Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: Unexplained symptoms aren’t always long covid

BMJ 2023; 380 doi: (Published 21 March 2023) Cite this as: BMJ 2023;380:p654
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

On busy days in general practice I often long for straightforward presentations—the sort where the patient seems to have read a medical textbook, as the history and symptoms fit so neatly with the examination findings. Diagnosis and management are simple, the patient is helped, and I feel useful. An added bonus is that the consultation is likely to be achievable within the allotted time (I might even fit in a cup of tea).

However, especially now that we’ve passed many of general practice’s more predictable elements to other healthcare workers, most of our work isn’t so tidy. Sometimes the symptoms suggest sciatica, but the examination findings are much more in keeping with arthritis (does the patient have both?), or the various elements of a patient’s history don’t seem to fit together to make any physiological or pathological sense.

How we respond to presentations that we don’t immediately understand makes a difference to us and the patient. At my best, I engage with such cases with empathy and enthusiasm, working with the patient to reach a diagnosis. I share my uncertainty and the various possibilities—ranging from the “likely and harmless” to the “unlikely but definitely needs excluding”—and discuss how we might investigate or who we might ask for advice. As long as I attend to the patient’s immediate needs (time off work, analgesia, or other symptom control) I can demonstrate that, although I don’t know the answers, I do take the questions seriously. When I’m stressed and rushed, it takes effort to muster this enthusiasm and suppress that feeling of “heart sink” that comes when I feel as though I have little to offer.

Long covid throws this problem into sharp relief. Two million patients in the UK have persistent symptoms after covid infection, and 1.2 million have had these symptoms for over a year.1 Fatigue, breathlessness, muscle ache, and loss of smell are the most common symptoms, but there’s a very long list of possible effects involving almost every system and part of the body.2 Currently, we have an incomplete understanding of what’s happening and little in the way of effective treatment.

As the vast majority of people in the UK have now had at least one episode of covid infection, a real concern is that patients or their doctors may attribute symptoms too readily to long covid and so miss other conditions.3 In our practice we’ve recently diagnosed two cases of lung cancer, which might have presented sooner if the persistent cough and malaise hadn’t been misinterpreted as the lingering effects of covid infection. When the patient opens with, “I’ve not been right ever since I had covid,” we must take care to exclude other diagnoses before we blame the virus.


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