Native Nuggets Full Note Updated September PDF

NATIVE SCA NUGGETS Overview of the SCA The Simulated clinical assessment exam is one part of the MRCGP exams. There are 12 stations in the exam with each station lasting 12 minutes. You will be assessed based on the following clinical experience groups Patient less than 19 years old...

NATIVE SCA NUGGETS Overview of the SCA The Simulated clinical assessment exam is one part of the MRCGP exams. There are 12 stations in the exam with each station lasting 12 minutes. You will be assessed based on the following clinical experience groups Patient less than 19 years old Gender, reproductive and sexual health, including women's, men's, LGBTQ+, gynae and breast Long-term condition, including cancer, multi-morbidity, and disability Older adults, including frailty and people at the end of life Mental health, including addiction, smoking, alcohol, substance misuse Urgent and unscheduled care Health disadvantage and vulnerabilities, including veterans, mental capacity, safeguarding, and communication difficulties Ethnicity, culture, diversity, inclusivity New presentation of undifferentiated disease Prescribing Investigation / Results Professional conversation / Professional dilemma There are 3 domains for marking Data gathering and diagnosis Interpersonal skills/ relating to others Clinical Management and complexity Domain marking Clear pass- 3 marks Pass- 2 marks Fail- 1 mark Clear fail- 0 Total marks available in the SCA= 126  Data gathering and diagnosis= 36 marks Interpersonal skills/relating to others=36 marks Clinical management and complexity= 54 marks Clinical management and complexity have weighting, so failing this part of the exam is dangerous. However, you should take all part serious as 1 mark can make a difference of pass or fail-Yes there are those that fail with 0.5 marks. Early preparation is recommended. DO NOT TAKE THIS EXAM FOR GRANTED or it will take you for granted and your 1,180 pounds (which can be used for a decent vacation in Canary Islands) will go to waste. Proforma for tackling the SCA by Dr Native Data gathering and diagnosis History-salient points and red flags ICE Psychosocial Diagnosis-MUST GIVE A DIAGNOSIS to get full mark for data gathering and diagnosis. If you do not give a working diagnosis-you will leave patient in an uncertain situation and this is not a good thing. Where there is uncertainty, you must explain most likely diagnosis and give other differential- for example- A 75- year-old male smoker patient who has bloody mucus coming out from ipsilateral nose and mouth for 2 months with weight loss and night sweats, who is also on Apixaban and suffers with recurrent sinusitis, there are lots of differentials but there is something much more serious and likely to be the diagnosis which should not be missed—so you explain: Thanks for explaining all that Mr. O'Toole, I agree with you that sinusitis could cause the blood mucus coming from the back of your throat, I also did think that the apixaban could also contribute to it. However, I’m worried that it could also mean something serious…. when I say serious, I mean cancer … cancer at the back of your throat called sinonasal cancer. Management Address ICE first!!!!! -This is where your skill for relating to others shows itself Investigations- further investigations even if it’s an investigation station- there may be other bloods and scans that may need doing to aid the already blood test. For  example, isolated mcv showing microcytosis, you must do ferritin to confirm if it’s iron deficiency as other things can cause microcytosis Treatment: Drug- must ask allergy and must state at least one side effects and duration of treatment if it requires- for example- Mr. Native, I would prescribe you nifedipine to help prevent your condition (Raynaud's). Can I just heck, do you have any allergy? This medication is usually used to treat high blood pressure but has been found to help with this condition-common side effects include feeling dizzy but most people do well on this medication, if this becomes a problem, do let us know. Health promotion -e.g. stop smoking, stop alcohol. Immunization- pneumococcal, covid, flu for COPD, CKD, asthma Etc. Safety net/ follow up- All stations have at least one of them. It’s a remote consultation, so appropriate safety netting or follow up or even both is necessary to ensure safety and good practice For good explanation of conditions: For every chronic condition- start with this statement It’s a long-term condition that tends to flare from time to time (for conditions that flare) like eczema, psoriasis, asthma, COPD etc NATIVE NUGGETS Musculoskeletal/Rheumatology notes FOR ALL MUSCKULOSKELETAL/RHEUMATOLOGY--OFFER LEAFLET FROM VERUS ARTHRITIS GOUT History taking Ask about pain Ask about swelling Ask about redness Ask if he/she can move the joint Ask if any other joint affected Ask if any lumps or bumps Ask about fever Ask about how this has affected his day-to-day activities and occupation Ask about alcohol, smoking etc Gout explanation--- This is a long-term condition that tends to flare from time to time. there is accumulation of small crystals in the joint caused by accumulation of a chemical called uric acid which causes pain in the joint Management Offer F2F Examination if not already done If on NSAID and EGFR is low, stop NSAID and offer colchicine NB: Colchicine should not be repeated for at least 3 days after completing a course of treatment. For example, if a patient takes colchicine for gout and had a course for 4 days and stopped the course as symptoms resolved. If symptoms start again 1-2 days after, the patient cannot have another course of colchicine. Alternatives includes NSAIDS and if patient has contraindications the options include prednisolone 30-35 mg once a day for 3-5 days. or Intraarticular injection with rheumatology Advise people with gout that ice packs can also be applied to the affected joint to help alleviate pain Can also use paracetamol as adjunct pain relief Continue treatment with urate-lowering drugs (allopurinol or febuxostat) if they are already taking these. If on Thiazide diuretics, change to other antihypertensives (Amlodipine or ACEi if patient has CKD) In a person with heart failure, continue diuretics during an acute attack, don't stop it. Offer further investigations—for example, if patient has CKD, then offer Urine ACR. Don’t forget U+ E’s Uric acid CRP, ESR if not done Offer referral to Rheumatology if patient has chronic kidney disease (CKD) stages 3b to 5 (GFR categories G3b to G5). Offer lifestyle advice – eat healthy, balanced diet, lose weight, reduce alcohol Offer follow up 2-4 weeks after a flare subsides to discuss urate lowering therapy (Allopurinol and febuxostat) Safety net re septic arthritis ---if worsening pain, swelling, UNABLE TO MOVE THE JOINT, FEVER, then seek urgent medical advice (111 or call the surgery urgently) Offer leaflet on Versus-Athritis to read more about gout NOTE PLEASE : For people taking: Allopurinol — monitor closely for hypersensitivity syndrome when therapy is initiated. Allopurinol can cause drug reaction, if this happens, please, ask about  Onset of rash Extent of spread of rash/location of rash Itchiness Fever Contact with persons with similar rash Fluids or discharge from rash/ weeping Tongue swelling, lip swelling, SOB and wheeze to out-rule anaphylaxis Rash or ulcers in mouth (Cutaneous areas to rule out steven Johnson syndrome) Management involves stopping Allopurinol and waiting for a while before initiating Febuxostat. Please, do LFTs before starting febuxostat—give one common side effects of febuxostat—tummy upset, then re-assure that most people do well on it and if any concerns, should seek medical advice RHEUMATOID ARTHRITIS History taking Ask if unilateral or bilateral Ask about pain Ask about swelling Ask about stiffness and how long stiffness last (Usually more than 1hr) Ask about redness Ask if he/she can move the joint Ask if any other joint affected Ask if any lumps or bumps Ask about fever Ask about Rheumatoid nodules — hard, firm swellings over extensor surfaces occur in a third of people with RA. Ask about extra-articular features such as vasculitis or involvement of other body systems (for example, eye (Redness of eyes or blurry vision), lungs /Heart (SOB, wheeze). Systemic features of malaise, fatigue, fever, sweats, and weight loss. A family history of RA. Ask about how this has affected his day-to-day activities and occupation Ask about alcohol, smoking etc Management  As usual, address ICE first Offer face to face to examine hand Further investigations include Rheumatoid factor, Anti-CCP, FBC, U+E’s, LFTs, CRP, ESR and Xray (Only do this if not done already and if newly diagnosis or suspicion, however, when patient is known to have rheumatoid arthritis and there is a flare, then you can offer FBC, CRP, ESR) Offer Naproxen (PLEASE CONFIRM IF PATIENT HAS ASTHMA/COPD OR TUMMY UPSET OR ALLERGIES BEFORE PRESCRIBING) -- Offer PPI with it Refer urgently, within 3 working days of presentation (even with a normal acute- phase response, negative anti-cyclic citrullinated peptide [CCP] antibodies or rheumatoid factor) if there are any of the following: ❖ Small joints of the hands or feet are affected. ❖ More than one joint is affected. ❖ There has been a delay of 3 months or longer between the onset of symptoms and the person seeking medical advice. If affecting job- offer amended duties or referral to occupation health (Remember occupational therapy is different from occupational health. Occupational therapy does same job as physio and occupational health addresses health issues that affect work) Offer physio Health promotion: Offer pneumococcal and yearly influenza vaccinations Offer Qrisk- explain to patient—this condition increases your risk of getting conditions that affect the heart such as heart attack , stroke etc. So we will put all your information in a medical calculator which will tell us your risk of having a heart attack or stroke in the next ten years SAFETY NET RE SEPTHRIC ATHRITIS /OFFER FOLLOW UP DEPENDING ON SITUATION If patient has been on DMARDs but stopped or has no current supply Ask why patient stopped and ask if he/she is having bloods to monitor DMARDs If patient has no recent bloods, ask why? Ask about side effects of DMARDs, let's take methotrexate for example: Ask about Agranulocytosis (Sore throat, fever, recent flu symptoms) , Ask about Pulmonary fibrosis (SOB, wheeze, cough) , liver toxicity (e.g. nausea, vomiting, abdominal discomfort, and dark urine), blood disorders (e.g. sore throat, bruising, and mouth ulcers)  restart DMARDs, refer to rheumatology, offer bloods for monitoring (LFTs, U+E, s FBC, ESR, CRP) especially for methotrexate (Please stress the importance of having DMARD monitoring bloods to avoid things like agranulocytosis) Offer face to face to listen to chest, BP etc Remember to offer folic acid 5mg once weekly to be taken on different day to methotrexate dose (For prevention of methotrexate side effects) ANKYLOSING SPONDYLITIS History taking Ask about pain: SOCRATES Ask about if radiating/ paraesthesia in lower limbs Ask about night-time symptoms and if pain wakes patient up from sleep Ask about fever , weight loss , night sweats Ask about Cauda equina symptoms- weakness in lower limbs, numbness in back passage, urine/bowel incontinence Ask about anterior uveitis (Red eyes, pain, blurry vision) Ask about skin changes Ask about gastrointestinal symptoms ( Diarrhoea, abdo pain) Ask about urinary symptoms, penile discharge, urine frequency, dysuria Ask about occupation Ask about smoking , alcohol , home situation Management Offer further investigations—Xray to outrule fracture , FBC, ESR, CRP Offer HLA B27 if patient is newly diagnosed—but if has been diagnosed, no need to offer this Offer face to face to examine back. Offer analgesia –Naproxen and PPI Offer referral to rheumatology to consider DMARDS Refer to physio Offer to calculate Qrisk of patient is above 25 (Please remember to do cholesterol ) Advise the person that they may be more prone to fractures and that they should seek medical advice following a fall or physical trauma, especially if they have increased pain. Offer assessment for osteoporosis which is done every 2 years (DEXA SCAN )  Safety net re cauda equina Follow up depends on the situation PAGETS DISEASE History Ask about pain in affected area Swelling, lumps or bumps, redness, stiffness Night pain/waking him up from sleep Is he/she able to walk If he/she has pain in any other joint Night sweats, weight loss, loss of appetite Ask about deafness and tinnitus as this is a complication of pagets Ask about joint above and joint below, for example if knee is affected (hip and ankle) Ask about occupation, social history Note: pagets can have night pain Explain that Pagets disease is a common condition that affects the normal cycle of bone renewal causing the bone to become weakened and can lead to pain Management Offer bloods for bone profile- ALP, calcium, PTH, vitamin D, etc If he/she has been seen by colleague, no need to bring in. If not, can bring in to examine joint Refer to joint clinic of rheumatology and orthopaedics Advise that they will offer him biphosphonates Offer patient naproxen + ppi cover for pain Warn patient of risk of fracture and osteosarcoma- safety net- if unable to walk or use joint/ worsening pain (fracture) If worsening pain/worsening night pain, unwell, lumps or bumps, weight loss, then to contact us immediately If any hearing issues or tinnitus to let us know as this can be a complication of pagets Remember: Referral is not needed for older patient who is asymptomatic Offer leaflets RAYNAUDS History Ask if bilateral hands are affected Ask about change in colour and how many minutes it takes to resolve Ask about triggers-cold, vibrating tools, emotion Ask about paraesthesia, numbness, tingling. Ask about extremities other than the digits that may be affected such as the tip of the nose, ear lobes, tongue and nipples. Ask about ulcers, pain in hand Ask about weakness in hand Ask about itchiness (happen in chilblains) Ask about neck pain Ask about CREST Syndrome (Difficulty swallowing, dry skin, rashes, swelling or hands /legs) Ask about smoking, alcohol, occupation Ask about family history Explain that Raynaud's disease is narrowing of blood vessels of the hands causing change in colour after been exposed to triggers such as cold, vibrating tools, etc Management Offer F2F investigations to assess hands for pulse, ulcers, BP Offer bloods- autoimmune screen, ESR, FBC, cholesterol (Outrule cardiovascular cause) Offer Nifedipine (Usually if lifestyle has failed) —inform patient that it can cause dizziness. Can use continuous or Intermittent prophylactic use (in cold weather or when participating in outdoor winter activities) may be sufficient. Keep the whole body (including the hands and feet plus scalp) warm: Avoid sudden temperature changes. Do not allow the hands and feet to get cold. Wear gloves and warm footwear in cold environments. Offer referral to Rheumatology if greater than 30 years of age as this will indicate secondary Raynaud's –if less than 30, no need for referral. Safety net – if worsening symptoms, change in colour lasting more than 10- 20 minutes, ulcers, pain, seek urgent medical advice as this may mean disruption in blood supply.  Follow up in 1-2 weeks to see how patient is doing OSTEOPOROSIS History If patient presents after a fall, please start by asking about fall Ask about mechanism of fall Ask if there was any dizziness, SOB, chest pain prior to fall Ask if anybody witnessed fall Ask how many minutes patient spent on the floor before getting help Ask if any head injury If patient sustained wrist fracture-ask about what hand was affected and ask if patient is right handed as if right hand was affected then ask how he/she is coping at home with daily activities If vertebral fracture- ask about cauda equina symptoms Ask about any other injuries Ask about previous fall Ask about risk factors for osteoporosis- such as age of menopause and if patient used HRT, family history of osteoporosis, low BMI Ask about smoking Ask about other medical conditions Ask about medications Management Offer blood test to check TSH levels, vitamin D, calcium, FBC, U+E’s Offer to make appointment with nurse or health care assistant to check BMI Offer Dexa scan ( You do not need this if a vertebral fracture, just go ahead and treat ) Offers to calculate calcium intake Offers to ask Physio/ occupational therapy to review home condition to prevent future fall and can also send to fall prevention program (Falls prevention program has OT and physio) Offers falls alarm if patient lives alone Suggest to patient about seeking help from family members and if none, then offer help such as meals on wheels (If difficulty making meals) or discuss with frailty co-ordinator to organise carers once a day until fracture gets better if patient lives alone and right hand is affected for example.  Inform patient about bisphosphonates if osteoporosis is confirmed –gives side effects, advised to make appointment with dentist to ensure dental hygiene is okay Offer patient vitamin D after checking vitamin D levels as if levels are in deficient or insufficient zone, dose will be different Make a follow up appointment to discuss dexa scan results. Safety nets about future falls /fracture to seek help If vertebral fracture, safety net about cauda equina NB: If patient has contraindication to bisphosphonates for example—gastritis/PUD, then advise patient that we take caution before prescribing bisphosphonates and because of that, you will seek advice from rheumatologist if we can offer bisphosphonates or other options such as I.M Denosumab (Prolia) Or oral Raloxifene Note that osteoporosis can occur in young people, especially those with LOW BMI- Body mass index of less than 18.5 kg/m² (which is a risk factor for osteoporosis). Approaching this is in GP is similar to the way you approach the elderly History Ask about history of multiple fractures and how they happened/mechanism of injury, this can tell you if this suggests fragility or not If current fracture is recent, ask if it has healed and if in pain Rule out risk factors; Ask about diet- if eating healthy to rule out eating disorder Ask about how patient feels about their weight and if they have fear of gaining weight (This will let you know if there is an underlying eating disorder) Ask about if she is on any over the counter medications eg steroids, omeprazole Ask about bowel symptoms (Diarrhoea, abdominal pain) --to rule out coeliac disease Ask about periods –if a female—the reason is to rule out endocrine problems and also, excessive exercise can cause loss of periods in female - hypothalamic inhibition with suppression of gonadotrophin releasing hormone pulsatility (the frequency at which pulses of the hormone are released by the hypothalamus). The consequences can include musculoskeletal injuries (in particular stress fractures), infertility, and the general medical consequences of hypo- oestrogenism. Ask about family history of osteoporosis or any other condition Ask about smoking, alcohol or illicit drug use Ask ICE Management  Advice on bloods- FBC, U+E’s, Thyroid function, LFTs, Hba1c, Calcium/bone profile, Vitamin D, hormone profile Frax score if the patient does not have a major risk factor for fragility fracture eg- if BMI above 18.5 But if BMI 18.5 and below, then go straight for DEXA Assess for vitamin D and calcium deficiency –use calcium calculator for calcium and then check for vitamin D levels in bloods and ask about exposure to sunlight If excessive exercise, can ask to reduce level of exercise to maintain a healthy weight and at the same time to be fit, best to speak with sports physiotherapist Advice that if calcium and vitamin D is low, you will replace If Dexa scan shows she has osteoporosis, then she will be started on bisphosphonates- discuss risk and benefits and inform patient to have dental check up Safety net on repeat fracture Book follow up to discuss results and further care POLYMYALGIA RHEUMATICA History Ask about pain/stiffness Ask how many minutes stiffness last Ask about movement of joints Ask how many other joints are affected Ask about fever Ask about night time symptoms or if symptoms wakes patient up from sleep Ask about night sweats, weight loss Ask about lumps and bumps around joints or anywhere else Ask about muscle weakness Ask about home situation, occupation Ask about smoking alcohol etc Ask about GCA Symptoms- blurry vision, headache, scalp pain, jaw pain Management Offer Bloods including FBC, ESR, CRP if not already done If above done: Offer steroids – Prednisolone 15mg OD for 3 weeks Review in 1 week to see if patient is responding to steroids Inform patient about side effect of steroids and what you will do  Steroids can cause issue with control of glucose and high blood glucose—so will regularly check for blood sugar Steroids can cause thinning of bone—so offer appointment to discuss bone protection Steroids can increase risk of infection—offer vaccination—pneumococcal, influenza, COVID. Also advise to avoid close contact with people who have chickenpox, shingles, or measles if they do not have immunity to chickenpox or measles and seek medical advice if they are exposed. Steroids should not be stopped abruptly, so offer blue steroid card Inform steroids treatment can continue for 1-2 years Safety net on GCA symptoms Review in 1 week CARPAL TUNNEL SYNDROME History Asks about the onset, duration, site, severity, and impact of symptoms. Ask if it is both hands or just one hands Ask about relieving factors/ aggravating factors. Ask about associated pain, change in colour in hands, muscle wasting, loss of grip strength, hand weakness, and reduced manual dexterity, for example when doing up buttons, holding objects, and opening jars. Ask about history of trauma Ask about nighttime symptoms and if this wakes patient up from sleep Occupational effects and psychosocial history Red flags—neck pain, ulcers/change in colour of hands, severe pain, weight loss , numbness anywhere else in the body to suggest b12 deficiency Management Offer F2F to examine hand and perform Phalen's/Tinel's test Offer a 6-week trial of conservative treatment(s) in primary care, if available. Options include: Use of a wrist splint in a neutral position at night which may be fitted by the local musculoskeletal service, depending on local referral pathways. A single corticosteroid injection into the carpal tunnel. This may be carried out in primary care if there is appropriate expertise and experience available, otherwise arrange referral to the local musculoskeletal service or orthopaedic surgeon, depending on local referral pathways. Hand exercises and median nerve mobilization techniques. These may be offered by the local musculoskeletal service, depending on local referral pathways. Advise to avoid repetitive hand/wrist movements and take regular breaks from tasks at work that precipitate symptoms. Can offer Amended duties at work due to symptoms. Advise on the possible need for a work-place assessment if there are work-based risk factors, and encourage referral to an Occupational Health department, if clinically appropriate and available Offer leaflet on versus arthritis website PLANTAR FASCITIS History Ask about the nature of the heel pain, Ask about the onset of the symptoms and any precipitating, aggravating or relieving factors. What brings it on? What makes it worse? Plantar fasciitis is often at its most severe during the first few steps after prolonged inactivity, such as sleeping or sitting. Sitting with the foot elevated usually relieves the pain. For those who are on their feet all day, pain is worst at the end of the day. Walking barefoot, on toes, or upstairs can precipitate pain. Ask about Risk factors: Overweight or obesity Running. Prolonged standing or walking. Poor-fitting shoes. Improper gait Ask about previous trauma to the foot. Ask about measures tried to relieve pain Psychosocial and impact of heel pain on job Red flags- fever, weight loss, night pain Management ♦ Offers face to face examination to examine foot—if suspicion of Calcaneal Fracture, then to offer Xray ♦ Give self-care advice to relieve foot pain, promote healing of the fascia, and /or prevent future episodes including: Rest the foot (by avoiding standing or walking for long periods) where possible. Wear shoes with good arch support and cushioned heels (such as laced sports shoes). Avoid walking barefoot.  Consider purchasing insoles and heel pads to insert in their shoes, with the aim of correcting foot pronation ♦ Lose weight ♦ Simple analgesics, such as paracetamol (with or without codeine) and nonsteroidal anti-inflammatory drugs (NSAIDs), may provide pain relief. ♦ Advise the person to apply an icepack (covered with a towel) to the foot for 15– 20 minutes for symptomatic relief. ♦ Recommend self-physiotherapy to stretch the plantar fascia and relieve symptoms. While seated, the person should be advised to roll the arch of their foot over a rolling pin, a drinks can, or a tennis ball. They should allow the foot and ankle to move in all directions as it rolls over the object. The exercise is continued for a few minutes or until there is some discomfort. Repeat the exercise at least twice a day. ♦ If symptoms are having a significant impact on the person and short-term relief of symptoms is required, consider injection of the plantar fascia with a corticosteroid. Be aware that the injection is often very painful and post- injection pain may last for several days. Symptoms commonly return within a month following the injection. Rarely a corticosteroid injection can cause fat pad atrophy or plantar fascia rupture. ♦ Consider earlier referral to a podiatrist or physiotherapist for people with more severe symptoms that are having a significant impact on their ability to function normally. ♦ Amended duties at work Give information on plantar fasciitis: Explain that most people will make a complete recovery within a year. ♦ Follow up in 4 weeks' time to see if any benefit / safety net for worsening symptoms MECHANICAL BACK PAIN History Same as in Ankylosing spondylitis Explanation of chronic back pain: It simply means long term back pain. We usually expect an injury at the back to heal within 3 months. However, in long term back pain, the tissue at the back are sending incorrect signals to the brain, interpreting this as pain and because of this, we will like to offer CBT (Talking therapy) to help you rewire how you respond to these signals and how you think and behave when in pain. Management Offer F2F to assess back Offer use of START BACK TOOL TO ASSESS BACK PAIN Offer CBT Offer Physio If taking codeine—ask about how long, ask about dose patient is taking, how patient is getting codeine and when last patient took this. Also ask what happens if patient does not take codeine THIS IS VERY IMPORTANT AS IF PATIENT IS HAVING WITHDRAWAL SYMPTOMS, YOU WILL NOT STOP CODEINE ABRUPTLY, RATHER YOU WILL GIVE WEANING DOSE OTHERWISE, offer Naproxen with PPI Advice patient to be active/exercise as this will help relax muscles around back Safety net re cauda equina If work is affected, offer amended duties/occupational health NATIVE NUGGETS -CARDIOLOGY CARDIOLOGY Hypertension History- From head to toe Ask about headache Ask about blurry vision Ask about weakness in one part of the body Ask about chest pain, palpitations, SOB Ask about waterworks and if any blood in urine Ask about ankle swelling Ask about family history of hypertension, heart attack, stroke. Ask about Smoking, alcohol, diet, occupation, caffeine, stress Management Points to note 1. If a patient has clinic BP reading either at GP surgery or at the hospital (for example while admitted for fracture, laceration sepsis etc) and BP is raised, PATIENT WILL NEED EITHER HOME BLOOD PRESSURE OR AMBULATORY BLOOD PRESSURE TO CONFIRM THE DIAGNOSIS. Simply explain to the patient and give options...Mr Adam, we can confirm if you have high blood pressure by either giving you a machine which you will have on your arm for 24hrs and it gives us and average of your blood pressure or you can get a blood pressure machine and record your blood pressure twice daily for at least 4-7 days. 2. While waiting for HBPM OR ABPM –offer investigations, don't wait to confirm before offering investigations as per NICE 3. However, if the patient already has HBPM or ABPM done and the average given to you is hypertensive, then management as follows: Blood investigations include: FBC, U+E, HBA1c, Lipid profile, Other investigations include Urine ACR (first void urine –early morning sample) ECG and Fundoscopy  Offer to calculate Qrisk – Mr Adam, we will calculate something we call Qrisk, we will put your details in a medical calculator that will tell us your risk of having a heart attack or stroke in the next 10 years. If this is high, we will discuss treatment options Discuss lifestyle, exercise, diet, low salt, discourage caffeine, etc Offer drug treatment according to age and ethnicity – if black or over 55 —CCB (Amlodipine), if white and under 55, then ACEi (Ramipril) If patient is unwilling to seek drug treatment, find out why: if possible, re-assure If patient is unwilling for drug treatment, assess capacity by ensuring he knows risk of what will happen. For example, Mr Adam, the reason we advise on treatment is because, if blood pressure is uncontrolled, it can increase your risk of heart attack, stroke, kidney problems, problems with vision and heart problems. Do you understand? Can you tell me what will happen if your blood pressure is not well controlled?....... accept it and then say, we will support you the best way we can to see how to control your BP. In this instance, advise patient to continue to check BP regularly for 2 weeks, inform the goal is for BP to be less than 135/85 at home and 140/90 in the clinic. Review in 2 weeks' time and safety net on stroke symptoms etc. Sometimes, a patient might be on numerous antihypertensives (for example- amlodipine, ramipril, indapamide etc) and yet blood pressure is not controlled. You approach this patient by asking about compliance. Mr Adam, can I just check, how often do you take your medications and how do you take them? If patient is not taking medication as prescribed-ask why? Ask if he/she is experiencing any side effects and elicit any beliefs he/she has about the medication. Then take history of hypertension as above. Management involves ensuring compliance, do not offer another additional tablet or increase the tablets if compliance is an issue. For example: Mr Adam is on Amlodipine 10mg OD, ramipril 5mg OD, indapamide 2.5mg OD And his BP is still around 150/110 and he is non-compliant. You may be tempted to increase his ramipril to 10mg OD or probably add another medication to control his blood pressure. The Ideal thing to do is to find out how long he has been non-compliant, that is, has he been non-compliant since additional medications were added or is it something new?. Let’s say he was initially placed on Amlodipine and on addition of ramipril and indapamide, he became non-compliant. You cannot be certain that ramipril did not work, so, it is safe to stop indapamide and continue ramipril at current dose while ensuring compliance and then reviewing the blood pressure in another week NOTE: If they are not complaint with medication-please inform them the importance of compliance and why it is important to control blood pressure. Do this in a non- judgmental manner. For example. Mr Native, I understand that some people do not like pills and it may be difficult for them, however, it is important we control your blood pressure to prevent complications like stroke, heart attack, eye problems, kidney problems etc. Are you happy to continue to take these tablets? Sometimes, patient ask if blood pressure tablets will be life-long. An example of a good answer is: Mr Emeka, you may need to take blood pressure medicine for the rest of your life. But we might be able to reduce or stop your treatment if your blood pressure stays under control for several years. Another interesting thing about antihypertensives are –most men fear erectile dysfunction as most antihypertensives have this side effects. In fact, medically induced erectile dysfunction is one of the major reasons for non-adherence and treatment discontinuation Note: Untreated hypertension can also lead to erectile dysfunction, so how do you handle this? You can explain to the patient: Mr Tunde, I understand you may be worried about erectile problems with antihypertensive tablets and yes you are absolutely correct that this is a side effect of most antihypertensives. However, untreated hypertension can also lead to erectile problems (carries a higher risk of erectile dysfunction than when taking high blood pressure tablets) and worse off, also lead to other medical conditions such as stroke, heart attack, etc. Not everyone on antihypertensives (Blood pressure tablets ) will experience erectile dysfunction and if you do, we have tablets and ways of managing it. How does this sound? Amlodipine-can cause erectile dysfunction but it is uncommon Alpha blockers like doxazosin ---they cause sexual dysfunction but it is uncommon ACE and ARBs- they can cause sexual dysfunction but frequency is unknown—it is not usually seen as a common side effect Spironolactone- BNF states it causes libido disorder but frequency is unknown Betablockers, verapamil, diuretics (Indapamide) are culprits in causing erectile dysfunction. See below NICE summary flow chart for choice of antihypertensives POSTURAL HYPOTENSION History Ask about dizziness- check if it happens only when upright Clarifies what patient means by dizziness—does this mean light headedness or spinning sensation Ask for timing and how many minutes does it last  Ask for any head injury Ask if anyone has witnessed it Ask for loss of consciousness Ask for associated symptoms dizziness, light-headedness, blurred vision, weakness, fatigue, nausea, palpitations and headache. Also ask for syncope, dyspnoea, chest pain and neck and shoulder pain. Ask for alcohol Ask if anyone at home Ask how this has affected him/her Ask about medications—even if prescribed from the GP surgery, check indications of each of them and check if patient started one newly that corresponds to onset of symptoms Management Offer investigations - FBC, HBa1c, ECG, if this has not been done F2F examination for lying and standing BP It may be necessary to deprescribe; to stop drugs like, bisoprolol, amlodipine, etc, if possible and if has no current use If patient had a fall and lives alone, offer falls alarm which is given by frailty practitioners Avoid triggers- high temperature or extremes of temperature Advise on fluids Advise to get up from a sitting position to standing slowly Follow up in 1-2 weeks to see how patient is doing Safety netting re chest pain, palpitations, syncope, SOB, worsening symptoms INTERMITTENT CLAUDICATION/PAD History As usual, every pain should start with SOCRATES Ask if leg/calf pain is unilateral or bilateral Ask if pain occurs in buttocks/thigh Ask if pain occurs at rest Ask if there is any back pain –to rule out spinal claudication Ask about 5 P’s -Pallor, Paraesthesia, Paresis, Pain, perishingly cold. Ask about swelling/ redness in legs to rule out DVT Ask about ulcers or skin changes /hair loss on leg/foot  Ask about erectile dysfunction Ask about chest pain, palpitations Ask about back pain –rule out spinal claudication Ask about smoking, alcohol, diet, lifestyle Ask about occupation—as if a post man for example, will need addressing in management Management Offer Face to face to examine legs Offer ABPI to be done by nurse Offer further blood tests including HBa1c, Lipids, U+E’s, FBC, TFTs Offer smoking cessation, weight loss Offer Clopidogrel 75mg daily—give side effects eg tummy upset Offer statins –Atorvastatin 80mg OD-gives side effects eg muscle cramps. Inform patient he will need LFTs and lipid profile in 3 months' time Offers supervised exercise program to help with symptoms—if patient is not having time for supervised exercise, offer unsupervised exercise for approximately 30 minutes three to five times per week, walking until the onset of symptoms (that is, until patient starts to feel pain), then resting to recover Safety nets on acute limb ischaemia Follow up in 4 weeks to see if symptoms are improving—if no better, then refer to vascular team. ACUTE CHEST PAIN IMPORTANT Point to Note—Anyone with a cardiac sounding chest pain within the last 12hrs should be admitted, especially if you cannot get an ECG General guide for cardiac sounding chest pain presentation Active chest pain or chest pain just immediately before patient gives you a call-999 Chest pain within 12 hrs but not active at the time of call -same day emergency admission-if they have someone who can take them, then can go in by themselves but safety net to call 999 if any chest pain along the way Chest pain 12-72 hours-same day admission usually via acute medical unit or same day cardiology assessment unit  Chest pain greater than 72 hours- rapid access chest pain clinic to be seen within 1-2 weeks –heavily safety net patient Chest History Of course, you ask about the nature of pain – dull, crushing, sharp –all can be cardiac Ask about location of pain Ask if the patient is currently having pain and the last time, he had pain Ask how many minutes the chest pain last before resolving Ask about relieving factors – like rest Ask if pain radiates to jaw, shoulders etc Ask about associated symptoms- eg SOB, palpitations, dizziness Ask about fever (rule out things like infective endocarditis, pericarditis, pneumonia, etc) Ask about family history of heart attack/stroke/ sudden death Ask about lifestyle, smoking, alcohol, diet, occupation Management Admit anyone who has had a cardiac sounding chest pain within last 12hrs PLEASE ADVICE THE PATIENT THAT YOU WILL ARRANGE AN AMBULANCE AND THE PATIENT SHOULD NOT DRIVE OR GET THERE BY THEMSELVES Advise them that if they get another episode of chest pain while awaiting ambulance, they should dial 999 Inform then that when they get to hospital, they will do an ECG (Electric tracing of the heart) and they will also do blood test to check for a chemical which is released by the heart when the heart is stressed called troponin and if this is found to be raised, then they will either use medications or they will do a procedure to unblock the blood vessels of the heart Advise that post discharge, patient should make an appointment to discuss what happened in hospital as well as lifestyle changes, diet etc. ANGINA Points to note  A patient who has angina symptoms and has an angiogram that was clear could still be having angina---Microvascular angina Microvascular angina refers to disease in the small blood vessels, less than half a millimetre across and therefore too small to be detected using standard tests like angiogram. Further investigations like MRI can be done for this For initial Angina diagnosis –refer to rapid access chest pain clinic Provide patient with GTN spray and Aspirin 75mg Inform patient that if they get the chest pai, they should stop whatever they are doing and rest, use the gtn spray. Can repeat after 5 minutes if pain not resolved, call 999 if pain has not resolved 5 minutes after the 2 nd dose BRADYCARDIA History Ask if patient was unwell in anyway Ask about dizziness Ask tiredness/fatigue Ask about collapse history Ask about chest pain Ask about SOB, especially on exertion - eg exercise- must say this- because if can tolerate exercise without getting SOB , it lets you know if this patient will need cardiac pacemaker or not Ask about racing of heart or aware of heart beat Ask about any form of seizures Ask about family history of heart problems or sudden death Ask about smoking, alcohol, illicit drug use Over the counter meds Ask about hobbies /occupation and if patient is an athlete Management Face to face to examine pulse manually, listen to heart etc (you will not do this if a colleague has already done this) Bloods (unless already done)- thyroid function very important, electrolytes, FBC Offer to discuss with cardiology - same day if symptomatic Advise that cardiology may offer pacemaker  Can offer 24hr tape if you suspect tachy-brady syndrome Echo can be offered if there is any evidence of murmurs (If colleague has seen and found murmur) Safety net on red flags PALPITATIONS History Ask patient onset of palpitations Ask if this comes and goes or it is always there Ask patient if palpitations feel regular or irregular Ask patient if it happens at rest or if this happens during activity Ask patient if there is SOB Ask if there is chest pain Ask if there is dizziness or syncope Ask if there is there is family history of sudden death or heart problems Ask if any triggers Ask if it is getting better, worse or still same Ask about smoking, alcohol, diet, caffeine use, stress If you suspect anxiety or mental stress—for example-in a patient who is going through a bereavement or if the patient is going through a divorce and having palpitations—ask about tingling sensation in lips, mood, suicidal thoughts (especially overdose) Management If palpitations are associated with SOB alone—this can be managed in primary care. But if breathlessness is severe (patient reports that they can't breathe and feel like they are dying during episodes, then same day assessment) If palpitations are associated with any of the following: Chest pain (NICE considers this routine referral, however, cardiology likes to see a combination of palpitations with chest pain same day) dizziness or syncope, palpitations brought on by exercise then this needs urgent same day assessment via Acute medical unit or cardiology unit If palpitations are associated with family history of sudden death alone—then this requires urgent cardiology referral If palpitations are continuous and patient reports they are actively having them while speaking to you- same day admission via AMU for assessment  For all other people or while waiting to see cardiology- offer investigations like ECG, 24hr, 48hr, 72hr or 7 days Holter monitor depending on frequency of patient’s palpitations (Example—if a patient says my palpitations come on once a week—7 days Holter is sensible. But if patient says frequency of palpitations occur every day, then 24hrs ECG/Holter is sensible to capture any arrythmia. Bloods including Hba1c, Thyroid functions, U+E’s , LFTs, FBC (Looking for anaemia ) F2F to assess for murmurs –if murmur present, then echo If anxiety is present-talking therapy can help. If it is caused by stress- head space app is a good app that teaches relaxation methods and ways to help stress. If bereavement- bereavement counselling will help Safety netting on red flags- chest pain, SOB, dizziness, syncope –to seek urgent medical advise-either contact the surgery or 111 ATRIAL FIBRILLATION If you get an ECG which shows Atrial fibrillation History Ask if patient feels unwell in anyway Ask if patient has experienced racing of the heart If patient has experienced palpitations, then ask when? If within 48hrs, may need admission into hospital for cardioversion Ask about Breathlessness, palpitations, chest pain, syncope or dizziness. Ask about stroke symptoms-weakness in one part of the body, slurred speech Ask about alcohol, smoking, diet, caffeine use, over the counter medications etc Take other psychosocial history and family history Management IF YOU ARE GIVEN CHADsVASC/ORBIT score then manage accordingly. If you are not given, then you will immediately calculate chadsvasc using patient’s comorbidity and age , you can determine if it is above 2 or not ORBIT SCORE – 0-2 (Low risk of bleeding), 3 (Medium risk), 4-7 (High risk of bleeding) CHADVASC – if greater than > 2 ---then, needs anticoagulation Offer anticoagulation with a direct-acting oral anticoagulant (DOAC) -Inform side effect of bleeding and safety net about bleeding/head injury (Will need CT head if any head injury)  Offer a rate-control treatment, either a standard beta-blocker (other than sotalol) or a rate-limiting calcium-channel blocker (diltiazem or verapamil) as first-line treatment for most people with AF — base the choice of drug on the person's symptoms, heart rate, comorbidities, and preferences. For example, in a patient with COPD –offer verapamil as betablockers can cause bronchospasm Offer follow up Within 1 week of starting rate-control treatment (or any dose alteration) Offers face to face to assess for murmurs (if not already done by your colleague) and if murmurs present then, to send for echo Offer further testing for lipid profile Offer to calculate Qrisk Safety netting-if any chest pain, SOB, worsening palpitations, dizziness or syncope then to seek urgent medical attention Few things to note If patient’s CHADVASC is high and orbit score is also high. Inform patient that we have put your details into a medical calculator, and you do have increased risk of stroke with this condition and therefore we advocate for blood thinners to reduce this risk. On the other hand, we also calculated your risk of bleeding, and the risk is also high, which means giving you a blood thinner increases your risk of bleeding. In other words, Mr Adam, not giving you this medication reduces your chances of bleeding but that will mean leaving you at risk of stroke. Whereas, giving you this medication reduces your chances of stroke but increases your chances of bleeding what are your thoughts? When you reach crossroads like this, it is best you give patient full information and let them decide which risk they can live with If patient agrees to go for Apixaban, inform patient you will see how best to reduce chances of bleeding such as close monitoring of apixaban using creatinine clearance and monitoring FBC (looking at HB level and platelet levels) If patient is on Aspirin and has no indication, this can be stopped. If patient has an indication for it, for example previous M.I and Aspirin/clopidogrel cannot be stopped, you can discuss with cardiology to see if there is a chance it can be stopped (Although unlikely) RAISED CHOLESTEROL AND STATIN INITIATION History. Ask reason for doing blood test Ask for any chest pain, SOB, palpitations Ask about weakness in one part of the body. Ask about lumps or bumps around knuckles or ankles (Tendon xanthomata) Ask about yellowish lump around corner of eye (Xanthelasma) Ask about diet Ask about level of physical activity Ask about smoking, alcohol. Ask about family history of heart disease, stroke etc ( Suspect familial hypercholesterolaemia (FH) in adults with: A total cholesterol level greater than 7.5 mmol/L and/or; A personal or family history of premature coronary heart disease (CHD, an event before 60 years in an index person or first-degree relative- parents, siblings, children) Ask if on any medication over the counter. NOTE: Here, you can ask ICE in two different ways. ICE before giving results: Before we go ahead and discuss the results, do you have an idea of what it may show? or I have your results with me but just to be sure we are on same page, was there anything you were expecting the results to show? And asides the results, was there anything else you hoped that we will discuss? ICE after giving results: Now I have told you about your results, is there anything that comes to your mind or that bothers you as regards the results? Explain that the blood test shows you have raised cholesterol levels. Then you can further say: I would like to ask, what do you understand by raised cholesterol David? Cholesterol is a fatty substance made from the liver from the fat eaten in our diet. We have the good cholesterol called HDL and bad cholesterol called LDL. Accumulation of cholesterol in our blood system can block the blood vessels in the body leading to serious conditions such as stroke, heart attack etc. We went further to calculate your risk of having a heart attack or stroke in the next 10 years and that came back as 11%. This means in a crowd of 100 people with the same risk factors as you, 11 are likely to have a heart attack or stroke within the next 10 years. Management Discuss diet, exercise and benefits of weight loss Discuss statin initiation- advise on benefits and side effects. Ensure you ask patient if they have any allergy. For example: We usually recommend a tablet called atorvastatin 20mg once at night for people who have their Qrisk above 10% to help lower their cholesterol. It does have some side effects of muscle cramps; tummy upset and sometimes can affect the liver but most people do well on this medication. Is this something you are happy to take? Inform that you will repeat cholesterol in 3 months to see if it is reduced. You will also be doing a blood test to check for liver functions as it can affect the liver. If other bloods are not done, then consider offering other investigations- HBa1c, LFTs, U+ E’s, Thyroid function If you are not sure about Simon-Broome criteria- advise the patient that we have a criterion to check if raised cholesterol runs in the family called Simon-Broome criteria, you do not need to worry about the name. It is important for us to check this as if you are found to have this condition, then your children will also be screened and treated and you will be further screened for heart diseases by the heart specialist. Safety net patient re stroke, heart attack and follow up in 3 months to check cholesterol levels and LFTs. NATIVE nuggets RESPIRATORY Asthma Few salient points to note in Asthma For asthma to be suspected, there must be presence of MORE THAN ONE of the following symptoms of 1. wheeze, 2. breathlessness, 3. chest tightness and 4. Cough. Other supporting features are: 1. Symptoms are worse at night and in the early morning. 2. Symptoms are triggered in response to exercise, allergen exposure and cold air. 3. Symptoms may also be triggered after taking aspirin or beta-blockers. 4. In children, symptoms may also be triggered by emotion and laughter. Diagnosis involves: FeNO testing (fractional exhaled nitric oxide) --- Adults aged 17 and over- 40ppb or higher is a positive result and in children 5-16 years 35ppb or higher is a positive result Spirometry – FEV1/FVC ratio lower than 70% Bronchodilator reversibility-----In adults, an improvement in FEV1 of 12% or more, together with an increase in volume of at least 200 mL in response to beta-2 agonists or corticosteroids is regarded as a positive result. In children, an improvement in FEV1 of 12% or more is regarded as a positive result.  Variable peak expiratory flow (PEF) readings---A value of more than 20% variability after monitoring at least twice daily for 2-4 weeks is regarded as a positive result in both Adults and children NB: Adults here refers to Aged 17 and over. Management Prescribe SABA - salbutamol or salamol to everyone you suspect maybe having asthma Criteria for ICS /Criteria for changing to a new medication or going to next step Use an inhaled SABA 3 times a week or more Have asthma symptoms 3 times a week or more Waking up at night once a week or more For everyone above age 5 who has had asthma attack requiring oral steroids treatment Example of ICS - Clenil (beclomethasone) A reasonable starting dose is usually a low dose for adults, and a paediatric low dose for children aged 5 to 16 years Higher doses may be required in people who are previous or current smokers as smoking reduces the effectiveness of ICS therapy. Dose of ICS –Beclomethasone used an example For Adults; 400mcg (100mcg 2 puffs BD) is low dose. 800mcg (200mcg 2 puffs BD) is moderate dose More than 800mcg is considered high dose In children; 200mcg (50mcg 2 puffs BD) is NICE paediatric Low dose (BTS/SIGN consider this paediatric very low dose) 400mcg (100mcg 2 puffs BD) is NICE paediatric moderate dose (BTS/SIGN consider this paediatric low dose) 800mcg (200mcg 2 puffs BD) is NICE paediatric high dose (BTS/SIGN consider thus paediatric moderate dose) Steps after Saba and ICS 1. LTRA - Montelukast tablet 2. Offer LABA in combination with ICS for example- Fostair (Beclometasone with formoterol), Symbicort (budesonide and formoterol) 3. MART -maintenance and reliever therapy containing both ICS and fast acting LABA. Example Fostair Mart, DuoResp spiromax Mart, Symbicort Turbohaler Mart----WITH MART, YOU DO NOT NEED SALBUTAMOL, BECAUSE MART ACTS AS BOTH RELIEVER AND MAINTENANCE 4. This step involves increasing dose of MART from low dose ICS MART to moderate dose and if no improvement, then High dose ICS MART or a trial of an additional drug (for example, a muscarinic receptor antagonist or theophylline)--at this stage , you can be considering discussing with a specialist. For children under 5 Offer an eight-week trial of a paediatric moderate dose of ICS if there are symptoms that clearly indicate the need for maintenance therapy (occurring 3 times a week or more, or causing waking at night, or uncontrolled with a SABA alone). After 8 weeks, stop ICS treatment and continue to monitor the child's symptoms. If symptoms did not resolve during the trial period, consider an alternative diagnosis. If symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy. If symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8-week trial of a paediatric moderate dose of ICS. Asthma history-either for review of uncontrolled Asthma or newly diagnosed/suspected Ask about SOB Ask if it is getting worse, getting better or still the same Ask about wheeze Ask about cough. If cough, any phlegm? Colour? Any blood?  Ask about night-time symptoms ( if known to have asthma, ask how many times in a week the patient uses SABA at night? Because if patient is having one or more night-time symptoms, will need to step up to next step in management) Ask about how many times patient have asthma symptoms overall in a week / USE of SABA overall in a week/ daytime (if above 3 times, then you will go to next step in Asthma management) Ask red flags- chest pain, palpitations, fever, recent/current viral infection Ask about triggers- exercise, pets, moulds at home, rugs/carpets, stress, emotions, etc Ask about over the counter medications- e.g. Ibuprofen, Aspirin Ask about personal or family history of atopy(eczema) and asthma Ask about smoking and ask if anyone else is smoking around patient Ask about occupation and if it’s a trigger Ask about any recent hospital admission, if yes, ask about ITU admission ( this helps you to know how severe their asthma is, because if they come to you in exacerbation, you will have a low admission threshold ) If they’re on inhalers, ask if they’re taking it as prescribed and if their technique has been checked or anyone thought them how to use the inhalers when they were started on it or not Ask about peak flow - what is usual peak flow reading and what is the current reading Management Address ICE as usual Bring in for face to face to examine chest, check weight/height, for adults- BP and pulse Offer treatment depending on stage (montelukast, ICS+ LABA, etc). Give side effect of medication and re-assure most people do well on the medication Advise that you will refer to asthma nurse who will do the following ; Nurse will offer PEFR or Spirometry to monitor asthma control Personalised Asthma plan- This is a plan that talks about the patient’s asthma, the list of medications they are taking, their normal peak flow readings, how to recognise a flare and what to do when they have a flare Offer vaccinations- influenza in kids. Pneumococcal, influenza and COVID in adults Safety net and follow up Follow up in 4 weeks with yourself if you give any medication Exercised induce Asthma  For people who report that their asthma is exacerbated by exercise, review regular treatment as this can indicate poorly-controlled asthma. In a person whose asthma is otherwise well-controlled: 1. Alongside an ICS, consider use of an LTRA, a LABA, sodium cromoglicate or nedocromil sodium. 2. Advise use of a SABA immediately prior to exercise. COPD Few salient points to note in COPD: Suspect COPD in people aged over 35 years with a risk factor (such as smoking, occupational or environmental exposure) and one or more of the following symptoms: 1. Breathlessness — typically persistent, progressive over time, and worse on exertion. 2. Chronic/recurrent cough. 3. Regular sputum production. 4. Frequent lower respiratory tract infections. 5. Wheeze. Diagnosis of COPD A post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction. Other investigations include; Chest X-ray — to help exclude other causes (such as lung cancer, bronchiectasis, tuberculosis, and heart failure). Full blood count — to identify anaemia or polycythaemia. Management 1. Offer SABA- salamol or salbutamol 2. LAMA + LABA eg anoro ellipta ( umeclidinium + vilanterol) OR LABA + ICS if asthmatic features eg Fostair, Symbicort  3. LAMA + LABA + ICS eg Trimbow (beclemetasone +formoterol + glycopyrronium bromide) or Trelegy Ellipta ( fluticasone +umeclidinum and vilanterol). 3 months trial if no better go back to step 2 Asthmatic features Raised eosinophils on FBC Personal history of atopy/asthma Night time symptoms/ diurnal variation Bronchodilator reversibility Criteria for going to next step in COPD 1. Day to day symptoms affecting quality of life 2. Has exacerbations despite use of SABA alone or any of the steps Known COPD History and management Ask about SOB Ask if SOB happens at rest Ask about how many distance he/she goes before getting SOB Ask about orthopnea/PND Ask about ankle swelling Ask about cough? Sputum production, haemoptysis Ask about chest pain Ask about palpitations Ask about fever Ask about visible neck veins Ask for asthmatic features- personal or family history of atopy (eczema) or asthma, Nocturnal wheeze Ask about weight loss, night sweats, fatigue, appetite changes, lumps and bumps anywhere Ask about inhaler and if using them, ask if any issues using inhalers, ask if he/she was thought how to use inhalers and if anyone has checked their inhaler technique 2 main important questions 1. In the last one year, how many times have you had a flare requiring steroids  2. In the last one year, how many times have you been admitted to hospital due to your COPD Ask about home conditions and if struggling Ask about mood (remember to ask this on all patient with chronic health conditions and all patient who have hospital stay for more than 2 weeks) Ask about vaccinations What's the difference between an acute exacerbation of COPD and poorly controlled COPD? The answer is simple—Acute exacerbation will present acutely—for example 2- 3 days history of cough, SOB, wheeze, sputum production etc. Poorly controlled COPD will present as a chronic course- for example-shortness of breath ongoing for 1-2 months and the patient may also have history of recurrent exacerbations. Management Offer further investigations: Chest Xray to out-rule cancer, Bloods for BNP to rule out heart failure, FBC to check for anaemia (as this can be a cause of SOB) , polycythaemia (if this is found, patient may be eligible for LTOT) , raised eosinophils (asthmatic features) ECG to rule out angina Spirometry to stage COPD Offer treatment based on stage of COPD Offer pulmonary rehabilitation (explain that you will refer to chest physiotherapist for breathing exercises which helps to improve the breathing and expand lungs). This is offered to those with MRC scale 3 and below and those with recent hospital admission NB- do not offer pulmonary rehabilitation to those who have unstable angina/recent M.I or are unable to walk Offer vaccinations - pneumococcal, influenza and COVID Offer personalised COPD plan - this is a plan that talks about COPD, medication that he/she is taking, how to recognise a flare and what to do when there is a flare and when to seek help Safety net and follow up If in exacerbation, please confirm allergies before prescribing antibiotics (Amoxicillin 500 mg three times a day for 5 days or Doxycycline 200 mg on first day, then 100mg once a day for 5-day course in total or Clarithromycin 500 mg twice a day for 5 days) Remember, not all exacerbations need antibiotics—consider infective cause and need for antibiotics if there is sputum colour changes and  increase in volume or thickness beyond normal. Other things to consider as well includes exacerbation and hospitalisation history, risk of complications, and previous sputum culture results. If in exacerbation- Offer 30 mg oral prednisolone once daily for 5 days Follow up in 4-5 days' time to see how patient is doing if you have not seen face to face If patient has 1 or more flares requiring steroids in last one year, patient will need rescue pack (back up steroids and antibiotics to keep at home which they can use when they have another exacerbation) If patient has 3 or more exacerbation requiring steroids in a year AND one hospital admission, patient should be referred to respiratory for consideration of prophylactic antibiotics (usually azithromycin). But they will need ECG to rule out Long QT Syndrome Criteria for admission in a flare up Oxygen saturation less than 90% on pulse oximetry Cyanosis (In history you will ask for bluish discoloration of lips or skin/extremities) Acute confusion or impaired consciousness Severe breathlessness. Already receiving long-term oxygen therapy. Inability to cope at home (or living alone). What can you do if a patient is unable to use their inhaler due to dexterity  If they are taking an MDI -- Like this picture below Offer them a dry powder inhaler like the picture below Most inhalers that have metered dose inhaler (MDI), also has dry powder form. Alternatively, you can offer the patient spacer device with their metered dose inhaler just like the picture below Review of patient’s on LTOT (Long term oxygen therapy) in Primary care. Note: Most reviews are done by respiratory specialist but occasionally, we get involved. History Ask about SOB Ask how long patient needs to walk before getting short of breath (ask if 100 metres) Ask about orthopnoea (how many pillows he/she uses in sleeping) Ask about Paroxysmal Nocturnal Dyspnoea (do they get sudden shortness of breath during sleep) Ask about chest pain, palpitations, wheeze, secretions/sputum. If present, ask for haemoptysis Ask about ankle swelling, distended neck veins Ask about bluish discolouration of lip Ask how many litres of oxygen the patient is on Ask how many hours a day does the patient use his/her oxygen If patient wants to travel: Ask how many supplies of oxygen he/she gets and if travel plans has been discussed with supplier Ask about recent hospital admissions/ICU admission Ask about how many flares of COPD requiring steroids in a year Ask if patient is taking his inhalers appropriately and if he has had his technique assed by COPD nurses. red flags- weight loss, night sweats Psychosocial, smoking history etc  Do not forget to ask about mood if he has been discharged from hospital (Patient who have long hospital admission are at risk of depression) Management Offer referral to be assessed by respiratory physicians for review of LTOT Offer vaccinations- pneumococcal, influenza and COVID Offer pulmonary rehabilitation (physical exercise training tailored to patient’s needs and ability – such as walking, cycling and strength exercises which is done to help open up airways and improve breathing) Offer to optimise personalised COPD plan If he’s had one hospital admission and 3 flares of COPD requiring steriods then needs referral to respiratory physician for consideration of azithromycin prophylactic antibiotics but needs ECG to outrule long QT syndrome Needs COPD nurse to assess inhaler technique and to perform spirometry to assess his FEV1 to assess progression of disease NB: If a patient is travelling : Advise patient to discuss with their oxygen supplier if they can deliver oxygen to where he is traveling to Ask if any access to hospital close to where he/she will be travelling to If outside UK- needs medical insurance If flying- needs to inform flight to check oxygen requirements while on-board and the flight’s policy regarding oxygen Advise to stay away from smokers, barbecue and any form of fire Safety net and follow up COUGH Few things to note Acute cough- less than 3 weeks – common causes include viral URTI, COVID, acute exacerbations of asthma, COPD, bronchiectasis, pulmonary embolism, or pneumothorax. Sub-acute cough – within 3-8 weeks – common causes- post infection cough— from mycoplasma, viral infection, whopping cough, etc Chronic cough- more than 8 weeks- common causes- Lung cancer, GORD, Post nasal drip, asthma, copd, smokers cough, use of ace inhibitors History for cough Ask about cough onset Ask if productive Ask about haemoptysis Ask about wheeze Ask about fever, SOB, chest pain, palpitations Ask about precipitating factors Ask if worse at night Ask about flu like symptoms/Postnasal drip—blocked nose, runny nose, feeling of mucus at back of throat Ask about reflux symptoms- heart burn, sour taste in tongue Ask about hoarse voice Ask about red flag cancer symptoms--weight loss, night sweats, loss of appetite, fatigue Ask about smoking history –if patient says NO, ask if patient has ever smoked or exposed to smoke Ask about occupation and if there is any stress or if cough happens mostly at work Ask about any allergies Management Post-nasal drip-- prescribe an antihistamine (for example, chlorphenamine) and a decongestant (for example, pseudoephedrine). Advise the person to avoid allergic or environmental triggers if possible, and that symptoms should improve within 1–2 weeks of starting treatment, but resolution may take several weeks and occasionally as long as a few months. GORD- manage as normal way of managing reflux. Offer an urgent chest X-ray (to be performed within 2 weeks) to assess for lung cancer in people aged 40 years and over if they have TWO or more of the following unexplained symptoms, or if they have ever smoked and have one or more of the following unexplained symptoms: Cough. Fatigue. Shortness of breath. Chest pain.  Weight loss. Appetite loss. Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they: Have chest X-ray findings that suggest lung cancer, or Are aged 40 years and over with unexplained haemoptysis. NATIVE NUGGETS –Ear, Nose and Throat and EYES Obstructive sleep apnea They usually present with snoring or unrefreshed sleep or excessive day time sleepiness or tired all the time History Ask about snoring Ask about apnea episodes (choking while sleeping or waking up gasping for air, witnessed pausing of breathing by partner) Ask about restless and frequent waking at night Ask about early morning headache Ask if patient wakes up feeling unrefreshed Ask about day time sleepiness Ask how this has affected him Ask about job Ask if patient’s drive and if this affects driving  Ask if patient operates machinery and if this affects it Ask about lump or bumps around neck Ask patient if any weight changes particularly weight gain Ask about smoking/alcohol. Explain that obstructive sleep apnea is a common condition where the walls of the throat relax and narrow or close during sleep, causing interruption of breathing leading to snoring and pauses of breathing during sleep. NB: Some people have simple snoring and they will not have episode of apnea or gasping for breath and other symptoms of OSA Management Offer patient face to face to assess neck, look into mouth to examine back of throat, examine nostrils, listen to chest, check weight, BP etc. Offer patient a questionnaire to aid diagnosis and assessed severity of symptoms--- Epworth sleepiness scale or STOP BANG Offer to refer to sleep clinic and they will offer sleep studies – 4 weeks urgent referral for group 2 drivers/ people who operate machinery eg forklift drivers, Also offer urgent referral for pregnant women, those with comorbid COPD, Heart failure, nocturnal angina or undergoing pre-operative assessment for major surgery. Routine referral for everyone else Inform patient that sleep studies can be done at home or in the hospital-although most are now done at home. The patient will be given a device to wear overnight- sensors are attached to the body to monitor breathing, oxygen levels, heart rate, sleep position and activity throughout the night. The equipment is lightweight and most patients report that it is comfortable to wear while sleeping. Patient will be free to move about and use the toilet if they need to during the night. Most patients are able to do this study in their own home. Advise on weight loss, good diet, exercise etc Advise to avoiding sleeping on their back and to sleep on their side, where possible. The use of positioning pillows may be helpful—see picture below in next page Advise about driving- For both group 1 and 2 - if they have suspected or confirmed Mild OSA - They must stop driving if day time sleepiness affects driving or has excessive day time sleepiness If they have confirmed moderate or severe OSA- they must also stop driving Advise a person that they may continue to drive and do not need to notify the DVLA if they have suspected or confirmed OSAS but do not have excessive sleepiness which is having, or is likely to have, an adverse effect on driving Advise them that if sleep apnea is confirmed, they will be given a CPAP device –a machine that gently pumps air through a mask into your nose and mouth to help you breathe while you are asleep. This is an example of a positioning pillow Otitis media in children History Ask if pain is in both ears or just one Ask if the pain is worse by pulling the ears (Otitis externa is worse by pulling tragus) Ask about onset  Ask about discharge Ask about swelling at the back of ears Ask about fever Ask about hearing loss Ask flu symptoms-runny nose, blocked nose Ask about sore throat Ask about swimming or use of bath (Usually this leads to otitis externa) Ask if patient normally suffers from recurrent ear infection Ask about red flags- neck stiffness, lack of balance, headache Ask if making urine or wetting nappies okay Management Offer face to face to assess ears, vitals etc If parents cannot come in with child, offer advice over the phone. CRITERIA FOR ANTIBIOTICS Otorrhoea (ear discharge) or those aged less than 2 years with bilateral infection If patient does not meet this criterion, you can either offer NO prescription or delayed prescription ---advising them to use antibiotics if symptoms do not start to improve within 3 days or worsen significantly or rapidly at any time; and seeking medical help if symptoms worsen rapidly or significantly, or the child becomes systemically very unwell Most otitis media will settle within 3 days and sometimes up to a week. Advise on regular fluids Use of paracetamol or ibuprofen Safety net on worsening symptoms, swelling/redness behind ear (Mastoiditis), neck stiffness, lethargic, not making urine or wetting nappies Follow up in 3 days. Dizziness (Vertigo) Data gathering Clarify the meaning of dizziness—is this light headedness or is this spinning sensation  Ask when it started Ask if it is constant or intermittent (Comes and goes) Ask how many minutes each episode of vertigo last before resolving (BPPV is episodic and each episode last few seconds before resolving. Vestibular neuronitis and labyrinthitis is constant, imitating a central cause of vertigo. Ask if it is triggered by movement of the head--- vestibular neuronitis and labyrinthitis are not triggered by movement but may be exacerbated by movement (vertigo due to benign paroxysmal positional vertigo (BPPV) is episodic and triggered by movement). Ask about hearing loss (In vestibular neuronitis there is no hearing loss. In labyrinthitis, there is hearing loss. Pnemonic to remember –Labyrinthitis has L for loss and Vestibular neuronitis has N for no hearing loss. Ask about feeling of pressure /fullness in the ear (Meniere's disease causes this) Ask about tinnitus Ask if any headache Ask about blurry vision Ask about slurred speech Ask about weakness in one part of the body Ask about recent flu symptoms/ sore throat (In both labyrinthitis and vestibular neuronitis, there is a history of recent flu symptoms Ask if patient has had a fall from this vertigo Ask if patient drives Ask if patient operates machinery at work or at home Ask how patient is coping at home Ask about smoking, alcohol, occupation etc NOTE: Both vestibular neuronitis and Labyrinthitis has episode of flu-like symptoms and they cause vertigo but hearing loss differentiates them. The vertigo in BPPV is episodic and each episode last few seconds Central cause of vertigo will present as a constant vertigo like vestibular neuronitis and labyrinthitis. The main difference is, with central cause of vertigo, there is inability to stand up or walk even with the eyes open but in vestibular neuronitis and labyrinthitis the patient is able to walk, although unstable. Also, in central cause of vertigo, the patient may also present with new onset headache, focal neurology like weakness in one sided part of the body, dysarthria etc and they may have cardiovascular risk factors. It is also uncommon to have hearing loss in central cause of vertigo Meniere's disease will cause vertigo and hearing loss but will also present with ear fullness and tinnitus Management Offer Face to face to examine ears, to do some maneuver's eg head impulse test for vestibular neuronitis (check with patient they have no neck pain or issues around neck), Dix Hallpike maneuver for BPPV and to examine nerves of the body and check blood pressure Offer antiemetics---short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine). to alleviate the nausea and vomiting. Use maximum for 3 days. Symptomatic drug treatment is not usually helpful for people with BPPV Offer to Epley’s manoeuvre in BPPV and if patient cannot come in, then advise them to perform Brandt-Darroff exercises at home Encourage fluids Advise that bed rest maybe necessary if vertigo is constant Offer review in 1 week time Safety net- if worsening symptoms, constant dizziness, not better after 1 week, or if patient develops new symptoms, to seek urgent medical care by calling back or 111 Advise not to drive when feeling dizzy Epistaxis History taking Ask about bleed- is there current bleeding? Is the bleeding from one nostril or both? Ask about history of trauma Ask about picking of nose If this is a 2nd presentation of nose bleed within 24-48hrs after cauterization, you also ask? Any heavy lifting? Strenuous exercise, drinking alcohol, blowing or picking nose? Ask about red flags; Cancer- facial pain, visual symptoms, headache, blocked nose, hearing loss Aneamia symptoms- 2 head, 3 chest 2 head- headache, light headedness or dizziness 3 chest- chest pain, SOB, palpitations Ask about naseptin use (if on nasapetin) Ask about family history of blood disorders /bleeding disorder Ask about over the counter medications for example ibuprofen Ask about occupational exposure to wood dust Management Do bloods for FBC and clotting ( do this if this is 2nd presentation or an underlying cause is suspected) If patient is on naseptin, you can increase naseptin to 4 times a day Stop ibuprofen if patient is taking this as this can cause thrombocytopenia and cause nose bleed. Look for alternatives for pain management. For example, give codeine/paracetamol or can consider using topical ibuprofen and book another appointment to discuss pain management in detail Recommend that for 24 hours after a nosebleed they avoid: blowing or picking the nose, heavy lifting, strenuous exercise, lying flat, drinking alcohol or hot drinks Safety net/advise- if bleeding, pinch soft part of nose and lean forward- If no better in 15 mins, then seek urgent medical advise If this is 2nd presentation and they’re red flags, then refer to ENT If a patient is on DOAC for Atrial fibrillation or for whatever reason, the consider below If bleeding is acute, you can withhold DOAC temporarily and offer to check for FBC (to look for aneamia) and Kidney function ( to calculate creatinine clearance to know if you will reduce dose of DOAC). You will also offer clotting profile. Warn the person about risk of stroke and review in 4-5 days' time to see if bleeding has settled and you will calculate ORBIT score again to see determine if DOAC can be resumed. Safety net on aneamia and blood loss If bleeding is chronic for example- post nasal drip of blood for 2-3 months and weight loss and you suspect cancer. You ask for red flags - 2 head - light  headedness/dizziness and 3 chest- SOB, palpitations and chest pain. If negative. Inform the patient of risk vs benefits Tell the patient stopping Apixaban will reduce your chances of bleeding, however this will also mean that risk of stroke increases. Then allow patient make a choice by asking what are their thoughts Do FBC (to look for aneamia) and Kidney function (to calculate creatinine clearance to know if you will reduce dose of DOAC if patient wishes to be on DOAC) and also coagulation profile. Eye- Pterygium and pinguecula Pterygium-looks fleshy Pinguecula-looks like a lipid deposit History for both pterygium and pinguecula Ask when patient first noticed changes in the eyes (How long symptoms has been there) Ask if it is painful Ask if it itching Ask if it is affecting their vision If given picture of just one eye, ask if other eye is affected Ask if intermittent redness or swelling Ask if patient worked or lived in areas exposed to sun or hot climates Ask about occupation (Pterygium is common in those who spend time outdoors like farmers) Ask about psychosocial-how symptoms are affecting patient, smoking, alcohol, etc. Management for both No need for F2F if picture is very diagnostic Ophthalmology review same day is required if there is associated redness or inflammation  Referral urgently to Ophthalmology if pterygium is encroaching the cornea (the part that covers iris and pupil) and causing a reduction in vision or recurrent inflammation or rapid increase in the pterygium –this is not usually 2WW but they see them quickly and enlist them for operation. If patient is worried about cosmesis—refer routinely Otherwise- re-assure If eyes are dry-give ocular lubricants-artificial tears – e.g hylo-forte artificial tears (Sodium Hyaluronate), Hypromellose eye drops Advice use of sunglasses when patient is out to reduce UV exposure Safety net-if redness, blurry vision, pain in eyes, any other concerns, seek urgent medical advice or 111 Red eye History As patient onset of red eye Ask if bilateral or unilateral Ask if painful Ask if vision is affected- seeing haloes, blurred vision, curtain coming over eyes Ask for history of trauma or foreign body in eye Ask if there is any discharge-in viral conjunctivitis –discharge is clear, bacterial conjunctivitis discharge is yellowish /purulent with crust Ask about photophobia –if patient can tolerate looking at light Ask if patient ever wore contact lenses (keratitis) Ask if any previous eye problems Short sightedness + blurry vision = Open angle glaucoma Long sightedness + blurry vision + acute red eye =closed angle glaucoma Ask if any fever, recent flu symptoms, unwell. Ask about any headaches Ask about nausea/vomiting Management Painful red eye- Needs same day admission for assessment by ophthalmologist – causes include acute close angle glaucoma, corneal abrasion, anterior uveitis, trauma, scleritis Non painful red eye – Conjunctivitis, subconjunctival hemorrhage (Check blood pressure and ask for straining-constipation or coughing), episcleritis Non-painful red eye does not usually require admission and can be managed by GP but if you are not confident about the cause—please speak to ophthalmology or send to eye casualty Sub-conjunctival hemorrhage- Check BP and coagulation profile only if on blood thinners --reassure –review in 1 week Episcleritis – re-assure, offer NSAIDs and artificial tears- review in1 week Conjunctivitis – manage as per if bacterial, viral or allergic. Usually for bacterial conjunctivitis –-if coming within 3 days- options include—re- assure, back up topical antibiotics to use if not resolved in next 2-3 days - Chloramphenicol 0.5% drop. Also advise on self-care –see below Remember bacterial conjunctivitis is self-limiting and resolves within 5-7 days. If viral – advise self-care- Cool compresses applied gently around the eye area, use of lubricating agents or artificial tears, Bathing/cleaning the eyelids with cotton wool soaked in sterile saline or boiled and cooled water to remove any discharge If allergic- advise self-care, offer topical antihistamine or dual action mast cell stabilizer/topical antihistamine (E.g. topical Azelastine eye drops). Safety netting on worsening symptoms, swelling around eye, pain when moving eyes to seek urgent medical advice. SQUINT Most patient that present with squint are children. Most common presentation is “Doctor, my child has crossed eyes “or "My child’s eyes seem to wander sometimes, especially when they're tired. Or "I noticed one of my child’s eyes looks different in photos." Most children under 3 months may have an intermittent squint, but anything after this age should be taken seriously. Also, any child at all with constant squint should also be taken seriously History Ask when squint was initially noticed Ask if both eyes or one eye Ask if child cries and holds head (For little children) and for older kids who can speak-ask if child has complained about headaches Ask if there is nausea or vomiting If child is grown enough—can ask if he/she complains about double vision Ask PBIND –especially pregnancy and birth—finding out if child has this issue at birth, also find out if child is developing okay Ask about family history of squint Explain that squint is a condition where the eyes point in different direction Management Offer F2F to properly assess eyes, check for red reflex Refer urgently to ophthalmology-usually same day or within a week , if there is nystagmus on examination or patient reports double vision , headache or there is abnormal neurology Refer routinely if no red flags Inform mum that they will assess and ensure there is nothing else contributing to squint, they will offer things like corrective glasses or an eye patch to cover the unaffected eye to correct the affected eye and in some instances, they may offer operation Offer leaflets Advice if any other concerns to let us know NATIVE NUGGETS – PAEDIATRICS ADHD Most children are hyperactive and that doesn’t mean they have ADHD. So careful history will give this out. Remember, in general, male children are more hyperactive than females. For ADHD to be suspected, the child should have at least 6 inattention symptoms AND/OR 6 hyperreactivity-Impulse symptoms. History Ask about inattention- symptoms Is the child easily distracted? Is this child forgetful with regard to daily activities? Does the child appear not to listen to what is being said, as if his/her mind is elsewhere, without any obvious distraction? Is there difficulty in maintaining concentration when performing tasks or play activities? Does the child fail to give close attention to detail or making careless mistakes in schoolwork, work, or other activities Is this child forgetful with regard to daily activities Does this child lose items necessary for tasks or activities such as pencils, mobile phones, or wallets.  Is there any reluctance, dislike, or avoidance of tasks that require sustained mental effort? Ask about Hyperactivity-impulsivity symptoms Does this child fidget or taps his/her hands or feet when seated? Does this child interrupts or intrudes on others? Does this child talk excessively? Has the school complained that he/she leaves the seat where remaining seated is expected in class? Does this child blurt out an answer before a question has been completed? Does this child act restless? Always running or climbing around in situations that are inappropriate? Does this child find it difficult to engage in leisure activities quietly? Other part of the history Ask if anyone else has noticed or pointed out this child’s behaviour Ask if patient has issues with interacting with his peers Ask if patient has other siblings Ask how patient is with other siblings Ask for family history of ADHD or Autism ADHD affects sleep, so ask if sleep is affected Ask about PBIND (Pregnancy, birth, immunization, nutrition and development) Ask if school has complained about child Ask if child spends his time elsewhere like with cousins, grandparents etc Ask if they have also noticed issues with patient Explain that ADHD is attention deficit hyperactivity disorder. It is a common condition that affects the way a child behaves and interacts with others. In children with ADHD, they are hyperactive, lack attention and they act on impulse Management Offer parental classes for 10 weeks both to the parents of patient who you suspect has ADHD and to a patient who you suspect has no ADHD and he/she is just hyperactive. For example, Mrs Adams, parental classes help you learn more about ADHD, how it affects your child and ways to help you support your child and manage difficult behaviours.  For a patient who you suspect may not have ADHD- the reason for parental classes is for mum to interact with parents who have ADHD and understand her child better (to understand her child is just been hyperactive and nothing more) Re-assure parents who you suspect their child is just simply being a child by being hyperactive and not necessarily that they have got ADHD If a child is suspected to have ADHD and symptoms are severe and mother does not want parental class- refer to CAMHS If CAMHS waiting list is long and patient has sleep issues, offer to seek advice from CAMHS to see if melatonin can be offered. Also offer sleep hygiene measures. Offer follow up in 4-6 weeks to see how patient is doing- this can be a face-to- face examination to check weight, height and see the child for general observation. Autism In children with Autism, Mothers will usually present with either speech delay or difficult behaviours History Ask about history of difficult behaviour-How long has mother noticed all the behaviour she is complaining about? Ask about any speech or developmental delay? Ask about frequent repetition of words Ask about difficulty responding to their name Ask if patient avoids eye contact Ask about repetitive movement, such as flapping their hands, flicking their fingers or rocking their body For older children above 5 – Ask about liking a strict daily routine and getting very upset if it changes Ask if child finds it hard to make friends or prefers to be on their own Ask about sleep issues Ask if this child is under/over sensitive to light, sound, taste or touch If child has started attending school, ask if teachers has complained about him/her Ask about family history of ADHD/Autism Ask about PBIND (Pregnancy, birth, immunization, nutrition and development) history IF this child if suspected to have Autism and is already on the pathway to getting diagnosed but waiting time is prolonged and mother is stressed and has come to you for help. History includes Ask about the nature of the difficulty mother is experiencing? This can range from child having a difficult behaviour when his/her routine is changed or Mother finding it difficult to understand child and respond to his needs or the mother is spending a lot of time to look after child which is now exhausting for her (Stress due to child care duties) leading to lack of self-time and self-care or the child is not sleeping (We covered insomnia later down in this book) The two most common difficult/challenging behaviours are meltdowns and stimming (Self stimulating behaviour) Meltdowns are a complete loss of control caused by being totally overwhelmed. Stimming is a kind of repetitive behaviour—example--rocking, jumping, spinning, head-banging, hand-flapping, finger-flicking, flicking rubber bands, repeating words, phrases or sounds, staring at lights or spinning objects As a GP—your duty is to find out the nature of the difficulty—questions include Does the child seem to be in pain Does this difficult behaviour happen when exposed to bright light, noises or strange environment Does it happen when his schedule has changed Has mother noticed any pattern Is there any support at home Are there other kids and how are the kids Is mum part of any support group for Autism? Is she stressed mentally and physically? How is her mood? Does this child have a preferred method of communication What measures has the mum tried? Then of course, PBIND and other social history. Explain Autism- Autism is a condition that affects the way a child behaves, communicate and interact with the world around them. Autism is a spectrum. This means everybody with autism is different. Some autistic people need little or no support. Others may need help from a parent or carer every day. Management  Offer face to face to see the child if this is an initial diagnosis or you suspect child maybe unwell Refer to paediatrician or CAMHS depending on local pathway Offer parental classes- some areas run these as courses via zoom or weekly meetings. The parents get to learn more about Autism and ways to support the child and manage difficult behaviours. She can also network and meet other parents who their kids suffer with Autism. If the child has sleep issues and the waiting time to be assessed by CAMHS is long, you can offer to write an advice and guidance to CAMHS to see if they are happy for melatonin to be prescribed while the child is waiting to be assessed. Meanwhile offer sleep hygiene (We discussed this further down this book in insomnia topic) If mum is stressed and burnt out from looking after child- ask if any family member can be of support, if no support, then liaise with social prescriber to see if they can help with getting paid carers to support, short respite