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Common Presentations. Dr J Tomkinson 16/10/13. 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

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Common presentations

CommonPresentations

Dr J Tomkinson

16/10/13


Importance

  • 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


Scabies

  • 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


Head lice

  • 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


Hyperhidrosis

  • 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


Hyperhidrosis1

Primary

  • First line:Aluminium chloride antiperspirants

    (e.g. Anhydrolforte, Driclor, Odaban).

  • Second line:Iontophoresis

    (for hands, feet and axillae).

Hyperhidrosis


Hyperhidrosis2

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


Secondary causes of hyperhydrosis

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


Secondary causes of hyperhydrosis1

Other causes include:

TBPhaeochromocytomaParkinson's diseaseMyeloproliferative HIVCarcinoid syndromeNeuropathiesLymphoma

EndocarditisAcromegalyDiabetes

Hyperhidrosis Support Group 

www.hyperhidrosisuk.org

SecondARY causes of hyperhydrosis


Common presentations

1

A

C

  • 2


Sore throat

  • 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


Centor criteria

>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


Sore throat1

  • 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


Referral criteria

  • 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


Common presentations

  • 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)


Role play

ROLE PLAY


Sinusitis

  • 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


Otitis media

  • 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


Onychomycosis fungal nails

  • Are you sure it is fungal?

  • Does any treatment work? If so, which is better; oral or topical?

Onychomycosis (fungal nails)


Common presentations

  • 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%


But i ve been coughing for 3 weeks doctor surely you can do something

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


Acute bronchitis

  • 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


How do i know it isn t pneumonia

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?


Common presentations

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


How long will it last

  • 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?


Antibiotics

  • 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?


Common presentations

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)


Common presentations

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!


Summary acute bronchitis cough

  • 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


Alopecia

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 ofbaldness). 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


Treatments for alopecia areata

  • 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


Tinea capitis scalp ringworm

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)


Shingles

How do you explain shingles to a patient?

shingles


Shingles1

  • 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


Treatments

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:


Warts and verrucae

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


Warts and verrucae1

Treatment Options:

  • Cryotherapy

  • Salicylic acid

  • Duct tape

  • Herbal – egthuja

Warts and verrucae


Warts and verrucae2

  • An RCT of 240 people with warts/verrucas compared salicylic acid with cryotherapy

  • There was no difference in cure rates between the two groups.

  • At 12w cure rate was 14% in both groups and around 33% at 6m. Not that encouraging…

    (BMJ 2011;342:d3271)

Warts and verrucae


Impetigo treatments

Oral or topical antibiotics?

  • Topical antibiotics are as effective as, if not more effective than oral antibiotics & have fewer side-effects. However, oral therapy should be used if impetigo is widespread.

  • Which antibiotic?

  • Fusidic acid cream

  • Flucloxacillin

  • Macrolides (e.g. erythromycin) and cephalosporins are also effective.

  • There is no evidence for disinfecting treatments

  • Retapamulinointment 1% (Altargo) is a new therapy for impetigo (no clinical benefit vsfucidin and much more expensive)

Impetigo treatments


Common presentations

MolluscumContagiosum


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