A Day in the Life of General Practice

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A Day in the Life of General Practice ST 2 teaching session, Wed 17 A Day in the Life of General Practice ST 2 teaching session, Wed 17 th Feb

Aims At the end of this sessions those attending will have: 1) more of Aims At the end of this sessions those attending will have: 1) more of an understanding of the types of work occurring in a standard GP session including: • letters, reviewing results, surgery contact, telephone calls and home visits 2) a better understanding of the approach taken in General practice, with regards to clinical anagement, resources available, but also issues such as patient safety, confidentiality and consent. 3) had an opportunity to discuss and practice the above using case scenarios.

BLOOD RESULTS BLOOD RESULTS

Bloods • • Hb MCV WBC PLT Na K Ur e. GFR 8. 8 Bloods • • Hb MCV WBC PLT Na K Ur e. GFR 8. 8 68 9. 2 491 136 3. 9 4. 7 70 73 yr woman Routine bloods with PN P 90, BP 126/74 Felt slightly tired when seen. • Meds: ramipril, bisoprolol, ISMO, clopidogrel • PMHx: MI (2001), IHD. • •

What might you do next? • Consider GI bleed • Ask patient to see What might you do next? • Consider GI bleed • Ask patient to see dr ASAP? • ? History of melena, or change in bowel habit. Weight loss? New IHD symptoms? • Meets criteria for urgent referral. Upper or lower depending on symptoms. • Check Ferritin • ? Start iron and monitor

Bloods • • • Hb 11. 3 MCV 117 WBC 4. 0 PLT 120 Bloods • • • Hb 11. 3 MCV 117 WBC 4. 0 PLT 120 U&E normal LFTs normal • 48 male • Infrequent attender, bloods taken following recent chest infection • Previous concerns over alcohol abuse.

What might you do next? Macrocytosis ? Alcohol related ? Nutritional Further bloods – What might you do next? Macrocytosis ? Alcohol related ? Nutritional Further bloods – B 12, folate Discuss alcohol, assess for dependence and willingness to address. • ? Thiamine 100 -200 mg od • •

Bloods • • TC LDL HDL TG LFTS U&E e. GFR Hb. A 1 Bloods • • TC LDL HDL TG LFTS U&E e. GFR Hb. A 1 c 5. 4 3. 6 1. 0 2. 0 normal 62 7. 8% • 54 yr old woman • New diagnosis of diabetes – bloods done • BP 148/96, P 76 reg • BMI 27 • Dipstix NAD • Started on meformin only.

What might you do next? • Hyperlipidaemia in type 2 Diabetes – Aim: TC What might you do next? • Hyperlipidaemia in type 2 Diabetes – Aim: TC < 4. 0 OR LDL <2. 0 • if no evidence of nephropathy – threshold for intervention with antihypertensive therapy is a BP >= 140/90 mm. Hg and the optimal blood pressure target is < 130/<80 mm. Hg – audit standard is <140/<80 mm. Hg • if nephropathy – target blood pressure is < 130/80 mm. Hg, or lower (<125/75 mm. Hg) when ACR >70 mmol/l

Bloods • AST • GGT 72 125 (8 -40) (11 -50) • Bili 11 Bloods • AST • GGT 72 125 (8 -40) (11 -50) • Bili 11 (3 -17) • ALP 100 (30 -170) Previous result (2 years ago) • AST 68 (8 -40) • GGT 102 (11 -50) • ALP • Bili 114 14 (30 -170) (3 -17) • 51 year old man recently diagnosed with type 2 diabetes • Seen in recent consultation by another doctor who decided to start a statin but wanted to check liver function first • No clear follow up arrangement recorded in the notes

What might you do next? What might you do next?

LETTERS LETTERS

Letter from patients solicitor • Patient is applying for leave to remain. • Patient Letter from patients solicitor • Patient is applying for leave to remain. • Patient consents to information being given (form included) • Letter asks for information about her mental health. – – Diagnosis Likely cause of illness Treatment required and prognosis Whether the patients health is sufficient to attend a hearing.

Letter – from patients solicitor • • • 32 indian women Been with practice Letter – from patients solicitor • • • 32 indian women Been with practice 6 yr Mild asthma (prn inhalers) One pregnancy 2 yr ago Seen by GP in october ? Low mood Sectioned in november: ‘acute psychosis’ – letter from acute assessment team. Now under early intervention team. No new letters.

What might you do next? • GMC / MPS – Disclosure of records requires What might you do next? • GMC / MPS – Disclosure of records requires patients consent – Considering checking that the patient is aware of what information may be disclosed. Eg HIV status, TOP, genetic disorders. – Reports can withhold information that may be harmful to physical or mental health. – But cannot be presented as a complete record, “ this is the record save those items not consented”

MPS advice: Writing reports • Your report should be: – Detailed – it is MPS advice: Writing reports • Your report should be: – Detailed – it is better to provide too much information than too little – Clear – avoid ambiguity and be clear about who did what and when – Objective – state the facts. Do not use the report to criticise others or make general comments on hospital politics. • Your report should be based on: – The medical records – Your own recollection – Your usual practice. • Do not. . . – Exceed your level of competence or ‘field of expertise’. – Deliberately conceal anything – this will cast doubts on your integrity and will make subsequent comments less credible.

 • What would you have done if this letter was asking about her • What would you have done if this letter was asking about her asthma?

MORNING SURGERY MORNING SURGERY

“BACK PAIN” • 27 yr old office worker • 3/7 lower back pain, is “BACK PAIN” • 27 yr old office worker • 3/7 lower back pain, is effecting work • Not helped by paracetamol

What would you ask next? • No radiation • No red flag symptoms: • What would you ask next? • No radiation • No red flag symptoms: • Normal Examination/SLR • PRN paracetamol used Cauda equina syndrome Significant trauma - ? # Weight loss History of Cancer Fever Intravenous Drug Abuse Prolonged steroid use Patient less than 20 or over 50 Severe, unremitting night-time pain Pain worse on lying flat Thoracic bony pain

What if? • Same patient – but. . . • 8 weeks of symptoms What if? • Same patient – but. . . • 8 weeks of symptoms • Now pain radiates down into left leg • Using tds diclofenac and qds paracetmol which • Reduced sensation to L 3 help. -4 dermatome and reduced knee reflexes. • ? New approach NICE 09 – low back pain: if not responding to basic measures after 6 weeks, consider referral for physical therapy Often managed as for mechanical lower back pain. But nerve root symptoms not improving, or progressing – consider orthopaedic referral and imaging.

What if ? • 48 yr old women with • 72 year old man What if ? • 48 yr old women with • 72 year old man severe rheumatoid • Progressive pain to arthritis. lower back over past • Sudden onset of pain to week, now severe. back yesterday. • Has had problems passing water. ? High previous steroid use, sudden pain maybe suggestive of osteoporotic collapse ? Urinary obstruction previously (? Prostate enlargement) also consider for urinary retention (? Spinal compression. ? Ca with mets

“CHEST PAIN” • A 35 year old businessman has had several episodes of chest “CHEST PAIN” • A 35 year old businessman has had several episodes of chest pain in the last few months. They last a few minutes, he feels breathless and ‘like he’s going to die’, then they settle down. There’s no obvious cause.

What would you ask next? Life threatening causes of chest pain: • • • What would you ask next? Life threatening causes of chest pain: • • • MI PE Dissecting aortic aneurysm (pericarditis) Pneumothorax (abdominal cause) Most common cause of new presentation of chest pain in GP • • • Musculoskeletal Dyspepsia Anxiety/panic Pneumonia Cardiac

What if? • 68 year old man with no • 33 year old woman What if? • 68 year old man with no • 33 year old woman has previous history of chest pain and tightness, cardiovascular disease. especially when she takes a Tightness in chest for deep breath. several months, comes and • On COCP, flew to Spain 3 goes weeks ago, had bad cough • Mainly comes on when while there, seemed to start taking dog for walk on hills. around then. Thinks mother Father had stroke in 60 s. A had a DVT after a knee bit short of breath with it, operation. sometimes radiates to neck. • O/E: tenderness of chest Always goes if stops walking lateral to sternum, RR 12, HR 70, SPO 2 97%, chest clear bilat, no calf swelling.

“FEELING LOW AND CAN’T SLEEP” • 32 yr old electrician • Separated from wife “FEELING LOW AND CAN’T SLEEP” • 32 yr old electrician • Separated from wife and 2 kids • Happened 2 weeks ago as had an affair. • “I’m feeling really low and I can’t sleep”

What would ask next? • “Just keeps thinking over • No high alcohol intake What would ask next? • “Just keeps thinking over • No high alcohol intake what a mistake he made” • Has one friend – not tearful. But feels (neighbour) who is low most days supportive. • Sleep poor as thinks • No past psych history. about things over and over. No EMW. • Appetite slightly low, feels hard to concentration at work. • Not suicidal – but feels “as if thrown everything away”

What if • Same patient, but 6 wk • States feels able to keep What if • Same patient, but 6 wk • States feels able to keep and tearful, sleep poor himself safe. Children with EMW, has stopped protective feature. work as poor concentration. • Had 1 yr on SSRI for depression 3 yrs ago. Feels similar. • Can’t see things getting improving, sometimes thinks life not worth living.

What if Separated for 6 months. Not really leaving house Has stopped seeing kids What if Separated for 6 months. Not really leaving house Has stopped seeing kids States can’t see the point in hoping for change. • Drove to a river 3 nights ago, but just sat there for hours. Not sure what he would do. Vague on suicide questioning. Had been drinking that night. • •

“DYSPEPSIA” • 40 year old woman with burning pain in chest, sometimes feels nauseous “DYSPEPSIA” • 40 year old woman with burning pain in chest, sometimes feels nauseous with it. Worried as mother recently had MI • Sometimes gets when hasn’t eaten for a while, sometimes at night. Not exercise related, lasts an hour or so.

Management of Dyspepsia • NICE guideline 2004/2005 referral for urgent endoscopy if dyspepsia and: Management of Dyspepsia • NICE guideline 2004/2005 referral for urgent endoscopy if dyspepsia and: • • • progressive unintentional weight loss progressive difficulty swallowing persistent vomiting iron deficiency anaemia epigastric mass or suspicious barium meal Aged 55 or over with unexplained and persistent recent onset dyspepsia

Management of Dyspepsia • NICE guideline: Intervention for uninvestigated dyspepsia “Initial therapeutic strategies for Management of Dyspepsia • NICE guideline: Intervention for uninvestigated dyspepsia “Initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori. There is currently insufficient evidence to guide which should be offered first. “

What if? • 65 year old woman with • 58 year old man with What if? • 65 year old woman with • 58 year old man with epigastric pain after burning chest pain at meals. night and an unpleasant taste in his mouth. Not • Endoscopy 10 years ago had symptoms previously, showed gastritis, treated normally fit and well. at the time with ranitidine. • Started on 40 mg • Gaviscon not helping. omeprazole daily by another GP 1 month ago, thinks symptoms have improved a bit

“PAINFUL EAR” • • 2 yr old boy Painful ear for 2/7 Not sleeping “PAINFUL EAR” • • 2 yr old boy Painful ear for 2/7 Not sleeping with pain Temp 38. 2 Could consider there may benefit for antibiotic treatment in specific sub-groups of patients. For example, children: • under two years with bilateral infection • with discharge from the ear • who are systemically unwell (e. g. fever or vomiting) • with recurrent infections

What if • 3 yr old • 1/7 • Temp 37. 0 85% of What if • 3 yr old • 1/7 • Temp 37. 0 85% of children with non-supperative otitis media will be pain free within 24 hrs. Review if not settling after 3 days or if pain worsens

What if • 58 yr old • Itchy then painful ear Swelling to Exturnal What if • 58 yr old • Itchy then painful ear Swelling to Exturnal Auditory Canal, itch and then pain very suggestive. Could also look for exudate. Topical anti-biotics and steroids, but given degree of swelling these may not easily enter. Could discuss with ENT as may need a wick inserted.

What if? • Same patient as above, but also poorly controlled DM • Ear What if? • Same patient as above, but also poorly controlled DM • Ear pain described as ‘terrible’ despite analgesia Consider Malignant Otitis Externa Often in diabetics with disproportionate pain in OE.

What if • 62 yr old DM, • Ear symptoms mostly of bad smell What if • 62 yr old DM, • Ear symptoms mostly of bad smell and discharge from ear for several weeks. Attic crust seen, bad smell and diabetes – all risk factors for cholesteatoma. Needs ENT review

Billy’s got a limp • 4 yr old • What might you ask? • Billy’s got a limp • 4 yr old • What might you ask? • Thought he might have had a sore leg yesterday. • Not wanting to walk on it today.

Billy’s got a limp • Had a temp with runny nose and cough 4/7 Billy’s got a limp • Had a temp with runny nose and cough 4/7 ago • Doesn’t seem to hurt when resting • No Hx of trauma • No knee pain, reduced int/ext rotation and abduction right hip • Temp 36. 8 • What might you do? Afebrile Likely transient synovitis from history and examination Review if worsens or not settled after a week?

Billy’s got a limp • • • Same story Pain also when resting Same Billy’s got a limp • • • Same story Pain also when resting Same hip findings Temp 37. 8 P 138 • What might you do? Febrile, not moving joint May well be transient synovitis – but discuss with paeds A&E, urgent bloods would help exclude septic arthritis.

What if? • 15 months • Mum think he tripped on carpet • Won’t What if? • 15 months • Mum think he tripped on carpet • Won’t WB on left • ? Tender to lower left leg Consider for toddlers fracture • 8 yr old boy • Gradual onset of pain to right groin, over last 1/12 • Some discomfort on int rotation and abduction • Temp 35. 6 Age and gradual onset ? Perthes – needs x-ray

What if • 12 yr old boy • Overweight • Sudden onset of pain What if • 12 yr old boy • Overweight • Sudden onset of pain to left leg/knee • Pain to left hip internal rotation. • Temp 36. 2 ? Slipped Epiphysis – needs urgent Frog Leg view x-rays and • 14 yr old girl • Limping slightly • Pain noticed in knee more on walking, especially on stairs, also in rising. • No Hx of trauma ? Chondromalacia Patellae

Can I have the morning after pill? • 13 year old presents alone asking Can I have the morning after pill? • 13 year old presents alone asking for emergency contraception • What would you ask next? 18 year old boyfriend – patient is consenting UPSI 2 days ago Not told parents No intention of speaking to parents LMP start date / length of cycle / which day of cycle was UPSI Any other UPSI this cycle Other medication

What would you do next? • Contraception. • Discuss MAP use • Discuss on-going What would you do next? • Contraception. • Discuss MAP use • Discuss on-going contraception? • Child protection • Explain legal factors and confidentiality • Speak to child protection lead in surgery • Contact community CP officer (usually works with community paeds) • MDU • Parental involvement

What if • Patient was 14 yrs old • Boyfriend was same age • What if • Patient was 14 yrs old • Boyfriend was same age • UPSI was 4 days ago Cu coil is alternative to hormonal EC Can be inserted up to 5 days after UPSI, or longer if approx timing of ovulation can be calculated (no longer than 5 days after ovulation)

Gillick Competence / Fraser Guidelines • the young person will understand the professional's advice Gillick Competence / Fraser Guidelines • the young person will understand the professional's advice • the young person cannot be persuaded to inform their parents • the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment • unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer • the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent • “Fraser Ruling Competent”

Considerations • Gillick/Fraser competence • STI risk • Long term contraception planning • LARC Considerations • Gillick/Fraser competence • STI risk • Long term contraception planning • LARC • COC / POP • Liver enzyme inducing drugs

What do you tell them? • Need another dose of hormonal EC if vomit What do you tell them? • Need another dose of hormonal EC if vomit within 2 hours of taking tablet • Need to do a pregnancy test if menses more than 7 days late or lighter than usual • EC does not provide contraceptive cover for remainder of cycle

“FEVERISH ILLNESS IN CHILDREN” • There are four phone calls on your list after “FEVERISH ILLNESS IN CHILDREN” • There are four phone calls on your list after surgery all relating to children who are unwell: – Jonny: 8 yr old boy who has had a painful ear for the last 24 hours. He has a temperature which settles with paracetamol, and has otherwise been fairly well eating and drinking and remaining active – Connor: 2 month old boy previously fit and well. Has seemed unsettled overnight, mum thinks he feels hotter than normal. He is alert but off his food today. – Candice: 6 year old girl who has had cold symptoms for several days. Today her mother has noticed a rash on her chest. She checked it blanches with a tumbler, and it does. – Keeley: 3 year old girl with temperature symptoms for 2 days, seems to be passing more urine than normal. Vomited last night but has managed some fluids this morning.

Assessment of feverish child: • Thorough examination essential to determine source of infection. Document Assessment of feverish child: • Thorough examination essential to determine source of infection. Document temp, HR, RR, cap refill time • Do not prescribe oral antibiotics to children with feverish illness without obvious source • Remember different ages have different normal physiological parameters • NICE guideline feverish illness <5 years • Traffic light system • ‘Amber’ features (with no diagnosis) provide parents with safety net or refer to paeds • ‘Red’ features – refer for paediatric assessment

Home Visit- ‘Breathlessness’ • You have a home visit for Mr AG. He is Home Visit- ‘Breathlessness’ • You have a home visit for Mr AG. He is a 70 year old man with COPD. He was seen a week ago with a cough and shortness of breath, and prescribed a course of prednisolone and amoxicillin. • He has no other medical history, and takes no regular medication except his ventolin and seretide inhalers.

Home Visit – ‘Breathlessness’ • He lets you in to the house and you Home Visit – ‘Breathlessness’ • He lets you in to the house and you see that he has become breathless walking to the door. • What would you look for in your examination? • You’re not sure whether to continue his antibiotics and steroids, whether to order a chest X-ray or whether to admit him to hospital. What might guide your decision?




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