Vaginal discharge is a common symptom; it may be either physiological or pathological. The most common cause of vaginal discharge is physiological, which is usually clear, non-offensive and non-pruritic. Pathological causes of vaginal discharge include infections, both non-sexually as well as sexually transmitted. It is imperative to assess these patients thoroughly for accurate diagnoses and appropriate management.
Reflective practice is the core competency required to retain a licence to practice under current medical revalidation regulations. The concept of reflection, however, is often misunderstood. Much of the confusion arises from context. In terms of professional regulation, doctors are considered safe when they demonstrate the ability to self-correct. Self-correction requires both reflection and action. In some contexts reflection without action is entirely appropriate, but in many professional contexts the quality of reflection is judged by the effectiveness of actions arising from it. This article explores the nature of reflective practice and its relationship to professional freedom and regulation.
Shoulder pain is commonly treated in general practice; its causes are often multi-factorial. The focus of this article is on sports-related shoulder injuries likely to be seen in the community. This article aims to overview the presentation, assessment and management of these conditions in general practice.
Asthma affects 1 100 000 children in the UK and is thus the most common long-term condition of childhood. The prevalence of childhood asthma symptoms in the UK is among the highest worldwide and this contributes to the estimated £1 billion annual cost of asthma care to the NHS. Children still die from asthma despite advances in its management, and mortality rates have changed very little over the past 20 years. The recent national review of asthma deaths provided a stark reminder of ‘why asthma still kills’ and made key recommendations for children with asthma. However, evidence-based recommendations are still poorly implemented. This article seeks to enthuse the next generation of GPs to prioritise the improvement of asthma care in children.
Clinicians have always personalised patient management. There is a growing momentum to improve this further through the integration of genomic information into clinical care. This will incorporate powerful new tools, through which clinicians can further tailor healthcare, improving disease prevention, prediction, diagnosis and treatment. This article aims to suggest ways in which this revolution in healthcare will affect GPs.
In our first article on an introduction to quality improvement we discussed the philosophy and principles of quality improvement, and our second article discussed the model for improvement. In this article we discuss measurement for improvement, and how it differs from research and audit. We explore the selection, and types, of measures before explaining how to understand and analyse variation in your data in order to answer the question ‘How do we know a change is an improvement?’ posed by the model for improvement.
Disorders of puberty are relatively common problems that affect young people and include precocious puberty and delayed puberty. The disorders of puberty may go unrecognised, as the signs and symptoms may be subtle, and the patient may be embarrassed to bring concerns to the attention of the GP. They are not only a source of significant emotional distress for young people, but also can also lead to long-term adverse consequences, such as failure to achieve target height. Disorders of puberty may also be a sign of a serious underlying condition, which if promptly diagnosed may be treatable. Therefore, early recognition of such disorders by GPs is vital for both the psychological and physical health of the patient. This article aims to give an overview of normal pubertal development, as well as the causes, diagnosis, and treatment of both precocious and delayed puberty.
Acute kidney injury is a clinical syndrome that has become increasingly recognised as a marker of severity of illness in the acutely sick patient. It can lead to, or worsen, chronic kidney disease, and as a result, increase cardiovascular risk. This article sets out the relevance of acute kidney injury for general practice, detailing the identification, management, follow-up and strategies for prevention.
Pelvic organ prolapse is the descent of one or more of the pelvic organs, (including the bladder, uterus and rectum) from their normal anatomical position into the vaginal canal in women. This is a result of failure of the fascial, muscular and ligamentous supports of the pelvic organs and is a common problem encountered in primary care. Pelvic organ prolapse can have a profound and significant impact on quality of life, and it is important for GPs to understand how to diagnose and manage women with this condition. The majority of women presenting with pelvic organ prolapse are suitable for initial management in a primary care setting.
Dealing with a medical emergency in an environment with limited life-saving resources is a frightening situation. Oncology emergencies can be especially challenging and life-threatening. Although these rarely present in primary care, they require specific urgent treatment, and therefore their recognition is important. This article intends to give an insight into diagnosis and management of oncology emergencies in a primary care setting.
Haematuria is the presence of red blood cells in the urine, it is classified into two types: visible and non-visible. Non-visible haematuria is considered significant if blood is detected in two-out-of-three urine samples taken 2 to 3 weeks apart. Common causes of haematuria in adults include urinary tract infection, exercise-induced haematuria, nephrological disease, bladder cancer and renal stones. Common causes of haematuria in children include hypercalciuria, IgA nephropathy and post-streptococcal glomerulonephritis. Patients with visible haematuria should be referred for investigation to exclude urological cancer. Patients with non-visible haematuria should have their blood pressure, urinary albumin-to-creatinine ratio and estimated glomerular filtration rate measured, to determine if they require onward referral to secondary care. The new National Institute for Health and Care Excellence guidelines for recognition and referral of suspected cancer identify those patients with haematuria that should be referred through the 2-week wait pathway.
Pain is described as the fifth vital sign, yet its importance is frequently not fully recognised, despite 68 000 000 analgesic prescriptions being dispensed annually. GPs treat pain in the context of a wide spectrum of patient conditions and co-morbidities, recognising potential drug interactions and side-effects. They also factor in the patient’s anxieties, coping strategies, cultural background and previous experiences of pain. It is no wonder that we frequently do not get it right first time. This article discusses the pharmacological action of the major groups of analgesic drugs, considers common pitfalls, and suggests appropriate drug dosing. A titrated multi-modal approach is recommended to target nociceptor pain pathways, and to reduce the side-effects caused by large doses of monotherapy. It discusses the novel use of analgesic agents previously only used for chronic pain. It does not, however, discuss acute-on-chronic pain, drug tolerance, drug addiction or complex pain management.
The prevalence of diabetes mellitus in all of its forms is increasing, but especially type 2 and gestational diabetes due to their association with obesity. Although many will be under the care of a multidisciplinary team, including obstetricians, diabetologists, specialist nurses and dieticians during pregnancy, primary care is the ideal setting for much of the essential pre-pregnancy care and ongoing postnatal support. This is a patient group that can be difficult to manage, especially if there are issues of non-concordance with treatment. The aim of this article is to provide an overview of diabetes in pregnancy, with particular focus on what the best care will look like in general practice. It begins with some background information and continues by looking at each stage of the pregnancy from pre-conceptual advice, through to postnatal and long-term care.
Globally, the incidence of diabetes has reached epidemic proportions. The cardiovascular complications from diabetes lead to significant morbidity and mortality. In this article, we will look at the impact of diabetes on health and healthcare, particularly that related to cardiovascular complications. We will also explore our current understanding of the strong links that exist between diabetes and cardiovascular disease (CVD) and the key role played by primary care physicians in helping patients with diabetes reduce their risk of future CVD.
Postmenopausal bleeding is a common presentation in primary care. There is great emphasis placed on rapid referral for investigation to exclude endometrial malignancy, and it is the most common symptom for which women are referred to gynaecological rapid access clinics. However, it is widely accepted that only approximately 10% of patients at a postmenopausal bleed clinic will have cancer. Endometrial cancer is now often easily treatable with laparoscopic surgery, and certain pre-malignant changes can be managed with an intrauterine system, so it is important to deal with this common presentation effectively, while also knowing about the frequent causes.
This article focuses on the end-stage of diabetic foot disease: Diabetic foot sepsis. The aetio-pathogenesis and clinical diagnosis of diabetic foot disease is discussed. The article explores the management of limb- and non-limb-threatening diabetic foot infections, and in particular, the importance of utilising the diabetic foot clinic and the specialist multi-disciplinary team to prevent high-risk patients from further foot deterioration. The importance of preventing the development of diabetic foot disease through screening and primary and secondary prevention strategies is also discussed.
Testicular cancer is a malignancy of the male testicles. In the developed world, the incidence of testicular cancer is increasing every year. Although several risk factors have been identified, the cause of testicular cancer remains unknown. Chemotherapy has revolutionised the treatment and prognosis of this cancer, giving it the highest cure rate for any solid tumour. This article aims to inform readers of the signs and symptoms of testicular cancer that may be encountered during a busy consultation, and the most effective way of referring a suspected malignancy to secondary care. It also discusses potential complications and sequelae of treatment, as well as the role of testicular self-examination in practice.
This article aims to describe a methodical approach to leg ulcer management in the primary care setting. The key information that is required from history and examination will be reviewed. The three main types of ulcers – venous, arterial and diabetic – will then be examined in more detail and the management of each will be discussed.
In our first article, ‘An introduction to quality improvement’, we discussed the philosophy and principles of quality improvement and suggested that a structured and systematic approach to quality improvement is necessary. In this article we discuss the Model for Improvement as a simple and effective framework to achieve this objective.
As medical treatments and technology advance, increasing numbers of patients are surviving more severe forms of critical illness. The negative medical, physical, psychological and social effects of critical illness and its treatment are often long lasting and not limited to the time the patient spends on the intensive care unit. The primary care management of this complex patient group is as important as the initial resuscitation and treatment in hospital. Carefully coordinated, multi-disciplinary team treatment and rehabilitation is required in order to reduce the morbidity of survivors and their carers.
‘You must take steps to monitor and improve the quality of your work’ and ‘you must take part in systems of quality assurance and quality improvement’ are statements taken from the General Medical Council’s guidelines in Good Medical Practice. The requirement to undertake quality improvement activities, as part of the revalidation process, is a regulatory driver to enhance quality improvement. The RCGP revalidation toolkit confirms that revalidation allows flexibility in the choice of quality improvement activity. However, moving from compliance to a commitment to quality improvement can be an empowering and fulfilling exercise that can improve patient safety, clinical care, the culture of an organisation, and the many processes and protocols that lead to a functioning GP surgery. In this, the first of three articles, we discuss the principles of quality improvement. The second article offers an overview and application of a simple model, the Model for Improvement. In the final article we will discuss the importance of measurement for improvement.
Skin rashes are among the most common reasons for a paediatric visit to a GP, often causing a good deal of anxiety and uncertainty among caregivers. This article provides descriptions of the numerous skin rashes that can affect children of different ages, as well as guidelines for managing a wide range of conditions.
Continuity of care is a core feature of general practice; it creates multiple benefits for patients, doctors and society. Continuity increases trust, patient satisfaction, disclosure of information, take-up of preventive care, adherence to advice, reduction in socio-economic disadvantage, and reduces deaths. However, the level of continuity is reducing in general practice. About 15 consultations are needed with a patient for a GP to acquire enough ‘accumulated knowledge’ to develop a sense of continuing responsibility. This fosters GP sensitivity and mutual understanding, which enable GPs to provide ‘higher-level’ quality of care. The RCGP curriculum states two high-level aims: that GPs need to ‘enhance continuity of care’ and ‘build long-term relationships with patients’. This article analyses these aims by setting them in the context of international research on continuity of care.
Autism represents a spectrum of disorders, Asperger’s syndrome being part of that spectrum. The increased awareness of autism in recent years has increased the likelihood of parents seeking help from their GP regarding their child’s behaviour. This article aims to cover some of the challenges encountered in the diagnosis and management of autism in children. Autism in adults provides particular challenges; however, they are not discussed in this article.
Depression is one of the most-common psychiatric diagnoses among children and adolescents. Depression in children presents in many ways and can include decreased self-esteem, reduced capacity for fun, irritable and low mood, social withdrawal, impaired relationship building and worsening school performance. If undiagnosed and untreated, it confers an increased risk of substance misuse and self-harm. An accurate diagnosis of a child suspected of having depression requires input from multiple sources, and relies on a comprehensive biopsychosocial assessment. Throughout the assessment and treatment process it is vital to remain vigilant for any child safeguarding issues. This article aims to describe the primary care assessment, diagnosis and management of this condition.
The amount of foreign travel undertaken by UK residents is increasing, and with it comes the risk of imported infections, some of which can be life-threatening. Fever is a common presenting complaint in the returned traveller; it may be an indication of a serious illness, however, more benign illnesses that are unrelated to travel often present with similar symptoms. Therefore, it is important to take a systematic approach to a fever occurring after international travel, in order to identify patients with potentially serious infections, whether imported or endemic, and to recognise those who may have an infection with ramifications for public health.
The year after a baby is born is an important time in the life of any woman, and an essential period in the social and emotional development of a child. A significant number of women suffer from postnatal depression, however, only a small proportion of sufferers are diagnosed, and fewer are treated appropriately. Inadequate treatment has a detrimental effect on mothers and their families, and may lead to long-term problems in their children. Mental health problems, including suicide, are a leading cause of maternal death. Women who die due to mental illness in the postnatal period often have complicated social and medical problems. GPs are in an ideal position to detect and diagnose postnatal depression, initiate treatment and ensure referral to specialist perinatal mental health services when needed. GPs should be aware of red flag signs for postnatal mental health problems, and be able to coordinate between different services to detect and support women at high risk of harm.
Ensuring that a woman has effective contraception that suits her preferences and comorbidities is important regardless of her age. Although a woman’s fertility decreases with age, particularly after 35, GPs need to provide contraceptive advice until the menopause, in order to prevent an unplanned pregnancy. This is particularly important due to the increased risks associated with pregnancy in older women, and the higher risk of fetal chromosomal abnormalities. This article will focus on the age-related issues specific to particular contraceptive methods, as well as how to determine the menopause and when contraception can safely be stopped.
The haemoglobinopathies are the most common monogenetic diseases in the world. They include the thalassaemias and sickle cell syndromes. The sickle cell syndromes encompass several abnormal haemoglobin variants, of which homozygosity for the sickle cell gene – that is, sickle cell anaemia is the most common and most severe. Originally characteristic of the tropics and subtropics, recent mobility and migratory trends have meant that the prevalence of sickle cell disease (SCD) has significantly increased in the UK. It is important that GPs have an understanding of this disease, in order to help their patients deal with complications of every-day life. This article will address three main aspects of SCD: diagnosis, health maintenance, and some acute and chronic complications of SCD.
Limited exposure to sexual health training, combined with a fear of having difficult conversations, may drive anxiety in dealing with patients’ sexual health concerns. This article focuses on how to assess a patient’s risk of sexually transmitted infections and deliver basic services for managing these infections safely in primary care. Sexual health delivery is changing, but a role for GPs is likely to continue.
A stroke is defined by the World Health Organization as a clinical syndrome of rapidly progressing symptoms of cerebral dysfunction, caused by cerebral infarction or haemorrhage, and lasting greater than 24 hours or leading to death. A transient ischaemic attack (TIA) is similar, but should be fully resolved in less than 24 hours, with the majority lasting less than 2 hours. This article discusses the role that primary care can play in the prevention, diagnosis and management of stroke and TIA.
Head lice (Pediculus capitis) infestations are very common globally. Although the majority of head lice infestations are asymptomatic, they can be difficult to treat. However, the involvement of the caregiver and adequate education about treatment strategies can result in successful treatment. Pediculosis is likely to become more common over the next few years, as resistance continues to develop to chemical treatments. This article describes some of the problems associated with head lice, as well as providing an overview of the treatment strategies involved, including medical options and practical tips for parents.
Primary liver tumours are the second-most-common cause of cancer death in men worldwide, and the sixth-most-common cause of death in women. Hepatocellular carcinoma (HCC) is the most-common primary liver tumour, and is responsible for around 1500 deaths per year in the UK. There is evidence that the incidence of HCC is rising and is likely a result of the hepatitis C virus epidemic. Emerging risk factors, such as obesity, may play an important role in the future, due to its increasing prevalence, particularly in the context of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. The second-most-common primary liver malignancy is cholangiocarcinoma, along with rarer types including fibrolamellar carcinoma, hepatoblastoma and mesenchymal cancers of the liver. Secondary (metastatic) tumours of the liver are more common than primary tumours. The most-common sites of the primary malignancy metastasising to the liver include breast, lung and colonic cancer.
Elder abuse is prevalent and, as the population ages, it is likely to be a growing problem. It frequently goes unrecognised, but is often devastating and sometimes fatal to the victim. It is considered to be both under-funded and under-researched, but early recognition of those at risk and intervention in the primary care setting can reduce harm and sometimes prevent elder abuse occurring entirely.
Despite 340 000 000 primary care consultations annually in the UK, most of the literature on patient safety has focused on hospital-based services. To improve safety in primary care settings, we must know what methods, tools and indicators are available to measure and monitor patient safety. In collaboration with patient safety experts at the University of Dundee, we were able to identify a number of existing tools, and many of these were adopted for use in the Patient Safety Toolkit.
Cognitive behavioural therapy (CBT) is a psychotherapeutic approach that addresses unhelpful cognitions and behaviours that result in distress. It has been shown to be effective in the management of anxiety disorders, depression, eating disorders, chronic pain syndromes and personality disorders. Although there is a clear need for CBT services, access to them remains limited. GPs cannot be expected to fill this gap, but specific CBT techniques can help in the management of common conditions. In this paper, we will discuss several CBT techniques that a clinician can apply in 10-minute consultations with a case study to espouse how the techniques can be implemented in clinical practice.
Tinnitus, the abnormal perception of sound in the absence of a real acoustic stimulus, is a common presenting complaint to primary care. Its effect on individual patients may range from trivial to debilitating. The purpose of this article is to describe an approach for use by the GP to tackle this often challenging symptom.
Attention-deficit hyperactivity disorder (ADHD) is one of the most-common psychiatric disorders; it is highly comorbid with many other psychiatric disorders and associated with substantial role impairment. Untreated ADHD results in psychiatric comorbidity, relationship and parenting problems, underachievement, frequent job losses, and opportunistic delinquency. Nevertheless, ADHD remains the most under-recognised and undertreated mental health condition in adults. This article discusses the clinical presentation of ADHD in adulthood with a particular focus on recognition, assessment and management of ADHD in adults in primary care.
This article is about how primary care health professionals can approach the problem of female genital mutilation (FGM) when it is encountered in everyday general practice. An introduction to FGM is given, in order to provide an overview that creates understanding and raises awareness. It is written through my perspective, as someone from an FGM-practicing community from the horn of Africa. I had the good fortune to be born into a family that did not practice FGM, but many millions were not so lucky and are living with its aftermath. It is often said that ‘prevention is better than cure’ and that cannot be more pertinent than in the case of FGM. As primary care health professionals, we find ourselves well-positioned to not only prevent future cases of FGM, but also provide support and assistance to those living with the trail of destruction it leaves behind.
Domestic abuse is a subject that is difficult to deal with for most people. Health professionals often lack confidence when approaching the subject, due to various reasons, such as lack of training, not knowing how to manage the situation or how to communicate with the survivor. However, it is vitally important that awareness is increased at an individual and practice level, so that more survivors can get the help, support and protection they need. This article aims to educate the reader about: what comes under the umbrella term ‘domestic abuse’; how it presents, particularly in general practice; how to break down barriers to disclosure; and what resources are available to help.
Arrhythmias are disturbances in normal cardiac electrical activity. They occur in structurally normal hearts, but are sometimes indications of underlying congenital or acquired abnormalities. Arrhythmia can be a mild or transient problem; however, the potential exists for severe life-threatening pathology - even death. It is important that primary care practitioners can recognise various arrhythmias and understand their management. The GP’s role in arrhythmia care ranges from primary diagnosis, through initiation of treatment or monitoring to long-term management of some conditions e.g. atrial fibrillation. Patients require advice about driving or employment, and occasionally the GP may act as a critical link in the ‘chain of survival’ when responding to a cardiac arrest. This article highlights the key findings that can be identified from history and examination, and how these can guide subsequent investigation and diagnosis. The features of common, major arrhythmias and their immediate and subsequent treatment are discussed.
Acoustic neuromas are benign, slow-growing tumours arising from the Schwann cells that surround the vestibular nerve in the internal acoustic meatus. Therefore, pathologically they are termed vestibular schwannomas. The tumour develops in the nerve sheath and exerts its effects mainly through compression of the nerve rather than invading it. As the tumour grows, it spreads beyond the bony internal acoustic meatus causing progressive compression of other cranial nerves and eventually of the brain itself. Early diagnosis of these tumours improves patient morbidity and mortality, as a wider range of management options can be offered. This article is intended as an overview of acoustic neuroma: covering its diagnosis, investigation and management.
The term, glaucoma, describes a group of conditions that are characterised by progressive optic nerve damage. Untreated glaucoma causes progressive visual field loss and eventually blindness. There are four main types: primary open angle glaucoma, acute angle closure glaucoma, secondary glaucoma, and congenital glaucoma. Primary open angle glaucoma is a common condition; it affects 2.1% of the UK population and is the second-most-common cause of blindness in the UK. Incidence and prevalence increase with age. Intraocular pressure is the only modifiable risk factor for progression of glaucoma; treatment to reduce intraocular pressure can prevent progression of optic nerve damage and preserve vision. Acute angle closure glaucoma is an ophthalmic emergency and prompt recognition and treatment of the condition is sight-saving. This article will discuss the aetiology, diagnosis and management of primary open angle and acute angle closure glaucoma, the role of GPs in supporting patients with glaucoma, and summarise the Driver and Vehicle Licensing Agency guidance relevant to these patients.
The introduction of contraception has significantly improved lifestyle choices for women. The majority of women go to their general practice for contraception, and therefore, GPs have an important role in helping to guide their decision-making. The progesterone-only implant is one of the four available long-acting methods of contraception; it works mainly by preventing ovulation. It is a small 40-mm rod that is implanted into the subdermal tissue in the upper arm, where it provides contraception for up to 3 years. It is both one of the most reliable methods of contraception and is more cost-effective than traditional methods.
Fibromyalgia is a musculoskeletal condition that is characterised by chronic widespread pain and a constellation of associated symptoms. Its exact presentation is very variable, and this can lead to diagnostic delay and frustration on the part of both the patient and the clinician. Although fibromyalgia is not a degenerative condition, it does often have a very significant impact on the quality of life of those affected. The focus of treatment is usually symptom control rather than cure. There are, however, a variety of different treatment approaches that can help, and it is important that GPs are aware of the range of options and are able to discuss strategies for improving symptoms with their patients.
Head size naturally differs between female and male infants, and it is age-dependent. The skull is filled with the brain, cerebrospinal fluid and vascular structures. The shape and size of the head is determined by the above components, as well as skull thickness, rate of the fusion of the cranial sutures, and the development of the frontal sinuses. This article aims to outline a best practice assessment of head circumference and discuss abnormalities that could be seen in general practice.
Leadership in healthcare has been prioritised in recent years, following the Francis report it is now actively promoted in post graduate training as being everyone’s responsibility. Leading grassroots innovation is a challenging task in a traditional organisational model. This article looks at how the rise in the use of social media to discuss professional issues has acted as a leveler, and how the NHS leadership model and social media can enhance personal leadership qualities and facilitate how all doctors can influence healthcare delivery.
With our days as busy as they are in general practice, it can be difficult to find time to think about some of the bigger issues of our age; and they do not come much bigger than climate change and the sustainability of our environment. The GP curriculum is made up of many parts; however, there are some overarching themes that can help us to make sense of what it means to be a GP. Margaret Chan, the Director General of the World Health Organisation, has described climate change as the biggest threat to health in the 21st century. However, the implications for health will run for far longer than this century alone.
Chronic pancreatitis is a challenging condition for a variety of reasons: it is relatively poorly understood, difficult to diagnose, complex to manage, and is associated with significant morbidity and mortality. The aim of this article is to outline the important aspects of this fibro-inflammatory disease, highlighting the difficulties and providing guidance regarding these problems.
Death and resulting bereavement are universal life events, to which grief is a natural response. An average practice has 20 patient deaths per full-time GP every year, each resulting in newly bereaved persons. Often patients consult GPs regarding this, but it remains an area where there is very limited formal training. The majority manage with support from family, friends or faith, but some patients will require more intensive input.
Even small deteriorations in vision can be worrying for patients, due to the huge impact it may have on their daily activities. When this change is severe, sudden and possibly accompanied with pain, this anxiety becomes considerably magnified. This article will cover some of the common causes of sudden loss of vision, how they can be diagnosed and subsequently managed.
The majority of the women in the UK who deliver a baby vaginally sustain perineal trauma that requires suturing. GPs are frequently consulted by women regarding perineal health after delivery, either with specific concerns or opportunistically at the 6–8 week routine postnatal check. The aim of this article is to explore the common presentations and underlying pathologies of postpartum perineal problems, their management in primary care and when to refer. We also aim to emphasise the need for a holistic approach and to consider where perineal problems fit into the broader picture of postnatal health.
Every year, approximately one-in-four patient consultations with a GP are to seek advice about a skin-related problem. Many of these problems are benign and require no treatment. Ninety percent can be managed in the primary care setting. There is a wide range of benign skin conditions and GPs have a critical role in their diagnosis and treatment. If a GP is unable to identify benign lesions, an inappropriate priority may be given to referrals of benign lesions at the expense of more serious disorders. The aim of this article is to provide the reader with an overview of the benign skin lesions that are commonly seen in primary care, and how to recognise features that warrant referral for more specialist management. This article also provides an outline on how benign skin lesions can be treated in primary care.
Meningitis and encephalitis are medical emergencies that can be difficult to recognise. Although rare, they carry considerable mortality and morbidity, particularly when diagnosis and treatment are delayed. Both are notifiable diseases. This article will summarise the best practice approach to assessment and management in primary care.
Cancers of the kidney may be primary or secondary in origin. The vast majority of primary cancers are renal cell carcinomas, diagnosed incidentally on abdominal imaging. Secondary tumours found in the kidney are evaluated and managed depending on other clinical findings, including extent of the original cancer. The common original sites of spread include breast, lung, skin and lymph. Surgery remains the only curative therapy for renal cancer, and longer-term prognosis remains poor. Cancer referrals and diagnosis are an important aspect to increased successful curative treatment. The aim of this article is to evaluate renal cancer and give an overview of the important aspects from prevalence through diagnosis and staging, to treatment and management.
Peptic ulcer disease (PUD) collectively refers to the ulceration of the mucosa of the stomach or duodenum. An ulcer is a breach in the epithelium that penetrates the muscularis mucosae. National hospital data show that 10% of patients having endoscopy have a peptic ulcer; 25% of patients have a serious complication such as bowel obstruction, haemorrhage, perforation or gastric outlet obstruction. There is also an increased risk of gastric malignancy. This article looks at the presentation, causes and management of PUD in general practice.
Acute soft tissue knee injuries are commonly associated with sports and young active people. It should not be forgotten that there are also significant injuries that affect the older and less-active age groups. Most patients with acute severe knee injuries present to Accident and Emergency Departments, soon after their injury. However, patients may present to primary care at any stage. Early identification of these injuries allows prompt diagnosis, counselling and appropriate rehabilitation to prevent prolonged morbidity, and secondary cartilaginous or meniscus damage. This article focuses on traumatic knee swelling caused by anterior cruciate ligament rupture, patellar dislocation and meniscus injury.
Iron-deficiency anaemia is the most common nutritional deficiency around the world. This article looks at the presentation, causes and management of a common and potentially serious condition in general practice.
The management of an unconscious patient is a medical emergency, requiring prompt assessment and the appropriate use of first aid and life support procedures. Whether confronted by an unconscious patient on a home visit, or when needing to assess a collapsed patient at the surgery, a clear and stepwise approach to management is an important skill that should be acquired by all GPs.
Patients presenting to primary care often complain about excessive bleeding. The symptom may represent a significant underlying diagnosis that requires urgent specialist referral and treatment, but more often it is less critical in nature and the challenge is to analyse the symptoms and isolate those that warrant further investigation. Here we explore the components of a good clinical history and examination, offer advice on interpreting laboratory tests, and explore case studies of the most important diagnoses.
Health literacy is the ability to absorb and use information relating to health. Low levels of health literacy are associated with higher levels of hospital admissions, emergency department attendances and reduced up-take of screening and vaccinations. Additionally, low health literacy is linked to poorer general health and increased mortality. All doctors, but especially GPs, need a clear and sensitive approach to assess and adapt for low health literacy in the consultation. As GPs play a vital role in health promotion, a good understanding of health literacy is essential. This article aims to improve knowledge, awareness and understanding of health literacy and suggests ideas for everyday practice.
Dyspepsia is a common symptom that affects 40% of the UK adult population each year. It is estimated that only 2% of these patients consult their GP. The combined cost to the NHS of prescription medications and endoscopies is roughly £600 million annually. The majority of patients with dyspepsia are managed in the community. This article aims to provide a management approach to those who can be safely treated in the community and to revise those features in the history and examination that suggest a more serious pathology, thereby enabling identification of those requiring secondary care input.
Frozen shoulder can be a painful, disabling and prolonged condition that is commonly managed in the primary care setting. It can either occur spontaneously without an obvious predisposing cause or be associated with a variety of local or systemic disorders. True frozen shoulder is a clinical diagnosis, which can be easily spotted in general practice. The aim of this article is to define the clinical features of frozen shoulder and how to distinguish it from other painful conditions that can affect the shoulder. The possible aetiology, clinical findings and management options are discussed.
Respiratory symptoms such as cough, wheeze and stridor frequently occur in children and may persist for a long time. Determining the underlying cause of these chronic symptoms can be difficult as they may be due to a series of unrelated respiratory infections occurring in close succession or there may be one discrete underlying infection or condition. A chronic cough can generate anxiety in both children and their carers and ignoring it could lead to diagnostic delay or progression of a serious underlying respiratory disease. Cough guidelines and clinical pathways for a chronic cough in children vary and are not evidence based, so decisions regarding the investigation and treatment of the child with a chronic cough need to be made on an individual basis. This article provides a structured approach to managing the presentation of a chronic cough in children in general practice.
One cannot fail to notice the media interest surrounding the emotive subject of assisted dying. Multiple, high profile cases, celebrity commentary and legal proceedings are underpinned by tragic personal stories involving individuals who find themselves in the unimaginable position of wanting to end their lives but being unable to do so without assistance. As GPs, patients may come to us to discuss the issue of assisted dying. We need to be prepared for these difficult consultations. This article will clarify the current legal position and explore possible changes that are being debated. Arguments on both sides of the debate will be outlined in order to help inform your answer to the question: would you participate?
Autistic spectrum disorders are life-long complex disorders that typically present in the first 3 years of life. This article focuses on promoting awareness of early signs and symptoms, as familiarity with them can facilitate timely recognition and referral of the child for expert management. Caring for an autistic child has a significant psychological impact on the well-being of parents and family, and the GP can be key in coordinating care, particularly at the time of transition from paediatric to adult services.
Neonatal blood spot testing is offered to all babies in the first week of life as part of the UK Newborn Screening Programme. A blood sample is taken from the heel and used to screen for phenylketonuria, congenital hypothyroidism, cystic fibrosis, sickle cell diseases and medium-chain acyl-CoA dehydrogenase deficiency. This article aims to discuss the principles of screening as applied to neonatal blood spot testing, the blood spot test and the conditions which screening aims to detect.
Cerebral palsy (CP) is the most common cause of physical disability in childhood. It is a non-progressive disorder of postural and motor dysfunction. This complex, lifelong condition impacts on both children and their families. Care of these children is therefore an important part of general practice. Not only must the GP correctly identify CP and coordinate multidisciplinary care, he or she is the key to ensuring a family-centred service is delivered and provide the important continuity in care during transition to adult services. This article aims to provide an overview of the knowledge base needed by the GP when faced with a child with CP and to promote a biopsychosocial approach to service delivery.