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Tailor treatment to the patient in polycystic ovary syndrome

24 Mar 2020Paid-up subscribers

Polycystic ovary syndrome (PCOS)is a condition characterised by hyperandrogenism, multifollicular ovaries and ovulatory dysfunction. It affects 8-13% of women of reproductive age and is associated with insulin resistance, hyperlipidaemia and obesity. Baseline measurements should include blood pressure and BMI. Clinical signs of hyperandrogenism including hirsutism, acne and androgenic alopecia should be assessed. A hormone profile should be done during days 1-5 of the menstrual cycle or as a random sample when there is amenorrhoea.

Have a high index of suspicion for ectopic pregnancy

24 Mar 2020Paid-up subscribers

Ectopic pregnancy is estimated to occur in 1-2% of all pregnancies and continues to be the leading cause of maternal mortality in early pregnancy. Most ectopic pregnancies are located within the fallopian tube and carry a risk of tubal rupture and intra-abdominal bleeding. Women with ectopic pregnancy can present in a wide variety of ways, from acute collapse following rupture to asymptomatic and unaware that they are pregnant. Symptoms may include vaginal bleeding and abdominal pain. There may also be non-specific symptoms such as Gl and urinary symptoms, rectal pressure, dizziness, shoulder tip pain, fainting or syncope. 

Prompt recognition key in glomerulonephritis

24 Feb 2020Paid-up subscribers

Glomerulonephritis is the second most common cause of end stage renal disease in the UK and the most common cause in those under 35. Some forms can respond well to treatment if diagnosed early. However, if glomerulonephritis goes unrecognised, it can lead to irreversible loss of renal function. Glomerulonephritis can present in a wide variety of ways, ranging from asymptomatic urinary abnormalities to fulminant disease with life-threatening acute kidney injury and extra-renal manifestations. Asymptomatic invisible haematuria is common. In the absence of infection or a urological cause, glomerulonephritis should be considered. Significant proteinuria (> 1 g/day) in the absence of an identifiable cause warrants referral. 

GPs play an important role in identifying acute kidney injury

24 Feb 2020Paid-up subscribers

Acute kidney injury (AKI) is a common complication in hospitalised patients and is associated with an increased risk of chronic kidney disease (CKD) and higher mortality. Two thirds of AKI cases develop in the community prior to hospital admission. AKI may be challenging to recognise because it is typically asymptomatic. It is usually detected incidentally in the setting of another illness when a rise in serum creatinine from baseline is identified. Risk factors for AKI include age 65 or over, diabetes, CKD, neurological or cognitive impairment, heart failure and the use of potentially nephrotoxic medications. Recognition of those at risk should prompt earlier and more frequent testing of U&E during any acute illness. 

Identifying the cause of late life psychosis

23 Jan 2020Paid-up subscribers

Late life psychosis may be caused by organic conditions including: delirium, dementia, drug intoxication or withdrawal, or a general medical condition. In these situations there should be evidence of a temporal relationship between the psychosis and the underlying condition. Around 60% of older adults presenting with new onset psychosis have an identifiable underlying organic cause. If an underlying medical condition can be excluded, and there is no evidence to support a diagnosis of delirium or dementia, then the cause of psychosis may be functional. This is more likely if there is a family or personal history of mental illness.

Elderly onset RA: a diagnostic and therapeutic challenge

23 Jan 2020Paid-up subscribers

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.

Early intervention key in first episode psychosis

20 Dec 2019Paid-up subscribers

Psychosis is a state of mind in which a person loses contact with reality in at least one important respect while not intoxicated with, or withdrawing from, alcohol or drugs, and while not affected by an acute physical illness that better accounts for the symptoms. Common positive symptoms of psychosis include delusions and hallucinations. These symptoms are strongly influenced by the underlying cause of the psychosis: delusions in schizophrenia tend to be bizarre; delusions in depression negative; delusions in mania expansive. When a patient presents with psychotic symptoms, it is important to take a full psychiatric history, perform a mental state examination and complete relevant investigations, as indicated in each individual case.

GPs are central to improving care of schizophrenia patients

20 Dec 2019Paid-up subscribers

Schizophrenia often runs a chronic course and is associated with considerable morbidity and mortality. While psychotic symptoms are the most obvious manifestations of the condition, negative symptoms (e.g. apathy and withdrawal) and cognitive symptoms (especially deficits in executive function) are often more disabling. It generally presents in late adolescence or early adulthood. Schizophrenia typically develops insidiously, potentially over several years. The GP is ideally placed to respond to family concerns, identify prodromal symptoms, screen for psychotic symptoms and initiate either a mental health review or active monitoring in primary care.

More patients could benefit from referral for cardiac rehabilitation

25 Nov 2019Paid-up subscribers

Cardiac rehabilitation is a combination of medical and behavioural interventions designed to facilitate recovery and prevent future cardiovascular disease events. A cardiovascular prevention and rehabilitation programme (CPRP) is a critical element within the management pathway for most patients with heart disease and has a particularly strong evidence base for those with either symptomatic atherothrombotic vascular disease or heart failure. Following acute MI and/or coronary revascularisation, attending and completing a CPRP is associated with an absolute risk reduction in cardiovascular mortality from 10.4% to 7.6%.

Reducing stroke risk in patients with atrial fibrillation

25 Nov 2019Paid-up subscribers

Stroke is the most debilitating complication of atrial fibrillation (AF). AF-related strokes account for 20-25% of all strokes and are generally more severe and disabling and more likely to recur. Oral anticoagulation (OAC) remains the cornerstone of AF management with a clear prognostic benefit. It reduces stroke risk by two-thirds and mortality by a quarter. The decision to anticoagulate is taken irrespective of the pattern and duration of AF (paroxysmal, persistent or permanent). A large evidence base supports the use of OAC in men with a CHA2DS2-VASc score of 2 or more and women with a score of 3 or more. Hence, in the absence of absolute contraindications, OAC is strongly recommended.

Detecting obstructive sleep apnoea hypopnoea syndrome

24 Oct 2019Paid-up subscribers

Obstructive sleep apnoea hypopnoea syndrome (OSAHS) is characterised by repeated episodes of partial or complete collapse of the upper respiratory passages, mainly the oropharyngeal tract, during sleep. Obesity is the strongest risk factor for OSAHS; other risk factors include smoking, excessive drinking, sedatives and hypnotics. Habitual snoring, unrefreshing sleep and daytime somnolence suggests the possibility of OSAHS. When this is combined with a partner’s account of nocturnal apnoeas or snoring pauses the diagnosis becomes highly likely. However, negative screening results or the absence of clinical features by themselves should not be used to rule out OSAHS.

Improving COPD outcomes in primary care

24 Oct 2019Paid-up subscribers

Diagnosis of COPD is based on the presence of airflow obstruction after the administration of a bronchodilator i.e. post-bronchodilator spirometry. However, the National COPD Audit report for 2017-18 found that 59.5% of people hospitalised with a COPD exacerbation in England and Wales had no spirometry result available and in 12% of those who had undergone spirometry the test showed no airflow obstruction. Patients with COPD should be reviewed annually. It is advisable to repeat spirometry if there is a significant change in symptoms. It is important to determine objective measures of breathlessness (MRC dyspnoea score), quality of life (CAT questionnaire) and exacerbations (annual exacerbation and hospitalisation rate) as part of this review.

Optimising the management of neuropathic pain

25 Sep 2019Paid-up subscribers

Neuropathic pain is defined as ‘pain that is caused by a lesion or disease of the somatosensory nervous system.’ The International Association for the Study of Pain (IASP) pain grading system is a simple way of determining the likelihood of a neuropathic component. If the history suggests a relevant neurological lesion or disease and the patient describes pain in an anatomically plausible distribution of a nerve, neuropathic pain is ‘possible’; it is ‘probable’ if there are corresponding examination findings in that same distribution and ‘definite’ if there is a confirmatory diagnostic test. 

Optimising the treatment of inflammatory bowel disease

07 Aug 2019Paid-up subscribers

Inflammatory bowel disease (IBD) is a chronic inflammatory condition which runs a relapsing and remitting course. Ulcerative colitis (UC) is more common than Crohn’s disease (CD). UC almost always affects the rectum and extends proximally and continuously to the colon to a variable extent. CD most commonly affects the terminal ileum or colon but can affect any part of the gastrointestinal tract from the mouth to the anus. The vast majority (90%) of people with UC report bloody stools compared with less than 50% of those with CD. CD is characterised by a triad of abdominal pain, diarrhoea and weight loss.

Early detection of liver cancer key to improving outcomes

07 Aug 2019Registered users

Hepatocellular carcinoma (HCC) accounts for around 90% of liver cancer cases and intrahepatic cholangiocarcinoma (CC) for 9-10%. Most cases of HCC occur in the context of chronic liver disease with cirrhosis, particularly in those with chronic hepatitis B or C. Other major risk factors include excessive alcohol consumption, obesity and aflatoxins. Overall, 10-15% of cirrhotic patients will develop HCC within 20 years. Patients presenting with an upper abdominal mass consistent with an enlarged liver should be referred for an urgent direct access ultrasound scan within two weeks. 

Improving outcomes in allergic rhinitis in children

24 Jun 2019Paid-up subscribers

Allergic rhinitis can affect a child’s physical health, reduce their quality of life, sleep and concentration, and impact on school performance. Children with allergic rhinitis are at increased risk of developing asthma. Around 85% of those with asthma have allergic rhinitis, which can complicate diagnosis and management and also increase the risk of hospitalisation for asthma exacerbations. However, appropriate management of allergic rhinitis can improve asthma control. The diagnosis of allergic rhinitis can usually be made on the basis of the patient’s history and examination alone. 

Managing common skin conditions in infants

24 Jun 2019Paid-up subscribers

Atopic eczema, or atopic dermatitis, affects up to 20% of children and often presents in infancy. Cow’s milk allergy can also manifest as eczema and gastrointestinal (GI) symptoms. Food allergy should be suspected if there is a clear history of a reaction to a food in infants with moderate to severe eczema not responding to standard treatment, in infants with very early onset eczema (under 3 months) and those with GI symptoms. Seborrhoeic dermatitis is often an early manifestation of atopic eczema. Naevus simplex is a common congenital capillary malformation occurring in up to 40% of newborns. Port wine stains are less common, affecting about 0.3% of infants. 

Education the key to improving outcomes in gout

22 May 2019Paid-up subscribers

The most common presentation of gout is a flare, characterised by acute onset of one, or occasionally more, hot, red, swollen joints which are very painful and tender. Less common is insidious onset of chronic usage related joint pain, especially in joints already affected by osteoarthritis. Subcutaneous tophi can also be the presentation, particulary in older people. In typical cases, clinical assessment alone is sufficient for diagnosis. Gout is also associated with comorbidities such as nephrolithiasis, chronic kidney disease, metabolic syndrome and heart disease, and increased mortality.

Optimising the management of systemic lupus erythematosus

22 May 2019Paid-up subscribers

Systemic lupus erythematosus (SLE) is a multisystem, autoimmune disease. SLE mainly affects women and causes fatigue, rashes (often associated with photosensitivity), hair loss and inflammatory arthritis. However, it can also affect men in whom it is often more severe with a greater likelihood of renal involvement and a greater degree of organ damage. According to the British Society for Rheumatology guideline, the diagnosis of SLE requires a combination of clinical features and the presence of at least one relevant immunological abnormality.

History key in identifying cause of nocturia in men

24 Apr 2019Paid-up subscribers

Nocturia can be a symptom of an underlying disease process or behavioural. The history should not just focus on lower urinary tract symptoms but should also include past medical history, current medications and fluid intake. It is important to ask specifically about the onset and progression of symptoms, and to what extent the patient is troubled by the nocturia. An abdominal examination should always be performed and should exclude urinary retention. A digital rectal examination of the prostate should also be offered.

Early recognition and treatment vital in acute prostatitis

24 Apr 2019Paid-up subscribers

Acute prostatitis is an acute bacterial infection of the prostate gland, often associated with other urinary tract infections. Patients with acute prostatitis present feeling generally unwell with fever, rigors, pelvic pain and lower urinary tract symptoms. Acute prostatitis can also present with, or lead to, acute urinary retention. Patients who are systemically unwell should be referred urgently to secondary care for intravenous antibiotics and further investigation, as should those failing to respond appropriately or deteriorating on review after 48 hours. Chronic bacterial prostatitis is characterised by symptoms that last for more than three months. 

Investigating the cause of heavy menstrual bleeding

25 Mar 2019Registered users

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.

Diagnosis and management of premenstrual syndrome

25 Mar 2019Paid-up subscribers

The term premenstrual syndrome (PMS) refers to a constellation of mood and physical symptoms that occur during the luteal phase of the menstrual cycle. The National Association for Premenstrual Syndrome suggests that: ‘If PMS symptoms affect personal and/or social and/or professional quality of life then this should be regarded as being clinically significant PMS.’ Some women give a clear history of onset during the luteal phase of the menstrual cycle, with improvement taking place within a few days after the onset of menses. However, other women present with fluctuating symptoms without making a connection with their menstrual cycle. There are no diagnostic tests for PMS; diagnosis is dependent on the history. 

Management and prevention of renal and ureteric stones

22 Feb 2019Paid-up subscribers

Kidney stones are common with as many as 1 in 10 people developing a symptomatic stone. Up to 50% of stone formers will have at least one further symptomatic stone in their lifetime. Ureteric colic is unaffected by posture with patients often writhing in seemingly futile attempts to relieve pain. Immediate management comprises effective analgesia while urinalysis is the first step in confirming the diagnosis. One of the challenges facing the GP is to differentiate patients who warrant immediate hospital referral from those who can be seen less acutely.

Tailoring dialysis modality to the patient

22 Feb 2019Paid-up subscribers

End stage renal disease can be defined as the requirement for kidney transplantation or dialysis therapy. In the UK in 2016, of the 63,162 people receiving renal replacement therapy 53% were renal transplant recipients, 41% were on haemodialysis and 6% were on peritoneal dialysis. Dialysis should be started when: symptoms of uraemia impact on day to day living; the need is indicated by biochemical measures or uncontrollable fluid overload or at an eGFR of 5-7 ml/min/1.73 m2 in the absence of symptoms. The choice of dialysis modality is influenced by the individual’s functional status, social circumstances and confidence.

Diagnosing and treating mood disorders in older people

05 Feb 2019Registered users

Depression in older adults is common. Depressive symptoms may be part of a recurrent depressive disorder or experienced for the first time in later life as a result of changes in risk and resilience factors. There is an association between cerebrovascular pathology, vascular risk factors and depression. Physical illnesses, particularly those associated with frailty, are also important risk factors for depression. Depression has a distinct presentation in late life and low mood may not be the predominant presenting symptom. Older patients may present with physical symptoms, apathy, cognitive symptoms, agitation, retardation, fatigue or weight loss.

Managing arrhythmias in coronary artery disease

23 Jan 2019Registered users

A detailed history is essential in patients with coronary artery disease (CAD) to elucidate red flag symptoms necessitating urgent specialist assessment. Red flags include syncope and presyncope, particularly in patients with concomitant left ventricular systolic dysfunction. Palpitations with severe chest pain and breathlessness also warrant urgent assessment. Undiagnosed atrial fibrillation (AF) is common in older populations. LVEF of 35% or less is a predictor of increased risk of sudden death. All patients with CAD should therefore undergo assessment of LVEF, usually by transthoracic echocardiography.

Diagnosis and treatment of Sjögren’s syndrome

20 Dec 2018Registered users

Primary Sjögren’s syndrome is a chronic systemic immune-mediated condition of unknown aetiology characterised by focal lymphocytic infiltration of exocrine (mainly salivary and lacrimal) glands. It affects 0.1-4.6% of the European population and 90% of cases are female. Although it usually presents in the fifth or sixth decade, it can be seen in younger people who tend to present with systemic disease and are less likely to have classical sicca symptoms. Patients should be referred to a rheumatologist to confirm diagnosis, and this may involve scintigraphy/sialography and/or labial gland biopsy.

Managing low back pain in primary care

20 Dec 2018Registered users

Chronic low back pain is a common problem. Lifetime adult prevalence rates vary from 50 to 80%, and around a quarter of adults say they have experienced back pain during the past month. One in 40 report disabling back or neck pain. Each year around 7% of patients consult their GP with back pain. In 65-70% of primary care patients with low back pain there is no known pathoanatomical cause. Their pain is described as nonspecific and is postulated to arise from muscle strain or ligamentous injury. A further 15-20% of patients have mechanical low back pain with an identifiable cause such as degenerative disc or joint disease. 

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.