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 illnesses57 million GP consultations/yr OR accounts for over an hour a day for every GPIn 90% of cases a prescription will be issued costing est £370 million/year
6 Question 1What is this?It is normal for the foreskin to be attached to the head of the penis until what age?1year3years5yearsCircumcision can be done on the NHS for religious and cultural reasons (true/false)
7 PhimosisForeskin is very tight and cannot be pulled back over the head of the penisNormally attached to the head of the penis until 5yrs and is still attached in 60% of 6-9yr oldsConsider referral if recurrent infections, ballooning, painful, poor streamConsider referral after 6 yrsIncidence of circumcision in the UK is 1/15 in boys under 15 yrsNot 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 capillariesNot present at birth1/20 babies develop them at few days/weeks of ageIncreased in femalesUsually stop growing at around 6/12 and begin to shrink and fadeUsually gone by 7yrsIf 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 conjunctivaUsually lasts <2weeksSymptoms – itch, swelling of the eyelid, purulent dischargeExclude red flags50% viral aetiologyDifficult to clinically distinguish viral and bacterial casesViral often occur with an URTI and may last couple of weeksBacterial usually last 2-5daysNo evidence of benefit in treatmentConsider treatment if prolonged (>2weeks) or severe symptomsAdvise on cleaning eyes/avoiding transmissionChloramphenicol is available OTC for people aged over 2yrs
12 Question 4 What is this rash? Is it contagious? How long does the rash typically lastUpto 2 weeksUpto 2 monthsUpto 18 months
13 Molluscum Contagiosum Pink or pearly white papules with central umbilication, upto 5mm diameterCaused by DNA virus of pox familyLesions can occur anywhere except palms of hands and soles of feet.Children – trunk, flexures, anogenitalAdults – sexual contact may cause lesions in thighs, pubis, genitals, lower abdoImmunocompromised (HIV, steroids) – atypical presentationSelf limiting, usually resolves by 18monthsInfectious, avoid sharing towels/bathsCan suggest trauma (by squeezing after bathing) or cryotherapy if appropriateIf 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? 6mths1year18mths of ageThere 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 subfertilityRetractile testicles – exaggerated cremasteric reflex, can be manipulated downBecome 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 lossReceding frontal hairlineThinning of hair at temples and crownHair follicles become over sensitive to dihydrotestosterone (DHT), it makes hair follicles shrinkRx optionsReassuranceFinasterideStops conversion of testosterone to DHT, takes 4/12 for effectSome regrowth in 2/3rds of menNot available on NHSMinoxidil lotion?how it worksSlows balding in 50%, 15% experience hair regrowth
18 Question 7Sore throats are self limiting and improve within a week without treatment in75%85%95%Consultation rates for sore throats are approximately1/10 patients per year1/20 patients per year1/40 patients per year
19 Sore throatIndependent of causative organism, self limiting and resolves in 7 days in 85% of patientsCentor 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 exudateTender ant cervical LN’sAbsence of coughHistory of feverIf unwell with ¾ of above risk of quinsy is 1:60, compared to 1:400 withoutPen V antibiotic of choice. Consider delayed prescriptionPeople who receive antibiotics are more likely to present in future with minor illnesses
20 Question 8In acute sinusitis there is evidence that decongestants help (true/false)In acute sinusitis antibiotics are of no benefit (true/false)
21 Acute SinusitisUsually occurs as secondary bacterial infection after a viral URTIOther causesallergic rhinitits, swimming, diving, high altitudes, dental infection, traumaSymptoms usually occurring a week after URTIpain on bending, maxillary pain, purulent rhinorrhoea, tooth painRed flagsUnilateral signs, bleeding, diplopia/proptosis, maxillary paraesthesia, orbital swelling, immunocompromisedFirst line treatmentParacetamol, brufen +/- codeineNo evidence decongestants helpIf persistent symptoms >2/52Nasal 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 antibioticsIf 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 olds1/60 lifetime risk, GPs can expect to see 1 case every 2-3 yrsCause used to be largely unknown, now thought predominantly due to herpes virusUsually LMN – affects muscles of one side of faceUMN – affects lower half of face, eye sparedLoss of taste anterior 2/3rds of tongueIf patient presents within first 72hrs of symptoms can give prednisolone 25mg bd for 10/7, otherwise no treatment85% recover fully within 9months
24 Bell’s Palsy – Differential Diagnoses Lyme disease – bilateral, tick exposure, rash, arthralgiaOtitis media – examine ears, otalgia, hearing lossRamsey Hunt – rash, prodrome of painSarcoidosis – if affecting parotid gland may be recurrent, usually bilateralGuillain-Barre Syndrome – usually bilateralHIV – bilateral + lymphadenopathyTumours – cholesteatoma, parotid gland tumour, primary/secondary brain tumoursMS – consider in a young patient if unilateral, painless and resolves in a few weeksStroke
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 moreup valuable time’ a pretext to a more demandingserious problem’ consultations’‘Patient takes noresponsibility for ‘Rather see than ‘Opportunity to alterillness’ miss an important health behaviour’illness’
27 Why do patients with minor illness consult rather than self care?
29 Patient FactorsDemographics e.g age (elderly),socioeconomic group,religionIllness itself i.e perceived threatHealth beliefs, poor educationPrevious experienceOther events in patients’ life e.g bereavement,work stress; (therefore not coping)Secondary gain prescription eg sick note
30 Society FactorsMedia 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 GPsSocietyDifferent cultures eg Asian & Eastern European may present moreCertain groups eg Refugees ( often because of the ‘hell’ they’ve endured)The ‘it’s free on the NHS’ society
31 Doctor FactorsAccess – greater the access, the more likely patients are likely to use/abuseDoctor 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 counsellingNot defining boundariesPrevious 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 AccessConsultation 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
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