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Managing mild to moderate asthma in adults

22 Nov 2018

The National Review of Asthma Deaths found that most patients who died were actually considered to have mild to moderate asthma, with 57% of fatal cases not under specialist care at the time of their death. In cases of fatal asthma there was widespread underuse of inhaled corticosteroids and an overreliance on short-acting beta-agonists. Referral to secondary care should take place when there is diagnostic uncertainty or atypical features, the possibility of hypersensitivity to inhaled material or concerns over treatment or exacerbations. Patients who have suffered even a single life-threatening asthma attack should be under specialist supervision. 

Diagnosing and managing cystic fibrosis in children

22 Nov 2018Registered users

Cystic fibrosis (CF) is a multisystem genetic disorder affecting around 1 in 2,500 live births in the UK. Although all newborns undergo screening for CF, around 15% of infants will present shortly after birth with meconium ileus and some will already have faltering growth when the screening results are available at 3-4 weeks of age. Infants who present with meconium ileus should be treated with a high index of suspicion for CF until proven otherwise. Mucociliary dysfunction leads to accumulation of mucus in the airways and secondary infection. Respiratory symptoms may be non-specific initially and include cough and wheeziness, frequent respiratory infections and, in older children, sinusitis.

Managing complications of cystic fibrosis in adults

22 Nov 2018Registered users

Overall survival has improved dramatically for patients with cystic fibrosis (CF) since the millennium such that median life expectancy now extends into the fifth decade. However, with increasing longevity comes a range of comorbidities, some as complications of the disease itself but others as a consequence of long-term treatments required to manage CF. Chronic infection and inflammation eventually cause irreversible bronchiectasis and decline in pulmonary function, and 90% of CF deaths are caused by progressive respiratory failure.

Managing stable angina in primary care

22 Oct 2018Registered users

Around 50% of people diagnosed with ischaemic heart disease present with stable angina as the first symptom. The likelihood of a diagnosis of angina increases with the number of cardiovascular risk factors present. A resting 12-lead ECG is recommended for all patients with suspected angina. However, a normal result does not exclude the presence of underlying coronary artery disease.

Tracking down and treating the cause of syncope

22 Oct 2018Registered users

Syncope is a transient loss of consciousness (T-LOC) caused by cerebral hypoperfusion, characterised by a rapid onset, short duration and spontaneous complete recovery. It needs to be differentiated from other conditions that can cause T-LOC such as seizures, trauma, hypoglycaemia, and psychogenic causes. Three principal types of syncope can be identified: reflex or neurally mediated, orthostatic hypotensive and cardiac. The common denominator of all these conditions is low systemic BP causing global cerebral hypoperfusion.

Tackling medication overuse headache in primary care

24 Sep 2018Paid-up subscribers

Medication overuse headache (MOH) occurs as a complication of the management of primary headache disorders, mainly migraine and tension type headache. MOH does not occur in cluster headache unless there is associated migraine. MOH is defined as headache occurring on 15 or more days per month, that has evolved in association with the frequent use of acute medication over a period of more than 3 months. Any medication used for the acute treatment of headache can cause MOH.

Diagnosis and management of sleep-related epilepsy in adults

24 Sep 2018Registered users

Nocturnal epilepsies account for 10-15% of all epilepsies, and 80% of nocturnal epilepsies in adults are focal. They present a diagnostic challenge as they can be difficult to differentiate from normal movements and behaviour during sleep and also from several non-epileptic, sleep-related, motor and behavioural disorders. More than 90% of the seizures in sleep-related hypermotor epilepsy (SHE) occur during sleep. Seizures in SHE are simple partial seizures which easily wake the patient so that they will usually be able to recall the seizures, often describing auras of somatic sensations or feeling unable to breathe. SHE seizures have a rapid onset and offset, a short duration (usually < 2 min), and a stereotyped motor pattern for that individual.

Diagnosing and managing colorectal cancer

25 Jul 2018Registered users

Colorectal cancer is the fourth most common cancer in the UK and is the second most common cause of cancer deaths. Most cancers are thought to develop from colonic adenomas and incidence is strongly related to age. The majority of cancers are left sided and typically present with a change in bowel habit, blood in the stool or colicky abdominal pain. Rectal cancers can present with fresh red bleeding and large tumours can cause tenesmus (the intense and frequent desire to defecate, with little or no stool passed). Right-sided cancers most often present with anaemia. In both right- and left-sided cancers occasionally the patient may notice an abdominal mass or inexplicable weight loss.

Improving outcomes in pancreatic cancer

25 Jul 2018Registered users

The combination of an aggressive disease, vague presenting symptoms and insensitive standard diagnostic tests is a key factor contributing to poor outcomes with only 15% of patients with pancreatic cancer having operable disease at diagnosis. The NICE guideline on referral for suspected cancer recommends urgent referral via a suspected cancer pathway referral if the patient is aged 40 and over with jaundice. It also recommends that an urgent direct access computerised tomography (CT) scan referral should be considered in patients aged 60 and over with weight loss and any of the following: diarrhoea; back pain; abdominal pain; nausea; vomiting; constipation; new onset diabetes. Pancreatic cancer requires a CT scan for diagnosis.

Managing acute asthma in children

25 Jun 2018

The BTS/SIGN guideline specifies that the accurate measurement of oxygen saturation is essential in the assessment of all children with acute wheezing. It recommends that oxygen saturation probes and monitors should be available for use by all healthcare professionals assessing acute asthma in primary care. It is important to use the appropriate size paediatric probe to ensure accuracy. Any patient who presents to the GP practice with any features of a moderate exacerbation should be referred to an emergency department for further assessment and monitoring. 

Be vigilant for depression in children and adolescents

25 Jun 2018Registered users

The symptoms of depression in adolescents are similar to those in adults. Depression in children of primary school age may be very subtle and symptoms include mood fluctuations, tearfulness, frustration or temper tantrums. If depression is suspected, it is essential to evaluate the degree of risk. Risk has two key aspects: the likelihood of a potentially harmful incident occurring and degree of potential harm.

Improving the recognition of autism in children and adults

22 May 2018Registered users

Autism covers a wide spectrum across the dimensions of social communication, repetitive and stereotyped behaviours as well as other non-clinical and cognitive features. Individuals with autism can function well in certain environments, where there are fewer demands to multitask and factual information and pattern recognition are required, but they may not function well in highly social environments, or situations characterised by rapid and unpredictable change.

Managing patients with severe mental illness and substance misuse

22 May 2018Registered users

Co-occurring severe mental illness, usually schizophrenia or bipolar affective disorder, and substance misuse is termed dual diagnosis. Mental illness and its consequences may lead to substance misuse as a coping strategy. Substance misuse can lead to mental health problems, either by triggering a first episode in a susceptible person, or by exacerbating an existing disorder. However, substance misuse itself is unlikely to be the sole cause of a severe and enduring mental illness.

Identifying and managing men with early prostate cancer

23 Apr 2018Registered users

Prostate cancer is the most common cancer in men in the UK. Men have a 1 in 8 lifetime risk of being diagnosed with the disease. Factors associated with an increased risk of prostate cancer include: age > 50 years, black ethnicity, a first-degree relative with prostate cancer, and obesity. Patients may present with erectile dysfunction or lower urinary tract symptoms such as frequency, hesitancy, nocturia, or haematuria.

Managing acute and chronic urinary retention in men

23 Apr 2018Paid-up subscribers

Urinary retention is the most common urological emergency and more than 95% of cases occur in men. Acute urinary retention (AUR) is defined as the sudden inability to pass any urine voluntarily associated with a painful, palpable or percussable bladder. In chronic urinary retention (CUR) there is a non-painful bladder, which remains palpable or percussable after the man has passed urine, with a post-void residual volume > 300 ml. In acute on chronic urinary retention no urine can be voluntarily passed but the condition is relatively painless and the residual volume on catheterisation is > 1.5 litres.

Symptom recognition key to diagnosing endometriosis

22 Mar 2018Registered users

Endometriosis affects around one in ten women of reproductive age in the UK. NICE guidance highlights the importance of symptoms in its diagnosis. A normal abdominal or pelvic examination, ultrasound, or MRI should not exclude the diagnosis. Endometriosis should be suspected in women and adolescents who present with one or more of: chronic pelvic pain, significant dysmenorrhoea, deep dyspareunia, period-related or cyclical GI or urinary symptoms, or infertility. If endometriosis is suspected or symptoms persist, patients should be referred for further assessment.

Managing osteoporosis in postmenopausal women

22 Mar 2018Paid-up subscribers

Most patients with osteoporosis are asymptomatic unless they suffer a fragility fracture. A fragility fracture is a type of pathological fracture that occurs as a result of normal activities, such as lifting, bending, or a fall from standing height or less. There are three fracture sites said to be typical of fragility fractures: vertebral fractures; fractures of the neck of the femur; and Colles' fracture of the wrist. Following fracture risk assessment a dual energy X-ray absorptiometry (DXA) scan may be recommended.

Visible and non-visible haematuria may herald serious disease

22 Feb 2018Paid-up subscribers

Both visible (VH) and non-visible haematuria (NVH) may herald serious pathology e.g. malignancy or vasculitis. All patients with VH or symptomatic NVH should have urinalysis, urinary protein estimation (albumin:creatinine or protein:creatinine ratio), and a renal function test. These should also be requested if asymptomatic NVH persists, i.e. in two out of three samples over 6-8 weeks.

Prompt investigation improves outcomes for kidney cancer

22 Feb 2018Paid-up subscribers

Renal cell carcinoma should be suspected in the presence of: localising symptoms such as flank pain, a loin mass or haematuria; constitutional upset including weight loss, pyrexia and/or night sweats; or unexplained test results. Smoking, obesity and hypertension are common risk factors and all three demonstrate a dose-response relationship with the relative risk of renal cell carcinoma.

Timely diagnosis of vascular dementia key to management

23 Jan 2018Paid-up subscribers

Vascular dementia is the second most common type of dementia, after Alzheimer’s disease, and accounts for 15% of cases. The core diagnostic features include cognitive impairment in at least two domains (orientation, attention, language, visuospatial function, executive function, motor control and praxis), which affect social or occupational function, together with evidence of cerebrovascular disease (focal neurological signs or neuroimaging). Crucially there should be a temporal relationship between cerebrovascular disease and the onset of cognitive changes.

Pulmonary rehabilitation improves exercise capacity and quality of life

23 Jan 2018Registered users

Pulmonary rehabilitation is a multifaceted programme of exercise and education that aims to improve breathlessness, exercise capacity, and quality of life, and aid self-management. Patients with chronic respiratory failure, those on long-term or ambulatory oxygen and patients with anxiety and depression can all benefit from rehabilitation. It is one of the most beneficial and cost-effective treatments for COPD and should be considered a fundamental component of disease management rather than an option.

Prompt diagnosis can prevent joint damage in psoriatic arthritis

20 Dec 2017Registered users

Psoriatic arthritis (PsA) is a chronic, autoimmune inflammatory condition that can affect up to 30% of patients with psoriasis. It is part of the seronegative spondyloarthropathy group of rheumatic diseases which also includes reactive arthritis and ankylosing spondylitis. It can be a multisystem disease affecting the eyes, the gut and the tendons and is associated with comorbidities such as ischaemic heart disease and metabolic syndrome. Early diagnosis is key as structural joint damage can occur within two years of disease onset. 

Early recognition pivotal in the management of spondyloarthritis

20 Dec 2017Registered users

The spondyloarthritis group is divided into two main subgroups: axial spondyloarthritis and peripheral spondyloarthritis. These may exist as separate entities or coexist in the same patient. Classically, axial spondyloarthritis presents with insidious onset inflammatory lower back pain, which is typically worse in the morning and after rest, and improves with activity. Peripheral spondyloarthritis can present with peripheral joint pain and/or swelling, swelling of the digits (dactylitis), tendon and entheseal pain that is not secondary to a mechanical cause. Early referral of patients with suspected spondyloarthritis to specialist care is strongly recommended as this can improve long-term outcomes.

Regular review pivotal in chronic asthma in children

23 Nov 2017

The aim of asthma treatment is complete control of symptoms as soon as possible while minimising side effects and inconvenience to the patient. All parents and older children should be offered a written action plan. This should include details of the patient’s regular medicines, how to recognise deterioration and what to do in the event of an attack. Children should be referred to secondary care if: the diagnosis is unclear; control remains poor despite monitored treatment; they have suffered a life-threatening attack or red flag features are present.

Improving outcomes in COPD

23 Nov 2017Paid-up subscribers

Cigarette smoking is overwhelmingly the most important risk factor for COPD. In some cases, other factors such as occupation, passive exposure to inhalants and fetal nutrition/low birthweight are also important. The diagnosis should be suspected in symptomatic patients with risk factors, usually cigarette smoking, aged 40 years or above, albeit a majority of people with COPD present when considerably older. The 2017 GOLD guideline recommends that management should be focused on two objectives. First, to relieve symptoms of breathlessness (assessed using the MRC dyspnoea scale) and improve quality of life (assessed by the COPD Assessment Test). Second, to reduce risk assessed by the number of exacerbations and hospitalisations in the previous year.

Improving uptake of cardiac rehabilitation

23 Oct 2017Registered users

Data from the National Audit of Cardiac Rehabilitation show that 50% of eligible MI, PCI, and CABG patients do attend cardiac rehabilitation and that figure continues to rise, but the rates for stable angina and heart failure remain low. There is evidence that programmes which have a basis in psychoeducation (goal setting, self-monitoring, relapse prevention) are more likely to achieve long-term behaviour change than those based simply on delivering a fixed agenda of exercise and education. A recent Cochrane review of exercise-based cardiac rehabilitation continues to show the benefit of exercise prescription in terms of cardiovascular mortality, hospital readmission rates, and quality of life.

Assessment and management of CVD risk in adults

23 Oct 2017Registered users

Cardiovascular disease (CVD) affects seven million people in the UK alone. Modifiable risk factors for CVD include smoking, abnormal lipid profile, hypertension, diabetes, abdominal obesity, psychosocial factors, diet, alcohol consumption, and lack of physical activity. The INTERHEART study concluded that these factors account for more than 90% of the risk of MI worldwide. Well validated studies have suggested that QRISK2 is a better predictor of a patient’s ten-year risk of CVD compared with the traditionally used Framingham equation.

Diagnosis and management of complex regional pain syndrome

22 Sep 2017Registered users

Complex regional pain syndrome (CRPS) is a chronic debilitating painful condition comprising unremitting pain, sensory, sudomotor, vasomotor and motor abnormalities in the affected extremity. It has a peak incidence in the 55-75 age group and there is an association with asthma and migraine. CRPS is three times more common in women than men. CRPS should be suspected in any patient presenting with persistent pain in an extremity beyond the expected period of tissue healing following an acute injury, sprain, fracture or surgical procedure. Severe pain in a glove or stocking distribution is the predominant symptom in > 90% of cases.

Identifying neurological causes of daytime sleepiness

22 Sep 2017Paid-up subscribers

The prevalence of sleep complaints in adults in a primary care setting is > 10%. The most frequently seen condition by far is that of primary insomnia, which affects 10% of adults on a chronic basis. In contrast to primary insomnia, in which most patients report tiredness and fatigue during the day but are unable to sleep during the day either, the second most frequent sleep disorder encountered, obstructive sleep apnoea, is typified by excessive daytime sleepiness. Patients with primary insomnia or fatigue syndromes typically will score low on the Epworth Sleepiness Scale (ESS < 3) whereas those with organic sleep pathologies or sleep restriction will score higher. A score > 10 is seen as 'pathological', with a mean ESS in the population of 5-6. 

Chronic pancreatitis may be overlooked and undertreated

28 Jul 2017Registered users

The prevalence of chronic pancreatitis is variable, with estimates between 4 and 52.4 per 100,000. A mismatch exists between reported incidence and prevalence in many studies suggesting chronic pancreatitis is under recognised. One cause for this mismatch is that once diagnosed many patients are lost to secondary care follow-up. Therefore, although a GP may only see two new cases during their career they are likely to encounter patients requiring recurrent consultations.