Vague, unexplained abdominal symptoms.

Bloating, constipation, abdominal pain, back pain and urinary symptoms may all suggest ovarian cancer (particularly in women over 50 years of age), although benign causes are much more common.

Intermenstrual bleeding.

Ask about any persistent intermenstrual bleeding and alterations in the menstrual cycle. Is there postcoital bleeding?

Vulva.

Any unexplained vulval lump or bleeding vulval ulceration is suspicious.

Urological cancer

Urinary symptoms.

In men, ask about lower urinary tract symptoms such as hesitancy, poor stream and haematuria. Is a recent prostate-specific antigen (PSA) result available? Recurrent or persistent urinary tract infection, particularly if associated with haematuria, may suggest cancer.

Testicular mass.

Any swelling or mass in the body of the testis is suspicious.

Penis.

Signs of penile carcinoma include progressive ulceration in the glans, shaft or prepuce of the penis. Lumps within the corpora cavernosa can indicate Peyronie's disease.

Haematological cancer

General symptoms.

Consider haematological cancer if there are symptoms such as night sweats, bruising, fatigue, fever, weight loss, generalised itching, breathlessness, recurrent infections, bone pain, alcohol-induced pain or abdominal pain, either alone or in combination.

Back pain.

Spinal cord compression or renal failure may occur with myeloma and will require immediate referral.

Skin cancer

Non-healing skin lesions.

Any non-healing keratinising or crusted tumour larger than 1 cm with induration on palpation should raise suspicion of skin cancer.

Sun exposure.

Ask for details about previous sun exposure and frequency of sunburns.

Features of melanoma.

Change in size.

Change in colour.

Irregular shape and borders.

Irregular and dark pigmentation.

Largest diameter 7 mm or more.

Change in sensation/itching.

Bleeding.

Head and neck cancer

Lumps.

Any unexplained lump in the neck of recent onset or a previously undiagnosed lump that has changed over a period of 3–6 weeks is suspicious. Also of concern are unexplained and persistent swellings of the parotid or submandibular gland.

Pain.

An unexplained persistent sore or painful throat or other pain in the head or neck for more than 4 weeks may suggest underlying cancer, particularly if associated with otalgia and normal otoscopy.

Ulcers.

Any unexplained mouth ulcer, mass or patches of the oral mucosa persisting for more than 3 weeks are suspicious, particularly if there is associated swelling or bleeding.

Thyroid swelling.

Any solitary nodule increasing in size, a history of neck irradiation, a family history of endocrine malignancy, unexplained hoarseness or voice changes, cervical lymphadenopathy or lumps in prepubertal patients or patients over 65 years of age raise the possibility of thyroid cancer.

Other symptoms.

Unexplained loosening of teeth or hoarseness persisting for more than 3 weeks requires further investigation or referral. Heavy drinkers and smokers over the age of 50 are especially at risk.

Brain tumour

Headaches.

Look out for features of raised intracranial pressure (e.g. vomiting, drowsiness, posture-related headache), pulse-synchronous tinnitus or other neurological symptoms, including blackout and change in personality or cognitive function. Any headache that is worse in the morning and gets progressively worse or changes its character should raise suspicions.

Central nervous system (CNS) symptoms.

Consider the possibility of brain tumour if there is progressive neurological deficit, new-onset seizure, mental change, cranial nerve palsy or unilateral sensorineural deafness.

Features suggestive of metastasis

Brain.

Ask about new and persistent headaches, fits or any change in personality (see also section on Brain Tumour).

Bone.

Bone pain due to malignancy is often intermittent at first and then becomes constant. It commonly keeps patients awake at night. Pathological fractures may occur.

Liver.

Metastases may not cause any symptoms. Features can include anorexia, fevers, nausea, jaundice, right upper quadrant pain, sweats and weight loss.

Skin.

Skin lesions may present as new nodules or as non-healing ulcerative lesions.

Social history

Home.

Ask about the patient's family circumstances and support network. Are home life and hobbies affected by any of the symptoms?

Work.

Are there any problems with work? Ask about exposure to carcinogens, including asbestos, which is a risk factor for lung cancer and mesothelioma.