Double Vision - Uniocular Double Vision Is Benign and Usually Due to Refractive Problems

Nov 21st

Double vision - uniocular double vision is benign and usually due to refractive problems.

Vertical binocular diplopia - think thyroid eye disease and fourth nerve palsies

Horizontal binocular diplopia - think MS and VI nerve palsies

Binocular double vision +

1. Scalp tenderness, headache, PMR symptoms etc - think TA.

2. Symptoms worse at night, fatigability and intermittent diplopia - think Myasthenia

3. Sudden onset - vascular compression or ischaemic event

Red flags - New onset headache, unilateral pupil dilatation, proptosis, ptosis and papiloedema

Nov 14th

NICE on the menopause - Average age in UK is now 51, premature menopause = < 40 years. Intrusive symptoms are usually present on average for 4 years. Severe symptoms effect 20% of women.

FSH should only be used as a test for menopause in women aged < 46 years with menopausal symptoms - beware cocp or high dose progesterone will produce false negatives.

Vasomotor symptom Rx - Offer HRT for up to 5 years first line. SSRIs and Clonidine should not be offered first line. Black Cohosh may help.

Low mood of menopause - Offer HRT, CBT

Urogenital atrophy - Offer topical vaginal oestrogen for as long as symptoms need to be relieved. Offer vaginal lubricant in isolation or in addition to topical HRT.

Re HRT start - warn bleeding in first 3 months is common but invx indicated if occurs after 3 months.

Re HRT stop - No difference between sudden cessation or dose tapering.

Risks -

Oral HRT increase VTE risk but transdermal does not.

Oral HRT additional VTE risk is 10 per 1000 women over 5 years

Consider transdermal in women at increased risk of VTE or BMI > 30.

Oestrogen alone is not associated with increased breast cancer BUT oestrogen with progesterone is. Risk returns to base line after Rx cessation.

Oestrogen & progesterone HRT - breast cancer risk is 5 per 1000 women over 7.5 years

1 HRT does not increase CVD risk if started before the age of 60

HRT does not increase DM risk

Nov 7th

Patellofemoral pain - Clarke's test is of little use. Use the 'squat test' with back straight, to see if the pain is reproduced - 80% sensitivity. No role for X-ray. Rx = Physio and shoe orthotics and takes 6 to 12 weeks for symptoms to improve.

Oct 31st

IGR - If lifestyle fails to reduce Hba1c try a six month trial of Metformin. It reduces progression to diabetes by 25%. Stop the Metformin if at the end of the 6 month trial the Hba1c has not dropped.

Consider a trial of Orlistat in patients with a BMI > 28 in patients who have been unable to loose weight. Consider Rx cessation after 12 weeks if weights has not fallen by 5%.

NICE recommend bariatric surgery for severely obese patients

Oct 24th

ACS - O2 only if Pox <94%, aspirin 300mg, analgesia & admit

STEMI presenting within 12 hours of onset of symptoms should have reperfusion treatment within 120mins of arrival in hospital. If thisis not possible they should have fibrinolytic treatment e.g. alteplase.

NSTEMI need cardiac catheterisation within 72 hours of arrival in hospital

Interestingly 12 months of aspirin & clopidogrel is now being replaced by aspirin and 12 months of P2 Y12 inhibitors e.g. Ticagrelor.

Troponin levels are taken at presentation and 6-9 hours later.

Normal tropinin levels, ECG and atypical cardiac pain can be sent home from A&E

Hyperkalaemia: Mild 5.4-6.0mmol/l, moderate 6.1- 6.5 and severe > 6.5

Moderate to severe = admission by ambulance

ECG required in moderate to severe hyperkalaemia ('Tented' tall and narrow T waves > 10mm in precordial leads and > 5mm in the chest leads, widening QRS and PR prolongation)

Usual causes: AKI, CKD, DKA, medication e.g. ARBs or ACE in presence of volume depletion

Achilles tendon rupture

2 Beware - they still will be able to plantarflex against resistance and walk on tip toes because other plantar flexors are intact!

Simmond's triad applies to a patient lying pronewith their feet dangling over the couch: palpable gap in the tendon, reduced plantarflexion with the squeeze test and when lying prone and relaxed the affected foot is more dorsiflexed compared to the other.

DVT is more common post achilles rupture

20% of cases are missed by non specialists

Oct 10th

Contraception an HRT after VTE

Never use cocp or Depot Provera

HRT = Transdermal oestrogen with oral Provera or Duphaston or Mirena

Re cocp - VTE risks greatest with triphasic cocp!

VTE risk and stopping menstruation - use Provera 10mg tds in preference to Norethisterone.

Oct 3rd

Calcium supplements: There is no evidence of advantage to eating calcium rich foods.

There is no evidence of fracture risk reduction with calcium and vitamin D supplements (except for institutionalised patients > 80 with prior hypocalcaemia and significant vit D deficiency)

Parkinson's disease: Non motor symptoms are common; sleep disorder, bladder and bowels problems, fatigue and dementia. If anti-psychotics needed use clozapine or quetiapine

First line treatments are:

Levodopa (a dopamine precursor) is considered in all patients, except the young. Especially useful in patients with serious motor impairment. It has greater motor benefits than any other drug and fewer neuro-psychiatric effects. Watch out for hypotension, impulsivity as a side effect and after 5 years on/off phenomena and dyskineasias.

Dopamine agonists: Non ergot derived e.g. Pramipexole, and ropinerole and ergot derived e.g. Cabergoline, bromocryptine and pergolide

MOA inhibitors e.g. Rasageline and Selegiline - DO NOT prescribe SSRIs or TCAs alongside these drugs (Trazadone can be used). Do not prescribe opiates due to risk of hyperpyrexia. Avoid abrupt withdrawal.

September 26th - Bisphosphonates

3 Bind to the bone mineral surface and inhibit bone resorption by osteoclasts. This improves bone mass and the micro-architecture of bone. They persist in bone long after treatment stops having a therapeutic effect.

The risk of GI side effects can be reduced with proper drug administering (appropriate water quantity and post dose positioning).

Osteonecrosis of the jaw is rare. Risk increases with treatment over 3 years, dental extractions or oral bone surgery.

Atypical femur fractures are very rare,

Bisphosphonates are usually contraindicated in eGFR falling below 30-35.

Only evidence for benefit is in patients with fragility fracture or BMD worse than -2.5

Identifying patients for DEXA scan - use FRAX (in the > 50s) but the threshold for requesting a DEXA scan changes with age so you must look at the graph!

Resedronate is approved for the prevention and treatment of postmenopausal osteoporosis and in men. Also it is approved for prevention and Rx of steroid related treatment.

When to change rx away from oral bisphosphonates

1. Two or more fragility fractures on rx.

2. Worsening Dexa T score after 3 years of rx.

When to consider a 3 year drug holiday

1. After 5 years of Rx and improved repeat Dexa T scores and a repeat Dexa T score better than -2.5

September 19th - Facial nerve palsy

In addition to facial palsy (forehead and lower face) the patient may suffer drooling, dry eyes, hyperacusis and altered taste. Remember the facial nerve provide sensory information for the anterior 2/3 of the tongue, parasympathetic supply to the lacrimal and submandibular glands and motor supply to stapedius)

Refer all children with Bell's Palsy as 50% will have underlying pathology

Underlying pathology: UMN pathology, Viral (Zoster), Acoustic neuroma, Parotid malignancy, Malignant otitis externa, Lyme's disease, temporal bone fracture, regional malignancy

Examine ears, mastoid, oropharynx, parotid and the scalp to exclude underlying pathology

4 Rx - eye care, Oral prednisolone 25mg bd for 10 days if started within 72 hours of onset of symptoms. Only use antivirals if Ramsay Hunt syndrome is suspected

If untreated 7/10 make a complete recovery over 3 to 5 months

If treated 8/10 make a complete recovery over 3 to 5 months

If incomplete eye closure refer ophthalmology

Useful link to a video from facialpalsey.org regards how to tape the eyes shut.

Use eye drops 2 hourly and lacrilube at night

September 12th - Coeliac Disease

NICE guidance summary on coeliac disease

Prevalence 1%

Usual symptoms: 80% Fatigue, 80% diarrhoea, 80% folate deficiency, 15% Vit D deficiency

More common in patients with a Hx of autoimmune thyroid disease or Type 1 DM

More common if they have a first degree relative with Down's Syndrome or Coeliac disease

Screening test = TTG antibodies, refer if +ve and advice them not to switch to a gluten free diet until investigated by the consultant

The guidance, however, was not specific about what to do at annual review, as many coeliac patients are no longer under hospital review.

This triggered me to look up the advice from BSG and Coeliac UK regards annual reviews by GP

1. Review dietary compliance

2. Check for symptoms of relapse: fatigue, diarrhoea, wt loss

3. Ht & wt and bloods (TTG abs, FBC, B12, Folate, Ferritin, Adj calcium)

4. Consider need for DEXA scanning

I also went on the coeliac uk website to review glute free product prescribing and the concept of units for gluten free prescibing and the units/age advice

September 5th - NICE Type 1 DM

Target Hba1c in adult is 48 mmol/l

5 Target BS 5-7 mmol/l before breakfast, 4-7 mmol/l before other meal times and if post prandial testing 5-9 mmol at 90 mins after meals

Hba1c measurement every 3 to 6 months

HBGM 4 to 10 x a day

All type 1 patients should be offered a basal bolus regime

Patients > 50 or with BMIs > 25 may still present with Type 1 DM

Beware LADA

Consider auto-ab testing (Insulin auto antibodies IAAs and anti-GAD antibodies) or C -peptide measurement if late onset Type 1 considered

August 22 - Febrile convulsion

Occurs between 6 months to 6 years

Common - 1 in 30 children

More common (1 in 5 ) if a sibling has febrile convulsions

I in 40 children with febrile convulsions will go on to develop epilepsy

If Temp < 38.8 febrile convulsion is unlikely to be the diagnosis

Duration < 5 mins with generalise tonic-clonic features

No/mild (sleepy) post-ictal phase lasting < 1 hour

I/3 will have febrile convulsions in the future

If prone to recurrent febrile convulsions buccal midazolam can be given by parents if the tonic-clonic component lasts more than 5 mins.

Use of paracetamol or ibuprofen in febrile illness does not decrease the risk

August 8th - A raised ferritin

Low ferritin levels provide absolute evidence of iron deficiency

Raised ferritin levels may be due to

 Iron overload: oral supplements, repeated iv infusion, multiple transfusions, haemotchomocytosis

Haemochromatosis is common (autosomal recessive with variable penetration).

6  Non iron overload: Acute or chronic inflammatory disorders, liver disease, alcohol excess, malignancy, renal failure and metabolic syndrome.

Iron overload vs non iron overload can be differentiated by using FASTING transferrin level

Invx of a raised ferriting = Cr&Es, LFTs, gamma GT, fasting BS/HBa1c, lipids and CRP CRP & BP check

Ferritin > 1000 = refer regardless of cause.

Raised transferrin and ferritin = refer

Ferritin 300 - 1000 and normal other ivx = lifstyle changes with check blood after 3 months

August 1st - ear wax removal

Some evidence wax softners help

Dont' syringe an ear if the person is deaf in the other one, as irrigation can cause TM damage and hearing loss

Don't syringe if patients have a hx of ear surgery or ear pathology

Management of sharp injuries (health care worker)

Gently encourage bleeding from the puncture site and wash the area with soap and water and do not scrub the site or use antiseptics. Cover with an impermeable dressing.

High risk sharp injury - Deep injury, sharp had been use for intravascular, recently used sharp, visible blood on sharps

Low risk - Superficial injury e.g. scratch, needle used for suturing or sc injection, old/discarded sharp, and blood not visible on sharps

If source patient unknown (bloods stored Day 0, 3 months and 6 months)

? client base high risk, if so then immediate HIV prophylaxis (liaise with GUM)

If hep B immune consider Hep B booster at time of injury

Hep C is usually tested at 3 months post exposure

July 18th - Paracetamol

Paracetamol: Good for dental pain, headache and probably no benefit for knee or hip pain

Increased risk of GI haemorrhage when used alongside nsaids or antideps!

Nsaids and antideps: Increased risk of intracranial haemorrhage as well as the well known GI risks

7 July 11th- Antivirals for Herpes Simplex

Aciclovir reduces severity of symptoms, duration of illness and shedding of virus

Suppressive Rx is indicated if a patient has 4 or more attacks a year, if less than 4 then ? home supply for prompt Rx of relapse

Topical rx does not work

Beware high dose aciclovir in patients with renal impairment

July 4th - NICE - suspected cancer & symptoms

NICE - suspected cancer guidance- very useful flow charts based on symptoms

Change in bowel habit > 60 years = 2ww

Chane in bowel habit with rectal bleeding > 50years = 2ww

Patients who do not meet the 2ww criteria for lower GI but you wish to refer - consider an FOB test (e.g. change in bowel habit in the < 60s) as that may convert to a 2ww referral.

Breast lump in women > 30 years or nipple changes > 50 years = 2ww referral

Breast lump < 30 years - breast clinic (non 2ww referral)

Haemoptysis in > 40 years = 2ww referral

Persistent hoarseness in > 45 years = 2ww

Persistent mouth ulceration > 3 weeks = 2ww

Iron deficiency anaemia in > 60s = 2ww

June 27th - IBS

Unusual to develop > 50 years. Constipation predominant IBS (IBS-C) is more in women and diarrhoea predominant in men (IBS-D).

Non drug

Avoid caffeine and carbonate drinks

Low FODMAP diet as this reduces bloating& wind

Exercises improves bowel transitand gas transit

8 Probiotics - some evidence they help

Insoluble fibre makes things worse but soluble fibre improves symptoms

Peppermint oil, Buscopan, may help

Biofeedback for IBD-C

Dug Based

Loperamide for IBS-D

Amitriptyline for IBS-D

Ondansetron for IBS-D

Lubipristine is new laxative (a chloride channel activator) which improves abdo pain

Linaclotide is a new tablet which may also help

June 20th NICE summary re anaemia and CKD

1 in 20 adults have CKD

15% of these have anaemia of CKD

Usually due to erythropoietin, iron, b12 or folate deficiency

It is normochromic & normocytic

Very unusual in CKD3a

Iron is poorly absorbed and utilised in CKD so higher ferritin levels are needed to drive erythropoeisis. If oral iron therapy fails iv iron may be required

In the past transferrin saturation < 20% and ferritin levels below 100 were used to diagnose relative iron deficiency of CKD

Now percentage of hypochromic cells (>6%) or reticulocyte Hb content (<29pg) is the test of choice BUT analysis has to be performed within 6 hours of collecting the sample - so not that relevant for primary care.

Consider Rx if Hb < 110g/dl, aiming for a Hb > 100g/dl (target range 100 to 110g/dl)

May 9th

Idiopathic pulmonary fibrosis

Usually presenting as dry cough and increasing SOBOE over months. Most

9 commonly presents between 60 to 70 years of age

? reflux a possible contributory cause Drugs can cause fibrosis: Amiodarone, Methotrexate, Sulphasalazine, leflunamide, SSRIs, Statins, ACE inhibitors, some chemotherapies and some anti-TNF agents. In 20% of cases there is a FH

O/E half of patients have clubbing, bilat basal inspiratory creps.

Investigation in Primary Care (BTS): FBC, Cr&Es, CRP, ESR LFTs, adj calcium, Spirometry (restrictive pattern) and CXR

High Resolution CT will often show; reticulation, honeycombing and traction bronchiectasis

Rx; Prednisolone, cyclophosphamide NO LONGER USED

Pirfenidone (only Rx recommended by NICE) and Nintedanib reduce the rate of progression

Don't forget palliative care team involvement

May 2nd

SIDS Increased risk: lying prone, smoking in pregnancy, smoking after pregnancy, sleeping with parents on a sofa/couch or in their bed, use of duvets, head covering and prematurity.

Peak incidence between 2 and 4 months usually during sleep. Thought to be due immature cardiorespiratory control in conjunction with a failure of arousal from sleep.

Avoiding SIDs: Infants should be placed in the supine position for all sleep positions. Under 6 months should have their own cot with a firm mattress. Avoid blankets, pillows and toys in the cot. Consider using an infant sleeping bag but it must not cover the baby's face or head. Mums should avoid smoking during and after pregnancy. Breast feeding and use of dummies also seems to reduce the risk. Avoid bed sharing. April 18th

Managing a relapse in MS

85% of patient with MS have relapsing-remitting MS but half will covert to progressive MS after 15 years.

1/4 of patients failed to report their last relapse to their GP/MS- Nurse/Neurologist

Stress, systemic infection and the post partum period increase the risk of relapse.

10 Liaise with neurologist and/or MS-Nurse if relapse suspected

Before starting oral steroids for a relapse a rapid infection screen is needed (urine dip test, temperature and ask re systemic symptoms).

Oral methylprednisolone 500mg a day for 5 days is used to treat clinically significant or severe relapses.

Significant recovery occurs within the first two to three months but relapses may continue to improve over 12 months.

Availability of potent immunotherapy has led to a treatment concept NEDA - No Evidence of Disease Activity.

Variable compliance with immunotherapy is under recognised.

March 28th

Management of toothache and dental infections

Simple tooth ache is not helped with antbx - use Paracetamol, NSAIDs and the patient needs to see a dentist.

Dental abscess (gum or facial swelling) is usually associated with caries or partially erupted wisdom teeth. If they can see a dentist the same day do not give antbx. If they can't see a dentist the same day then use a short course of Amoxycillin or Clindamycin pending dental review.

Patients with trismus, drooling or signs of sepsis need max-fax review the same day. Also consider if patient has a simple dental abscess but is immunocompromised. March 14th Investigating chronic diarrhoea in young adults

Symptoms suggesting organic cause: Nocturnal or continuous diarrhoea, onset > 45 years, short duration of symptoms < 3months.

Red flags: unintentional wt loss, rectal bleeding, FH or bowel OR OVARIAN cancer, anaemia and palpable mass.

Some often missed causes: drugs (metformin), antacids, sorbitol containing foods and alcohol excess, bile acid diarrhoea and lactose intolerance

NICE re IBS ivx - FBC, CRP and coeliac abs (note coeliac abs false negative in IgA deficiency). Also consider in chronic diarrhoea to help identify organic causes - LFTs(hypoalbuminaemia), electrolytes (hypokalaemia), HIV testing, Cl difficile & stool culture including OCP

Note CRP is normal in up to half of patients with inflammatory bowel disease, so consider faecal calprotectin which has a high negative predictive value

March 7th

Diagnosis of asthma in children

Typically children may have 10 or more related colds a year with symptoms commonly lasting 2 weeks.

Asthma is suggested by: reports of wheeze, dry cough and breathlessness, typically worse at night or associated with triggers (exercise, urti, exposure to smoke, aeroallergens etc). Parental report of wheeze correlates poorly with objective heard wheeze, so an open mind regards the diagnosis of asthma must be kept until a health professional has heard and documented hearing a polyphonic expiratory wheeze.

Diagnosis = Peak flow variability over 2 weeks if pfr normal (variability ? > 12%) If pfr below normal then consider 400mcg of salbutamol via a spacer, wait 20 mins ? PFR increased > 12% Or a steroid trial (200mcg beclomethasone for six weeks, stop, if symptoms have resolved review in 6 weeks, if symptoms have recurred this suggest asthma)

Acute asthma oral pred doses = 30-50mg for children > 5 years and 20mg for < 5 but > 2 years - OVER THREE DAYS ONLY Feb 21st

Use of preimplantation genetic diagnosis

Situations in which preimplantation genetic diagnosis is currently considered appropriate  Autosomal recessive diseases in which both parents are known genetic carriers, such as cystic fibrosis, Tay-Sachs disease, or sickle cell disease

 Autosomal dominant diseases, such as Huntington’s disease, in one or both parents

 Certain known genetic mutations with important consequences, such as mutation of the BRCA gene  X linked diseases, such as hemophilia

 Certain balanced chromosomal translocations or inversions Situations in which preimplantation genetic diagnosis is not currently considered appropriate

 Medical conditions in parent(s) where a definitive genetic cause has not been identified

 Evaluation of certain phenotypic traits, such as hair color Situations in which preimplantation genetic diagnosis is currently considered controversial

 Sex selection for the purposes of “family balancing”

 HLA matching for the purposes of creating a tissue donor for an existing diseased sibling

 Certain cases with severe male factor infertility Feb 14th

Chronic pain assessment in the elderly - a useful tool

Elements of a comprehensive geriatric pain assessment - not al to be used in consultation but can be covered over a number of consultations to identify a

12 tailored package of solutions which may reduce the burden of chronic pain.

Sensory - Please tell me all of the places you experience pain or discomfort. What does it feel like? What words come to mind? Is your pain or discomfort with you all of the time or does it come and go? How long has it been present? What makes it better, what makes it worse?

Emotional impact - Has pain affected your mood, sense of wellbeing, energy level? Are you worried about your pain or what may be causing it?

Functional impact - Has pain affected your ability to do everyday activities? To do things you enjoy? How about relating with others? If so, how? Sleep - Has pain affected your sleep? Do you have trouble falling asleep or need to take drugs to help you sleep on account of your pain?

Attitudes and beliefs - Do you have any thoughts or opinions about experiencing pain at this point in your life that you believe would be important for me to know? Do you have any thoughts or opinions about specific pain treatments that you believe would be important for me to know?

Coping styles - What things do you do to help you cope with your pain? This could be listening to your favorite music, praying, sitting still, or isolating yourself from others

Treatment expectations and goals - What do you think is likely to happen with the treatment I have recommended? What are the most important things you hope will happen as a result of the treatment?

Resources - Is there anyone at home or in the community that you can turn to for help and support when your pain is really bad

Feb 10th

Identifying patients at risk of SUDEP

In 2013 there were 680 deaths from epilepsy among people aged under 75. 30% of deaths were unintentional, mostly from drowning and burns

 People with epilepsy and alcohol problems had an almost threefold increased risk of death.  Risk in patients who had not collected their most recent anticonvulsant prescription in the past three to six months was nearly doubled.  Having “a history of injury” during the previous year increased risk by 40%  Having had treatment for depression increased risk by about the same. So should GPs look for patients who have not collected their most recent anticonvulsant prescription in the past three to six months, encourage referral to alcohol services, arrange epilepsy nurse review for patients with a hx of epilepsy related injury in the previous 12 months? Feb 3rd

Bone pain due to cancer

Bone pain is the most common type of pain from cancer and is present in around one third of patients with bone metastases. Cancer induced bone pain is a specific pain state with overlapping but distinct features of both inflammatory and neuropathic pain. Cancers most often involved are those of the prostate, breast, and lung, as well as myeloma. The most common sites of metastases are vertebrae, pelvis, long bones, and ribs.

Don't forget discussing behaviour modifications, such as avoiding strenuous movement, and referring patients for any appropriate movement aids (walking stick, Zimmer frame) or home adaptations (bath rails) can make important contributions to the maintenance of function and quality of life.

Strong opioids are the mainstay of treatment for background pain in patients with cancer induced bone pain.

Radiotherapy has been shown to reduce pain significantly and is the most effective treatment that is specific for cancer induced bone pain.

Bisphosphonates such as pamidronate and zoledronate are used to reduce both pain and skeletal events in patients with bone metastases.

Denosumab is a novel agent that specifically inhibits RANK-ligand. Clinical trials have shown important benefits in reducing skeletal related events.

Jan 24th

Highly selective troponin tests

Conventional Troponin assays are optimally sensitive 10 to 12 hours after the onset of symptoms. It is as essential test for diagnosing NSTEMI. Newly available highly sensitive troponin assays are able to rule out NSTEMI quicker and more accurately. Bloods done at presentation and two hours later result in inappropriate discharge of NSTEMI in only 1.4% of cases. Sex specific thresholds increase the diagnostic performance in women.

Gestational diabetes

Increasing prevalence. Accounts for 80% of diabetes cases in pregnancy. Due to increased insulin resistance and reduced capacity to produced insulin in response to a glucose load. Metformin has been used in gestational diabetes for a few years now but studies have shown that Glibenclamide seems safe and is now being more widely used BUT not as much as Metformin, as Metformin seems to be associated with less maternal weight gain and less 'fetal overgrowth'.

3rd of Jan 2015

Breathlessness in palliative care

 Optimised treatment of underlying disease e.g. anaemia

14  Relief of co-existing symptoms, which exacerbate breathlessness, such as pain  Use of walking aids, wheel chairs etc  Preferred treatment is low dose sustained release opioids (e.g. MST 10mg bd) and pulmonary re-hab  No evidence for benzodiazepines or supplemental oxygen!