Acute pyelonephritis is a bacterial infection of the kidney parenchyma that can cause organ damage and be life-threatening. It is associated with systemic symptoms and flank pain which are not usually present in lower urinary tract infections. Early recognition and aggressive management of sepsis is required to prevent serious complications. Patients should be urgently referred to the emergency department if they are unwell and showing signs of sepsis (hypotension, tachycardia, hypothermia or pyrexia, signs of systemic illness such as rigors). Patients at higher risk of severe disease (elderly comorbid patients or those in other risk groups) may also warrant urgent referral.

Although classically asthma is characterised by variable airflow obstruction and inflammation, leading to symptoms of breathlessness, wheeze, chest tightness and cough, it can present with a broad spectrum of symptoms that have a wide differential diagnosis. Clinical examination is frequently entirely normal and clinical history alone is not sufficient to diagnose asthma. There is over-reliance on short-acting beta-agonists and a widespread underuse of inhaled corticosteroids. In mild to moderate disease, fluctuating symptoms can lead to an over-reliance on short-acting reliever treatment at the expense of preventative inhaled steroids. This risks the concealment of deteriorating symptoms and the potential build-up of critical airways inflammation.

Autoimmune destruction of the pancreatic beta cells leads to onset of type 1 diabetes (T1D). Although T1D can occur at any age, 85% of patients are diagnosed under the age of 20. Patients usually present with typical features of thirst, polyuria, weight loss and hyperglycaemia, with or without ketosis. In adults, symptoms are similar to those in children but there is a wider differential diagnosis. The presence of certain other autoimmune diseases, in the patient or relatives, is highly suggestive of an autoimmune cause of diabetes.

Age-related macular degeneration (AMD) is a cause of painless, gradual loss of vision. Epidemiological evidence suggests 4-8% of people aged over 65 years in the UK have visually significant AMD. Patients with suspected neovascular AMD (NvAMD) should be seen by ophthalmology within two weeks, and if the diagnosis and progressive disease are confirmed, treatment should commence within the same timeframe. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents cause regression of neovascularisation and reduce macular oedema. There is no treatment for dry AMD.

Elderly onset rheumatoid arthritis (EORA) is defined as rheumatoid arthritis (RA) with age of first onset 65 years or over. It comprises an acute onset proximal or large joint arthritis with a prominent systemic syndrome characterised by constitutional symptoms and a higher ESR than in the younger patient with RA. Investigations should focus on trying to establish the cause and ruling out differential diagnoses. They should include inflammatory markers, serum uric acid, full blood count, rheumatoid factor/anti-CCP antibodies, and X-rays of the affected joint as well as the hands and feet. The possibility of malignancy should always be borne in mind. NICE recommends urgent referral of all suspected cases.

Rheumatoid arthritis (RA) classically causes a symmetrical, small joint polyarthritis which left untreated can lead to joint destruction and deformity. NICE recommends that any adult with suspected persistent synovitis of undetermined cause should be referred for a specialist opinion. Patients should be referred urgently (even with a normal acute-phase response, negative anti-CCP antibodies or rheumatoid factor) if any of the following apply: the small joints of the hands or feet are affected; > 1 joint is affected; there has been a delay of ≥ 3 months between onset of symptoms and seeking medical advice.

Around 60,000 people in the UK are estimated to have cirrhosis. It is now the third most common cause of premature death. Decompensation represents a watershed moment for patients with cirrhosis, with the median survival falling from > 12 years for compensated cirrhosis to approximately two years. Patients with cirrhosis should undergo six-monthly ultrasound to screen for the early development of primary hepatocellular carcinoma. They should also undergo an initial upper gastrointestinal endoscopy to screen for varices.

The incidence of epilepsy in the UK is estimated to be 50 per 100,000 per year and up to 1% of the population have active epilepsy. The diagnosis of epilepsy will usually be made in a neurology clinic. A generalised seizure as part of a generalised epilepsy syndrome may occur without warning but may be preceded by blank spells or myoclonic jerks. A generalised seizure with focal onset may be preceded by an aura. Brain imaging is required in almost all cases where epilepsy is suspected, the only possible exception being people with generalised epilepsies proven on EEG. MRI is the imaging modality of choice.

First trimester miscarriage affects up to one in four pregnancies. While some women will experience bleeding and pain, others have no symptoms and are given the diagnosis at their 12-13 week booking scan. In 50-85% of cases the cause is due to a spontaneous chromosomal abnormality, most commonly trisomy. Many women suffer from psychological sequelae including PTSD, anxiety and depression. GPs should offer a follow-up appointment to all women who have had a miscarriage to: discuss any questions the woman has regarding her miscarriage; assess the woman’s psychological wellbeing and offer counselling if appropriate.

Heavy menstrual bleeding has been defined as ‘excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life’. Heavy menstrual bleeding affects 25% of women of reproductive age and is estimated to be the fourth most common reason for gynaecological referrals. Women should be asked about pelvic pain which might suggest endometriosis and pressure symptoms which might suggest significant fibroids. Examination is appropriate if there is intermenstrual or postcoital bleeding and, if the woman is actively bleeding, may identify the source of the bleeding.

My dad was a GP. He died when I was a young teenager, and I will never forget his funeral - the huge number of patients who came to say a silent thank you. He was an immense inspiration to me and my career, and one of my abiding memories of him at work as a doctor involves The Practitioner.

‘What would you do, doctor?’ is a question we should be very cautious about answering, without understanding a great deal about the patient’s health beliefs and priorities.

Some years ago, I tried using a simple stress diary when I was going through a particularly rough patch. The technique may sound like some sort of Californian psychobabble, but it certainly helped me.

Evening dosing of antihypertensive medication does not improve major cardiovascular outcomes compared with morning dosing in patients with hypertension, a large UK clinical trial, published in the Lancet, has found.