Beruflich Dokumente
Kultur Dokumente
1 Cardiovascular
o 1.1 AF
o 1.2 Chest Pain
o 1.3 Familial hypercholesterolaemia
o 1.4 Heart Failure
o 1.5 Hypertension
o 1.6 Peripheral artery disease
o 1.7 Statins
2 Dermatology
o 2.1 Acne vulgaris
o 2.2 Eczema
o 2.3 Psoriasis
o 2.4 Skin cancer
3 Endocrine
o 3.1 Diabetes (Type 2)
o 3.2 Hyperhidrosis
o 3.3 Hypothyroidism
4 Eyes and ENT
o 4.1 Conjunctivitis
o 4.2 Sinusitis
5 GI
o 5.1 Upper GI cancer
o 5.2 Lower GI cancer
6 Gynaecology
o 6.1 Ovarian cancer
o 6.2 Endometrial cancer
o 6.3 Other gynae cancers
7 Haematology
o 7.1 Leukaemia
o 7.2 Lymphoma
o 7.3 Myeloma
8 Lifestyle
o 8.1 Obesity
o 8.2 Smoking
9 Neurology
o 9.1 Stroke & TIA
o 9.2 Brain and CNS cancer
10 Paeds
o 10.1 Childhood cancers
o 10.2 Fever
11 Respiratory
o 11.1 Asthma
o 11.2 Bronchiolitis
o 11.3 COPD
o 11.4 Lung cancers
12 Sexual Health
o 12.1 Contraception
o 12.2 Pregnancy
13 Urology
o 13.1 Male Stuff
o 13.2 Bladder and kidney cancer
14 Women's Health
o 14.1 Breast cancer
o 14.2 References
Cardiovascular
AF
Atrial fibrillation is very common. If they are haemodynamically stable, then you want to do
an ECG to confirm. Once confirmed, consider starting anticoagulation, and think about
Rate/Rhythm control.
Anticoagulation
Do a CHA2DS2Vasc.
CHA2DS2Vasc Score
CCF 1 point
Hypertension 1 point
Diabetes 1 point
Stroke 2 points
The proper tool has a point for gender too, but that needlessly confuses things with the
guidance. Ignore gender, and anyone that scores 2 or more needs to be considered for
anticoagulation.
You then do a HASBLED score, which tells you their risk of bleeding. Score 3 or more, and
it becomes less sensible to start warfarin.
HASBLED Score
Hypertension
1
(uncontrolled >160 syst)
Age (65+) 1
Stroke 1
Kidney issues 1
Knackered liver 1
Unstable INR 1
Alcohol use 1
You then start them on Warfarin. You can definitely also consider a NOAC, they appear to be
pretty equally good.
Rhythm Control
If fits the criteria below, then refer for cardioversion. (Will need warfarinisation before
cardioversion for at least 4 weeks.)
New onset AF
AF with reversible cause
Heart failure suspected to be caused by AF
Rate Control
Most people - your standard 70 year old with an incidental finding of AF on examination -
will need rate control. You want to:
Chest Pain
Medical Emergency - Likely acute coronary syndrome with active chest pain will need
sending to hospital by ambulance.
You need to give them:
GTN
Aspirin 300mg
Do an ECG
Measure O2 saturation, consider giving oxygen.
If they have no pain currently, but have had within the last 72 hours, will likely still need to
go to hospital for ECG and Troponin.
Stable chest pain
Assess them, looking for cardiac risk factors,
especially diabetes, smoking and hyperlipidaemia.
For most of them, you will want to do further tests to identify likelihood of angina. This will
often be an exercise ECG, myocardial perfusion scan or similar. Either way, best access route
is usually rapid access chest pain clinic.
Managing angina
Once you've confirmed angina, manage it with
GTN spray
Lifestyle interventions
Beta blocker (or calcium channel blocker)
Aspirin 75mg
Statin - atorvastatin 80mg.
ACE inhibitor if they have diabetes
Familial hypercholesterolaemia
Inherited as an autosomal dominant condition. Anyone with cholesterol over 7.5 or LDL
more than 4.9 needs to be considered for this
Management
Pretty simple. They will likely need:
DNA testing
Lifelong statins.
Aggressive lifestyle modification.
Heart Failure
Heart failure diagnosis is pretty easy. Suspect heart failure?
If they've had a previous MI, just refer them for an urgent echo and specialist review.
Otherwise, measure a BNP or NTproBNP.
o If BNP is under 100 (or 400 for NTproBNP), chill out, unlikely to be heart failure.
o 100-400 (400-2000 NTproBNP), refer for routine assessment.
o 400+ (2000+ NTproBNP), needs an urgent review like with MI.
Anti-hypertensives
Commence antihypertensives in following order, stepping up if condition not controlled:
Management
Start them on clopidogrel 75mg OD, atorvastatin 80mg and refer to vascular!
Statins
Primary prevention with statins is based pretty heavily on the QRISK2 tool (try it here)[7].
Start atorvastatin 20mg in anyone with one of these:
Over 85
Who scores more than QRISK 10%
Chronic kidney disease
Type 1 Diabetes? If over 40, or had diabetes more than 10 years then start the pills!
Annually
Muscle pains
Check CK.
If more than 5 times normal, consider stopping or reducing statin.
Dermatology
Acne vulgaris
Managing acne involves some helpful people skills[8]
Mild acne
Moderate acne
Add in a topical antibiotics with one of the topical agents above if not helping. Ideally
don't give for more than 12 weeks.
Consider oral antibiotics combined with a topical retinoid or benzoyl peroxide.
o Use tetracycline, oxytetracycline, doxycyline or lymecycline.
o Don't use without a topical agent
o Don't give both topical and oral antibiotics.
Severe acne
If all that has failed, refer them to Dermatology, who will consider starting oral isotretinoin.
Eczema
Robby Robinson, former Mr Universe, opposes use of anabolic steroids in bodybuilding, but
finds a little clobetasone just the thing for his eczema...
1. Emollients are the mainstay of treatment in eczema. Make sure you explain that it
should be applied around 4 times a day, and that they should be getting through
buckets of the stuff - or they aren't using it properly.
2. Topical steroids are next, if a decent emollient regime isn't curing it.
1. Start with mild or moderate steroids (see image on the right)
2. On the face and thin skin in flexures, don't progress beyond moderate.
3. With children, especially on the face, start with mild.
4. Apply steroids once or twice a day, after applying emollient to the area.
5. If steroids aren't working, consider infected eczema, and consider a blood test
to rule out coaeliac disease which can present with dermatitis herpetiformis,
which looks a fair bit like eczema.
3. If that's not working, topical tacrolimus is an option, but should be initiation
by dermatologists.
Psoriasis
Skin cancer
Malignant Melanoma
Refer to rule out melanoma with any pigmented lesion with 3 or more points (see below)[11].
Change in size
Irregular shape
Irregular colour
You need two results showing fasting glucose ≥7, or HbA1c ≥ 48mmol/mol.
If having symptoms of diabetes, such as thirst, polyuria, you only need one.
Lifestyle
Step one is aaaaaaaaaaaaaall about lifestyle changes. Losing 5-10% body weight can even
revert HbA1c to normal in some cases.
Obviously, need to sort out their blood pressure, smoking, etc. However, if HbA1c is still
more than 48, you'll need to intensify.
Anti-glycaemic drugs
Sulphonylurea (gliclazide)
Monotherapy Gliptin (sitagliptin)
Pioglitazone
Repaglinide
A key question for drivers is "Have they had an episode of hypoglycaemia requiring the
assistance of another person in the last 12m?". If so, cannot drive!
Generally, aside from that, there is slightly more strict guidance for HGV drivers compared to
normal divers, but with insulin:
They need to have full awareness of when they are having a hypo.
The DVLA always need to be informed of their condition.
They will expect the driver to measure blood sugar 2 hourly whilst driving.
Hyperhidrosis
This is excessive sweating. Management is mostly in secondary care, but it can be a useful
red flag[12]...
1. Step one is to rule out secondary causes of nightsweats or excessive sweating; such
as TB, Cancer, Menopause, Diabetes, etc.
2. If you are confident it is primary hyperhidrosis, consider topical aluminium
chloride. Apply 12.5% at night, and wash off in morning. Increase up to 30% if
needed.
3. If that's ineffective, refer to Dermatology.
Hypothyroidism
If you clinically suspect hypothyroidism, or have an incidental finding in TFTs[13]
Generally you can manage without referral, but go for it if patient unwell, painful goitre,
treatment resistant, under 16, or any possibility of Addison's disease.
Eyes and ENT
Conjunctivitis
Evidence shows that antibiotics don't really do much[15] - it might resolve slightly earlier, but
by 7 days there's no difference between groups.
Sinusitis
Very common, sinusitis is almost always self limiting. According to a Cochrane review[17],
"there is no place for antibiotics for the patient with clinically diagnosed, uncomplicated
acute rhinosinusitis".
Advised the patient it should get better in 2-3 weeks, and that antibiotics do not reduce how
long the pain lasts.
GI
Upper GI cancer
You will want to refer via 2WW anyone with an upper abdominal mass that suggests stomach
cancer, or anyone over 40 with jaundice.
Send for urgent OGD
Dysphagia
55+ with weight loss and pain/reflux symptoms.
Haematemesis
55+ with:
o Non resolving dyspepsia.
o Upper abdo pain and anaemia
o Raised platelets with any upper GI symptoms
o Nausea and vomiting with weight loss/reflux/pain
Diarrhoea or constipation
Back pain
Abdominal pain
Nausea/Vomiting
New diabetes
Some of these are a bit odd, because you would probably already be sending on a Lower GI
cancer referral...
Consider urgent USS
Anyone who has a mass that feels like an enlarged liver or gallbladder mass deserves a
cheeky USS.
Lower GI cancer
Gynaecology
Ovarian cancer
You need to refer urgently if you suspect ascites, or find any unexpected pelvic/abdominal
mass[11].
Consider ovarian malignancy and do CA125 if
50+ woman with bloating, early satiety, pelvic pain, or increased urinary symptoms.
Any unexplained weight loss, fatigue or bowel habit changes.
New onset of IBS in women over 50.
The key is that ovarian cancer is easily missed and diagnosed late, so always have it at the
back of your mind.
Endometrial cancer
Send anyone 55+ with postmenopausal bleeding via 2WW[11]. Consider it strongly in anyone
under 55 too.
Go for an urgent USS if...
55+ with unexplained vaginal discharge for the first time, or with thrombocytosis, or with
haematuria.
Haematuria with anaemia, raised platelets or high blood sugars.
If the cervix is abnormal in appearance, they are going to need an urgent referral[11]. Same
with any weird vulval lumps, ulcers or bleeding.
Haematology
Leukaemia
Do an FBC within 48 hours in any children or adults with one of these:
Lymphoma
Refer anyone with unexplained lymphadenopathy or splenomegaly for 2WW. Refer kids
even more urgently. Especially think about fever, night sweats, SOB, itchiness, weight loss.
Myeloma
In patients over 60 with bone pain, particularly back pain or unexplained fractures
do FBC, serum calcium and ESR/plasma viscosity.
If they have raised calcium, or raised viscosity, do protein electrophoresis and Bence Jones
protein urine test within 48 hours. Refer with 2WW if these suggest myeloma.
Lifestyle
Obesity
Smoking
Neurology
Stroke & TIA
Anyone with a suspected TIA needs assessing under ABCD2
ABCD2 points
Age
1
(more than 65)
Blood pressure
1
(more than 140 or 90)
Motor weakness: 2
Clinical features
Speech changes no weakness: 1
Less than 10 minutes: 0
Duration 10-60 minutes: 1
More than 60 minutes: 2
Diabetes 1
If thrombotic:
Adults with a progressive loss of CNS functions, or any sign of intracranial lesion should
have an urgent MRI[11]. Children should have an urgent Neurology review.
Paeds
Childhood cancers
All the below need a 2WW referral to rule out neuroblastomas, retinoblastomas and Wilm's
tumours[11]...
Fever
Hugely common problem, most kids run a temperature when they are unwell. For managing
fever, there is no benefit to using both paracetamol and ibuprofen, just recommend one or the
other
In deciding if a child needs urgent help, use the traffic light
system:
Refer is still symptomatic after treatment, any occupational link suspect, scary CXR findings
or eosinophilia > 1x109
Management
Step wise management for everyone, progressing to next step if symptoms not managed. For
adults:
Similar for children 5-12, but earlier cut off for referral:
Acute Asthma
Moderate asthma:
Can be managed with salbutamol via spacer, and oral prednisolone for 5 days. Only give
antibiotics if signs of infection.
Treat these patients with oxygen, and 5mg nebulised salbutamol. Consider adding
ipratropium 0.5mg also. If they don't have life threatening signs, and are improving, consider
allowing home with steroids, otherwise admit urgently.
Bronchiolitis
1 in 5 children under one years old get this each year[21]. Peak incidence is at 3-6 months.
RR>60
Feeding difficulties (less than 75% normal intake)
Dehydration
Give the kids O2 - but there's no value in giving antibiotics or bronchodilators, they don't
help.
COPD
Diagnosis of COPD[22] is through spirometry. Consider doing it on anyone over 35 who have
a smoking history and:
SOB on exertion
Chronic cough
Regular sputum production
Frequent winter "bronchitis"
Wheeze
If spirometry shows FEV1/FVC <0.7 without reversibility, treat for COPD. If reversible,
consider asthma.
Lung cancers
anyone with a suggestive CXR, or anyone over 40 with unexplained haemoptysis you need
to refer them through 2WW
Otherwise, consider:
Urgent CXR if over 40 and 2 of these:
Contraception
UKMEC guidance says the combined pill should be avoided in anyone:
Cancer risk
The Combined Oral Contraceptive increases risk of some female cancers. The easy way to
remember risk: Oral = Oh no!
Oh no! Outermost, Improves Innermost:
Male Stuff
Women's Health
Breast cancer
Sarah has a rare X-linked allergy to Jaffa cakes, and has two 1st degree, 2 second degree and
a 3rd degree relative suffering from this terrifying disease.
First step is to understand what a first, second and third degree relative is - its simply just the
number of steps from you along a family tree: