Is it just a cough, or something more? Why not every rash is chickenpox and not all back pain needs a scan. Photo / 123RF
From cervical screening to back pain and blood pressure – Dr Oscar Duke on classic patient concerns, and how he answers them.
For years I worked as a hospital doctor but found I never actually knew the answers to those simple, practical and often rather important questions that family members, friends, patients and just about everyone I meet chucks your way as soon as they realise they’ve got time with a doctor.
In the pub, or at a dinner party, I would desperately try to recall what you were meant to do if you’d missed a dose of your contraceptive pill. Medical school seemed a distant memory. I could sort out your non-invasive ventilation and decide whether your kidneys were failing, but was your nephew’s rash actually chickenpox? I wasn’t sure either.
So I decided to retrain as a GP. A colleague likened being a GP to the role of a secular priest. My parish, it seems though, is eternal WhatsApp queries, photos that need deleting and a small queue of camera operators wanting “just a minute of your time” as I come off set from recording BBC1’s Morning Live. As I write, my phone vibrates with a chasing message from my brother wanting thoughts on his latest medical conundrum. Do I mind? Absolutely not. I live and breathe this stuff. Come one, come all.
“Don’t be a GP”, some said, “it’s just coughs and colds”. But as any discerning Dr Googler knows, it is far more complicated than that. The cough, poses a challenge for patient and doctor alike. Your search may have planted seeds of concern about TB or cancer, but this list of rarer causes is never far from your doctor’s mind either. The skill, the chase, and the ultimate satisfaction lies in balancing the patient’s clinical history on the scales of medically trained probability.
A viral illness that will eventually self-resolve, far outruns the pack of most-likely bothersome cough causes, but the extensive options from search results will make you grateful to live in an era of high-speed broadband. Coughs lasting a few days? These are sadly a thing of the past. Many will take you into three or four weeks of misery. If a virus is to blame no antibiotic will help, but we are encouraged to consider self-care while the virus burns itself out.
Even the national guidelines from Nice take us through options such as honey and over-the-counter cough remedies as potential soothers. Evidence to suggest these shorten symptom duration or improve quality of life is limited but whether it’s placebo, distraction or just allowing time to tick by, most will settle. And if they don’t, further investigation is required.
The Covid pandemic gave us a taste for home monitoring, with finger-tip oxygen meters flying off shelves. Many bathroom cabinets now resemble a well-stocked cubicle from the local Emergency Department. Whether you’re checking it at home or being requested to pop by your local pharmacy or GP practice to give a reading, knowing your blood pressure is one of the single best things you can do to monitor your health.
The brain and other vital organs must receive blood. When we’re standing, it takes considerable pressure to pump blood up to those lofty heights. As the heart muscle squeezes, the highest pressure is created – known as the systolic blood pressure – and when the heart relaxes, a lower pressure – diastolic – is recorded. It is vital that even during the relaxation phase some pressure is maintained to keep blood flowing to our vital organs.
Much like central heating systems, a total drop in pressure can have equally chilling results. Extremely high pressures can cause the pipes to burst, but for most with mild or moderate elevations in their blood pressure, this isn’t the major concern. Modestly elevated pressures, left unattended over time, wear away at the walls of our blood vessels, roughening the inner surface lining of the pipes and allowing fats such as cholesterol to deposit, fur up, and increase the risk of cardiovascular diseases such as heart attack and stroke. Should you check it? Yes. But more importantly, act to reduce it when required.
By reputation these cholesterol-lowering drugs are ranked beneath most politicians. Often the mere suggestion of starting one will result in facial contortion of the patient sitting opposite me. I recently interviewed a cardiologist and asked him why statins had received such bad press? His response was that – as far as your heart was concerned – he had never seen a bad news story for statins. Of course, all drugs have potential side effects. Top of the disgust list for patients are stories of muscle pain and weakness. Reassuringly, a meta-analysis study in The Lancet, showed that over 90% of muscle pain blamed on statins had nothing to do with the statin at all.
The benefits of statins in reducing the rate of cardiovascular diseases have been shown repeatedly. Not only do these drugs reduce the artery-clogging bad cholesterol, known as LDL, but they are also thought to have a separate anti-inflammatory effect on the blood vessels themselves. If stroke and heart disease prevention aren’t enticing enough, a recent study following more than 571,000 patients over 34 years showed a 26% reduction in dementia in patients with low levels of bad cholesterol. This risk was shown to drop by a further 13% in those on a statin. Rethink the grimace. I certainly am.
That sudden twang after a bend or unplanned heavy lift, so often followed by a spine-clutching waddle into the consulting room. Back pain is a nightmare when it strikes, not just for the individual patient, but for society as a whole. Estimates vary, but the cost of treating back pain and the indirect costs associated with work absence, run into many billions of pounds of UK GDP each year.
Modern lifestyle does little to help. Our spines – hardly evolved from the days of active hunter-gatherer humans – simply disagree with sofa culture and desk time. The good news for the vast majority, is that our ancestors also offer a cure. The days of medical advice being to take yourself to bed with strong painkillers are long gone. Patients will often offer their own solution.
The pain is better when standing or walking and worsens when sitting or lying down. There then lies the answer. Walking, moving and back pain exercises will settle things for most – but it can take time. Red flags that need urgent medical review are weakness, numbness, unintentional weight loss and problems controlling your bladder or bowels.
Loyal friends and fellow sufferers may well-meaningly advocate an MRI scan. While these certainly have their place, there’s perhaps caution here against an overly-hasty trip to the scanner. For low-risk back pain, without red flags, scanning within the first four to six weeks has been shown in some studies to actually increase the length of duration of symptoms. Exactly why this happens is uncertain. Perhaps overly medicalising the problem has an impact on our speed of recovery. Not every bit of wear and tear seen on a scan is responsible for the symptoms we feel.
The reality is that early cancer detection really can save lives. Fear of testing and fear of results all play their part, but my greatest fear is you forgetting. If you’ve got a “poo-in-the-post” packet sat on your kitchen table, follow the instructions. If there’s a letter – it may seem Dickensian – open it. Elevate screening on your list. It should be up there with checking the smoke detectors. Get to it before the chirping beep starts annoying you.
Here come the picture messages and anxious family members in the waiting room. Childhood rashes bring fear thanks to the well-publicised, but fortunately rare, rash associated with severe infections like bacterial meningitis. Have you pressed a glass onto it to see if it disappears? A rash that remains – or doesn’t blanch – needs urgent attention. The most important question here though is, how is the child? Many simple viral illnesses in childhood bring rashes that can safely be managed at home with medical advice. But is it chickenpox? Characteristic fluid-filled itchy blisters? Surely it should be easy. Can I finally answer with certainty and be the doctor that the world around me appears to need? Sometimes.
In reality, medicine is more of an art than a science.
New York Times: The internet is reframing the humble fizzy drink as an indulgent escape.