Common Presentations

1. CommonPresentations Dr J Tomkinson 16/10/13

2. 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 importance

4. Highly contagious and often missed as a diagnosis. • Diagnosis is based on history and examination: you don't need to see the parasite. • Whole family (and all close contacts) must be treated, even if asymptomatic. 5% permethrin cream is recommended 1st line as this has the best evidence base. SCabies

7. Wet combing is cheapest and can be used for all the household and for recurrences. Persistence is required, along with cooperation and patience from all involved • Insecticides are as effective as wet combing but resistance is common and many want to avoid chemicals. Ensure patients follow the instructions above, not those on the packet! • Non-insecticide based shampoos seem not to be associated with resistance, and may be more effective than wet combing/insecticides. They are, however, chemicals, and some may not want to use them for that reason. • Patient choice and good compliance are clearly important here! Head lice

9. Primary Patient may not want a prescription Non phamacological suggestions • Avoid known triggers egspicy foods and alcohol. • Use antiperspirant spray frequently • Avoid wearing tight, restrictive clothing and man-made fibres • Wearing black or white clothing can help to minimise the signs of sweating. • Armpit shields can help to absorb excessive sweat and protect your clothes. • Wear socks that absorb moisture • Buy shoes that are made of leather, canvas or mesh, rather than synthetic material. Hyperhidrosis

10. Primary • First line:Aluminium chloride antiperspirants (e.g. Anhydrolforte, Driclor, Odaban). • Second line:Iontophoresis (for hands, feet and axillae). Hyperhidrosis

11. Primary For more generalised hyperhidrosis, anticholinergics (e.g. oxybutinin) and glycopyrronium can be used, but have significant side-effects. Endoscopic sympathectomy only if all other therapy fails. Botulinum toxin very effective for the axillae but often not available on the NHS because of cost (£300–500 per treatment, usually required 3 monthly). Retrodermal curettage also useful in axillary disease, but again, usually not available on the NHS Hyperhidrosis

12. The commonest causes are: • Menopause • Hyperthyroidism • Intoxication / withdrawal from drugs / alcohol • Drugs: Antidepressants (SSRIs, tricyclics….) Antipyretics (aspirin, NSAIDs) Hormonal drugs (tamoxifen, GnRH agonists) SecondARY causes of hyperhydrosis

13. Other causes include: TBPhaeochromocytoma Parkinson's disease Myeloproliferative HIV Carcinoid syndrome Neuropathies Lymphoma Endocarditis Acromegaly Diabetes Hyperhidrosis Support Group  www.hyperhidrosisuk.org SecondARY causes of hyperhydrosis

14. 1 A C • 2

16. 40% of sore throats will be better by day 3. • Antibiotics increase re-attendance rates. • SIGN advise adequate analgesia usually all that is required in most cases. • Consider using Centor score to aid diagnostic acumen. Sore throat

17. >3y (1 point for each of the following). • Tonsillar exudate • Tender anterior cervical lymph nodes • History of fever • Absence of cough Score 1: 2–23% chance of having group A b-haemolytic strep (GABHS) Score 4: 25–86% chance of having GABHS NICE say treat if unwell and score more than ¾ Treatment : Phenoxymethylpenicillin 500mg qds 10 days (or macrolide) Analgesia Centor Criteria

18. Evidence for tonsillectomy in children is lacking but SIGN provide referral criteria to determine who to refer to secondary care. • Oral steroids have a small evidence base in adults only. Not yet recommended. • Lemierre's syndrome is very rare but Fusobacteriumnecrophorum, the organism responsible, can cause sore throats and quinsy. Consider FN as a cause in young adults with sore throat who are more unwell than expected. Sore throat

19. Infections must be documented, clinically significant and adequately treated. • 7 or more in last 1y OR 5 or more in each of last 2y OR 3 or more in each of last 3y • The sore throats are due to acute tonsillitis • The episodes are disabling and prevent normal function. • Appropriate stress should be placed on whether the frequency of episodes is increasing or decreasing and SIGN suggest an ENT surgeon might consider a six-month period of watchful waiting prior to consideration of tonsillectomy, particularly if the history is patchy. Referral Criteria

20. If an adult patient has had 4 episodes of sore throat in 12m or 3 in 6 months then… • If they decide NOT to have the op they would expect to have 2 episodes in the next 6 months (12 days of sore throat, 2–3 days of fever) • If they decide to have the operation they should expect 13 days of severe pain post-op and an average of 3 days of sore throat in the next 6 months • Minor post-op complications are possible, life-threatening ones are rare. (BMJ 2007;334:909)

21. ROLE PLAY

23. Most people get better on their own with or without antibiotics. • Antibiotics have an NNT of 15. • Although some research suggested that no clear sub-groups could be identified who might benefit from antibiotics more than most, other research has suggested that those with multiple symptoms, or persistent symptoms (>10d) or a biphasic illness (worsening after 5–7d) are more likely to have a bacterial infection. Sinusitis

25. 80% of children get better within 3 days without antibiotics. • NNT runs between 3 and 7 depending upon how you measure success. • NNH can be just as high. • The National Prescribing Centre does not recommend routine use of antibiotics. • Antibiotic use may increase the risk of future AOM infections. Otitis media

26. Are you sure it is fungal? • Does any treatment work? If so, which is better; oral or topical? Onychomycosis (fungal nails)

27. First check that what you are looking at really is infected! • Warn patients that treatment is for a long time (often months) and success rates are modest to good but with quite significant relapse rates. • Nail lacquers are not as effective. • Systemic treatment example: • Terbinafine 250mg daily • 12-16 weeks average treatment • Clinical success 70% but relapse 15%

28. 'But I've been coughing for 3 weeks doctor; surely you can do something….'

29. Acute bronchitis is a self-limiting lower respiratory tract infection, presenting almost always with a cough • It is usually viral but can be bacterial • MeReCrecommend that acute bronchitis is a likely diagnosis in someone presenting with cough, no new focal chest signs and no systemic upset. Acute Bronchitis

30. The British Thoracic Society (BTS) defines pneumonia as: Cough and at least one other lower respiratory tract symptom AND New focal chest signs on examination AND EITHER sweating, fevers, shivers, aches and pains or fever >38°C AND No other explanation for symptoms. How do I know it isn’t pneumonia?

31. Crp not felt to be usefulcxr Not helpfulCough medicines have no proven benefitB-Agonists have no evidence to support use

32. The average cough lasted 12 days, although 25% were still coughing 2.5w later. • Antibiotics made no impact on duration of cough (or any other outcome). • Those given delayed or no antibiotics were less likely to believe in the benefit of antibiotics next time. • Those not given immediate antibiotics had slightly lower satisfaction scores! (JAMA 2005;293:3029–35): • Average duration of cough was 3 weeks.Antibiotics made no difference to the duration of the cough. (BJGP 2008;58:88–92) How long will it last?

33. Neither sputum production nor sputum colour are good predictors of severity of illness.  • Antibiotics do not offer more than minor and clinically insignificant benefits e.g. a reduction of cough by half a day two weeks into the illness. • Those with more significant illness may benefit from antibiotics. Antibiotics?

34. NICE guidance on respiratory tract infections recommends not prescribing or using a delayed script for acute cough unless: Co-morbidity or >65y with at least 2 of the following or >80y with at least 1 of the following: • Hospitalised in the last 12m • Diabetes (type 1 & 2) • Heart failure • On steroids (NICE 2008, CG69)

35. RCT of over 800 people over the age of 3 with a LRTI (not URTI) showed that: • Those offered antibiotics were twice as likely to re-attend with the next illness. • Offering a delayed prescription reduced re-attendance rates by a whopping 78% compared to those given immediate antibiotics!

36. There is no evidence for cough mixtures or beta-agonists in acute bronchitis. • The cough with bronchitis lasts, on average, 3 weeks. • Antibiotics do not make the cough get better more quickly. • Neither sputum production, nor sputum colour, are good markers of severity. • In children, even if quite unwell, antibiotics do not speed recovery. Summary:Acute bronchitis & cough

38. Areata • Autoimmune, non-scarring disorder of hair growth. Often a genetic link. • Diagnosis is clinical. Often you see a circular bald patch with exclamation hairs (isolated short broken-off hairs in a patch of baldness). Lifetime prevalence 1.7%. Alopecia totalis (all of head hair loss) is rarer and alopecia universalis (loss of all body hair) rarer still. • Prognosis In an initial patch: 33% will have re-grown in 6m, 50% in 12m BUT 33% will never recover. Almost everyone who gets a first patch will do so again, but this may be many years later. Alopecia

39. 50% resolve spontaneously • Intra-lesionalcorticosteroids (triamcinolone). This is usually used first line. • Dithranol. Often used second line in persistent disease. Aim is to induce low-grade dermatitis. • Topical immunotherapy. Dinitrochlorobenzene, diphencyprone and SADBC used, but not in primary care. The aim is to induce a low grade contact dermatitis that stimulates hair regrowth. The more extensive the hair loss, or the longer it has been present, the less effective this treatment is. • Topical super-potent steroids (often under occlusion) or less potent steroids in the form of a foam. Only small trials, showing limited effectiveness. • Systemic corticosteroids. Only one tiny RCT showing one third of patients responded but relapse rates were high. Rarely used because of systemic side-effects. • Minoxidil. May be most beneficial in preventing relapse rather than to induce hair growth initially. Treatments for alopecia areata

41. Complications • Severe hair loss • Scarring  alopecia • Psychological impact (ridicule, bullying, isolation, emotional disturbance, family disruption) Treatments Topical rx : eg ketoconazole shampoo / terbinafine cream Systemic rx: egterbinafine TineaCapitis(scalp ringworm)

46. How do you explain shingles to a patient? shingles

47. Shingles is an infection of a nerve area caused by the varicella-zoster virus • Causes pain and a rash along a band of skin supplied by the affected nerve • Symptoms usually go within 2-4 weeks • Post herpetic neuralgia: up to 1 in 4 people with shingles, over the age of 60, has pain that lasts more than a month shingles

48. Aciclovir800mg five times a day if within the first 72 hours Pain and post herpetic neuralgia • tricyclic antidepressants • anticonvulsants such as gabapentin • Capsaicin, a topical treatment made from chilli peppers, can be applied to the affected area several times per day (avoid any mucous membranes!) • oxycodone Treatments:

50. Left untreated, most viral warts will eventually disappear (some pts happy with this info) Warts and verrucae LEARNING POINT: Not everyone wants a prescription Remember reassurance / non-pharmacological treatments