General practice in the time of COVID

(I’m going to use this post to update any day-to-day information I need, and keep it on the front page. Some of it might be specific to my area, so none of it should be taken as official information, except for the links; it’s for easy reference for me.)

Work days 

  • When going into work, take a spare set of clothes, change at work, and change back at the end. Put used clothes into a pillowcase or cloth bag, throw the whole lot into the wash on getting home, wash at 60 deg, wash hands. A lot.
  • If a patient without COVID symptoms* needs to be seen, wear apron + mask + visor/goggles + gloves. Bare below elbows. Change apron and gloves between patients. Mask and eye protection can be used for whole session. Visor/goggles can be cleaned and saved if they don’t say ‘single use only’. Wash hands for 20s, going to elbows, between patients.
  • If a patient has possible COVID symptoms* on phone triage, add them to triage call list for hot hub: in SystmOne, click ‘Appointments’ and select ‘Remote Booking’. Tick ‘No’ for ‘Text Message Reminder’. If possible, add BSW category (see below). Explain to patient they will be seen in car park.
  • If home visiting, use PPE and take a waste bag to put it in.
  • If home visiting a patient with COVID symptoms who’s on non-invasive ventilation, additional precautions must be taken, but the SOP doesn’t say what.

*This also applies to people who are currently isolating due to a household member having COVID symptoms.

Remote assessment if possible COVID-19

  • Look for risk factors: immunosuppressants, chronic illnesses of major organs, diabetes, smoking, pregnancy
  • Check where the person is. If possible, check they have privacy.
  • Date symptoms started? (Note the ‘second week deterioration’. A post I’ve seen from a doctor in New Orleans says that typically respiratory deterioration starts on Day 5 and cytokine storm on Day 10.)
  • If medical condition not urgent, check why they’ve chosen to consult now.
  • Get descriptions of the state of breathing and (if on phone rather than video) colour of face/lips.
  • ‘How is your breathing?’ ‘What does it prevent you from doing?’
  • ‘Is it worse than yesterday?’ ‘What could you do yesterday that you can’t do now?’ (Change for the worse is important.)
  • If they actually are able to check any obs themselves/have instruments handy, get these. Interpret figures in context of wider picture but possible danger signs in COVID pneumonia include temp >38 deg, RR >20, HR >100 with new-onset confusion, O2 sats ≤94%.
  • If on video, look at skin colour, general demeanour, respiratory rate. (Don’t try to measure respiratory rate over the phone; it’s not reliable.)
  • Don’t use the Roth score. It’s not reliable enough.
  • If admission not needed but you have concerns they’re deteriorating, arrange FU by video (if consultation is as part of CCAS, arrange this with their own practice). The article says ‘If living alone, someone to check on them’: (??? how?)
  • Always safety-net: remember people with COVID-19 can deteriorate quickly.
  • If admission needed, if a friend or family member has already had significant exposure to the person and is happy to take them then they can do so. If not, arrange hospital transport. If 999 needed, remember to warn the ambulance service about the COVID.

(BMJ article; some triage details will change if working for CCAS.)

Notifying: Known cases of COVID-19 are notifiable (or will be if we ever get tests available), but also notify about suspected cases if in care home. (This also applies to some other group settings – schools, hospitals, prisons – but ‘care home’ is the one that’s relevant to my work.) Our local HPA is PHE Avon Glos. Wilts., 0300 303 8162 (as of 8th April the menu choices are option 1 both times, do not pick 9 for the helpline as it’s the one for the general public not for medics). (Latest SOP for general practice, 3rd April)

 

Some clarifying details on the ‘very high risk’ groups

  • ‘Severe asthma’ is defined as having frequent courses of oral prednisolone (the cut-off was 4 courses between July 2019 and Dec 2019; that’s because they needed a cut-off for pharmacy searches, not because that’s set in stone).
  • ‘Severe COPD’ seems to be defined as ‘triple inhaler therapy’, which seems too broad to me, but that’s how it’s reading.
  • Cystic fibrosis is automatically on the list.
  • bnf-8.2-drugs-affecting-the-immune-response is a list of the drugs that count as immunosuppressants for this purpose. (Methotrexate and most other DMARDs don’t seem to be on it, though azathioprine is an exception there.)

Local guidance on severity (opens PDF)

Government advice on isolation for affected households

EOL meds (opens PDF)

 

Managing symptoms in the community

Remember advance care planning.

Cough management:

  1. Avoid lying on back (makes it worse). Try a teaspoon of honey prn (not for <1-yr-olds).
  2. Codeine 15 – 30 mg prn qds. Can double that if necessary.
  3. Oramorph 2.5 – 5 mg prn up to four-hourly. Can double dose if necessary. If the person is on regular morphine, increase dose by a third. If eGFR <30, use equivalent doses oxycodone instead

Breathlessness:

  • Sitting upright
  • Relaxing/dropping shoulders
  • Leaning forward with arms bracing a chair or knees and upper body supported
  • Inhale through nose for several seconds with mouth closed, then exhale slowly through pursed lips for 4 – 6 seconds.
  • Physios can sometimes teach other breathing techniques remotely
  • In palliation, morphine, and/or Lorazepam which can be used sublingually

Other advice:

  • Drink fluids regularly, though no more than 2l/day.
  • Don’t use antipyretics just to bring temp down for the sake of it. If you do need to use them, paracetamol is preferred to NSAIDs.
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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

I use this blog to record my learning points/reflections arising from my CPD. It’s a very handy way of doing it, as it lets me refer back to it easily and use the search function and category menu to find the notes I’ve made on a topic when needed.

My CPD typically consists of a mixture of online modules, articles which I come across in the course of routine journal reading and find useful, answers to DENs that I’ve looked up, and the usual regular courses in CPR and (on a three-yearly basis) child safeguarding. Of the online modules, some are compulsory; the rest I pick based on DENs I identify, either specific (“I wonder what the answer is to this question that arose with this patient?”) or general (“I really need to brush up on my knowledge of skin cancers”).

To read my overall notes for this year, just click on the picture at the top to get to the home page; you can then read the posts in reverse date order (newest first). If you want to check the list of posts on CPD that isn’t from learning modules (as CPD credits for those are recorded separately), those are under the category ‘Credits ____’ with the current year. You can find this by scrolling down the category menu on the right (under the archive menu). I will normally also put in a direct link to this category in my appraisal record.

Hope that’s clear, but happy to discuss any questions at appraisal.

Posted in About this blog, Credits 2016, Credits 2018 | 2 Comments

ANCA-associated vasculitides

This is an umbrella term for a group of autoimmune small-vessel vasculitides, affecting multiple organ systems via granuloma formation and inflammation of arterioles/venules/capillaries. They include the syndromes that used to be called Wegener’s granulomatosis and Churg-Strauss syndrome, which both seem to have been renamed and acronymed, but I suspect remembering the new names won’t need to be a massively high priority for me so I’ll focus on presentation and investigation.

Presentation

The AAVs are, unfortunately, that awful combination of ‘massively wide possibilities for presenting symptoms’ and ‘really important not to miss’ (prognosis is good if picked up early and terrible if not picked up early, due to the extent of organ damage done during the delay). Almost any organ can be affected, and the diseases can also present with systemic symptoms of chronic inflammation.Therefore, look for multisystem symptoms and for symptoms associated with systemic symptoms. The most common systems affected are the upper and lower parts of the respiratory tract, the kidneys, the eyes, and peripheral nerves.

Systemic symptoms:

  • Fatigue
  • Fever
  • Night sweats
  • Weight loss
  • Myalgia/arthralgia

Respiratory symptoms:

  • Chronic sinus inflammation with pain, nasal discharge, or nasal crusting (in particularly long-lasting cases of chronic rhinitis, the bridge of the nose can collapse)
  • Deafness
  • Stridor due to subglottic tracheal stenosis
  • Shortness of breath
  • Haemoptysis; this can be a danger sign of alveolar haemorrhage, so haemoptysis associated with other signs of AAV requires same-day hospital assessment.

Kidneys:

  • Drop in renal function
  • Haematuria/proteinuria (more than a trace of either)

Eyes:

  • Scleritis

Peripheral nerves:

  • Hand or foot drop
  • Focal weakness or numbness
  • Difficulty walking

Skin:

  • Purpuric rash if associated with systemic symptoms. (AAV is unlikely to present as an isolated purpuric rash; that’s more likely to be immune complex vasculitis)
  • Nailfold infarctions
  • Splinter haemorrhages

Note that the two most severe complications of AAVs are alveolar haemorrhage and acute renal failure. Be on the lookout for haemoptysis with other symptoms, for worsening shortness of breath, for drop in renal function and for proteinuria/haematuria.

Investigations

ANCA will normally be done in specialist care, due to the risk of false negatives/false positives causing confusion. Investigations to check are FBC, inflammatory markers, E&C, LFTs, calcium, urinalysis and CXR. Typical abnormalities are:

  • Normocytic anaemia (from non-specific inflammation)
  • Microcytic anaemia (blood loss from gut involvement or gradual alveolar haemorrhage)
  • Renal failure
  • Low albumin (inflammation or nephrotic proteinuria)
  • Haematuria or proteinuria (more than a trace of either)
  • Nodular, fibrotic, or infiltrative lesions on CXR.

Note that LFTs/calcium are usually normal apart from the low albumin; abnormalities here can be a clue to a different diagnosis. The CXR can also pick up alternative causes; infection, cancer.

(BMJ article)

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Kidney stones

Management

  • Arrange urgent imaging within 24 hrs: non-contrast CT is first choice, but ultrasound should be used for pregnant people or children.
  • Arrange analgesia. Rectal analgesia doesn’t work any better unless N&V present. NSAIDs are first choice, paracetamol or opioids second-line if NSAIDs contraindicated or not sufficient.
  • If signs of possible UTI, start antibiotics empirically and send urine for C&S.
  • Refer urgently if pain is uncontrolled with oral analgesia or if there are signs of sepsis.
  • There is no evidence that antispasmodics such as hyoscine are helpful. (There is also no evidence that steroids are helpful, which is kind of moot as I wouldn’t have thought of trying them anyway, but I’ll add that in case the subject ever comes up.)

Conservative management is worth trying if all of the below are true:

  • The stone is distal and <10 mm diameter
  • Pain is under control
  • Renal function has not deteriorated
  • There is no evidence of sepsis.

Stones <4mm have a 95% chance of spontaneous passage in the next 40 days.

Upper tract stones are sometimes asymptomatic (very rarely, so are lower tract stones). Refer upper tract stones if:

  • >5 mm diam
  • Single kidney
  • Chronic obstruction
  • Recurrent UTIs

If not referred, monitor with active surveillance with annual follow-up/imaging (preferably with whichever imaging modality was originally used). Even if there is no sign of obstruction, infection, pain, or stone increasing to >5 mm in size, consider intervention after 2 – 3 years.

Long-term advice for recurrent stones

There is specific advice for stone subtypes, but general guidance is:

  • Good hydration. 2.5 – 3l water/day for adults, 1 – 2 for children; or advise drink till urine clear.
  • Avoid carbonated drinks.
  • Tea/coffee can be drunk, but keep it moderate.
  • Low sodium diet: <6g salt.
  • Normal calcium intake: 700 – 1000 mg for adults.
  • Avoid excess dietary protein (acidifies urine and promotes hyperuricosuria)
  • Avoid excess weight gain.

Risk factors for recurrence include onset <25 yrs, FH of onset <25 yrs in a 1st-degree relative, nephrocalcinosis, IBD, and Type 2 DM. These patients should be offered specialist metabolic screening.

Problems post-stent-insertion

Haematuria, frequency, urgency, dysuria and flank pain are all common post-insertion. Check for systemic symptoms, urinary retention (a possible sign of stent migration), or positive urine culture; if none of these are present and the symptoms are not severe or persistent, it’s fine to reassure the person and adopt W&S. Alpha-blockers or anticholinergics can be tried for stent colic symptoms.

 

(BJGP April 2020)

 

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Sudden sensorineural deafness, and vibration without a tuning fork

From this month’s BJGP: Sudden sensorineural hearing loss (SSNHL) is an otological emergency. The guidance is that sudden hearing loss that developed within the past 30 days needs to be referred for assessment within 24 hrs. If over 30 days ago, it should still be referred within 2 weeks. The most urgent part of this is steroid treatment, and, while this can be done via intratympanic injection, it can also be done orally. The article gives an example regime of 1 mg/kg (maximum 60 mg) od for 7 days. This should ideally be started within 48 hrs, but can still be started if within 2 weeks of onset of symptoms.

(In a rather awkward bit of timing, the authors stated that the attitude should be ‘Why should I NOT prescribe steroids?’ Excellent advice at almost any other time, but here we are, less than a month later, with a very good reason to be wary of prescribing steroids when we don’t have to. But, of course, they couldn’t really have anticipated this.)

And a useful practical piece of information: I’ve dithered over whether to get a tuning fork, and not, as yet, done so as they were quite expensive when (admittedly some time ago) I last checked on Medisave. Well, seems I don’t have to. The authors of this article experimented with doing Weber’s test with a mobile phone app called Real Razor, on silent vibration mode with a bottom corner of the phone placed on the centre of the patient’s forehead. Although the app vibrates at 163 Hz rather than 256, their results still showed >97% agreement with the results from tuning forks. (Note, however, that the tested group consisted of 74 adults post middle-ear surgery, and, as it’s described as a ‘bedside test’, this implies that it might have been done during the recovery period from surgery. I don’t know how this would affect the results as compared to a population of patients in general practice, so I’m wary. Still, I’ve downloaded the app; better than nothing.)

Posted in Credits 2020, ENT, Hearing loss | Leave a comment

A couple of tips on skin cancers

From last week’s BMJ, this article on non-melanotic skin cancers. Again, mostly visual, but here are a couple of things I want to remember:

Deciding whether a lesion is an AK or SCC? Look for:

  • Induration
  • Ulceration
  • Tenderness
  • Rapid enlargement

If it has none of those four features, it should be OK.

Morphoeic BCCs: Difficult to pick up, but look like gradually enlarging white scars. Tricky bastards.

Posted in Credits 2020, Dermatology | Leave a comment

5-Fluorouracil

This week’s BMJ has an article about Bowen’s disease and its differential diagnosis. As you might expect, revision from this one was mostly visual, reminding my occipital cortex of what the different images look like; it doesn’t translate well into notes. (Though remember the 5 Ps of lichen planus: pruritic polygonal purple papules and plaques. And remember the thin translucent rolled border around superficial BCCs, which can be used to distinguish them from Bowen’s disease.)

However, there was one very useful bit of advice about using 5-fluorouracil on lesions that are at high risk of ulceration (lower legs in elderly person); start with more infrequent use and increase gradually. So, start with twice-weekly application. After a fortnight, move to alternate nights. Then, daily. Finally, up to bd. If the area becomes bright red and sore, reduce the frequency.

Having never forgotten the time when my well-meaning insistence on treating a frail elderly lady’s lower leg lesion with 5-fluorouracil resulted in her developing a leg ulcer that had still not healed up when she died a few months later from one of her other co-morbidities… well, for one thing, I’m a lot more cautious about that sort of thing than I used to be, and I have definitely learned to abide by the Jurassic Park advice that just because you could do something doesn’t mean you should. But sometimes these lesions do need treating, so I definitely appreciated this snippet.

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Bell’s palsy

Management

  • Eye care (lubricants + night-time taping)
  • If seen in 1st 72 hrs, 50 mg Prednisolone daily for 10 days
  • If Ramsay-Hunt syndrome (look for painful vesicles around ear, mouth, or scalp) also antivirals.

Note that rates of complete resolution without steroids are 72%, but with steroids (within 72 hrs) are 83%, so NNT about 10.

Indications for referral

In early phase: concerns about either 1. eye or 2. accuracy of diagnosis.

Eye: ophthalmology review if corneal irritation or ulceration or if persistent dry eye.

Accuracy of diagnosis: Refer to ENT or to neurology, whichever seems more appropriate, if any of the following features of concern are present:

  • Other neurological findings besides the facial palsy
  • Bilateral facial palsy
  • Onset over >3 days
  • Palpable pre-auricular mass
  • Systemic constitutional symptoms

Later: Refer if no improvement by 3 weeks or incomplete resolution after 3 months. However, the pathway is different: in both cases referral should be in order to exclude an alternative aetiology, but in the second case there’s another reason, which is to look at whether early surgical or non-surgical interventions might improve the short-term or long-term outcome. Therefore, if no improvement by 3/52 then the referral should be to a facial palsy service run by ENT, but if incomplete resolution by 3/12 it should be to facial palsy services run by plastic surgery.

 

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