Oxford GP (Extract) PDF

 v Contents Preface vii Acknowledgements viii Abbreviations used in the text x Standard abbreviations xi 1 What is general practice? 1 2 Practice management 29 3 Consulting with...

 v Contents Preface vii Acknowledgements viii Abbreviations used in the text x Standard abbreviations xi 1 What is general practice? 1 2 Practice management 29 3 Consulting with patients 59 4 Social aspects of primary care 81 5 Medicines and prescribing 111 6 Minor surgery 131 7 Healthy living 143 8 Chronic disease and elderly care 171 9 Cardiology and vascular disease 203 10 Respiratory medicine 263 11 Endocrinology 311 12 Gastrointestinal medicine 343 13 Renal medicine and urology 407 14 Musculoskeletal problems 445 15 Neurology 507 16 Dermatology 559 17 Infectious disease 617 18 Haematology and immunology 635 19 Breast disease 663 20 Gynaecology 677 21 Sexual health and contraception 709 22 Pregnancy 761 23 Child health 825  CONTENTS vi 24 Ear, nose, and throat 907 25 Ophthalmology 931 26 Mental health 963 27 Cancer care 997 28 Palliative care 1011 29 Emergencies 1033 Index 1111 x x Abbreviations used in the text Evidence-based superscripts N NICE guideline G Guideline from a major guideline-producing body C Cochrane review S Systematic review or meta-analysis published in a major peer- reviewed journal R Randomized controlled trial published in a major peer- reviewed journal Referral times E Emergency admission U Urgent referral S Soon referral R Routine referral Handbook symbols " Note ! Warning E OHGP cross reference M Web link F Telephone number ♀ Female ♂ Male  Controversy 3 Don’t dawdle 1° Primary 2° Secondary i Increased/increasing d Decreased/decreasing l Leading to/resulting in ~ Approximately 8 Approximately equal ± With or without  xi Standard abbreviations AAA abdominal aortic aneurysm ABPI ankle–brachial pressure index ABPM ambulatory blood pressure monitoring ACE angiotensin-converting enzyme ACS acute coronary syndrome ACTH adrenocorticotrophic hormone ADH antidiuretic hormone ADHD attention deficit hyperactivity disorder AED automated external defibrillator AF atrial fibrillation AFP alpha fetoprotein AIDS acquired immune deficiency syndrome Alk phos alkaline phosphatase ALT alanine aminotransferase ANF antinuclear factor APH antepartum haemorrhage APMS Alternative Provider Medical Services ARB angiotensin receptor blocker ASD atrial septal defect ASO antistreptolysin O AST aspartate aminotransferase AV arteriovenous AXR abdominal X-ray BASHH British Association for Sexual Health and HIV BCG Bacille Calmette–Guérin bd twice daily BMA British Medical Association BMJ British Medical Journal BNF British National Formulary BP blood pressure bpm beats per minute Ca2+ calcium CABG coronary artery bypass graft CCF congestive cardiac failure CCG Clinical Commissioning Group CF cystic fibrosis CHC combined hormonal contraception  STANDARD ABBREVIATIONS xii CHD coronary heart disease CIN cervical intraepithelial neoplasia CMV cytomegalovirus CNS central nervous system COC combined oral contraceptive COPD chronic obstructive airways disease Cr creatinine CRP C-reactive protein CT computed tomography CVA cerebrovascular accident CVD cardiovascular disease CXR chest X-ray d day(s) DDH developmental dysplasia of the hip DES Directed Enhanced Service DH Department of Health and Social Care DIPJ distal interphalangeal joint DLA Disability Living Allowance DI diabetes insipidus DM diabetes mellitus DN district nurse DOAC direct-acting oral anticoagulant DRE digital rectal examination DVLA Driving and Vehicle Licensing Authority DVT deep vein thrombosis EBV Epstein–Barr virus ECG electrocardiogram Echo echocardiogram EEG electroencephalogram ENT ear, nose, and throat EPAU early pregnancy assessment unit ESR erythrocyte sedimentation rate ESRD end-stage renal disease FBC full blood count FBG fasting blood glucose FEV1 forced expiratory volume in 1 second FH family history FSH follicle-stimulating hormone FSRH Faculty of Sexual and Reproductive Healthcare FVC forced vital capacity g grams  STANDARD ABBREVIATIONS xiii GA general anaesthetic GI gastrointestinal GGT gamma glutamyl transferase GMC General Medical Council GMS General Medical Services GP general practitioner GPC General Practitioner Committee GTN glyceryl trinitrate GTT glucose tolerance test GU genitourinary GUM genitourinary medicine h hours Hb haemoglobin HbA1c glycosylated haemoglobin HBPM home blood pressure monitoring HBsAg hepatitis B surface antigen hCG human chorionic gonadotropin HDL high-density lipoprotein Hib Haemophilus influenzae type b HIV human immunodeficiency virus HOCM hypertrophic obstructive cardiomyopathy HPV human papilloma virus HRT hormone replacement therapy HSV herpes simplex virus HV health visitor HVS high vaginal swab ICP intracranial pressure Ig immunoglobulin IHD ischaemic heart disease IM intramuscular INR international normalized ratio IT information technology IU international units IUCD copper intrauterine device IUD intrauterine device IUS progestogen-containing intrauterine system IV intravenous IVP intravenous pyelogram JVP jugular venous pressure K+ potassium kg kilograms  STANDARD ABBREVIATIONS xiv KUB kidney, ureters, and bladder X-ray L litres LA local anaesthetic LBBB left bundle branch block LFT liver function test LH luteinizing hormone LIF left iliac fossa LMP last menstrual period LMWH low-molecular-weight heparin LN lymph node LRTI lower respiratory tract infection LTOT long-term oxygen therapy LUQ left upper quadrant LVF left ventricular failure LVH left ventricular hypertrophy m metres MAOI monoamine oxidase inhibitor M,C&S microscopy, culture, and sensitivity MCP metacarpophalangeal MCV mean cell volume MDI metered dose inhaler mg milligrams MHRA Medicines and Healthcare products Regulatory Agency MI myocardial infarction min minutes mL millilitres MMR measles, mumps, and rubella MND motor neurone disease mmHg millimetres of mercury mo months MRI magnetic resonance imaging MS multiple sclerosis MSU midstream urine Na+ sodium NAAT nucleic acid amplification test NHS National Health Service NI National Insurance NICE National Institute for Health and Care Excellence nocte at night NSAID non-steroidal anti-inflammatory drug NSTEMI non-ST elevation myocardial infarction  STANDARD ABBREVIATIONS xv O2 oxygen OA osteoarthritis OCD obsessive–compulsive disorder od once daily OOH out-of-hours OT occupational therapy OTC over-the-counter PAN polyarteritis nodosa PCI percutaneous coronary intervention PCO primary care organization PCOS polycystic ovarian syndrome PD Parkinson’s disease PE pulmonary embolus PEFR peak expiratory flow rate PET pre-eclamptic toxaemia PHCT primary healthcare team PIP Personal Independence Payment PIPJ proximal interphalangeal joint PMH past medical history PMS Personal Medical Services PN practice nurse po oral PO43– phosphate POP progesterone-only pill PPE personal protective equipment PPH post-partum haemorrhage PR per rectum prn as needed qds four times daily QOF Quality and Outcomes Framework RA rheumatoid arthritis RBBB right bundle branch block RCGP Royal College of General Practitioners RCOG Royal College of Obstetricians and Gynaecologists RhD rhesus factor RIF right iliac fossa RPOCT rapid point-of-care test RR relative risk RTA road traffic accident RUQ right upper quadrant s seconds  STANDARD ABBREVIATIONS xvi sc subcutaneous SH sexual health SLE systemic lupus erythematosus SOL space-occupying lesion SNRI serotonin and noradrenaline reuptake inhibitor SSRI selective serotonin reuptake inhibitor stat immediately SpO2 peripheral oxygen saturation STEMI ST elevation myocardial infarction STI sexually transmitted infection SVC superior vena cava TB tuberculosis TCA tricyclic antidepressant tds three times daily TFT thyroid function tests TIA transient ischaemic attack u units U&E urea and electrolytes UC ulcerative colitis URTI upper respiratory tract infection US(S) ultrasound (scan) UTI urinary tract infection VF ventricular fibrillation VSD ventriculoseptal defect VT ventricular tachycardia WCC white cell count wk weeks y years " All other abbreviations are defined in the text on the page in which they appear. Elderly care and child health flags: conditions peculiar to children or elderly people, or in which management varies for these groups, are flagged as follows: Child health Elderly care  Chapter 7 143 Healthy living Prevention and screening 144 Prevention of travel-related illness 146 Diet 148 Obesity 152 Exercise 154 Smoking 156 Alcohol 158 Management of alcohol misuse 160 Assessment of drugs misuse 162 Management of drugs misuse 166 Insomnia 168 481 148 CHAPTER 7 Healthy living Diet The role of the GP and primary care team Screening Identification of obese patients and patients in need of dietary advice for other reasons Assessment Current diet, motivation, and barriers to change Discussion and negotiation Exploration of knowledge about diet; negotiation of goals Goal setting Provide information and 2–3 food-specific goals on each occasion—set a series of mini-targets that appear realistic and achievable; tailor them to existing diet and usual schedule Monitoring progress Barriers to a good diet Ignorance Posters in surgeries, leaflets, screencasts on waiting room screens, and/or information on the practice website may help Cultural differences Modify information to be relevant; provide information in multiple languages as appropriate Enjoyment Perception of healthy diet as not enjoyable Poverty Fresh fruit/vegetables and lean meat/fish are expensive—some elements are cheap, e.g. potatoes, pasta, rice Lifestyle Convenience foods contain a lot of salt, sugar, and fat Peer pressure Children are under pressure to eat sweets, crisps, etc. Habits of a lifetime We like the foods we have grown up with Confusion about what is good Packaging may be misleading, e.g. breakfast cereals claiming health messages but containing high sugar Mixed messages One minute the press says something is good for you, the next it causes some horrible disease and should be avoided Fatalism/apathy The ideal diet See Figure 7.1, E p. 150, Adjust composition/portion size of each meal to maintain a healthy weight. Include a variety of foods: Use starchy foods (e.g. bread, rice, pasta, potatoes) as the main energy source Eat plenty of fruit and vegetables (>5 portions of fruit/vegetables daily); do not overcook vegetables—steaming is preferable to boiling, and keep delay between cutting and eating fruit/vegetables to a minimum Eat plenty of fibre—good sources are high-fibre breakfast cereals, beans, pulses, wholemeal bread, potatoes (with skins), pasta, rice, oats, fruit/vegetables Eat fish at least 2×/wk including 1 portion (maximum 2 portions if pregnant) of oily fish (e.g. mackerel, herring, pilchards, salmon) Cut back on cooked red or processed meat; consider substituting meat with vegetable protein (e.g. pulses, soya) Choose lean meat—remove excess fat/poultry skin and pour off fat after cooking; avoid fatty meat products (e.g. sausages, salami, meat pies); boil, steam, or bake foods in preference to frying; when cooking with fat use unsaturated oil (e.g. olive, sunflower oil) and use cornflour rather than butter and flour to make sauces Use skimmed milk and low-fat yoghurts/spreads/cheese (e.g. Edam or cottage cheese) Avoid adding salt to foods—aim for 3) Slightly increased risk (RR 1–2) Mortality (BMI >30kg/m2) Cancer (breast in post-menopausal Type 2 DM (BMI of 35kg/m2 women, endometrial, oesophageal, confers a 92× i risk of DM) colon)—14–20% of cancer deaths Gall bladder disease are due to obesity Dyslipidaemia Reproductive hormone Insulin resistance abnormalities Breathlessness PCOS Sleep apnoea Impaired fertility Moderately increased risk (RR 2–3) Low back pain CHD (5–6% of deaths are due Stress incontinence to obesity) Anaesthetic and postoperative risk i BP Fetal defects associated with OA (knees) maternal obesity Hyperuricaemia/gout Suicide School/workplace prejudice intake of ~600kcal/d, and a target BMI of 25 kg/m2, in steps of 5–10% of original weight. There is no health benefit of weight d below this. If simple diet sheets are not effective, refer to a dietician Very low-calorie diets (3mo only if weight d is ≥5% of initial body weight. Surgery Consider if BMI >40kg/m2, or BMI 35–39.9 kg/m2 and suffering from a condition that could be improved by weight loss, and non-surgical measures have failed. Adjustable gastric banding is the most common pro- cedure. Complications: band slippage/damage; gastric erosion; pouch dilata- tion; infection; malabsorption. Maintenance of weight loss Once a patient has lost weight, continue to monitor diet. Ongoing follow-up helps to sustain weight loss. Weight fluctuation (yo-yo dieting) may be harmful. Further information National Obesity Forum M www.nationalobesityforum.org.uk SIGN (2010) Management of obesity. M www.sign.ac.uk/sign-115- management-of-obesity.html NICE (2014) Obesity: identification, assessment and management. M www.nice.org.uk/guidance/cg189 541 154 CHAPTER 7 Healthy living Exercise In the UK, 60% of adults are not active enough to benefit their health. Recommended amounts of activity Adults: ≥30min/d moderate intensity exercise on ≥5d/wk Children: ≥1h/d moderate intensity exercise every day Assessing levels of physical activity See Figure 7.3. Use a validated tool to assess levels of physical activity, e.g. General Practitioner Physical Activity Questionnaire (GPPAQ). Health benefits of exercise Regular physical activity: d risk of DM—through i insulin sensitivity Obesity—E p. 152 Cardiovascular disease—physically inactive people have ~2× i risk of CHD and ~3× i risk of stroke Osteoporosis—exercise d risk of hip fractures by ½ Cancer— exercise d risk of colon cancer by ~40%. There is also evidence of a link between exercise and d risk of breast and prostate cancers Is a useful treatment for i BP—can delay onset of hypertension, and result in 10mmHg drop of systolic and diastolic BP in people with established hypertension Hypercholesterolaemia— exercise results in i high-density lipoprotein (HDL), and d low-density lipoprotein (LDL) Cardiac rehabilitation (E p. 230) and COPD (E p. 286) DM—exercise improves insulin sensitivity and favourably affects other risk factors for DM, including obesity, HDL/LDL ratio, and i BP Arthritis and back pain—exercise maintains function Mental illness—exercise d intensity of depression and d anxiety Benefits for the elderly Maintains functional capacity d levels of disability d risk of falls and hip fracture Improves quality of sleep Occupation Physical exercise Sedentary Standing Physical Heavy and/or cycling (h/wk) manual 0 Inactive Moderately Moderately Active inactive active Some but 60y (12%). 6% of school children aged 11–15y are regular smokers (♀ 10%; ♂ 8%). Surveys of smokers show 73% want to stop and 30% in- tend to give up in 90% are smokers); lip; mouth; stomach; colon; bladder Cardiovascular disease CHD, CVA, peripheral vascular disease Chronic lung disease COPD, recurrent chest infection, exacerbation of asthma (29% of respiratory deaths result from smoking) Problems in pregnancy PET, IUGR, preterm delivery, neonatal and late fetal death DM Thrombosis Osteoporosis Dyspepsia ± gastric ulcer Passive smoking is associated with i risk of coronary heart disease and lung cancer (i by 25%) i risk of cot death, bronchitis, and otitis media in children Helping people to stop smoking Advice from a GP results in 2% of smokers stopping—5% if advice is repeated. See Figure 7.5. Aids to smoking cessation Nicotine replacement therapy (NRT) i the chance of stopping ~1½×. All pre- parations are equally effective. Start with higher doses for patients highly de- pendent. Continue treatment for 3mo, tailing off dose gradually over 2wk before stopping (except gum which can be stopped abruptly). Contraindicated immediately post-MI, stroke, or TIA, and for patients with arrhythmia. Bupropion Smokers (>18y) start taking the tablets 1–2wk before intended quit day (150mg od for 3d, then 150mg bd for 7–9wk). i cessation rate >2×. Contraindications: epilepsy or i risk of seizures, eating disorder, bipolar disorder. Varenicline Smokers (>18y) start taking the tablets 1wk before intended quit day (0.5mg od for 3d, 0.5mg bd for 4d, then 1mg bd for 11wk). d dose to 1mg od if renal impairment/elderly. i cessation rate >2×. If the patient has stopped smoking after 12wk, consider prescribing a further 12wk treat- ment to d chance of relapse. Contraindications: caution in psychiatric illness. e-cigarettes Heat a liquid (usually comprising propylene glycol and glycerol ± flavours) into an aerosol for inhalation. Vary in nicotine content from none to >20mg/mL. Although good-quality evidence is currently lacking, the general consensus is that e-cigarettes do i smoking cessation rates—both through nico- tine replacement, and by addressing sensory/behavioural aspects of smoking addiction. e-cigarettes are not licensed as medicines currently and are not avail- able on NHS prescription. Long-term effects of ‘vaping’ are as yet unclear. Alternative therapies Hypnotherapy may be helpful in some cases.  SMOKING 157 Remind smokers of the importance of stopping smoking with leaflets and posters around the surgery Assess smoking status of all patients at least 1×/y if possible If smoking Offer to refer to the smoking If willing cessation clinic to stop Help the patient to set a quit date Advise smokers to stop Advise the patient to stop smoking Assess willingness to change completely on the quit date ‘not even one If not puff’ willing to stop Recommend nicotine replacement therapy, buproprion, varenicline or Record advice given to stop smoking e-cigarettes Give the patient an advice leaflet to Consider offering a follow-up take away appointment to check progress Repeat advice to stop smoking whenever Support the information given with an the patient is seen in the GP surgery advice sheet Nicotine withdrawal symptoms: Urges to smoke (70%) Poor concentration (60%) Increased appetite (70%—mean 3–4kg Irritability/aggression (50%) weight i) Night-time wakening (25%) Depression (60%) Light-headedness (usually just the first Restlessness (60%) few days after quitting) (10%) Figure 7.5 Suggested management plan for smoking cessation Support In many areas, ‘stop smoking’ services are provided by PCOs. These programmes consist of a combination of group education, counsel- ling ± individual support in combination with nicotine replacement, bupro- pion, varenicline, or e-cigarettes. Prescribing smoking cessation medication Prescribe only for smokers who commit to a target stop date. Initially, prescribe only enough to last 2wk after the target stop date, i.e. 2wk nicotine replacement therapy, 3–4wk bupropion, or 3wk varenicline. Only offer a second prescription if the smoker demonstrates continuing commitment to stop smoking. 0 If unsuccessful, the NHS will not fund another attempt for ≥6mo. Smokeless tobacco Misri India tobacco, qimam, naswar, gul, khaini, gutkha, zarda, mawa, Manipuri, or betel quid with tobacco. Particularly used in South Asian communities. Carries risk of nicotine addiction, CVD, dental disease, and mouth/throat cancer. Provide brief advice to stop; consider NRT. Further information Hartmann-Boyce J, et al. (2018) Electronic cigarettes for smoking cessa- tion. BMJ 360:j5543. NICE (2012) Smokeless tobacco cessation: South Asian communities. M www.nice.org.uk/guidance/ph39 NICE (2018) Stop smoking interventions and services. M www.nice.org. uk/guidance/ng92 Useful contacts Action on smoking and health (ASH) M www.ash.org.uk NHS Smokefree M www.nhs.uk/smokefree Quit F 0800 00 22 00 M www.quit.org.uk 581 158 CHAPTER 7 Healthy living Alcohol ‘An alcoholic is someone you don’t like who drinks as much as you do’ Dylan Thomas (1914–1953) Alcohol misuse is a major public health and social concern. Alcohol-related problems cost the NHS ~£1.7 billion/y. Most harm is caused by non- dependent drinkers. Screening (Figure 7.6) and brief interventions in pri- mary care can identify drinkers in this group and d consumption and harm. What is a unit of alcohol? 1 unit = 10mL (or 8g) of pure alcohol. It is the amount of alcohol that an adult can process in ~1h—though speed of elimination does vary. It can be calculated. The ‘alcohol by volume’ (ABV) is stated on the packaging of all alcoholic drinks sold in the UK. Calculating units from ABV: number of units = ABV × volume (mL) ÷ 1000. As a rough guide, 1 unit 8 ½ pint of beer, a small glass of wine, or a single shot of spirit. Recommended limits ≤14U/wk for ♂ and ♀. Prevalence of alcohol misuse Hazardous/harmful drinking—excess drinking causing potential or actual harm but without dependence—affects 32% ♂; 15% ♀ Binge drinking (>8U for ♂ or >6U for ♀ in 1d)—affects 21% ♂; 9% ♀ Alcohol dependence—affects 6% ♂; 2% ♀ Alcohol and health Moderate consumption (1–3U/d) may d risk of non-haemorrhagic stroke, angina, and MI—but overall risks >> bene- fits. Risk depends on other factors too (e.g. smoking, heart disease). Potential harms: Death 15,000–22,000 deaths/y in the UK are associated with alcohol misuse—most related to stroke, cancer, liver disease, accidental injury/suicide. Physical health Obesity (high DM Poor sleep calorie content) Cancer of the mouth, Tiredness Fatty liver larynx, and oesophagus Brain damage Hepatitis Breast cancer Sexual dysfunction Cirrhosis Haemopoietic toxicity Infertility Liver cancer (i MCV) Fetal damage Oesophageal varices Nutritional deficiencies Back pain ± haemorrhage Neuropathy Interactions with Gastritis Myopathy prescribed drugs Pancreatitis Cardiomyopathy Injuries due to i BP alcohol-related CVA activity (e.g. fights) Mental health Anxiety, depression, and/or suicidal ideas; dementia and/or Wernicke’s encephalopathy ± Korsakoff ’s syndrome (E p. 553). Social harms of alcohol Marriage breakdown Poverty Social isolation Loss of work Absence from work Loss of shelter/home  ALCOHOL 159 Questions 1) How often do you have a drink containing alcohol? Scoring: 0 Never 3 2–3×/wk 1 1×/mo 4 ≥4×/wk 2 2–4×/mo 2) How many drinks containing alcohol do you have on a typical day when you are drinking? Scoring: 0 1 or 2 drinks 3 7–9 drinks 1 3 or 4 drinks 4 ≥10 drinks 2 5 or 6 drinks 3) How often do you have 6 or more drinks on one occasion? 4) How often during the last year have you found that you were not able to stop drinking once you started? 5) How often during the last year have you failed to do what was normally expected of you because of drinking? 6) How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7) How often during the last year have you had a feeling of guilt or remorse after drinking? 8) How often during the last year have you been unable to remember what happened the night before because of your drinking? Scoring: 0 Never 3 Weekly 1 1 occasion before deciding how to proceed. Exceptions are severe withdrawal symptoms and/or evidence of an estab- lished regimen requiring continuation. Points to cover: General information Check identification (ask to see an official document) Contact with other agencies (including last GP)—check accuracy Current residence: family—partner, children Employment/finances Legal problems/criminal behaviour—past and present History of drug use/risk-taking behaviour Reason for consulting now and willingness to change Current and past usage Knowledge of risks Unsafe sexual practices Medical and psychiatric history Complications of drug abuse, e.g. HIV, hepatitis, accidents General medical and psychiatric history and examination Alcohol abuse Overdose—accidental/deliberate Investigations Consider urine toxicology to confirm drug misuse Consider blood for FBC, LFTs, hepatitis B/C, and HIV serology (with consent and counselling—E p. 720), and other tests according to medical history/examination  ASSESSMENT OF DRUGS MISUSE 163 Specific drugs See Table 7.5, E p. 164. 0 Gabapentin/pregabalin are increasingly being used as drugs of abuse, particularly in prisons Preventing prescription drug dependence Benzodiazepines and z-drugs E p. 169 Opioids E p. 167 Prescribing for drug misusers Approach with special caution. Some controlled drugs can be dispensed to substance misusers in instalments providing they are prescribed on special NHS prescription forms (FP10 MDA—England; WP10 MDA—Wales; GP10—Scotland; HS21—Northern Ireland). The prescription specifies: number of instalments; intervals be- tween instalments and, if necessary, instructions for supplies at weekends or bank holidays; total quantity of controlled drug providing treatment for a period ≤14d; and quantity to be supplied per instalment. As a general principle, substitute opioid medicines are prescribed in daily instalments. 0 The prescription must be dispensed on the date on which it is due. Other equipment for drug misusers Doctors, pharmacists, and drug workers may provide supplies of alcohol swabs, sterile water (≤10 ampoules of 2mL or less), mixing utensils, filters, and citric acid to drug mis- users for the purposes of harm reduction. Notification of drug misusers Patients who start treatment for drug misuse in the UK in specialized drug treatment centres have their details passed anonymously to national drug monitoring services. All types of problem drug misuse are reported. Databases cannot be used as a check on multiple prescribing as data are anonymized. Driving and drugs misuse E p. 99 Overdose E p. 1098 Travelling abroad with controlled drugs E p. 125 0 The RCGP Substance Misuse Unit provides certificate courses in man- agement of drug and alcohol misuse. M www.rcgp.org.uk Further information DH (2017) Drug misuse and dependence: UK guidelines on clinical management. M https://www.gov.uk/government/publications/ drug-misuse-and-dependence-uk-guidelines-on-clinical-management Advice and support for patients and their families ADFAM Support for families M www.adfam.org.uk Benzodiazepines M www.benzo.org.uk Drugs-info M www.drugs-info.co.uk Drugwise M www.drugwise.org.uk Know the Score (Scotland) F 0800 587 5879 M www.knowthescore.info Solvent abuse F 01785 810762 M www.re-solv.org Talk to FRANK (England and Wales) Government-run information, ad- vice, and referral service. F (24h) 0300 123 6600 M www.talktofrank.com  641 164 Table 7.5 Commonly misused substances in the UK Name (street names) How usually taken Effects sought Harmful effects CHAPTER 7 Heroin (smack, horse, gear, H, Injected, snorted, or Drowsiness, sense of warmth and Dependence/tolerance junk, brown, stag, scag, jack) smoked well-being Overdose—can lead to coma and death Sharing injecting equipment brings risk of HIV/hepatitis infection Cocaine (coke, charlie, snow, C) Snorted in powder form, Sense of well-being, alertness, and Dependence, restlessness, paranoia injected confidence Damage to nasal membranes Crack (freebase, rock, wash, Smokable form of cocaine Similar to those of snorted cocaine As for cocaine but, because of the intensity of its effects, stone) but initial feelings are much more crack use can be extremely hard to control Healthy living intense Additionally causes lung damage (‘crack lung’) Ecstasy (E, XTC, doves, disco Swallowed, usually in tablet Alert and energetic, but with a Nausea and panic biscuits, echoes, scooby doos) form calmness and a sense of well-being Overheating and dehydration—if dancing can be fatal Chemical name: MDMA towards others. Heightened sense of Use has been linked to liver/kidney problems sound and colour Long-term effects are not clear but may include mental illness and depression LSD Swallowed on a tiny square Hallucinations, including distorted/ There is no way of stopping a bad trip which may be a (acid, trips, tabs, dots, blotters, of paper mixed-up sense of vision, hearing, very frightening experience microdots) and time. LSD trip can last 8–12h i risk of accidents Can trigger long-term mental health problems Magic mushrooms (shrooms, Eaten raw or dried, cooked Similar effects to those of LSD, but As for LSD, with the additional risk of sickness and mushies) in food, brewed into tea the trip is often milder + shorter poisoning Khat (quat, chat) Chewed as leaves Stimulant, Insomnia, irritability, panic d sleep Barbiturates (barbs, downers) Swallowed as tablets/ Calm and relaxed state, larger doses Dependency/tolerance capsules; injected produce a drunken effect Overdose can lead to coma or death Severe withdrawal symptoms Amphetamines (speed, whizz, In powder form, dissolved Stimulates the nervous system, Insomnia, mood swings, irritability, panic uppers, billy, sulph, amp) in drinks, injected, sniffed wakefulness, feeling of energy and The comedown (hangover) can be severe and last for or snorted confidence several days Cannabis (hash, dope, grass, blow, Rolled with tobacco into a Relaxed, talkative state, heightened Impaired coordination and i risk of accidents ganja, weed, shit, puff, marijuana) spliff, joint, or reefer and sense of sound and colour Poor concentration, anxiety, depression smoked; smoked in a pipe; i risk of respiratory diseases, including lung cancer or eaten Tranquillizers (include: Valium®, Swallowed as tablets or Prescribed for the relief of anxiety Dependency/tolerance Ativan®, Mogadon® (moggies), capsules, injected and to treat insomnia, high doses i risk of accidents temazepam (wobblies, mazzies, cause drowsiness Overdose can be fatal jellies)) Severe withdrawal symptoms Anabolic steroids (many trade Injected or swallowed as With exercise, can help to build ♂: erection problems, risk of MI or liver disease names) tablets up muscle. Some debate about ♀: development of male characteristics whether i muscle power and athletic Injecting equipment: brings risk of HIV or hepatitis performance infection Poppers (alkyl nitrates, including Vapours from small bottle Brief and intense head-rush caused Hypotension/fainting amyl nitrate with trade names such of liquid are breathed in by a sudden surge of blood through Headaches as Ram, TNT, Thrust) through mouth or nose the brain Nausea Skin burns ‘Sudden sniffing death syndrome’—due to arrhythmia Solvents (including lighter gas refills, Sniffed or breathed into Short-lived effects similar to being Nausea, blackouts, increased risk of accidents aerosols, glues). Some painter the lungs drunk, thick-headed, dizziness, Fatal arrhythmias can cause instant death thinners and correcting fluids possible hallucinations ASSESSMENT OF DRUGS MISUSE 165 61 166 CHAPTER 7 Healthy living Management of drugs misuse Management aims to help the patient stay healthy until a drug-free life is achieved. In particular by d the risk of infectious diseases, drug-related deaths, and criminal activity to finance drug habits. Care can be difficult due to chaotic lifestyle and drug-seeking behaviour. Set clear rules of engagement. 0 GPs interested in working in specialist drug misuse treatment centres or providing substitute prescribing in the community should obtain spe- cialist training. The RCGP Substance Misuse Unit provides certificate courses in management of drug and alcohol misuse (M www.rcgp.org.uk). Role of the GP Important role in identifying drug misuse (including prescription drugs) and as- sessing willingness to modify drug behaviour (see Figure 7.8). GPs can also provide: Information and advice as appropriate about: Safe injecting, overdose prevention and specific risks of drugs (Table 7.5, E p. 164)—including local risks, e.g. contaminated street drugs Safe sexual practices (E p. 711) Driving and drug misuse (E p. 99) Other sources of support/information Medical care Routine medical care, including treatment of complications of drug misuse, e.g. infected injection sites Routine preventive care (e.g. cervical screening, contraception) Blood-borne viruses (hepatitis B/C, HIV)—testing as needed; hepatitis B vaccination to injecting drug misusers not already infected/immune, and close contacts of those infected—use an accelerated regimen— immunization at 0, 7, and 21d, and a booster after 12mo Precontemplation Patient is unaware that there is a problem Relapse Contemplation Can occur at any stage. Not a failure Ambivalence, might acknowledge a but a learning experience to improve problem and need for change chances the next time around Maintenance Decision Needs to consolidate gains to avoid Hypothetical point at which a decision relapse is made whether to change or not Action Patient seeks help Figure 7.8 Stages of change in addiction  MANAGEMENT OF DRUGS MISUSE 167 Referral for specialist assessment/treatment of drug misuse. 0 Patients requiring substitute prescribing (e.g. with methadone/buprenorphine for heroin misuse) should be referred to a specialist treatment centre Prescription benzodiazepine addiction E p. 169 Prescription opioid misuse Suspect if taking long-term opioid medi- cation for any non-cancer condition, particularly if drug-seeking behaviour (e.g. early requests/requests for replacement medication), refusal to see a GP for reviews, or reluctance/refusal to d the dose of opioids. Action Discuss your concerns with the patient directly. Offer patients the option of referral to a specialist drug treatment centre for substitute pre- scribing with methadone/buprenorphine, or detoxification. Detoxification Convert patients on patches to long-acting oral medica- tion. Agree a gradually d dose of opioid, e.g. 10–25% of the dose/mo. 0 Patients who detoxify should be warned of the risk of overdose if they relapse and restart opioids again at the same dose. Monitor frequently. Opioid withdrawal symptoms Within 24h muscle aches; restlessness/anxiety; watering eyes/runny nose; excessive sweating; yawning; inability to sleep Later Diarrhoea; abdominal cramps; goosebumps (‘cold turkey’); nausea/vomiting; blurred vision and dilated pupils; tachycardia; i BP Safe injecting advice Provide information about safer routes of drug administration, e.g. smoking/rectal administration for heroin abusers. Discourage IM/subcutaneous administration. Advise: Safe injecting—never inject alone; always inject with the blood flow; rotate sites—avoid neck, groin, penis, axilla, foot and hand veins, and any infected areas/swollen limbs. 0 Poor veins indicate poor technique—find out what the patient is doing Drugs/equipment—sterile injecting equipment with small-bore needle; dispose of equipment safely after use; avoid unsuitable preparations, e.g. crushed tablets and/or drug cocktails First aid—learn basic principles of first aid/CPR; encourage calling for an ambulance. Suggest a naloxone kit (available from drug treatment centres)—d deaths from opioid overdose Opioid overdose risk factors Injecting heroin Recent non-fatal overdose Longer injecting career High levels of use/intoxication Depression, suicidal thoughts High levels of alcohol use Lowered tolerance through detoxification/imprisonment Multiple drug use—particularly CNS depressants Sharing equipment/other high-risk injecting behaviour—may indicate low concern about personal risk Not being on/premature exit from a methadone treatment programme Further information DH (2017) Drug misuse and dependence: UK guidelines on clinical management. M https://www.gov.uk/government/publications/ drug-misuse-and-dependence-uk-guidelines-on-clinical-management Faculty of Pain Management Identification and treatment of prescription opioid dependent patients. M https://www.rcoa.ac.uk/faculty-of-pain- medicine/opioids-aware/clinical-use-of-opioids/identification-and-treatment 681 168 CHAPTER 7 Healthy living Insomnia From the Latin meaning ‘no sleep’: describes a perception of disturbed or inadequate sleep. ~1:4 of the UK population (♀ > ♂) are thought to suffer in varying degrees. Prevalence: i with age, rising to 1 in 2 amongst the over 65s. Causes Numerous—common examples include: Minor, self-limiting—travel, stress, shift work, small children, arousal Psychological ~½ have mental health problems: depression, anxiety, mania, grief, alcoholism Physical—drugs (e.g. steroids), pain, pruritus, tinnitus, sweats (e.g. menopause), nocturia, asthma, obstructive sleep apnoea Definition of ‘a good night’s sleep’ 10y or have established nephropathy or other CVD risk factors People with 10y CVD risk of ≥10% using the QRisk3 calculator (M https://qrisk.org/three/) 0 Current risk estimation tools give 10y CVD risk; the Joint British Societies tool provides an estimate of lifetime risk (M www.jbs3risk.com). This is particularly useful when discussing CVD risk with younger patients as their 10y risk is often very low regardless of risk factors. Factors used in the QRisk3 cardiovascular risk calculation Age Smoking CKD Gender Diabetes RA Ethnicity FH of CVD SLE Socioeconomic status AF Severe mental illness BMI BP Antipsychotic medication Cholesterol levels BP medication Steroid medication 0 If the risk score is near the threshold for intervention, consider other factors that may predispose to CVD and cause risk underestimation, e.g.: Has the person recently stopped smoking? Is the patient already taking lipid-lowering therapy? Does the patient have raised triglycerides? Are other conditions present that i risk (e.g. psoriasis, HIV, other systemic inflammatory disorder, taking immunosuppressant medication)?  PREVENTION OF CARDIOVASCULAR DISEASE 215 Secondary prevention Aims to stop progression of symptomatic car- diovascular disease. 46% people who die from MI are already known to have CHD. There is strong evidence that targeting patients with CVD for risk-factor modification is effective in d risk of recurrent CVD. Table 9.5 Risk factors for cardiovascular disease Non-modifiable Modifiable (proven benefit) Modifiable (unproven benefit) Age—i with age Smoking*—E p. 156 Haemostatic Sex—♂ > ♀ in those Hyperlipidaemia—E p. 222 factors—i plasma < 65y Hypertension*—E p. 218 fibrinogen Ethnic origin—in DM*—E p. 326 Apolipoproteins— the UK people who i lipoprotein(a)* Diet*—E p. 148 originate from the Homocysteine—i Indian subcontinent Obesity (particularly waist-hip blood homocysteine have i risk, Afro- ratio)*—E p. 152 Vitamin levels—d Caribbeans have d risk Physical inactivity*—E p. 154 blood folate, vitamins Socioeconomic Alcohol consumption*—E p. 158 B12 and B6 position* Left ventricular dysfunction/ Depression Personal history of heart failure (2° prevention)—E CVD p. 234 Family history of Coronary prone behaviour— CVD—60y have hypertension. Management aims to detect and treat i BP before damage occurs. Causes Unknown (‘essential’)—95%; alcohol (10%) or obesity may be contributory factors Endocrine disease—Cushing’s (both syndrome and 2° to steroids); Conn’s syndrome; phaeochromocytoma; acromegaly; hyperparathyroidism; DM Renal disease Pregnancy Coarctation of the aorta—E p. 252 Presentation Usually asymptomatic and found during routine BP screening or incidentally. Occasionally headache or visual disturbance May be symptoms of end-organ damage—LVH, TIAs, previous CVA/ MI, angina, renal impairment, PVD Measurement of blood pressure E p. 216 Diagnosis of hypertension BP is a normally distributed continuous vari- able; each 2mmHg i in systolic BP is associated with a 7% i risk of mortality from IHD and a 10% i risk of mortality from stroke. There is no figure above which hypertension can be diagnosed definitively. Criteria currently in useN: Stage 1 hypertension Clinic BP ≥140/90mmHg and subsequent daytime average ABPM/HBPM ≥135/85mmHg Stage 2 hypertension Clinic BP ≥160/100mmHg and subsequent daytime average ABPM/HBPM ≥150/95mmHg Severe hypertension Clinic systolic BP ≥180mmHg or clinic diastolic BP ≥110mmHg ! If the person has severe hypertension (systolic BP ≥180mmHg or diastolic BP ≥110mmHg), consider starting antihypertensive treatment immediately without waiting for the result of ABPM/HBPM. Refer for same day specialist assessment if suspected: Accelerated hypertension (BP >180/110mmHg ± papilloedema ± retinal haemorrhage) or Phaeochromocytoma (labile/postural hypotension, headache, palpitations, pallor, and excessive sweating) Isolated systolic hypertension Systolic BP ≥160mmHg—offer the same treatment as people with i systolic and diastolic BP. Further assessment Aims to identify target organ damage: Examination Check heart size, heart sounds, and for heart failure; examine the fundi, looking for silver wiring, AV nipping, flame haemorrhages and cotton wool spots Blood tests Creatinine, electrolytes, eGFR, glucose/HbA1c, lipid profile, consider GGT if excess alcohol is a possibility  HYPERTENSION 219 Urine Dipstick for RBCs and protein; laboratory sample for albumin: creatinine ratio Cardiovascular risk estimation E p. 214 ECG ± Echo (if LVH is suspected) 0 If i BP is not diagnosed but there is evidence of target organ damage (e.g. LVH, proteinuria), look for alternative causes. Education Patients will not take tablets regularly, be motivated to change lifestyle, or turn up for regular checks if they do not understand why treating their i BP is important. Conversely, some patients who were fit and well prior to their diagnosis will assume a sick role unless it is explained that they are well and treatment is designed to stop illness developing. Back-up verbal information with written information that patients can take home; reinforce information at follow-up and offer opportunities for discussion. Do not forget to warn patients about possible side effects of any medications. Lifestyle advice Offer lifestyle advice to all patients with a diagnosis of hypertension and those with FH of i BP. Reinforce advice with written information: Offer smoking cessation advice and help (E p. 156) d weight to optimum for height (E p. 152) Encourage regular exercise—dynamic is best, e.g. walking, swimming, cycling (E p. 154) d alcohol to 40y with hypertension and 10y CVD risk ≥10% Initiating antihypertensive drug treatment Stage 1 hypertension Offer drug treatment if 40y Puerperium Inflammatory bowel Smoking CHC/HRT use disease Obesity Surgery PMH of venous Immobility Recent trauma thromboembolism Recent long-distance Malignancy Inherited thrombophilic travel Heart failure clotting disorders Pregnancy Nephrotic syndrome Other chronic illness 0 Central venous catheters are a common cause of upper limb DVT. Presentation Unilateral leg pain, swelling, and/or tenderness ± mild fever, pitting oedema, warmth, and distended collateral superficial veins. Differential diagnosis Cellulitis Chronic venous Acute arterial Arthritis/muscle tear insufficiency ischaemia Ruptured Baker’s cyst Venous obstruction Lymphoedema Superficial Post-thrombotic Fracture thrombophlebitis syndrome Hypoproteinaemia Immediate action Clinical diagnosis is unreliable. 3cm greater than that of the unaffected leg Pitting oedema of affected but not unaffected leg Collateral superficial veins (non-varicose) Previous DVT Take away 2 points if: An alternative cause is as/more likely than DVT. Interpretation If score is 20 breaths/min) or deep (tidal volume i). If inappropriate, results in palpitations, dizziness, faintness, tin- nitus, chest pains, perioral and peripheral tingling (due to plasma Ca2+ d).  BREATHLESSNESS 265 Table 10.1 Causes of dyspnoea Cause Acute Subacute Chronic Cardiac Acute LVF Arrhythmia CCF disease Arrhythmia Subacute bacterial Valvular disease, e.g. Acute MI endocarditis mitral stenosis Aortic dissection Pericarditis Congenital heart Tamponade disease Lung Acute asthma attack Asthma Asthma disease COPD exacerbation COPD exacerbation COPD Upper airway obstruction Pneumonia Cystic fibrosis Pneumonia Pleural effusion Interstitial lung disease Acute pneumonitis, e.g. Lobar collapse Occupational lung due to inhaling toxic gas disease Pulmonary embolus Mesothelioma Pneumothorax Lung cancer Other Hyperventilation Aspirin poisoning Kyphoscoliosis Foreign body inhalation Myasthenia gravis Obesity Guillain–Barré syndrome Thyrotoxicosis Anaemia Altitude sickness Superior vena cava Neuromuscular Ketoacidosis obstruction weakness, e.g. MND, Polio MS Musculoskeletal pain Oesophageal pain Causes include: Anxiety (most common PE Lymphangitis cause) Hyperthyroidism Weakness of the Early pulmonary oedema Fever respiratory muscles Kussmaul respiration Deep, sighing breathing that is principally seen in meta- bolic acidosis, e.g, diabetic ketoacidosis and uraemia. Neurogenic hyperventilation Stroke, tumour, or CNS infection. Hypoventilation Abnormally d pulmonary ventilation. Respiration may be too slow or tidal volume d. Causes include: Respiratory depression, e.g. opioid analgesia, anoxia, trauma Neurological disease, e.g. Guillain–Barré disease; polio; motor neurone disease; syringobulbia Lung disease, e.g. pneumonia, collapse, pneumothorax, pleural effusion Respiratory muscle disease, e.g. myasthenia gravis, dermatomyositis Limited chest movement, e.g. kyphoscoliosis Cheyne–Stokes respiration Breathing becomes progressively deeper and then shallower (± episodic apnoea) in cycles. Causes: brainstem lesions/ compression (stroke, i ICP); chronic pulmonary oedema; poor cardiac output. It is enhanced by narcotics. Further information NICE (2015, updated 2017) Suspected cancer: recognition and referral. M www.nice.org.uk/guidance/ng12 6 2 266 CHAPTER 10 Respiratory medicine Cough A cough is a reaction to irritation anywhere from pharynx to lungs. Acute cough (65y with acute cough and ≥2 or more of the following, or aged >80y with acute cough and ≥1 of the following: Hospitalization in the previous year Type 1 or type 2 DM History of congestive heart failure Current use of oral glucocorticoids Chronic cough (>3wk) Causes: Postnasal drip Bronchiectasis Drug induced (e.g. ACE Post viral Pulmonary oedema inhibitors) COPD/asthma Foreign body Smoker’s cough Lung cancer Vocal cord palsy Ear wax Pertussis GORD Psychogenic TB LVF Idiopathic H Red flags: Weight d, night sweats, fever, haemoptysis. Management Offer an urgent CXR in those ≥40y if they have ≥2 (or if smoker/ex-smoker or exposed to asbestos and ≥1) of the following symp- toms: cough; fatigue; shortness of breath; chest pain; weight d; appetite dN. Treat the cause. If no cause is found, refer. Sputum 0 Absolutely clear sputum is probably saliva. Smoking is the leading cause of excess sputum production—look for black specks of inhaled carbon Yellow-green sputum is due to cell debris (bronchial epithelium, neutrophils, eosinophils) and is not always infected Bronchiectasis causes copious greenish sputum Blood-stained sputum (haemoptysis) always needs full investigation Pink froth suggests pulmonary oedema  COUGH 267 Haemoptysis Expectoration of blood/blood-stained sputum. Causes: Infection—bronchitis, pneumonia, Cardiac: acute LVF, mitral stenosis lung abscess, TB Blood dyscrasia/bleeding diathesis Violent coughing Idiopathic pulmonary Bronchiectasis haemosiderosis Lung cancer Bronchial adenoma PE (blood is not mixed with sputum) Mycosis, e.g. aspergilloma Inhaled foreign body Goodpasture’s syndrome Iatrogenic: anticoagulation, Collagen vascular disease, e.g. PAN, endotracheal tube granulomatosis with polyangiitis Trauma Idiopathic 0 Differentiate from haematemesis or local bleeding from the naso- pharynx or sinuses. Melaena may occur if enough blood is swallowed. Management Always requires investigation to find the cause. Admit as an acute medical emergency if the patient is compromised by the bleeding (i.e. tachycardia, low BP, postural drop) or has symptoms/ signs of a cause requiring acute admission (e.g. PE, acute LVF) Refer for urgent chest physician assessment if aged ≥40y with unexplained haemoptysisN 0 In patients with lung cancer who have a massive haemoptysis as a ter- minal event, consider treating with IV morphine/diamorphine and a seda- tive (e.g. midazolam or rectal diazepam) rather than admitting. Bronchiectasis Consider in patients with persistent or recurrent chest infections. Permanently dilated bronchi act as sumps for infected mucus. Causes: Congenital CF, Kartagener syndrome Post-infection TB, pertussis, measles, pneumonia Other Bronchial obstruction, aspergillosis (E p. 299), hypogammaglobulinaemia (E p. 658), gastric aspiration Presentation Mild cases Usually asymptomatic with winter exacerbations consisting of fever, cough, purulent sputum, pleuritic chest pain, dyspnoea More severe cases Persistent cough and sputum, haemoptysis, clubbing, low-pitched inspiratory and expiratory crackles and wheeze Investigations CXR; sputum—M,C&S; spirometry—reversible airways ob- struction is common; high-resolution CT detects disease in 97% of cases. Management Refer to a respiratory physician. Treatment includes physio- therapy, antibiotics, bronchodilators, vaccination (influenza and pneumo- coccal) and (rarely) surgery. Further information NICE (2008) Respiratory tract infections: antibiotic prescribing. M www. nice.org.uk/guidance/cg69 NICE (2015, updated 2017) Suspected cancer: recognition and referral. M www.nice.org.uk/guidance/ng12 8 7 2 278 CHAPTER 10 Respiratory medicine Asthma in adults Symptoms/signs of a severe asthma attack PEFR 33–50% predicted or Tachypnoea (respiratory rate ≥25 best breaths/min) Oxygen saturation ≥92% Tachycardia (heart rate ≥110bpm) Unable to talk in sentences Life-threatening signs PEFR 20 pack y) Symptoms with colds only Cardiac disease 0 Normal spirometry when asymptomatic does not exclude asthma. Tests Spirometry + reversibility is the preferred initial test; consider CXR with atypical/additional symptoms; eosinophil counts. 0 NICE advocates initial use of fractional exhaled nitric oxide (FeNO) testing.  ASTHMA IN ADULTS 279 Differential diagnosis Airflow obstruction = FEV1/FVC 200mL i in FEV1 suggests (>400mL i strongly suggests) asthma. If smaller improvement, decide whether to continue treatment by assessment of symptoms. Trial of treatment withdrawal may be helpful if doubt. Reasons for referral E = Emergency; U = Urgent; S = Soon; R = Routine Severe asthma exacerbation E Constant breathlessness S/R Monophonic wheeze/stridor E/U Poor response to treatment S/R CXR shadowing U Unexplained restrictive spirometry R Prominent systemic features Suspected occupational asthma R (myalgia, fever, weight loss) U/S Chronic sputum production R Diagnosis unclear S/R Eosinophilia (>1 × 109/L) R Unexpected clinical findings (e.g. crackles, clubbing, cyanosis) S/R 0 8 2 280 CHAPTER 10 Respiratory medicine Asthma management in practice  There are two competing national asthma guidelines in the UK which differ significantly from each other. The guidance in this section is based on BTS/SIGN guidance; a link to the parallel NICE guidance is provided. Aims of treatment To: d daytime symptoms and night-time waking due to asthma Minimize the need for reliever medication d impact on lifestyle, e.g. absences from work/school, exercise Prevent severe attacks/exacerbations Have normal lung function (FEV1 and/or PEF >80% predicted or best) d side effects from medications GP services Routine asthma care should be carried out in a specialized primary care clinic. Doctors/nurses involved need appropriate training and regular updates. Practices should keep an asthma register to ensure ad- equate follow-up and allow audit. 0 Not all patients want to attend a pre-arranged appointment. Telephone reviews may be as effective as face-to-face consultations. Reviews and monitoring Frequency depends on needs. Aim to re- view all patients with asthma at least annually (Figure 10.2). Check symptoms since last seen. Use objective measures, e.g. RCP 3 questions (E p. 273) Record smoking status and advise smokers to stop Include objective measures Symptoms e.g. RCP 3 questions, ACQ, ACT ( p. 273) Smoking status Record/advise about smoking cessation Exacerbations Numbers and circumstances Use/concordance Medication Problems/side effects Inhaler technique Examination Objective measures of lung function e.g. PEFR, spirometry Education Tailor to the individual: Treatment Monitoring Allergen avoidance Goals and next review Action plan Figure 10.2 Summary of the annual asthma review  ASTHMA MANAGEMENT IN PRACTICE 281 Record any exacerbations/acute attacks since last seen Check medication—use, concordance (prescription count—E p. 116), inhaler technique, problems, side effects. 0 If >1 SABA inhaler/mo, may have poor asthma control—consider stepping up treatment Check influenza/pneumococcal vaccination received Review objective measures of lung function, e.g. home PEFR chart, PEFR/spirometry at review Address any problems or queries and educate about asthma Agree management goals and date for further review Self-management All patients should receive: Self-management education Brief, simple education linked to patient goals is most likely to be successful. Include information about: nature of disease, nature of the treatment and how to use it, self-monitoring/ self-assessment, recognition of acute exacerbations, allergen/trigger avoidance, patients’ own goals of treatment Written action plan Focus on individual needs. Include information about symptom triggers and peak flow levels that indicate when asthma is worsening, and guidance about what to do under those circumstances. Action plans d morbidity and health costs from asthma PEFR monitoring Record PEFR at asthma review and if acute exacerbation. Home monitoring + action plan can be useful especially for patients with severe asthma, brittle asthma (i.e. rapid development of acute asthma attacks), and/or if poor perceivers of symptoms Management of acute asthma Ep. 1072 Non-pharmacological measures Smoking May i symptoms of asthma—advise to stop Weight There is some evidence that weight d in obese patients with asthma results in i asthma control Allergen avoidance House dust mite: there is little evidence that d house dust mite results in clinical improvement. Physical and chemical methods of reducing house dust mite levels are ineffective and should not be recommended, e.g. acaricides, mattress covers, vacuum cleaning, heating, ventilation, freezing, washing, air filtration, and ionizers Pets: there is no evidence that removing pets from a home results in improved symptoms, but many experts still advise removal of the pet if patients with asthma also have an allergy to the pet Drug therapy E p. 282 Further information BTS/SIGN (2019) British guideline to the management of asthma. M www.sign.ac.uk/sign-158-british-guideline-on-the-management-of- asthma.html NICE (2017) Asthma: diagnosis, monitoring and chronic asthma manage- ment. M www.nice.org.uk/guidance/ng80 Patient information and support Asthma UK F 0300 222 5800 M www.asthma.org.uk 8 2 282 CHAPTER 10 Respiratory medicine Drug treatment of asthma  There are two competing national asthma guidelines in the UK which differ significantly from each other. The guidance in this section is based on BTS/SIGN guidance; a link to the parallel NICE guidance is provided. Management of acute asthma E p. 1072 Exacerbations Treat early. In adult patients on 200mcg doses of inhaled steroids, a 5× i in dose reduces severity of exacerbations. Alternatively, use prednisolone 30–40mg od for 1–2wk. Use a stepwise approach Figure 10.3. Start at the step most appro- priate to the initial severity of symptoms. Achieve early control. Maintain control by i treatment if needed and d treatment if good control. Selection of inhaler device If possible, use a MDI. Inadequate tech- nique may result in drug failure. Patients must inhale slowly and hold their breath for 10sec after inhalation. Demonstrate inhaler technique before prescribing and check at follow-ups. Spacers/breath-activated devices are useful if patients find activation difficult. Dry powder inhalers are an alternative. Short-acting β2 agonists E p. 276—e.g. salbutamol/terbutaline. Work more quickly and with fewer side effects than alternatives. Use prn unless shown to benefit from regular dosing. Using ≥2 canisters/mo or >10–12 puffs/d is a marker of poorly controlled asthma. 0 A budesonide/formoterol combination inhaler is an alternative rescue medication as part of a MART regime. Inhaled corticosteroids E p. 276—effective preventer. May be beneficial even for patients with mild asthma. Consider if: exacerbation of asthma in the last 2y requiring steroids; using inhaled β2 agonists ≥3×/wk; or symptomatic ≥3×/wk or ≥1 night/wk. Oral steroids E p. 276 Add on therapy Aims to improve lung function/symptoms. Before initiating a new drug, check compliance, inhaler technique, and eliminate trigger factors. Only continue if of demonstrable benefit. Inhaled long-acting β2 agonists (LABA) E p. 276—e.g. salmeterol. Although there is no difference in efficacy, combination inhalers are recommended to improve inhaler concordance. A MART regime using a steroid/formoterol combined inhaler for both regular prevention and relief of acute symptoms is useful to d asthma attacks. Leukotriene receptor agonists e.g. montelukast. d exacerbations Theophylline Side effects are common e.g. nausea, gastric irritation Complementary therapies Buteyko breathing technique d symp- toms. No convincing evidence of effectiveness of any other therapies. Monocloncal antibodies e.g. omalizumab, mepolizumab. May be considered in patients with a high oral corticosteroid burden. Always spe- cialist initiated. Side effects include local skin reactions and anaphylaxis.  DRUG TREATMENT OF ASTHMA 283 Figure 10.3 Summary of stepwise management in adults Source: data from British Thoracic Society and Scottish Intercollegiate Guidelines Network, SIGN 158: British guideline on the management of asthma (revised 2019) https://www.sign.ac.uk/assets/sign158.pdf Stepping down Review and consider stepping down at intervals ≤3 mo. Maintain on the lowest dose of inhaled steroid controlling symptoms. When reducing steroids, cut dose by 25–50% each time. Difficult asthma Persistent symptoms and/or frequent exacerbations despite treatment at step 4/5. Check diagnosis and exacerbating factors. Assess adherence to medication. Find out about family, psychological, or social problems that may be interfering with effective management. Further information BTS/SIGN (2019) British guideline to the management of asthma. M www. sign.ac.uk/sign-158-british-guideline-on-the-management-of-asthma.html NICE (2017) Asthma: diagnosis, monitoring and chronic asthma manage- ment. M www.nice.org.uk/guidance/ng80 4 8 2 284 CHAPTER 10 Respiratory medicine Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a slowly progressive dis- order characterized by airflow obstruction. In the UK, it affects ~3million people, with two-thirds undiagnosed. ♂ > ♀. Responsible for 1 in 8 emer- gency hospital admissions and ~5% of deaths in the UKN. Causes: Tobacco smoking (90% of cases) Occupational exposure, e.g. coal, silica, welding fumes Air pollution Genetic—bronchial hyper-responsiveness; α1-antitrypsin deficiency Poor lung growth and development e.g. low birth weight, infections Incidental CXR/CT scan abnormalities E p. 272 Diagnosis Suggested by history, signs, and baseline spirometry. Consider in patients >35y with a risk factor for COPD (generally smoking) and typical symptoms: Shortness of breath on exertion—use an objective measure, e.g. MRC dyspnoea scale (Table 10.6) to grade breathlessness Chronic cough Regular sputum production Wheeze Frequent winter ‘bronchitis’ Table 10.6 MRC Dyspnoea Scale Grade Degree of breathlessness related to physical activity 1 Not troubled by breathlessness except on strenuous exercise 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath when walking at own pace 4 Stops for breath after walking 100m or after a few minutes on level ground 5 Too breathless to leave the house or breathless on dressing/undressing. Used with the permission of the Medical Research Council. If diagnosis is suspected also ask about Weight d, effort intolerance, waking at night, ankle swelling, fatigue, and occupational hazards. ! Chest pain or haemoptysis are uncommon in COPD—if present con- sider an alternative diagnosis. Signs May be none. Possible signs: Hyperinflated chest ± poor chest Tachypnoea expansion on inspiration Pursing of lips on expiration d crico-sternal distance (pursed lip breathing) Hyper-resonant chest with d cardiac Peripheral oedema dullness on percussion Cyanosis Wheeze or quiet breath sounds i JVP Paradoxical movement of lower ribs Cachexia Use of accessory muscles Spirometry E p. 272. Predicts severity and prognosis but not disability/ quality of life. Measured post-bronchodilator, e.g. 200mcg salbutamol via spacer. Diagnose airflow obstruction if FEV1/FVC 40y—U (if age >60y)/S/R Atypical features (i.e. not those listed above)—U/S/R  IRRITABLE BOWEL SYNDROME 389 Family history of bowel or ovarian cancer—R Patient is unhappy to accept a diagnosis of IBS despite explanation—R Treatment Reassure. Information leaflets are helpful. Encourage lifestyle measures, stress d, leisure time and regular physical exercise. Diet Encourage patients to have regular meals and take time to eat. Avoid missing meals or leaving long gaps between eating. Drink ≤8 cups of fluid/d, especially water. Restrict tea/coffee to 3 cups/d. d intake of alcohol and fizzy drinks d intake of high-fibre foods (e.g. wholemeal/high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice) d intake of ‘resistant starch’ found in processed or re-cooked foods Limit fresh fruit to 3 × 80g portions/d For diarrhoea, avoid sorbitol, an artificial sweetener For wind and bloating consider i intake of oats (e.g. oat-based breakfast cereal or porridge) and linseeds (≤1 tablespoon/d) Up to 50% may be helped by exclusion of certain foods. Diaries may help identify foods that provoke symptoms, e.g. dairy products, citrus fruits, caffeine, alcohol, tomatoes, gluten, and eggs. Refer to dietician Specific measures Fibre/bulking agents Constipation-predominant IBS. Bran can make some patients worse. Oats and ispaghula husk are better tolerated. Laxatives are an alternative but avoid use of lactulose Antispasmodics e.g. mebeverine, peppermint oil. Limited effectiveness. If no response in a few days, switch to another—different agents suit different individuals. Once symptoms are controlled use prn Antidiarrhoeal preparations e.g. loperamide. Avoid codeine phosphate as may cause dependence. Use prn for patients with diarrhoea- predominant disease. Use pre-emptive doses to cover difficult situations (e.g. air travel) Antidepressants There is some evidence that low-dose amitriptyline, e.g. 10mg nocte or SSRIs may help symptoms Probiotics Some evidence of effectiveness. Consider a 4wk trial Psychotherapy and hypnosis Evidence of effectiveness but limited availability. Consider for cases that have failed to respond to first-line treatment after >1y FODMAPs diet Some evidence of effectiveness. Refer to dietician Failure to respond to treatment Consider another diagnosis—review history and examination ± refer for further investigation. Prognosis >50% still have symptoms after 5y. Further information NICE (2013) Faecal calprotectin diagnostic tests for inflammatory bowel disease. M www.nice.org.uk/guidance/dg11 NICE (2008, updated 2017) Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care. M www. nice.org.uk/guidance/cg61 Advice and support for patients The IBS Network M www.theibsnetwork.org  Chapter 13 407 Renal medicine and urology Laboratory tests 408 Estimating renal function 410 Presentation of renal disease 412 Chronic kidney disease 414 Specific kidney diseases 416 Renal stones 418 Haematuria, bladder and renal cancer 420 Urinary tract infection 422 Incontinence of urine 424 Aids and appliances for incontinence 426 Urinary tract obstruction 428 Benign prostatic hypertrophy 430 Prostate cancer 434 Treatment of prostate cancer 436 Conditions of the penis 438 Testicular disease 440 041 410 CHAPTER 13 Renal medicine and urology Estimating renal function Direct measure of glomerular filtration rate (GFR) using 24h plasma or urinary clearance is most accurate but is time-consuming and difficult in practice. Instead, other methods are often used to estimate GFR. Renal function d with age (~1mL/min/y >40y). Always assume a degree of renal impairment in all patients >75y. Urine ACR and PCR E p. 409 Estimated glomerular filtration rate (eGFR) Method of calcu- lation of renal function based on serum creatinine levels. Various equations exist but, in the UK, laboratories report eGFR using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. This is adjusted for body surface area and uses age, sex (× 1.018 if ♀) and ethnicity (× 1.159 if of Afro-Caribbean origin) as variables. Limitations of eGFR calculation Do not use if rapidly changing renal function or AKI. May be affected by some drugs (e.g. trimethoprim) and dependent on muscle mass and diet: Overestimates eGFR If elderly, low-protein diet, amputee or muscle- wasting disorder (e.g. myasthenia gravis, late-stage muscular dystrophy) Underestimates eGFR If high muscle mass (e.g. high-level sport or body builder), high protein diet (e.g. taking protein supplements), muscle breakdown (e.g. after heavy exercise, myositis, muscular dystrophy) Interpretation of eGFR Table 13.2 and Figure 13.1 eGFR cystatin C Method of calculating eGFR using blood cystatin C levels instead of creatinine. Consider at initial diagnosis if: Standard eGFR (using creatinine) is 45–59mL/min/1.73m2, sustained for ≥90d, and No proteinuria (ACR 60mL/min/1.73m2. 0 Interpret eGFR cystatin C with caution if uncontrolled thyroid dis- ease: falsely i with hypothyroidism and d with hyperthyroidism. Cockcroft and Gault formula Box 13.1. Preferred method for estimating renal function if elderly (≥75y), high or low BMI (>40kg/m2 or 20%, markers of kidney markers of kidney indicates CKD may indicate damage are present, disease are present. If (E p. 414) significant d in e.g. ACR ≥3mg/mmol, no proteinuria (ACR renal function persistent microscopic ♂. Usually asymptomatic. May be associated with i BP. In later stages may cause nausea/vomiting, anorexia, lethargy, oedema, dyspnoea, ± itching. Causes DM CVD Polycystic kidneys Amyloid i BP i Ca Glomerulonephritis 2+ Myeloma Urinary tract obstruction Renovascular disease PAN Chronic pyelonephritis Interstitial nephritis AKI Nephrotoxic drugs SLE Classification of CKD Figure 13.1 (E p. 411). Both i ACR and d eGFR are associated with i risk of adverse outcomes (renal failure and CVD). In combination, risk is multiplied. Testing for CKDN Check eGFR + ACR (in most cases 1×/y) if ≥1 of: i BP AKI (E p. 412) DM (all type 2; type 1 if present >5y) Haematuria (E p. 420) CVD (stroke, TIA, IHD, heart failure, peripheral vascular disease) Structural renal tract disease, recurrent renal calculi, or BPH Multisystem disease with potential kidney involvement, e.g. SLE FH of end-stage kidney disease or hereditary kidney disease If prescribed drugs known to be nephrotoxic, e.g. calcineurin inhibitors (e.g. ciclosporin, tacrolimus), lithium, NSAIDs 0 Repeat test in 5–7y) but benefit disappears 51y HRT should not be considered first-line therapy for long-term prevention of osteoporosis. HRT remains an option where other therapies are contraindicated, cannot be tolerated, or if there is a lack of response; risks and benefits should be carefully assessed Teriparatide Third line for postmenopausal women and second line for men with past history of fragility fracture if other treatments are not tol- erated/ineffective and specific T-score and clinical criteria are met. Given by daily injection. Maximum duration of use is 18mo. Consider referral for consultant initiation if other treatment options are exhausted. Osteoporosis in men Currently only bisphosphonates and teriparatide are recommended for treatment of osteoporosis in men. Monitoring There is no consensus about duration of treatment for osteoporosis or monitoring of BMD during treatment. Circumstances in which repeat DXA scanning might be necessary include: Fragility fracture on treatment If considering a change in treatment When considering restarting therapy after a drug holiday Referral Consider referral to an appropriate specialist if (U = urgent re- ferral; R = routine referral): Another cause for fragility fracture is suspected (e.g. metastasis)—U Fragility fracture on treatment—R Unusual presentation of osteoporosis, e.g. premenopausal woman—R For consideration of treatment with IV bisphosphonate, denosumab, or teriparatide—R Further information National Osteoporosis Guideline Group Clinical guideline for the preven- tion and treatment of osteoporosis. M www.shef.ac.uk/NOGG NICE (2008, updated 2018) Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the primary and sec- ondary prevention of osteoporotic fragility fractures in postmenopausal women. M www.nice.org.uk/guidance/ta161 NICE (2010) Osteoporotic fractures—denosumab. M www.nice.org.uk/ guidance/ta204 NICE (2015) Menopause: diagnosis and management. M www.nice.org. uk/guidance/ng23 6 8 4 486 CHAPTER 14 Musculoskeletal problems Osteoarthritis Osteoarthritis (OA) is the most important cause of locomotor disability. It used to be considered ‘wear and tear’ of the bone/cartilage of synovial joints but is now recognized as a metabolically active process involving the whole joint—i.e. cartilage, bone, synovium, capsule, and muscle. The main reason for patients seeking medical help is pain. Level of pain and disability are greatly influenced by the patient’s personality, anxiety, depres- sion, and activity, and often do not correlate well with clinical signs. Risk factors i age (uncommon ♂; i in black and Asian populations; genetic predisposition; obesity; abnormal mechanical loading of joint, e.g. instability; poor muscle function; post-meniscectomy; certain occupations, e.g. farming. Symptoms and signs Joint pain ± stiffness, synovial thickening, de- formity, effusion, crepitus, muscle weakness/wasting, and d function. Most commonly affects hip, knee, and base of thumb. Typically exacerbations last weeks to months. Nodal OA, with swelling of the distal interphalangeal joints (Heberden’s nodes) has a familial tendency. Investigations X-rays may show d joint space, cysts and sclerosis in subchondral bone, and osteophytes. OA is common and may be a coinci- dental finding. Exclude other causes of pain, e.g. check FBC and ESR if inflam- matory arthritis is suspected (normal or mildly i in OA—ESR >30mm/h suggests RA or psoriatic arthritis). Management of osteoarthritis in primary care Employ a holistic approach. Assess effect of OA on the patient’s functioning, quality of life, occupation, mood, relationships, and leisure activities. Formulate a manage- ment plan with the patient that includes self-management strategies, effects of co-morbidities and regular review. Information and advice Give information and advice on all relevant aspects of osteoarthritis and its management. Arthritis Research UK produces a range of leaflets for patients. Use the whole multidisciplinary team, e.g. refer to: Physiotherapist for advice on exercises, strapping, and splints OT for aids Chiropodist for foot care and insoles Social worker for advice on disability benefits and housing Orthopaedics for surgery if significant disability/night pain d load on the joint Weight reduction can d symptoms and may d progres- sion in knee OA. Using a walking stick in the opposite hand to the affected hip and cushioned insoles/shoes (e.g. trainers) can also help. Exercise and improving muscle strength d pain and disability, e.g. walking (for OA knee), swimming (for OA back and hip but may make neck worse), cyc- ling (for OA hip and OA knee—but may worsen patellofemoral OA). Refer to physiotherapy for advice on exercises especially isometric exercises for the less mobile. Pain control Use non-pharmacological methods first (activity, exercise, weight d, footwear modification, walking stick, TENS, local heat/cold treatments)  OSTEOARTHRITIS 487 Regular paracetamol (1g qds) is first-line drug treatment for all OA and/ or topical NSAIDs for knee/hand OA only. Topical NSAIDs have less side effects than oral NSAIDs and are more acceptable to patients Use opioids, oral NSAIDs, or COX2 inhibitors as second-line agents in addition to, or instead of paracetamol. Use the lowest effective dose for the shortest possible time. Co-prescribe a proton pump inhibitor (e.g. omeprazole 20mg od) with NSAIDs if taking for >1wk Low-dose antidepressants, e.g. amitriptyline 10–75mg nocte (unlicensed) are a useful adjunct especially for pain causing sleep disturbance Capsaicin cream can also be helpful for knee/hand OAN Aspiration of joint effusions and joint injections Can help in exacerbations. Some patients respond well to long-acting steroid injections—it may be worth considering a trial of a single treatment. Hyaluronic acid knee injec- tions are not recommended by NICE. Complementary therapies 760% of sufferers from OA are thought to use CAM, e.g. copper bracelets, acupuncture, food supplements, dietary ma- nipulation. There is good evidence chiropractic/osteopathy can be helpful for back pain, but otherwise evidence of effectiveness is scanty. Advise patients to find a reputable practitioner with accredited training who is a member of a recognized professional body and carries professional indem- nity insurance.  Other drugs/supplements Glucosamine It is controversial whether glucosamine modifies OA progression. It is available OTC but not recommended by NICE Strontium ranelate d progression of OA, d pain, and i mobilityR. Place in OA management is yet to be determined Psychological factors Have a major impact on the disability from OA. Education about the disease, and emphasis that it is not progressive in most people, is important. Seek depression and anxiety with screening tools—E p. 173. Treat as needed. Refer To rheumatology To confirm diagnosis if coexistent psoriasis (psoriatic arthritis mimics OA and can be missed by radiologists); rule out 2° causes of OA (e.g. pseudogout, haemochromatosis) if young OA or odd distribution; if joint injection is thought worthwhile but you lack expertise or confidence to do it To orthopaedics If symptoms are severe for joint replacement. Refer as an emergency if you suspect joint sepsis Further information NICE Osteoarthritis: care and management. M www.nice.org.uk/guid- ance/cg177 Information and support for patients Arthritis Care F 0808 800 4050 M www.arthritiscare.org.uk Arthritis Research UK F 0800 5200 520 M www.arthritisresearchuk.org 8 4 488 CHAPTER 14 Musculoskeletal problems Rheumatoid arthritis Rheumatoid arthritis (RA) is the most common disorder of connective tissue affecting 71% of the UK population. It is an immunological disease, triggered by environmental factors, in patients with genetic predisposition. Disease course is variable with exacerbations and remissions. ! Refer all suspected cases of rheumatoid arthritis to rheumatology— early treatment with disease-modifying drugs can significantly alter disease progression. Refer urgentlyN if: Small joints of the hands/feet are affected >1 joint is affected There has been a delay of ≥3mo between onset of symptoms and seeking medical advice Presentation Can present at any age—most common in middle age. ♀:♂ 83:1 Variable onset—often gradual but may be acute Usually starts with symmetrical small joint involvement—i.e. pain, stiffness, swelling, and functional loss (especially in the hands)—joint damage and deformity occur later Irreversible damage occurs early if untreated and can l deformity and joint instability Other presentations—monoarthritis; migratory (palindromic) arthritis; PMR-like illness; systemic illness of malaise, pain, and stiffness Symptoms and signs Predominantly peripheral joints are affected— symmetrical joint pain, effusions, soft tissue swelling, early morning stiff- ness. Progression to joint destruction and deformity. Tendons may rupture. Specific features—Table 14.8. Differential diagnosis Diagnosis may not be easy—consider: Psoriatic arthritis Bilateral carpal tunnel syndrome Nodal OA Other connective tissue disorders SLE (especially in ♀ 50y Investigations Check FBC (normochromic normocytic or hypochromic, microcytic anaemia), ESR, and/or CRP (i). May have i platelets, d WCC Rheumatoid factor and anti-CCP antibodies are +ve in the majority. A minority have a +ve ANA titre X-rays—normal, periarticular osteoporosis or soft tissue swelling in the early stages; later—loss of joint space, erosions, and joint destruction Management A multidisciplinary team approach is ideal, e.g. GP, medical and surgical teams, physiotherapist, podiatrist, OT, nurse s