Pulmonary rehabilitation improves breathlessness and health status in a range of conditions. It is a multifaceted programme of exercise training, disease education and self-management. Many programmes also provide psychological support and advice about breathing control training and nutrition. All patients who complete a pulmonary rehabilitation programme should have a written programme for ongoing exercise, with or without a referral to a community exercise facility. Patients may need to repeat the programme after 1-2 years, as the benefits may diminish over that period.

More than 50% of renal cell carcinoma (RCC) cases are detected incidentally on imaging, often at a late stage. Patients may present with mass-related localised symptoms, constitutional symptoms and symptoms of metastatic disease. Ultrasound is the optimal initial investigation to screen individuals with suspected RCC. NICE recommends that patients aged 45 and over with isolated haematuria, in the absence (or following treatment) of a urinary tract infection, are referred for investigation of a potential renal malignancy.

Symptoms of deep vein thrombosis (DVT) typically consist of unilateral leg swelling, redness, pain and discomfort, and are usually of acute onset. However, symptoms are variable and can be minimal in up to 50% of patients. The symptoms and signs are non-specific, and only a third of patients with a clinical suspicion of DVT have the condition. A thorough history and careful examination will help rule out other causes. Patients with suspected DVT should have a Wells score performed in combination with a D-dimer assay. 

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.

Although nonoperative treatment for Achilles' tendon rupture produced similar outcomes to surgery (minimally invasive or open repair) with respect to patient-reported and clinically assessed function, rerupture rates were substantially lower in patients who underwent surgery, a study from Norway has found.

Patients with obsessive-compulsive disorder (OCD) are nearly four times more likely to develop substance use disorder than those without OCD, a Swedish cohort study has found. This association may be partially attributed to genetic factors, but environmental factors may also be involved.

Even mild aortic stenosis is associated with an increased risk of mortality, a large study from Australia has found.

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.

Professor Haslam mentions the value of the fresh pair of eyes that a medical student or trainee in the practice brings, and I would like to add the benefits of locums.