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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.
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.
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.
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.
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.
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.
PREGNANT & THE FLU JAB
Advise all pregnant women to have a flu jab.
Although uptake is often poor, IT DOES SAVE LIVES.
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.
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.
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).
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).
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.
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.
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,
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.
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!
EYE COMPLAINTS
Think about testing visual acuity. If visual acuity has gone off – something important is kicking off.
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):
https://www.bradfordvts.co.uk/wp-content/onlineresources/0002mrcgp/csa/red%20flags%20for%20the%20CSA.pdf
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)
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.
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.
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)
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.
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
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
EMOTIONAL WELL-BEING TOOLS
Whooley and GAD 2 screening tools
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
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.
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.
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.
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.
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
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
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.
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
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
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.
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.
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?
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
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
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
CONTRACEPTION & UKMEC -UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) 2016
Online only via http://www.fsrh.org
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.
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.
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.
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/
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
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!
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/
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