BMJ summaries from our GPSTs - keeping you up to date
2013 summary of BMJ key points (click)
2015 summary of BMJ key points (click)
2016 summary of BMJ key points (click)
2017 summary of BMJ key points (click)
Male infertility – Suboptimal semen contribute to nearly half of all couples presenting with infertility. Smoking, obesity and diabetes, recreational drugs and medications are common contributing factors. Ask about prior infections and surgery, sexual history as well as the ‘usual’ infertility questions. Examination should include secondary sexual characteristics, BMI and genital exam. Counsel re semen analysis which is the cornerstone investigation. If abnormal consider LH, FSH and 9am testosterone on a fasting sample. Azoospermia with normal hormones suggests obstructive or testicular cause. Address reversible factors and refer.
Chronic heart failure – NICE. BNP will guide the urgency of specialist review. FBC, TFT, Cr&Es, LFTs, BNP, ECG and possible spirometry and CXR would be usual baseline assessments. Reduced ejection fraction - offer ACE and betablocker. If intolerant of ACE or ARB consider hydralazine. Add spironolactone or eplerenone if still symptomatic. Use furosemide for symptomatic relief of fluid oververload. Cardiac re-hab and MDT support.
Specialists may replace ARB/ACE with Sacubitril-Valsartan, add in Ivrabradine (HR > 75) or digoxin.
Annual review. Manage co-morbidities, assess functional status and social support, medication optimisation, BP, Rhythm, ? fluid overload S&S, annual bloods, consider MDT review, consider palliative care.
NICE – Chronic pancreatitis. 80% of patient with chronic pancreatitis will develop Type3c diabetes. They are twice as likely to have poor control than patients with Type 2 diabetes. Half will be on insulin after 5 years from diagnosis of diabetes. Malabsorption is common and many will need Creon enzyme replacement with every meal or snack. Osteoporosis risk is significantly increased.
Offer 6 monthly Hba1c screening to identify the onset of diabetes and up to 2 yearly DEXA scans.
Hyperthyroidism - Graves accounts for 80%, in older adults toxic adenoma/multinodular goitre. Repeat initial TFTs and TRabs with FBC and LFTs (CRP if thyroiditis suspected). Don’t forget drugs e.g. Amiodarone or Lithium as a cause. If symptomatic and NO CI start betablockers for symptom control. If symptomatic (and transient disease unlikely) despite betablocker or if the patient has cardiac disease start Carmbimazole (not in pregnancy and speak with endocrinologist re dose) with check TFTs in 4 to 6 weeks and urgent endocrinology referral. Advise reliable contraception in women. Warn and document S&S of agranulocytosis and actions needed by the patient (risk 1 in 200). Advice re eye symptoms – ocular lubricants and OTC selenium100mcgtwice daily can help. Rx is 12 to 18 months using Block & Replace or Titration regimes. 50% relapse and need radio-iodine or surgery.
NICE guidance on Rheumatoid Arthritis - Refer urgently, if evidence of synovitis - small joints of hands or feet OR more than one joint is affected OR there has been a delay of 3 months in seeking medical advice from the onset of symptoms.
Disease activity is not just determined by inflammatory markers tools such as the DAS28 based on clinical symptoms and CRP are use to define remission, low disease activity or worse. A ‘treat to target strategy’ using DMARDs is employed with an aim of achieving remission or low disease activity.
1st line Rx are synthetic conventional DMARDs e.g. methotrexate, leflunomide and sulfasalazine with combination therapy if monotherapy fails. Hydroxychloroquine may be used first line for mild or palindromic disease.
Gout – Usually caused by underexcretion of uric acid. Other factors include drugs (low dose aspirin, diuretics and ciclosporin), renal impairment or excessive consumption of red meat or seafood, fructose sweetened drinks and alcohol (esp beer and spirits). First line treatments are NSAIDs +/_ PPI or colchicine (a low dose regime 0.5mg bd is often effective and has fewer side effects). Steroids are second line (Prednisolone 30mg a day for 5 days).
Consider urate lowering therapy for prevention in patients with; 2 or more attacks per year, the presence of tophi or urate arthropathy or renal impairment. Consider after the first attack if the patient is under 40 years or uric acid level is very high > 0.48. Target uric acid for ULT is < 0.3 and will often require an allopurinol dose > 300mg. Allopurinol slow (monthly, usually 100mg steps) uptitration should be covered by low dose colchicine 0.5mg a day or 0.5mg bd.
NAFLD - Non alcoholic fatty liver disease is common effecting 25% of adults in the UK (>70% of patients with obesity or type 2 diabetes). Usually identified on a raised ALT with negative liver screen bloods (Hep B&C, ferritin, liver autoantibody screen, immunoglobulins, alpha 1 antitrypsin, ceruloplasmin and coeliac screen) and an abnormal USS. Only a small minority of patients will go on to develop NASH (Non Alcoholic Steato-Hepatitis) or eventual cirrhosis but due to NAFLD prevalence this will represent a significant number of patients.
Use the ELF (Enhanced Liver Fibrosis test) blood test - > 10.5 refer and if < 10.5 repeat every three years. If the ELF blood test not available use the NAFLD fibrosis score which is based on ALT, AST, BMI, Platelet count and Albumin levels and age. If NAFLD score > 0.676 refer. When referred a second line test such as a FibroScan will be used to assess liver fibrosis.
NICE dementia guidelines – Avoid using MMSE, use the briefer 10 point Cognitive Screener. Reduce anticholinergic burden of regular drugs. Refer memory assessment service. Offer carer formal needs assessment and support. Alzheimer’s patients receive an anti-cholinergic for mild, moderate and severe disease with memantine being added for moderate and severe disease. Patients with Lewy body disease are offered donepezil and or rivastigmine. Patients should be offered group cognitive stimulation therapy and group reminiscence therapy. Don’t forget the value of OT interventions and support/respite for carers.
Antipsychotics may be used for agitation if it is causing the patient distress or putting others at risk. Lowest dose, for shortest period with regular 6 weekly review regards is it helping or should it be withdrawn?
Chronic pancreatitis – alcohol is not the cause in 70% of women and 40% of men. Smoking, obesity and long standing diabetes are risk factors. Often it is idiopathic. Diagnosis based on Hx. No diagnostic test. CT and more recently Endoscopic UltraSound (EUS) are useful. Over a period of 10 years many will develop pancreatic insufficiency. Pain management, pancreatic supplements (if insufficiency evident) and smoking & alcohol avoidance are the usual treatment.
Altitude illness – 10 to 20% of acclimatised people will suffer when ascending to 2500 - 3000 feet above sea level. Usually headaches, nausea, insomnia and soboe. Acetazolamide can help prevent altitude illness. Wilderness Medicine Society Guidelines 2014 mean GPs can prescribe it on a private script (125mg bd) for those deemed at moderate or high risk. It is contraindicated in a number of medical conditions e.g. renal and hepatic impairment. Don’t forget the basics - > 2l of fluid a day and no alcohol helps with altitude illness. Ascents should be no more than 500m a day (once above 2500m) with a rest day every third day. Descending just 300 to 500m often improves symptoms.
Orofacial pain Rx
Cluster headaches – High flow oxygen or sc tryptans
TMJ disorder – Simple analgesia, relaxation techniques, neuropathic drugs, joint injections/operation.
Tension headache – acute rx paracetamol and ibuprofen. Chronic Rx Accupuncture, TCAs e.g. amitriptyline
Migraines – Acute Rx Ibuprofen, aspirin, paracetamol or tryptans . Preventative Rx – Propranolol, Topirimate, Candesartan, TCAs and Flunarizine.
Midfacial segment pain – Rx = low dose amitriptyline. A condition often confused with chronic sinusitis but there is no change in smell and often the patient has forehead, periorbital or maxillary tenderness.
Sinusitis – good pointers to diagnosis = Pain worse on lying down. reduced smell, offensive nasal discharge NB facial tenderness and pain worse on bending over are POOR pointers to the diagnosis.
Bath emollients for children with eczema – do not add any advantage to standard treatment i.e. soap avoidance, leave-on emollients and prn topical steroids.
Femoroacetabular impingement – Causes anterior groin pain, sharp or pinching or deep seated. Pain while driving is very common. As it progresses they can have pain with walking, standing and sitting. Patient may feel catching in the hip when getting in and out of a car. The Flexion-Adduction-Internal rotation test is a good screening test. Typical effects people in their 30s and 40s. A-P pelvic X-ray is the first line investigation. Treatment is steroid injection or arthroscopic surgery.
Posterior circulation stroke – accounts for 20% of ischaemic strokes. A third are not diagnosed in A&E. Prompt diagnosis matters as secondary cerebral oedema can lead to brainstem compression. Sudden onset variety of symptoms depending on which territory is effected. They may have headache! Vertigo, disequilibrium, slurred speech, unsteady gate, diplopia and parathesia are all potential symptoms. Red flags – sudden onset of vertigo or disequilibrium with one or more post circulation symptoms. Sudden onset vertigo with normal HINTs examination Head Impulse Nystagmus Test of Skew. https://www.youtube.com/watch?v=1q-VTKPweuk
Lyme disease – Bacterial infection transmitted by tick bite. Can occur anywhere in the UK but note most tick bites do not lead to Lyme disease. The original tick bite may have not been noticed at the time. Consider in patients with erythema migrans (bulls eye like rash, not itchy or sore and lasts 1 to 4 weeks), fever, sweats, malaise, fatigue, fleeting joint pains, parathesia or headache. Send blood for serology. Rarely, there can be ocular or cardiac complications. A 21 days course of doxycycline is the usual choice of treatment. Symptoms may take months or years to resolve.
Telephone consultation tips. Identify with whom you are talking. Be aware of implications of third party consultations. Initially use open questions, a cue led approach (tone, content, emotive language etc), empathy and support are important, social impact and social support may also be very important (able to shop, cook, dress, wash and toilet etc). Explore ICE. Focussed questions and red flags. Don’t forget indirect physical examination – capillary return, pulse rate, parent may have a thermometer, breathing rate, range of movement, nature of a rash, neck stiffness, glass test, wet mouth, consider use of phone torch for parent to look in back of throat. Explanation of what you think is going on which make sense of the symptoms and management options, shared decision making, make sure they have understood the plan and robust safety netting and documentation.
Dyslipidaemia – Risk assessment tools do not apply in Type 1 DM, CKD, suspected familial hyperlipidaemia or patient with existing CVD. Fasting no longer required unless triglycerides > 4.5.
Use Atovastatin 20mg for primary prevention, with an aim of achieving 40% reduction in non HDL cholesterol. Muscle symptoms occur in about 10% of users – consider a statin holiday for 1 month and re-introduce, if recurs? try lower dose or alternative statin.
Familial hyperlipidaemia, autosomal dominant, untreated 50 % of men by 50 and 30% of women by 60 would have CVD. Suspect if FH of premature CVD and Cholesterol > 7.5 or LDL > 4.9. Use Simon Broome criteria.
Reduced foetal movements – Most women become aware of foetal movements around 18 to 20 weeks gestation. They increase in number up to 32 weeks gestation before reaching a plateau. They do not decrease in late pregnancy or prior to labour. They are more frequent later in the day and will be absent during foetal sleep cycles of 20 to 40 mins. A woman is said to have reduce foetal movements when there has been a change or reduction in the baby’s normal pattern of movements. 15% of women will experience reduced foetal movements in their pregnancy. Refer urgently (same day) to the maternity assessment unit. Of those 70% will have a normal outcome of pregnancy. Factors associated with increased risk are: maternal smoking, hypertension, pre-eclampsia, diabetes, high BMI, reduced movements for over 24 hours or prior episodes of reduced movements within this pregnancy.
Dealing with nightshifts and sleep. Day of first shift – Sleep until waking naturally in the morning (no alarm), avoid a morning coffee and have a 90 mins nap to complete 1 sleep cycle between 2 and 6 pm. During the night shift, try to stay active, eat lightly and to comfort, in the last few hours avoid nicotine or caffeine and try to avoid bright light exposure. Be extra careful on going home, as the risk of near miss or accidentis increased. Get to sleep as early as possible and accept that any sleep, even fragmented sleep, is better than none.
Resetting after night shifts – attempt 90 to 180 mins nap after the last shift. Then be active, preferably going outside after walking, avoid further daytime naps and go to bed at the normal time.
Abdominal migraine management (children) – Explanation and avoid known triggers e.g. sleep loss, stress or missed meals. Acute management – rest in a darkened room, simple analgesia and/or an intranasal triptan. Preventative therapy – Pizotifen (can be used in primary care) or specialist initiated Propranolol, Flunarazine or the antihistamine Cyproheptadine or Valproate.
DVT – Common, presenting with pain, swelling, redness oedema and often a throbbing pain which is worse with weight bearing and walking. Use Wells score to assess probability. Score <2 (unlikely) so do a d-dimer (same day). If normal DVT unlikely. Wells score has a high negative predictive value. If raised for lower limb USS (same day). If Wells score >1 then patient needs same day lower limb USS. If USS not available within 4 hours of presentation anticoagulation should be initiated pending the outcome of the test. DOACs are first line treatment. Rivaroxiban and Apixiban do not need initial treatment with low molecular weight heparin (unlike Dabigatran). There is no evidence that compression stockings help prevent post thrombotic limb syndrome.
Additional investigation of unprovoked DVT – low yield from screening for occult malignancy, so no longer part of NICE guidance
NB D-dimer can be raised in infection, pregnancy, renal impairment and malignancy.
Migraine in pregnancy – Prochlorperazine, cyclizine and ondasetron are safe in pregnancy. You can use ibuprofen (BUT NOT IN THE LAST TRIMESTER). Paracetamol is the analgesic of choice.
Prophylaxis – Aspirin 75mg a day is effective and can be used up to 36 weeks in pregnancy. Low dose propranolol (10 to 40mg tds) can be used as can low dose amitriptyline.
Advice – drink 2l of water a day, avoid caffeine, , good sleep hygeine, regular exercise and avoid skipping meals.
Antibiotics after small abscess I&D – Trimethoprim or clindamycin in addition to I&D improves short term cure rates reducing pain and recurrence rates and should be used.
Post Laparoscopy – total resorption of subcuticular sutures takes 40 to 120 days. Patients with adhesive dressing should avoid soaking the dressing, they usually fall off after a few days, there is no need to replace them. A degree of wound edge separation is normal. Heavy lifting to be avoided for 1 to 2 weeks but longer may be needed after bigger procedures. Post appendicectomy or cholecystectomy – driving safely is usually possible after 1 to 2 weeks (but longer after inguinal hernia surgery) and return to work is usually after 1 to 2 weeks. Flying is safe after 24 hours
Peripheral Vascular Disease – Does this patient have PVD?
- Do they have a classical history of IC?
- Do they have impalpable or reduced peripheral pulses?
- Is their ABPI <0.9
NB Inspection – other than looking for ulcers is of little value
Does this patient have risk factors for PVD?
- Check smoking status, BP, and examine for AAA
- Investigation - ECG, FBC, HbA1c and non fasting lipid profile, Cr&Es, and ALT (need statins).
Urgent referral to vascular surgery is very rarely required - needed if they have rest pain or ABPI < 0.5 or diabetic foot ulcer
Routine referral to vascular surgery is rarely required - The most effective therapy is walking for more than thirty minutes, at least three times a week, to near maximal pain, for at least six months.
Eosinophilic oesophagitis, commoner than you might think – More common in Caucasian men, prevalence of 0.5 to 1%! Causes reflux like symptoms, dysmotility, chest pain and dysphagia. Diagnosis on history, appearance and bx at endoscopy. It is due to chronic allergen driven immune mediated disease. Treatment with ppi, food elimination diets (empirical food elimination with sequential re-introduction) and topical steroids e.g. oral budesonide.
Fever in the returning traveller – Most are self limiting illnesses but up to 6% will require admission to hospital (Malaria being the commonest). Immigrants returning from visiting family and friends are high risk accounting for 70% of malaria cases and 90% of enteric fevers. Common significant illness – Falciparum malaria from sub-Saharan Africa, Rickettsial illness from S Africa, Dengue from SE Asia, Latin America and the Caribbean, Enteric fever and malaria from S Asia. 2/3of patients with significant illness will present within 6 weeks of travel but P vivax malaria may present within the first 12 months of travel.
E-cigarettes – 40% of people who try to stop smoking do so with the aid of e-cigarettes. The ASPIRE trial suggests they are as effective as conventional nrt. There is a risk of converting cigarette addiction to nicotine addiction but current evidence suggests the benefits far outweigh the harms of smoking. Half of people using e-cigs to stop smoking are no longer using e-cigs after 6 months. Quit rates with e-cigs vary from 12.5% to 50% but the most trials have not been double blinded randomised trials. Smokers with asthma or COPD generally show symptom improvement with a switch to e-cigs. There is no long term evidence available regards potential harms.
Chronic limb threatening ischaemia, easily missed – The red ‘sunset foot’ of chronic ischaemia can easily be mistaken for gout or cellulitis or inflammatory arthritis. The ‘sunset foot’ is due to reactive hyperaemia and is seen when the legs are dependant (patient sitting down). Unlike gout, cellulitis etc if you lie the patient down and raise the leg the red sunset foot disappears – Buerger’s test. So all patients with suspected chronic limb ischaemia should be examined lying down! Also be aware that ABPIs may be falsely normal due to arterial calcification.
Acute rotator cuff tears following injury – Often missed, especially if the clinician assumes that if the patient was seen in A&E and discharged that they do not have a significant shoulder injury!
Red flags – recent trauma, pain from the shoulder or lateral aspect of the arm, inability to abduct the shoulder above 90 degrees.
Clinical utility of other clinical tests/physical examination for acute rotator cuff tear are limited! Do check for regimental badge parathesia (axillary nerve damage) and any evidence of cx spine injury.
Same day plain X-ray to exclude bony injury. If patient have persistent symptoms two weeks post injury then urgent MSK referral is indicated (where they may have urgent USS or MRI) with a view to early surgical intervention which improve outcomes.
NB – all patient with a history of shoulder dislocation should be urgently reviewed in shoulder clinic as rotator cuff tear is very likely