About this blog: information for everyone else

Hi there! I’m a GP and this blog consists of the notes I take on journal articles, as part of my continuing professional development. It is intended purely for my own use in recording and remembering the things I learn so that I can refer back to them in the medical setting. While anyone is welcome to read it, please do not take it as any kind of substitute for seeing your own doctor for any medical-related queries or problems.

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About this blog: information for appraisers

This blog consists of notes made on any learning points I come across in the course of CPD and want to remember/look up later. The two main sources for this are on-line learning modules, and articles which I identify in the course of journal reading as meeting a learning need. Credits for the former are obviously counted elsewhere, so I’ve grouped the latter in a separate category in order to estimate the learning credits I’ve obtained from structured reading. You can find all posts in that category for the 2013 – 14 appraisal year here.

Posted in About this blog, Credits 2016 | 2 Comments

Signs of Kawasaki’s disease

Kawasaki’s disease is an arteritis (primarily affecting the coronary arteries).

Signs: high fever for 5 or more days and:

  • Polymorphous erythematous rash (can be urticarial, scarlatiniform or morbilliform and can contain small aseptic pustules)
  • Cervical lymphadenopathy
  • Bilateral conjunctival injection
  • Changes in the mucous membranes; can be pharyngitis, dry cracked lips, or strawberry tongue, so beware this as a possible differential diagnosis of scarlet fever
  • Changes in the extremities; oedema, erythema of the palms and soles, and, in the second week, desquamation that can also affect the nappy area.

So, when scarlet fever is suspected, look for conjunctival injection and erythema/oedema of the extremities, as it might be Kawasaki’s disease.

Posted in Dermatology, Paediatrics | Leave a comment

Indications for referring children with eczema

Immediately

  • Eczema herpeticum where child is systemically unwell

 

Within two weeks

  • Severe eczema not responding to optimal therapy within a week
  • Bacterially infected eczema not responding to treatment

 

(Quick Quiz BMJ module)

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Scabies

  • Permethrin 5% cream is first-line treatment; aqueous malathion is 2nd-line. If the first course doesn’t work, try the other one.
  • Everyone in the family needs to be treated simultaneously, and all clothing (including clothes which have been worn but are hanging in the cupboard), towels and bedding need to be washed at the same time.
  • Remember about getting treatment into all skin creases (finger webs, under breasts, around scrotum) and over scalp and any facial lesions in infants. Then reapply after one week.
  • Don’t treat infants under 2 months. In all infants under 6 months, the diagnosis should be confirmed by a dermatologist.
  • The lesions and itching can take several months to resolve; however, if treatment has been successful then no new lesions should appear. Treat secondary eczematisation with emollient and steroid.
  • Refer patients with recurrent scabies to secondary care to make sure diagnosis is correct.

(BMJ Quick Quiz module)

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Changes in the Mental Health Act

The MHA covers the legal aspects of when and how you can detain a person for assessment or treatment of a mental health disorder without their consent. It is primarily for ensuring that people with a serious mental disorder threatening either their health or the health of others can be treated without their consent if needed, while containing safeguards to protect them and uphold their rights.

Since I trained, there have been a number of changes under the 2007 amendment and the 2015 Code of Practice. The 2007 changes include:

  • Mental disorder is now defined simply as ‘any disorder or disability of the mind’.
  • There are now more criteria for being able to section someone under the MHA. The only one specified in the module was that people can only be detained for treatment if appropriate treatment is available in practice for that person in that situation. (An example could have helped here.)
  • The approved social worker can now be an approved mental health professional (AMHP); for example, a psychologist, nurse, or OT. AMHPs need to have had specialist training in mental health assessment and legislation.
  • The responsible medical officer can now be a responsible clinician, which can be a psychologist, nurse, OT or social worker. Responsible clinicians need to meet particular levels of competence; undertake a short course to demonstrate their state of readiness; and be approved by the strategic health authority. They have overall responsibility for a patient’s case.
  • Patients now have more say in who the ‘nearest relative’ with rights in the situation can be; if they don’t like the one who’s in the role, they can go to court to have that person displaced in favour of someone else.
  • The Secretary of State for Health now has a duty to provide advocacy services for all detained patients, patients under guardianship orders, and patients subject to community treatment orders. (The exceptions are patients detained under sections 4, 5, 135 and 136, which if I remember correctly are the various very short-term emergency ones of 72 hours or less, so that would make sense.) Medical staff have a duty to tell patients such advocacy services are available.
  • Patients now have more power to refuse ECT, either at the time if they have capacity or by advance decision. (This one seems unlikely to affect me in my job, but I suppose a patient might ask, so worth knowing.) Note also that, except in emergency, giving patients under 18 ECT can only be done with the approval of a second approved doctor. ‘Emergency’ here means that the treatment is necessary either to save the patient’s life or to prevent serious deterioration of their condition where the treatment does not have unfavourable irreversible consequences.
  • There is now a provision for patients under section to have their care in the community while still under section. If a patient in these circumstances refuses treatment, they need to be brought back into hospital for it to be administered (it can’t actually be forcibly administered with them still in the community). If this happens, the hospital manager has to refer the patient immediately to the tribunal.
  • The tribunal to which patients can appeal in England is now two-tier; the First-Tier Tribunal (Mental Health), and the Upper Tier, to which a patient can appeal regarding First-Tier decisions.
  • Hospital managers have to refer patients to the appeal tribunal at six months from when they were first detained. (This is apparently ‘six months to the day’, but I’m not sure whether that means, say, that someone detained on June 30th would have to be referred on December 30th or whether it would be calculated as 6 x 28 days or 6 x 30 days, or what. I would have thought the latter; apart from it working out as fairer, the former would cause problems when anyone was detained on the 31st of a month, or in the last couple of days of August, or whatever. Oh, well… another one I don’t have to worry about in practice, so I won’t.)
  • Hospital managers have a duty to ensure that patients under the age of 18 who are admitted under the MHA are placed in an environment that’s suitable for their needs taking into account their age. CCGs have a duty to let social services authorities know the whereabouts of services that can admit young people in an emergency (Section 140 of the MHA).

 

Learning disability and the MHA

It is important to note that people with learning disabilities but no other form of mental disorder can only be detained or made subject to guardianship if the learning disability is associated with either abnormally aggressive or seriously irresponsible conduct.

 

Code of Practice

This gives guidance to health professionals and hospital staff/managers on how they should proceed when undertaking duties under the MHA. There are five guiding principles:

  • Least restrictive option and maximising independence: Manage without detaining if possible. Give the patient as much freedom as is safe for themselves and others. Encourage and support independence wherever possible.
  • Empowerment and involvement: Involve patients fully in decisions about their care. If appropriate, consider the views of families and carers. Where it is necessary to act at odds with a patient’s wishes, the reason for this should be explained.
  • Respect and dignity: Fairly self-explanatory, but never forget to listen to patients.
  • Purpose and effectiveness: Decisions should be appropriate to the patient and in line with best available guidelines.
  • Efficiency and equity: This one is aimed system-wide; relevant organisations such as providers and commissioners should work together to ensure that mental health services are high-quality and given equal priority to physical health and social care services, and all relevant services should work together to facilitate timely, safe and supportive discharge from detention.

In addition, be careful to take all reasonable steps to avoid discrimination on grounds of protected characteristics.

(BMJ module)

 

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Acute red eye

Acute angle-closure glaucoma: Intermittent haloes around lights.  Nausea and sometimes vomiting. Photophobia. Severe visual impairment. Red eye with hazy cornea and fixed mid-dilated pupil. Eye feels firmer than other side to palpation through closed lid. (Do not palpate an eyeball with a possible penetrating injury as it risks extravasating the contents.) Admit immediately.

Uveitis: Presents with intense photophobia in the eye. Blurred vision is a later symptom and indicates urgency. In iritis (anterior uveitis) the redness is circumciliary (around the iris).

Scleritis: Deep boring pain which typically wakes the patient from sleep. Sometimes painful eye movements; this is a sign of inflammation at the sites of muscle insertion, and indicates scleritis or orbital cellulitis. Idiopathic, but is most commonly associated with connective tissue disease such as rheumatoid arthritis.

Corneal ulcer: Focal corneal staining with fluorescein under blue light. Visual acuity likely to be distorted unless ulcer small and peripheral. If eye too painful to open it to check, use a drop of local anaesthetic.

Preseptal and orbital cellulitis: Preseptal cellulitis often involves just the upper or lower lid, and the eye itself is not painful; can be safely managed with oral + topical antibiotics in general practice. Orbital cellulitis involves all the superficial periorbital tissues plus the deeper orbital contents, and is an ophthalmic emergency. When in doubt, discuss with ophthalmologist.

Herpes zoster ophthalmicus: This is any attack of shingles involving the ophthalmic branch of the trigeminal nerve, and doesn’t necessarily involve the eye. However, if the eye becomes red then the patient should be referred to an ophthalmologist. Note that ocular involvement is usually associated with involvement of the tip of the nose; if the tip of the nose isn’t involved, the eye is probably OK. Treatment is with valaciclovir.

Corneal foreign body: suspect if history of sudden trauma or possible high velocity foreign body impact (e.g. drilling).

Subconjunctival haemorrhage: Obviously, normally not a problem; however, beware the SCH that shows up following head injury, because if the posterior aspect isn’t visible laterally this can indicate a basal skull fracture and would need referral.

Episcleritis: typically takes about two weeks to resolve, doesn’t need treatment, typically affects young and middle-aged adults.

Viral conjunctivitis treatment: cold compresses, topical lubricants

 

Unilateral red eye with decreased vision; consider:

  • Acute angle closure glaucoma (fixed mid-dilated pupil, firm-feeling eye, nausea)
  • Corneal ulcer (focal staining)
  • Scleritis (painful eye movements)
  • Orbital cellulitis (painful eye movements)
  •  Iritis (significant photophobia)

Unilateral red eye with normal vision; consider:

  • Corneal abrasion or foreign body (focal staining)
  • Subconjunctival haemorrhage
  • Episcleritis
  • Herpes zoster ophthalmicus
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Scarlet fever

Pathology

S. pyogenes (also known as Group A streptococcus) is usually an unproblematic commensal in the skin or on the throat, but some forms produce superantigens including pyrogenic exotoxins; these can cause non-invasive infections such as scarlet fever.

Presentation

  • Initially non-specific; might include sore throat, headache, fever, N&V.
  • Rash appears after between 12 and 48 hours, initially on the chest and stomach but spreading rapidly.
  • Rash is red, pinhead, generalised, and feels like sandpaper; if the skin is too dark to see it, it will still be palpable. Remember flushed cheeks and perioral pallor. Rash often accentuated in flexures (Pastia’s lines). Persists for about a week.
  • Strawberry tongue: initial white coating peels off and tongue then looks red & swollen.
  • Rash may be followed by desquamation of tips of fingers and toes; less often, wide areas of trunk and limbs may desquamate.

Differential diagnosis

  • Measles
  • Glandular fever
  • Slapped cheek
  • Kawasaki
  • Staphylococcal toxic shock
  • Viral infections other than above
  • Allergies

Infectivity

  • Passed on by contact with mucus or saliva, airborne droplets, or contact with contaminated surfaces.
  • If untreated, can be infectious for two to three weeks after symptoms appear
  • If treated, typically no longer infectious after 24 hrs.
  • Risk of infection from an asymptomatic carrier is very low.

Prognosis

  • Usually mild and self-limiting; complications are uncommon. (It’s therefore unclear whether treating with antibiotics is actually necessary; currently recommended to minimise complication risk, speed recovery and reduce spread.)

Complications

  • May be suppurative or autoimmune.
  • Suppurative complications (e.g. otitis media, peritonsillar abscess) are caused by local or haematogenous spread and typically show up early.
  • Autoimmune (e.g. rheumatic fever, glomerulonephritis) typically show up later. Note that treatment reduces the risk of these but doesn’t fully protect against them.
  • Streptococcal glomerulonephritis has a good prognosis; permanent renal damage is rare.
  • Invasive GAS infection (iGAS) can occur and causes acute, frequently life-threatening infections: cellulitis, pneumonia, meningitis, septic arthritis, puerperal sepsis, necrotising fasciitis, and streptococcal toxic shock syndrome. This is most common in older people, the very young, or people with an underlying risk factor.
  • Admit patients with complications. Also admit those with pre-existing valvular heart disease or the substantially immunocompromised.

Treatment

Recommended treatment is Pen V qds for ten days. Alternatives include:

  • Amoxicillin bd for ten days in patients who won’t take the penicillin
  • Azithromycin od for five days in penicillin-allergic patients.

Prophylaxis of contacts is not normally given, but can be considered in cases of severe immunosuppression. Do, however, advise contacts to be on the lookout for signs or symptoms. If prophylaxis is given, the regime should be the same as for treatment.

(BMJ: Managing scarlet fever.)

 

Posted in Credits 2018, Infectious Diseases | Leave a comment

Apixaban interactions

Letter through from the pharmacy company regarding apixaban; apparently it interacts with SSRIs/SNRIs, which potentiate its action. So use with caution.

Clarithromycin does not potentiate its action, although the letter didn’t specify whether QT prolongation would be a potential issue.

Posted in Anticoagulants, Credits 2018, Medication | Leave a comment