Amy Tatham & Freeda Bhatti Minor Illness Amy Tatham & Freeda Bhatti

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.’

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

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

Quiz TIme Are you ready?

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)

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

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

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

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

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

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

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

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)

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

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)

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

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

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

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

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

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

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

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

How do patients consulting with minor illnesses make you feel?

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’

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

Health seeking behaviour

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

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

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

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

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