COUGH
Cough is very common. The cough reflex has almost certainly evolved to protect the airway from obstruction or damage by secretions and foreign bodies. It is not all bad therefore. However, cough can often be irritating and troublesome.

What are the signs that suggest you need to see us? These are the signs of a possible chest infection which would necessitate contacting us for advice or coming to surgery:

• Feeling generally quite unwell with a high fever.
• Cough productive of coloured sputum.
• Feeling noticeably quite breathless

RASHES
Our "on call" experience suggests to us that rashes are a cause of tremendous anxiety which is almost always misplaced. The one rash that really justifies this level of concern is the meningococcal rash which most people, especially those with children, have heard of. However, it is not an easy rash to describe but if you understand how it is caused then I think that helps.

The meningococcal bacteria when they get into the bloodstream cause the tiny capillaries to leak blood into the tissues. It is this that causes the typical rash which looks like blood spattering and which does not fade on pressure which other rashes do. There are other causes of this type of rash (called purpura) but they should be checked out with the doctor on call unless the rash has been present for 24 hours or more virtually unchanged and the patient is well but even then an appointment during the next working day should be requested. When the rash is due to meningococcus it often progresses quite quickly so you can almost see it developing in front of your eyes. Meningitis is not always present so there is not always a headache but the patient will always be unwell with symptoms of varying degree from a "fluey" feeling to coma. There is genuine urgency in this situation as an antibiotic injection followed by immediate transfer to hospital is potentially life-saving and time is of the essence.

A representation of the meningococcal rash is present on the Meningitis Research Association website.

The meningococcal rash is quite uncommon (most GP's only see a handful of cases in their whole career). Also very uncommon nowadays (because of the highly successful immunisation programme) is measles. Rashes we frequently see are:

Non-specific viral rashes. Many viruses cause a fine pink slightly raised rash on the body - especially babies. Sometimes this is Rubella (German measles) but increasingly rarely nowadays because of immunisation. The patient is rarely more than mildly ill and no treatment is usually required beyond perhaps Paracetamol. Exclusion from public places (including school) is wise whilst the rash lasts.

Allergic rashes. These can vary from a very fine pink rash to large weals (hives, nettle-rash). The rash is often very itchy, tends to come and go and you may be aware of what caused it (which may be something taken internally). Occasionally these reactions may be serious if there is swelling of the throat or the patient suddenly collapses - this serious kind of reaction tends to be with such things as bee stings, nut allergies and antibiotics. If there is just a rash on the skin this is rarely serious and simply requires an anti-histamine taken orally (not as a cream) - your pharmacist can advise although we can prescribe these.

Chicken pox. This is a unique rash consisting of water-blisters with reddened inflamed skin around it. The spots tend to start on the trunk but come in crops even spreading to the throat and ears. In children it is almost always mild but chickenpox can be serious for the following groups:

• People on steroids - usually prednisolone.
• Pregnant women - especially just before birth.
• People with impaired immunity - cancer patients having chemotherapy, patients with HIV and patients with congenital immune deficiency.
• People with serious chronic disease.
• The newborn - especially if acquired just prior to birth from their mother.

Hand, foot and mouth also causes blistering but confined to the soles of the feet, palms of the hands and ulcers in the mouth. It can be unpleasant and can cause outbreaks but is not serious.

Other rashes which may need treatment from us but which are not urgent include eczema, dermatitis, athlete's foot, ringworm and scabies.

TEMPERATURES
Temperatures are present in many conditions ranging from common colds to septicaemia (blood infections). The raised temperature is caused by the body's response to infection rather than the infection itself. In many ways it is a sign of a robust response by the body since the elderly and frail can get quite sick without a temperature.

When to worry? Rapid temperature rises in a few children under five can cause fits though most children don't get this. It is a reason though to try very hard to keep temperatures down in this age group. In the over fives the temperature itself isn't the worry so much as what might be causing it. Most temperatures are due to relatively mild viral infections and are self-limiting However in the following cases you should seek advice from the doctor on call:

• Recent return from a malaria zone - even if your plane just stopped there to refuel.
• Recent contact with a serious infectious illness such as meningitis.
• Splenectomy and other conditions affecting immunity such as cancer treatment and HIV.
• Feeling generally ill with symptoms such as severe headache, productive cough, abdominal pains, drowsiness, confusion etc. This may just be a flu-like illness but if you are worried talk it through with the doctor on call so that a decision can be made as to whether you need a visit.

Specific treatment. Most fevers are due to self-limiting viruses and need no specific treatment at all but some specific illnesses may need antibiotic therapy. In most cases this can wait till normal hours but if the patient seems very unwell or has additional symptoms beside the temperature and a few "aches and pains" then ring to seek advice as to what to do.

SIMPLE HEADACHE
Headache is exceptionally common as a symptom. Very few of us escape them completely. There are, unfortunately serious causes but these are relatively uncommon.

Common Causes.
Tension headaches. Stress, anxiety etc. cause muscle spasm in the scalp muscles which in turn can cause headache "like a tight band around the head". If simple painkillers alone are insufficient then relaxation techniques can help.

Musculo-skeletal headaches often come from the spine in the neck. They tend to cause headaches at the back of the head and around the side.

Eye strain. If you need glasses or if your glasses need updating then this puts a strain on the eye muscles and tends to give you a headache at the front of the head - especially after reading, watching TV or looking at the blackboard for any length of time.

Temperatures and infections. These often cause quite bad headaches. Obviously there is always a worry about meningitis but with a simple headache there is very little sensitivity to the light and the neck can be fully flexed forward - if there is any doubt ring to speak to the duty doctor for advice.

Sinus infections can cause pain around the face and above the eyes. Inhaling steam and simple painkillers can be very helpful in this situation but antibiotics may be required.

Treatment.
In the over twelves there is a choice of painkiller between paracetamol, aspirin, combination painkillers (e.g. Solpadeine) and ibuprofen (Nurofen, Brufen). For simple headaches paracetamol is perfectly adequate in most cases and relatively cheap. Soluble aspirin is quite useful if you also have a sore throat because it soothes the throat if used as a gargle. Other painkillers offer little extra but cost a lot more. Ibuprofen may be helpful if the headache is coming from the neck and can be combined with paracetamol if necessary. In patients under twelve paracetamol is the mainstay. Aspirin is no longer thought to be entirely safe in this age group and combination painkillers are inappropriate. Ibuprofen is marketed in a suitable form but we don't recommend it routinely unless there is a good reason not to use paracetamol (which is rarely the case). Paracetamol comes in various brands as well as the plain form. It also comes as soluble tablets and elixirs. Dose for dose all are equivalent so it is entirely down to your own and the child's preference (and the cost!). Patients with chronic on-going headaches may have prescription drugs to take as well. Do check what painkillers (if any) can be combined with them. Equally, if you are on drugs for other conditions - e.g. arthritis - you will need to ask your pharmacist about combinations with over-the-counter remedies.

EARACHE
Earache is a very unpleasant condition. It is often, though not always, due to an ear infection called otitis media. Also, in very young children we may find an ear infection on examination of an ill patient who hasn't got any obvious ear symptoms. It is rarely dangerous nowadays and definitive treatment with antibiotics is not always necessary but when it is it can usually wait for the next working day. The eardrum may sometimes rupture releasing some blood and pus but this needn't cause undue alarm as this usually leads to the relief of symptoms and provided the ear is kept dry for a couple of weeks whilst the drum is healing over and then checked for completed healing by us in a routine surgery appointment  no long-term harm should ensue.

In the first instance pain relief, usually with the maximum dose of paracetamol recommended for the age group, is important. Remember antibiotics are not painkillers! Before calling for further advice (unless the patient's condition gives cause for concern in other ways) do give an adequate dose of paracetamol (or whatever painkiller you are using) and give it time to work (at least 30 mins.). Also, if you are waiting for the doctor there is no reason to wait to be told that it is okay to give paracetamol for this condition. If the painkillers fail to work or the patient isn't keeping the medication down then call us for further advice.

CROUP
In Croup there is a noise which comes from the throat on breathing in called stridor. This sounds alarming, it usually happens in the "small hours" and so often wakes the patient (usually aged less than five) and his/her parents from sleep.

Some points:
Firstly, croup is common and is usually much more alarming than it is dangerous.
Secondly, croup is due to a viral infection which inflames the lining of the wind-pipe. It is very like laryngitis in the adult but because the tubes are so much narrower the small degree of swelling causes the wind-pipe to act a bit like an organ-pipe. Antibiotic treatment is not very useful in this condition therefore.
Thirdly, in croup although breathing may be very noisy it is usually not causing  to much difficulty to the child and so the child will not be blue or gasping for breath - if they are then this could be an emergency so call 999 for an ambulance.
Fourthly, the child  usually responds within 10 minutes or so to being sat up in a steamy atmosphere - if they don't then call for further advice.
Fifthly the child isn't usually too unwell in themselves. If they are very hot and unwell with a muffled voice, very sore throat and difficulty swallowing then this could be the much rarer condition called epiglottitis. This can be extremely serious and you should get in touch with the duty doctor straight away expressing your concerns.

What to do?
Don't panic! It's rarely as bad as it sounds. Check that despite their breathing being very noisy that they are actually breathing without too much effort, that their lips are pink and that they are not very hot and unwell. If all this is all satisfactory then take them into the bathroom or kitchen and get the atmosphere really steamy with the shower, kettle or hot tap - they don't need to be too near the source of the steam! In simple croup the response is usually rapid and fairly dramatic and if it is you can safely settle the child down with perhaps some paracetamol. If their condition is not satisfactory at the outset or they don't respond to the steam or rapidly deteriorate again then you need to seek advice. If the colour is poor (blue) or there is real breathing difficulty or they are drooling because they can't swallow then it would be appropriate to call an ambulance.