1. Amy Tatham & Freeda Bhatti
Minor Illness
Amy Tatham & Freeda Bhatti

2. Definition
‘Any condition which is self limiting and does not prevent the patient from carrying out their normal functions for more than a short period of time.’

3. Why is it important?
Around half of consultations in A&E and 20 – 40% of GP consultations are for minor illnesses
57 million GP consultations/yr OR accounts for over an hour a day for every GP
In 90% of cases a prescription will be issued costing est £370 million/year

4. Most common… Backache Eczema Sore throat/Ear pain Heartburn Rhinitis
Constipation
Migraine
Cough
UTI
Acne

5. Quiz TIme
Are you ready?

6. Question 1
What is this?
It is normal for the foreskin to be attached to the head of the penis until what age?
1year
3years
5years
Circumcision can be done on the NHS for religious and cultural reasons (true/false)

7. Phimosis
Foreskin is very tight and cannot be pulled back over the head of the penis
Normally attached to the head of the penis until 5yrs and is still attached in 60% of 6-9yr olds
Consider referral if recurrent infections, ballooning, painful, poor stream
Consider referral after 6 yrs
Incidence of circumcision in the UK is 1/15 in boys under 15 yrs
Not funded by NHS for religious/cultural reasons

8. Question 2 What is this? They are not present at birth (true/false)
They usually leave a small scar (true/false)

9. Strawberry Naevi/Capillary Haemangioma
Collection of raised capillaries
Not present at birth
1/20 babies develop them at few days/weeks of age
Increased in females
Usually stop growing at around 6/12 and begin to shrink and fade
Usually gone by 7yrs
If causing feeding/breathing/speech difficulties can be treated with laser/steroids

10. Question 3 What is this? What percentage are caused by viruses?
96%
72%
50%
Chloramphenicol is available OTC (true/false)

11. Acute Infective Conjunctivitis
Inflammation of the conjunctiva
Usually lasts <2weeks
Symptoms – itch, swelling of the eyelid, purulent discharge
Exclude red flags
50% viral aetiology
Difficult to clinically distinguish viral and bacterial cases
Viral often occur with an URTI and may last couple of weeks
Bacterial usually last 2-5days
No evidence of benefit in treatment
Consider treatment if prolonged (>2weeks) or severe symptoms
Advise on cleaning eyes/avoiding transmission
Chloramphenicol is available OTC for people aged over 2yrs

12. Question 4 What is this rash? Is it contagious?
How long does the rash typically last
Upto 2 weeks
Upto 2 months
Upto 18 months

13. Molluscum Contagiosum
Pink or pearly white papules with central umbilication, upto 5mm diameter
Caused by DNA virus of pox family
Lesions can occur anywhere except palms of hands and soles of feet.
Children – trunk, flexures, anogenital
Adults – sexual contact may cause lesions in thighs, pubis, genitals, lower abdo
Immunocompromised (HIV, steroids) – atypical presentation
Self limiting, usually resolves by 18months
Infectious, avoid sharing towels/baths
Can suggest trauma (by squeezing after bathing) or cryotherapy if appropriate
If unsightly or persistent other treatments include topical 0.5% podophllyotoxin or imiquimod 5% cream

14. Question 5 At what age should children be referred for orchidopexy?
6mths
1year
18mths of age
There is still an increased risk of cancer and subfertility after surgery (true/false)
Retractile testicles should fully descend by 3yrs of age (true/false)

15. Cryptorchidism Failure of testicular descent
Usually unilateral 80% (right 50%, left 30%), bilateral 20%
Increased in premature babies (20% incidence), compared to full term babies (2% incidence)
Increased risk of cancer and subfertility
Retractile testicles – exaggerated cremasteric reflex, can be manipulated down
Become less retractile with age, full descent may not occur until after puberty. No treatment required

16. Question 6 What do you notice about this man’s head?
Finasteride results in hair re-growth in a third of men (true/false)
Finasteride is not available on the NHS (true/false)

17. Male Pattern Baldness Hereditary Usually occurs in late 20’s-30’s
Set pattern of hair loss
Receding frontal hairline
Thinning of hair at temples and crown
Hair follicles become over sensitive to dihydrotestosterone (DHT), it makes hair follicles shrink
Rx options
Reassurance
Finasteride
Stops conversion of testosterone to DHT, takes 4/12 for effect
Some regrowth in 2/3rds of men
Not available on NHS
Minoxidil lotion
?how it works
Slows balding in 50%, 15% experience hair regrowth

18. Question 7
Sore throats are self limiting and improve within a week without treatment in
75%
85%
95%
Consultation rates for sore throats are approximately
1/10 patients per year
1/20 patients per year
1/40 patients per year

19. Sore throat
Independent of causative organism, self limiting and resolves in 7 days in 85% of patients
Centor guidelines can help you decide who needs antibiotics.
Patient’s unwell with tonsillitis who have ¾ of following are more at risk of infection with GpA β-haemolytic strep and complications:
Tonsillar exudate
Tender ant cervical LN’s
Absence of cough
History of fever
If unwell with ¾ of above risk of quinsy is 1:60, compared to 1:400 without
Pen V antibiotic of choice. Consider delayed prescription
People who receive antibiotics are more likely to present in future with minor illnesses

20. Question 8
In acute sinusitis there is evidence that decongestants help (true/false)
In acute sinusitis antibiotics are of no benefit (true/false)

21. Acute Sinusitis
Usually occurs as secondary bacterial infection after a viral URTI
Other causes
allergic rhinitits, swimming, diving, high altitudes, dental infection, trauma
Symptoms usually occurring a week after URTI
pain on bending, maxillary pain, purulent rhinorrhoea, tooth pain
Red flags
Unilateral signs, bleeding, diplopia/proptosis, maxillary paraesthesia, orbital swelling, immunocompromised
First line treatment
Paracetamol, brufen +/- codeine
No evidence decongestants help
If persistent symptoms >2/52
Nasal steroid may be of small benefit (73% vs 66%)
Antibiotics may be of small benefit 80% get better within 2/52 without treatment compared to 90% with antibiotics
If symptoms persist >12/52, red flags or frequent recurrent episodes – refer to ENT

22. Question 9 What is the diagnosis?
The herpes virus is thought to be the cause in the majority of cases (true/false)
Name some differential diagnoses

23. Bells Palsy Sudden onset facial paralysis, usually unilateral
Increase incidence in 15-45yr olds
1/60 lifetime risk, GPs can expect to see 1 case every 2-3 yrs
Cause used to be largely unknown, now thought predominantly due to herpes virus
Usually LMN – affects muscles of one side of face
UMN – affects lower half of face, eye spared
Loss of taste anterior 2/3rds of tongue
If patient presents within first 72hrs of symptoms can give prednisolone 25mg bd for 10/7, otherwise no treatment
85% recover fully within 9months

24. Bell’s Palsy – Differential Diagnoses
Lyme disease – bilateral, tick exposure, rash, arthralgia
Otitis media – examine ears, otalgia, hearing loss
Ramsey Hunt – rash, prodrome of pain
Sarcoidosis – if affecting parotid gland may be recurrent, usually bilateral
Guillain-Barre Syndrome – usually bilateral
HIV – bilateral + lymphadenopathy
Tumours – cholesteatoma, parotid gland tumour, primary/secondary brain tumours
MS – consider in a young patient if unilateral, painless and resolves in a few weeks
Stroke

25. How do patients consulting with minor illnesses make you feel?

26. Bad Ok Good
‘Frustration as they take ‘Can be used as ‘A break btwn more
up valuable time’ a pretext to a more demanding
serious problem’ consultations’
‘Patient takes no
responsibility for ‘Rather see than ‘Opportunity to alter
illness’ miss an important health behaviour’
illness’

27. Why do patients with minor illness consult rather than self care?

28. Health seeking behaviour

29. Patient Factors
Demographics e.g age (elderly),socioeconomic group,religion
Illness itself i.e perceived threat
Health beliefs, poor education
Previous experience
Other events in patients’ life e.g bereavement,work stress; (therefore not coping)
Secondary gain prescription eg sick note

30. Society Factors
Media e.g health stories like the Swine Flu, medicalisation of ‘normal’, Jade Goody effect (P.S. Were not saying they’re not justified
– Jade Goody effect resulted in a dramatic uptake for smears = good)
Government
- confusing on one hand keen to promote ‘self care’ e.g by increasing availability OTC medicines but also promote policies so patients have easier access to GPs
Society
Different cultures eg Asian & Eastern European may present more
Certain groups eg Refugees ( often because of the ‘hell’ they’ve endured)
The ‘it’s free on the NHS’ society

31. Doctor Factors
Access – greater the access, the more likely patients are likely to use/abuse
Doctor Behaviour in the Consultation – doctor may be too approachable encouraging people to drop in any time (“that dr won’t mind”)
Secondary gain – some doctors subconciously encourage minor illnesses (easy consultations, adds ‘relaxing’ time to their surgeries)
Ineffective opportunistic health education/self care counselling
Not defining boundaries
Previous doctor behaviour – eg someone who gave a patient abx for sore throat and thus they expect the same in the future

32. How can we as GPs encourage patients to self manage minor illness?

33. Consultation Behaviour
Access
Consultation Behaviour
- Chanign Our Attitude: not encouraging ‘simple’ consults
- Giving information, educating: pitching at the right level
- Prescribing (or not)
- Safety netting
- Doctors acting in a similar way eg no abx for sore throats