Quick Clinical Hints And Tips (Q-CHAT)

 Here are some quick clinical hints or tips to help you with your clinical practice.   If you have one to share yourself (or even more than one), scroll to the bottom and post something.  You don’t have to identify yourself when submitting the post – just type in anon into the name field (and email addresses are not disclosed but if you want to make one up that’s okay too).

51 Responses to Quick Clinical Hints And Tips (Q-CHAT)

  1. Ramesh 17 September, 2015 at 11:39 pm #

    HEADACHES & CT

    If ordering CT scan, ask for with contrast. CT does miss stuff.
    FH of brain aneurysms – first degree relatives has twice the risk of gen pop (but only 1 in 50 of those affected will end up with a rupture)
    FH of subarach haem = first degree relatives have 3-5 times the risk.
    Young patients, high BP, recurrent headaches not settling – may need referral.

  2. Ramesh 17 September, 2015 at 11:43 pm #

    ENT : SUDDEN HEARING LOSS

    Sudden Hearing Loss of the sensorineural type should be referred urgently. That of the conductive type is usually of less significance and if due to causes other than impacted wax (e.g. fluid from viral infections) may take around 4 weeks to settle. Both of these present as ‘ear fullness’ so how does one tell the difference? Ask the patient to hum a tune (e.g. bah bah black sheep, jingle bells, happy birthday to you) and ask which side do they hear it the loudest. If they hear it more on the good side, that is bad (sensorineural, urgent referral). If they hear it more on the bad side, that is good (conductive). Analogy: imagine the ear canal as a tunnel – if one end of the tunnel is blocked off with say a vertical thick layer of cement (conductive block), then it would make sounds echo louder.

  3. Anne 19 December, 2015 at 8:22 pm #

    NAUSEA & VOMITING IN PREGNANCY
    Nausea and vomiting is common in the first trimester. Urinalysis is essential to exclude infection or presence of ketones.
    Although unlicensed for use in pregnancy cyclizine or promethazine, with pyridoxine, are safe and effective to help reduce nausea.

  4. Anne 19 December, 2015 at 8:23 pm #

    GESTATIONAL DIABETES
    Pregnancy is a ‘stress test’ for a woman’s health. All women with Gestational Diabetes are at risk of developing the same problem in future pregnancies and of developing diabetes in later life. These women require an HbA1C at 13 weeks postnatally and annually thereafter and be counselled about the importance of weight management.

  5. Anne 19 December, 2015 at 8:26 pm #

    PERINATAL MENTAL HEALTH
    Maternal mental health problems are the 2nd leading cause of indirect maternal death. 20% of women (an incredible 1 in 5) suffer with postnatal depression which may affect bonding between mother and baby, health outcomes for both and the extended family. So screen for mood!
    And for those women who are already on the the severely mentally ill register, REFER them to the Community Mental Health Team regardless of present mental health.

  6. Anne 19 December, 2015 at 8:27 pm #

    POSTNATAL CONTRACEPTION
    Fertility can return as early as day 24 post-delivery. A repeat pregnancy within a year is high risk for both mother and infant. All healthcare professionals need to provide advice about contraception.

  7. Anne 19 December, 2015 at 8:28 pm #

    PREGNANT & THE FLU JAB
    Advise all pregnant women to have a flu jab.
    Although uptake is often poor, IT DOES SAVE LIVES.

  8. Louise 19 December, 2015 at 8:31 pm #

    GASTROENTERITIS IN UNDER 5s
    It is important to assess and record hydration status.
    For those children who are not clinically dehydrated, or who have some signs of dehydration (but without deterioration or signs of shock), oral rehydration and oral fluid challenges should be emphasised. Even in hospital oral or NG fluid challenges are used before IV fluids are considered.
    In Bradford, use the Systm1 to guide management (under ‘paediatrics’ on stickman) and give the parent/carer gastroenteritis advice leaflet that can be printed from there.

  9. Louise 19 December, 2015 at 8:33 pm #

    CANCER REFERRALS IN CHILDREN
    NICE guidance (2015): suspected cancer referrals in children are no longer seen within two weeks of referral (except retinoblastoma).
    The target times are now:
    · Immediate paediatric review – suspected leukaemia
    · Paediatric review within 48 hours – all other suspected children’s cancers (eg. Lymphoma, neuroblastoma, Wilms tumour, brain/CNS cancer,
    bone or soft tissue sarcomas)
    Therefore ALL suspected cancers in children should be discussed with the oncall paediatric CONSULTANT prior to the fast-track form being submitted.

  10. Louise 19 December, 2015 at 8:34 pm #

    THE WHEEZY CHILD
    ALL children with asthma or recurrent pre-school wheeze should have a management plan. Children with a management plan are FOUR times less likely to be admitted with an exacerbation than those without.
    In Bradford, remember to use the S1 wheezy child template when managing acute wheeze,and also for asthma reviews in children (good practice & ticks boxes for QOF).

  11. Catherine 5 January, 2016 at 2:45 pm #

    BREAST PAIN
    Is very common and is NOT a presenting feature of breast cancer. Ladies can be reassured about the benign nature of breast pain assuming normal examination. Patients need a good fitting, non-underwired bra and to take simple analgesia. Over-the-counter topical NSAIDs can help areas of focal tenderness. OTC Evening Primrose Oil will help around half of patients with cyclical mastalgia (2g/day).

  12. Catherine 5 January, 2016 at 2:46 pm #

    BREAST CANCER AND FAMILY HISTORY
    Patients who only have one first or second-degree relative diagnosed with breast cancer >40 years can be reassured they are not at an increased risk and do not need to be referred. Advice and guidance is available through Choose and Book and the Familial Breast Cancer template on SystmOne for those of you in Bradford and Airedale.

  13. Catherine 5 January, 2016 at 2:47 pm #

    NIPPLE DISCHARGE
    Refer single duct, spontaneous unilateral bloody or clear nipple discharges.
    Bilateral and/or multi-duct nipple discharge without blood is physiological in younger ladies and often caused by duct ectasia in older ladies. These patients can be safely reassured.

  14. Catherine 5 January, 2016 at 2:48 pm #

    BREAST ABSCESS
    Women with a breast abscess do not usually require surgical intervention. Antibiotics can be started and an appointment made to attend breast clinic the following day, for consideration of aspiration,

  15. Catherine 5 January, 2016 at 2:49 pm #

    MALE BREAST PROBLEMS
    Male patients >50 years with a firm breast mass +/- discharge +/- skin changes should be referred.
    Men with a clear cause for gynaecomastia do not necessarily need to be seen. Gynaecomastia surgery is not routinely funded on the NHS, funding should be sought from the Individual Funding Request panel prior to referral.

  16. Ramesh 7 January, 2016 at 4:10 am #

    HEADACHES
    With all headaches, ask about a personal medical history of cancer. If there is a previous history of cancer (and having taken the headache history into account) – consider doing a scan!

  17. Ramesh 7 January, 2016 at 4:17 am #

    EYE COMPLAINTS
    Think about testing visual acuity. If visual acuity has gone off – something important is kicking off.

  18. Ramesh 7 January, 2016 at 4:20 am #

    RED FLAGS
    Have you seen my Red Flags document? Things to always ask about for particular complaints? If they have any red flags – investigate or refer! See this link (and any improvements or suggestions are welcome):
    http://www.bradfordvts.co.uk/wp-content/onlineresources/0002mrcgp/csa/red%20flags%20for%20the%20CSA.pdf

  19. Ram 22 January, 2016 at 4:16 pm #

    COELIAC DISEASE
    Anyone with persistent unexplained GI symtpoms, with prolonged fatigue and unexpected weight loss should be serologically screened for Coeliac (as well as screened for cancer)

  20. Ram 22 January, 2016 at 4:29 pm #

    Patello-Femoral Pain Syndrom (PFPS)
    Patellofemoral pain syndrome often results in significant bursts of excruciating pain when a patient goes up and down steps, climbs ladders or squats. Ask a patient to squat slowly and if they have such pain it is highly likely they have PFPS. 75% of people with tenderness at the patellar edges have PFPS. Patellar grinding and apprehension tests are rubbish. Patients with this condition also have stiffness. It can be so debilitating that they reduce their activity levels.

    Patients over the age of 40 should be excluded for patellofemoral osteoarthritis. In this case order x-rays – including skyline views of the patella. For both PFPS and patellofemoral osteoarthritis – give exercises to work quads n particular Vastus Medialis. But they need to do the exercises for 6 to 12 weeks minimum.

  21. Youssef 2 March, 2016 at 12:46 pm #

    HYPERTENSION
    Empower patients to “Know their BP targets”. This helps with adherence and reduces the number of appointments required.
    Advise all hypertensives to consider buying an ‘accredited’ BP machine. They start at £10; i.e. Omron M2 Basic.
    Target BP for non-diabetics is <140/90 in surgery or <135/85 at home.
    There is growing evidence for lower targets in higher risk groups, 120/80 in a recent big RCT (SPRINT study). Good to aim for <135/85 at home for now.

  22. Youssef 2 March, 2016 at 12:49 pm #

    RESISTANT HYPERTENSION
    Resistant hypertension = patients on three or more antihypertensives with still uncontrolled BP.
    Biggest cause is poor adherence. One study showed over 50% of resistant hypertensives did not take their medication.
    If good compliance, offer spironolactone as a fourth agent provided potassium <4.5.
    If BPstill uncontrolled, consider e-consult to cardiology rather than clinic referral.
    Push lifestyle changes (diet and exercise to lose the weight)

  23. Youssef 2 March, 2016 at 12:52 pm #

    ACUTE KIDNEY INJURY (from D&V, UTI or dehydration) in those on nephrotoxic drugs (ACEI, ARB, Diuretics, NSAIDS)
    AKI carries a clear mortality and morbidity risk and is often preventable in the community.
    Consider the risk of developing AKI in people on nephrotoxic drugs (ACEi, ARB, diuretics, NSAIDs) and who have D+V, UTI, dehydration.
    Temporarily stop medication until better.

  24. Angela 6 April, 2016 at 1:31 am #

    DON’T GIVE VALPROATE IN WOMEN OF CHILDBEARING AGE
    Did you know…. 30-40% babies get developmental problems if valproate given in pregnancy & 10% have congenital abnormalities

  25. Angela 6 April, 2016 at 1:34 am #

    PREGNANCY AND SEVERE MENTAL ILLNESS HISTORY
    Pregnancy/childbirth can affect Mental Health and the risk of relapse. Optimise medication but DO NOT recommend discontinuation Advise about risk of medication in pregnancy and breast feeding

  26. Angela 6 April, 2016 at 1:35 am #

    EMOTIONAL WELL-BEING TOOLS
    Whooley and GAD 2 screening tools

  27. Pam 6 April, 2016 at 1:38 am #

    DYSPEPSIA & LIFESTYLE ADVICE
    If the patient does not warrant an endoscopy and you plan on giving lifestyle advice, remember to talk about
    1. diet – esp spicy food, fatty food, citrus drinks and caffeine (SFCC)
    2. stop smoking
    3. cut down alcohol
    4. lose some weight

  28. Pam 6 April, 2016 at 1:40 am #

    IF STOPPING AN PPI – provide cover with an alginate
    Please consider adding in an alginate 2 weeks prior to reducing or stepping down a PPI and continue with an alginate whilst stepping down or stopping the PPI.

  29. Pam 6 April, 2016 at 1:41 am #

    IBS SYMPTOMS IN 18-55 YR OLD – Check for FCP
    IBS symptoms – abdominal pain/discomfort, bloating or change in bowel habit for > 6mths.
    If recommended bloods and FCP are negative , reassure likelihood of IBS
    If FCP positive then refer to gastroenterology.
    Calprotectin indicates inflammatory bowel disease.

  30. Pam 6 April, 2016 at 1:42 am #

    BARRETTS SURVEILLANCE
    If Barretts segment is 3cm then a repeat OGD every 2 – 3 years.
    If Barretts segment is < 3cm and has gastric metaplasia then the patient may be discharged.

  31. Kerry 6 April, 2016 at 1:44 am #

    CAUDA EQUINA – always ask about these symptoms in back pain
    It is rare but must always be considered.
    Check for
    1. loss of bowel or bladder control,
    2. saddle anaesthesia or
    3. widespread or progressive motor disturbance.
    Refer to A&E immediately if possible concern.

  32. Kerry 6 April, 2016 at 1:45 am #

    BACK PAIN – ENCOURAGE EARLY ACTIVITY
    Gentle activity is not harmful, it reduces pain and physical fitness is beneficial.
    Prolonged bed rest is harmful and risks causing chronic problems.
    Refer patients to here:
    http://www.arthritisresearchuk.org/health-professionals-and-students/information-for-your-patients/exercise-sheets-and-videos/back-pain-exercises.aspx

  33. Kerry 6 April, 2016 at 1:46 am #

    BACK PAIN – try not to give narcotics!
    Prescribe simple analgesia , NSAIDS +/- PPI as indicated
    Promote regular, not prn, pain relief.
    Avoid narcotics if possible, if necessary limit course to 2 weeks only.
    If clear radicular pain consider neuropathic medication – low dose amitryptiline

  34. Kerry 6 April, 2016 at 1:47 am #

    PROMOTE POSITIVE ATTITUDES IN THOSE WITH CHRONIC PAIN
    http://www.bradfordpersistentpain.com/
    Promote positive attitudes to activity and work.
    Assess tendency for low mood, depression and start treatment if required.

  35. Kerry 6 April, 2016 at 1:48 am #

    BACK PAIN – refrain from unnecessary investigations
    Lumbar x-rays are high dose radiation and of very limited value in patients aged 20-55 unless traumatic onset and fracture suspected.
    MRI – not helpful or required in primary care management.
    Investigations may be organised at a later stage by specialist teams if indicated

  36. Kerry 6 April, 2016 at 1:49 am #

    BACK PAIN AND OLDER PEOPLE = PATHOLOGY IS MORE LIKELY
    If severe unremitting pain, not responding to simple analgesia PLUS red flags: weight loss/previous cancer/other systemic symptoms arrange urgent investigations or referral

  37. Matt 29 April, 2016 at 12:11 pm #

    PALPITATIONS – WHAT DOES THE PATIENT REALLY MEAN?
    ‘Palpitations’ is a term in common usage but when used by a clinician we are specific that this mean a ‘sensation of beating within the chest’. You need to make sure the patient is not describing other issues such as chest pain or nausea. Clarify what they mean by palpitations.

  38. Matt 29 April, 2016 at 12:11 pm #

    PALPITATIONS – RATE, RHYTHM & SPEED
    Try to assess the rate, rhythm and speed. It might help to tap out a regular or irregular rhythm on the desk. Rapid regular rhythms are most likely to be supraventricular tachycardias, Rapidly irregular rhythms – AF and slow plodding rhythms – ectopy.

  39. Matt 29 April, 2016 at 12:12 pm #

    PALPITATIONS & ASSOCIATED SYMPTOMS
    Associated symptoms – explore. When the palpitation occurs, how does the patient feel? Is there a sensation of pre-syncope or blackout? or nausea? or do they feel anxious? Do they occur only after a stimulant like coffee? Do they occur after heavy alcohol intake?

  40. Matt 29 April, 2016 at 12:13 pm #

    PALPITATIONS
    Family History is important. The family history of sudden arrhythmic death is important and should include the wider family. This should include any unexpected or unexplained deaths, such as drowning’s or RTA’s that may indicate a loss of consciousness

  41. Matt 29 April, 2016 at 12:14 pm #

    PALPITATIONS & ECG
    A 12 lead ECG is vital in this assessment. This has to be high quality with minimal base line movement or interference. If the automatic interpretation states it is normal, then this is reassuring, any other statement should be a reason for concern

  42. Matt 29 April, 2016 at 12:14 pm #

    PALPITATIONS & RHYTHM MONITORING
    Rhythm monitoring has limited value in managing palpitations. Risk assessment is more important than identification of the dysrhythmia. If the patient is at risk or very keen for the identification of the dysrhythmia referral rather than rhythm monitoring is recommended

  43. Anne 29 April, 2016 at 12:17 pm #

    CONTRACEPTION & UKMEC -UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) 2016
    Online only via http://www.fsrh.org

  44. Anne 29 April, 2016 at 12:17 pm #

    POSTNATAL CONTRACEPTION
    Progestogen-only methods (pill, injection or implant) can be started at any time – fertility may return by day 24 post-delivery.
    Combined hormonal methods are safe to use after 3 weeks in non-breast-feeding women provided they have no additional thrombotic risk factors and after 6 weeks in breast-feeding women.

  45. Anne 29 April, 2016 at 12:18 pm #

    CONTRACEPTION INTERACTIONS
    On-line drug interaction checker:
    http://reference.medscape.com/drug-interactionchecker
    HIV medications: http://www.hiv-druginteractions.org/interactions.aspx
    Intra-uterine contraception and depo-provera are the only reversible methods not affected by enzyme inducing medications.

  46. Anne 29 April, 2016 at 12:18 pm #

    CONTRACEPTION & RHEUMATIC DISEASES
    Women who are antiphospholipid antibody positive are at increased risk of CVD and VTE. All progestogen-only methods are safe to use, combined hormonal contraception must be avoided.

  47. Ram 10 June, 2016 at 11:30 am #

    DEMENTIA & CARERS
    Dementia causes a big strain on carers. Imagine seeing the person you love slowly fade, yet their physical body remains. It is incredibly hard and soul destroying. Carers can become stressed, depressed, anxious and suicidal. Many carers feel ashamed, guilty or embarassed about their own feelings and behaviours. Therefore, offer all carers a health check and remember to ask them about how they really feel – and help them with that. There are several carer support services out there – use them.

    http://www.dementiacarer.net
    http://www.ashcroftsurgery.co.uk/health-info/do-you-look-after-someone/

  48. Ram 10 June, 2016 at 11:36 am #

    MIGRAINE – easy peasy diagnosis

    The ID MIGRAINE TEST picks up 93% of migraine suffers (based on Lipton et al. [12])
    1. Over the last 3 months, have you limited your activities on at least 1 day because of your headaches?
    2. Do lights bother you when you have a headache?
    3. Do you get sick to your stomach or nauseated with your headache?

    Patients answering “yes” to at least two of these questions probably have migraine
    If patient has history of migraine and then gets a chronic headache treat as for chronic migraine

    Migraine attacks can be divided into four phases:
    • Prodrome
    • Aura
    • Headache symptoms
    • Postdrome

  49. Kay 10 June, 2016 at 11:41 am #

    CLUSTER HEADACHES – refer urgenty – they are called ‘suicide headaches’ for a reason.

    Presenting features include: Unilateral severe pain < 3 hours; patient agitated and pacing; prominent autonomic features.
    Usually causes a few attacks daily for several weeks and often a seasonal occurrence.

    http://ouchuk.org/home – great website for cluster headaches – but still refer urgently!

  50. Kay 10 June, 2016 at 11:42 am #

    MIGRAINE MANAGEMENT
    Acute medication is more powerful in combination: ANALGESIC + ANTIEMETIC + TRIPTAN works best (but warn not to use > 10 days / month to avoid getting medication overuse headache).

    Prophylaxis is best determined by patient factors eg co-morbidities and pregnancy risk. Approximately 50% respond to any prophylactic medication and a good response is 50% improvement. Keep expectations realistic and stop when better.

    ALWAYS include advice about fluids, regular food, exercise, stress management, smoking, sleep and trigger avoidance. Did you know that this often has greater benefit than any drugs! And of course, is cheaper, is without side-effects and promotes patient empowerment.

    https://www.migrainetrust.org/

  51. Ramesh 3 February, 2017 at 3:33 pm #

    ELDERLY THEIR KIDNEYS WHEN THEY ARE UNWELL
    Think in over 75s who
    (i) have an acute condition like infection or dehydration (stresses the kidney to fail)
    (ii) have been put on a new medication
    (iii) are vulnerable during the occaisional Summer heat waves we get (dehydration etc)

    WHAT TO DO WHEN THE ELDERLY ARE UNWELL
    Do a medication review and STOP/WITHOLD/AMEND/CONTINUE the following… (mnemonic SADMAN)
    S Sulphonylureas
    A ACE and ARB
    D Diuretics
    M Metformin
    A Aldosterone Antagonists
    N NSAIDs

    Also – Opioids, Metformin, Digoxin and Nitrofurantoin can accumulate quickly (because they are normally renally excreted). If worried, check U&E.

    1) Be clear how long to stop/ammend the medication and when to go back to usual doses.
    2) Set up Sick Day Rules – consider telling them to do this whenever patient very unwell in the future too. ” When Mr X is like this in the future, stop xxx for a minimum of 7 days and only re-introduce when he is definately looking better. If not, call us”
    3) Check out http://www.thinkkidneys.nhs.uk

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