Rapid-recall takeaways distilled from the MRCGP AKT question bank, grouped by specialty. One pearl per high-frequency concept. Use it for last-pass revision alongside questions, not as a replacement for them.
1,653 pearls · 23 specialties · Generated 6 November 2026
Gastroenterology
80 high-yield facts
IBS first-line per NICE CG61 = dietary advice + low-FODMAP diet (under dietitian) + soluble fibre; TCA is second-line after dietary measures fail; reserve repeat colonoscopy and GFD for specific indications.
IBS = pain + altered bowel habit + no red flags + calprotectin <50; low FODMAP + antispasmodics; don't over-investigate (NICE CG61, irritable bowel syndrome in adults).
NAFLD with advanced fibrosis (FIB-4 >2.67, FibroScan >9.6 kPa) = lifestyle modification targeting 7-10% weight loss plus optimize diabetes/lipids - most effective intervention.
Chronic watery diarrhoea + cholecystectomy/ileal disease + normal tests = SeHCAT for BAM diagnosis.
Gallstone pancreatitis = amylase >3× ULN + gallstones + ALT >150 (biliary); ERCP within 72h if obstruction, 24h if cholangitis; cholecystectomy same admission (prevents 30-50% recurrence).
Rectal bleeding mixed with stool needs assessment - offer FIT plus FBC, and refer on the 2-week wait pathway if FIT is ≥10 µg Hb/g or red-flag features emerge.
Negative celiac serology (tTG-IgA) + low total IgA = check IgG-based antibodies (tTG-IgG/DGP-IgG) - IgA deficiency causes false-negative results.
Positive tTG-IgA on a gluten-containing diet in an adult → confirm with duodenal biopsy (NICE NG20) before starting a gluten-free diet.
IBS = positive Rome IV diagnosis after excluding alarm features; first-line is dietary modification (low FODMAP) and symptom-targeted pharmacotherapy per NICE CG61.
NAFLD with metabolic syndrome = FibroScan to assess fibrosis and guide monitoring.
Pregnancy GORD stepwise ladder - lifestyle → alginates → PPI (omeprazole preferred, best pregnancy safety data per UKTIS/BUMPS) or H2RA (famotidine); misoprostol contraindicated; ranitidine no longer available in the UK; most symptoms resolve after delivery.
Infectious Diseases & Sexual Health
80 high-yield facts
Positive IGRA + clear CXR + asymptomatic = LTBI - treat with isoniazid + pyridoxine for 6 months OR rifampicin + isoniazid for 3 months (NICE NG33).
BV = thin grey discharge, fishy smell (worse after sex), pH >4.5, clue cells. Not an STI - no partner treatment. First-line = oral metronidazole 400mg BD for 5-7 days. Recurrence is common (50% within 3 months).
Necrotising fasciitis = disproportionate pain + rapid progression + systemic toxicity; urgent surgical debridement within hours plus piperacillin-tazobactam (or meropenem) and clindamycin, with sepsis management per NICE NG51 - do not delay for imaging.
Mumps orchitis = parotitis followed by testicular pain 3-10 days later; supportive care only; testicular atrophy in 10-30% but sterility rare.
Empyema = pH <7.2 or pus/organisms → chest tube + IV antibiotics 3-6w; fibrinolytics if loculated; VATS if refractory.
Cellulitis = erythema + warmth + swelling; flucloxacillin first-line; admit if Eron II-IV.
Legionella = pneumonia + diarrhoea + hyponatraemia; beta-lactams penetrate cells poorly - use a macrolide or fluoroquinolone.
Sepsis Six in 1h = O₂ + antibiotics + fluids + cultures + lactate + urine output; noradrenaline if refractory.
Severe or life-threatening CDI with colonic dilatation is a surgical emergency - high-dose oral vancomycin (up to 500mg QDS) plus IV metronidazole, stop the precipitant antibiotic, and a surgeon at the bedside (NICE NG199).
Herpes zoster is an HIV indicator condition per BHIVA/BASHH UK National Guidelines for HIV Testing - offer an HIV test routinely with verbal consent, regardless of perceived risk; do not wait for additional risk factors.
Cardiovascular
80 high-yield facts
CAC >400 = high-risk regardless of other scores - intensive preventive therapy (high-intensity statin, individualized aspirin decision after bleeding risk assessment, strict BP/glucose control). CAC is atherosclerotic burden score, not stenosis assessment.
AAA ≥5.5 cm (or expansion >1 cm/year, or symptomatic) = refer to vascular surgery. Surveillance intervals per NHS AAA Screening Programme: 3.0-4.4 cm annually, 4.5-5.4 cm 3-monthly.
AAA 4.5-5.4 cm in men = 3-monthly ultrasound surveillance per NICE NG156; repair at ≥5.5 cm or if expanding/symptomatic.
Inferior MI = ST elevation II, III, aVF; RCA territory (85%).
NSTEMI medical management (NICE NG185) - aspirin + ticagrelor + fondaparinux + high-intensity statin; switch fondaparinux to UFH if angiography within 24 h or eGFR <20.
Brugada = RBBB + coved ST elevation V1-V3 + syncope/sudden death + family history. Type 1 ECG + symptoms = ICD!
Dressler = pericarditis WEEKS post-MI. Treat with aspirin (not NSAIDs!) + colchicine for 3 months!
NICE NG136 step 1 - CCB if ≥55 or Black African / African-Caribbean; ACEI/ARB if <55 (or any age with diabetes / proteinuric CKD); offer a primary-prevention statin if QRISK3 ≥10% (NG238).
QRISK3 ≥10% → atorvastatin 20 mg OD for primary prevention; 80 mg for secondary prevention; target ≥40% non-HDL cholesterol reduction at 3 months (NICE CG181 / NG238).
NHS AAA screening = men aged 65, one-off ultrasound. ≥5.5 cm = surgical referral. 3.0-5.4 cm = surveillance. Smoking is the strongest modifiable risk factor. Screening reduces AAA death by ~45%.
Psychiatry & Mental Health
80 high-yield facts
Somatic symptom disorder = multiple genuine physical symptoms + normal investigations + excessive distress. Not deliberate. Key distinction: factitious = fabricated, malingering = fabricated for gain.
FND is a positive diagnosis based on clinical inconsistency (Hoover's sign, distractibility), not just exclusion. It is not malingering - symptoms are involuntary. Explain clearly as a real brain signalling problem. Treat with physiotherapy and CBT.
Primary care dementia screening: 6CIT (quick, free), GPCOG, or MMSE. Exclude reversible causes with blood tests (TFTs, B12, calcium, etc.). Refer to memory clinic for formal diagnosis. Don't diagnose dementia subtype in primary care.
"Bipolar II = Hypomania (4-6 days, NO impairment) + Depression!" Bipolar I = Mania (≥7 days, marked impairment).
"Panic disorder = Recurrent unexpected attacks + Fear of attacks + Avoidance!" CBT first-line, SSRIs second-line.
bulimia = binge + purge + normal weight. NICE first-line = guided self-help CBT-ED, then face-to-face CBT-ED; fluoxetine 60 mg as adjunct; monitor K⁺ and ECG.
Endocrinology & Diabetes
80 high-yield facts
APS-3 = autoimmune thyroiditis + another organ-specific autoimmunity → screen for coeliac with anti-tTG; gluten-free diet if confirmed (NICE NG20).
Metanephrines MANDATORY all incidentalomas (phaeochromocytoma fatal if missed); overnight dex for Cushing's; ARR if hypertensive; <4cm + <10 HU = benign observe; 5% develop function.
Spironolactone gynaecomastia in HFrEF → switch to eplerenone (NICE NG106; EMPHASIS-HF; RALES).
Acromegaly - acral enlargement (shoe 9→12), coarse facies (prognathism, macroglossia), bitemporal hemianopia (macroadenoma 2.5 cm chiasm), IGF-1 850 ↑ (screening), OGTT GH 18 fails suppress (<2 normal confirms), complications HTN/T2DM/polyps 2-3×/arthropathy/apnea, transsphenoidal surgery (first-line, cures 60% micro/30% macro), pre-op octreotide 3m (shrinks 30%), residual octreotide LAR monthly (IGF-1 60%) or pegvisomant (90%), radiotherapy last resort, screen polyps 5-yearly, prognosis normal lifespan if controlled.
Glucocorticoid use ≥7.5 mg/day for >3 months + fragility fracture = osteoporosis; first-line is alendronic acid 70 mg weekly with calcium and vitamin D plus lifestyle modification.
Nephrogenic DI - dilute urine + desmopressin response <50%, lithium commonest drug cause, amiloride + thiazide (↓ polyuria 30-50%), switch lithium if possible.
Neuropathy + ischaemia = high risk → specialist MDT every 1-2 months. Active problem (ulcer, infection, Charcot) = refer within 24 hours. 10g monofilament is the standard neuropathy screening tool. Always check pedal pulses at annual review.
Toxic MNG - longstanding goiter, TSH <0.01 + T4 38 + T3 12, hot nodules (patchy vs Graves diffuse), antibodies negative, AF 10-20% elderly, (first-line elderly 80-90%, hypothyroidism 40-70%, OR thyroidectomy if compressive), pre-treat carbimazole 4-6w (stop 3-5d before), anticoagulate AF, monitor TFTs 6-weekly.
Evidence Interpretation
80 high-yield facts
Macrolides (clarithromycin/erythromycin) inhibit CYP3A4 → ↑simvastatin/atorvastatin → rhabdomyolysis; use azithromycin (safe) or pause statin.
ACEi cough = ↑ bradykinin (10-15%); switch to ARB (does NOT cause cough); angioedema = life-threatening, AVOID ARBs; hyperkalemia = monitor K+; AKI risk bilateral RAS.
AIP = PBGD deficiency → ↑ALA + PBG → neurovisceral crises; urine darkens on standing; diagnose with ↑urinary PBG/ALA; treat with IV hemin + glucose; avoid CYP450 inducers.
NNT = 1/ARR (absolute risk reduction); number to treat to prevent 1 event; lower NNT = better (2-5 excellent, >50 marginal); this case: ARR 2% → NNT=50; contextual (disease severity, outcome); differs from RRR (relative, can mislead); NNH for harms; aspirin post-MI NNT~40.
Statin plus fibrate raises rhabdomyolysis risk - simvastatin with gemfibrozil is contraindicated (BNF/MHRA); where a fibrate must be combined with a statin, fenofibrate is the preferred fibrate.
ACE inhibitor dry cough - most common ADR (10-20%). Mechanism: ↑bradykinin (ACE normally degrades bradykinin) → bronchial irritation. Persistent dry cough (worse at night), onset weeks-months, not dose-dependent.
Zellweger = peroxisome biogenesis defect; neonatal hypotonia + seizures + hepatomegaly + ↑VLCFA diagnostic; no treatment; death <1 year.
HAE = C1-INH deficiency → ↑bradykinin → angioedema; no urticaria; ↓C4; acute = C1-INH concentrate/icatibant; antihistamines/adrenaline ineffective; avoid ACEi/oestrogen.
OR = (ad)/(bc); case-control studies; >1 = ↑risk, <1 = protective; approximates RR when outcome rare (<10%); CI excludes 1 → significant.
Per the BNF, drug clearance is governed by renal excretion (proportional to eGFR) and hepatic metabolism (CYP450 activity, hepatic blood flow, protein binding); dose-adjust renally cleared drugs in CKD and account for enzyme induction or inhibition in polypharmacy.
Dermatology
80 high-yield facts
Stasis eczema = bilateral gaiter dermatitis + haemosiderin + varicose veins; check ABPI then compression hosiery + emollients + short-course moderate topical steroid for flares; refer for endovenous ablation as definitive treatment.
Multiple skin tags in skin folds of an obese patient = acrochordons. Benign - reassure. Remove symptomatic ones with snip excision, cryotherapy, or ligation. Associated with insulin resistance.
Moderate plaque psoriasis first-line topical therapy is a vitamin D analogue per NICE NG153 - use combination with potent steroid or phototherapy if inadequate.
Dark, velvety skin in axillae and neck folds = acanthosis nigricans from insulin resistance. Treat the underlying metabolic syndrome. Rapid onset in older patients = exclude malignancy.
Rapidly growing bright red nodule that bleeds easily after minor trauma = pyogenic granuloma. Common in pregnancy and after injury. Treat with curettage and cautery. Always send for histology to exclude amelanotic melanoma.
Refer to dermatology for patch testing. Control eczema first. Avoid back TCS before test. Patient brings suspected products.
Pearly papule + rolled border + telangiectasia + central ulceration on sun-exposed site = nodular BCC. Commonest skin cancer. Locally invasive but extremely rarely metastasises.
500g for a child with moderate eczema ≈ 2 weeks. Adults need 250-500g/week. Prescribe generously - underuse leads to poor control.
In SJS/TEN, stop the culprit drug immediately and transfer to a burns unit - allopurinol and anticonvulsants are the commonest UK triggers, and SCORTEN predicts mortality.
Lip SCC = high-risk site → 10-15% metastatic risk; refer urgently via 2-week-wait (NICE NG12); first nodal stop is the cervical chain.
PMR = no synovitis + normal strength - think muscle pain, not joint disease.
Raynaud's = white → blue → red colour change - think triphasic vasospasm, screen for secondary causes.
Treat the acute flare first (colchicine, steroid or NSAID), then address urate lowering later once the joint has settled.
In limited cutaneous systemic sclerosis the first-line Raynaud treatment is a calcium channel blocker (nifedipine), alongside a PPI for reflux and annual ILD surveillance, in line with BSR systemic sclerosis guidance.
In a red, hot joint, especially in the elderly, “sepsis until proven otherwise” applies - crystals and negative Gram do not automatically rule out septic arthritis.
Methotrexate pneumonitis = exclude infection first - think BAL + HRCT, then steroids if infection excluded.
“CREST = anti-Centromere” and usually limited skin involvement, whereas “Scl-70 = Scleroderma with Sclerotic trunk” (diffuse disease and lung fibrosis).
Allopurinol = start low (100 mg), titrate slowly, give colchicine prophylaxis - prevents flares and AHS.
Pseudogout = chondrocalcinosis + rhomboid positively birefringent crystals; treat the acute flare with an NSAID + PPI, intra-articular steroid, or colchicine - not allopurinol.
SLE - hydroxychloroquine for everyone (BSR 2018, NICE CKS); screen for lupus nephritis and APS; high-dose steroids only for severe organ-threatening disease.
Prescribing Regulations
80 high-yield facts
Acute severe thrombocytopenia + new drug = DITP - stop drug immediately.
Serotonin syndrome = clonus + autonomic hyperactivity + altered mental status - stop drugs, supportive + benzodiazepines, cyproheptadine if severe.
ARB Cough Incidence: No Different from Placebo - recognise the key clinical and investigative features to guide appropriate management.
Cranberry inhibits CYP2C9 → ↑warfarin/INR; INR 5-8 + minor bleed = vitamin K 1-2mg PO; major bleed = IV vitamin K + PCC.
Statin + CYP3A4 inhibitor = rhabdomyolysis risk; simvastatin worst; STOP + aggressive IV fluids; switch to pravastatin/rosuvastatin.
per NICE CG184 and BNF, review long-term PPI annually and step down when possible - reserve indefinite PPI for Barrett's, severe erosive oesophagitis, or high-risk NSAID/anticoagulant users.
Theophylline + macrolides/ciprofloxacin/fluvoxamine = TOXICITY from CYP1A2 inhibition. Monitor levels, reduce dose, or avoid combination!
NSAIDs ↑lithium 20-50% (↓renal prostaglandin); aspirin safe; check level within 7d; use paracetamol instead.
Large Vd = tissue-bound, needs loading dose, NOT dialysable; small Vd = plasma-bound, dialysable.
statin + fibrate → fenofibrate ONLY; gemfibrozil is contraindicated (BNF interaction, cerivastatin 2001 withdrawal); monitor CK and U&Es; FIELD and ACCORD-Lipid support fenofibrate add-on for TG >2.3 and low HDL.
Clarithromycin + simvastatin = rhabdomyolysis - always switch to azithromycin or doxycycline for pneumonia.
Opioid rotation - reduce calculated equianalgesic dose by 25-50% for safety.
Renal & Urology
80 high-yield facts
Low ferritin + low TSAT = iron deficiency - treat iron first, then ESA if needed.
Milk-alkali = hypercalcaemia + AKI + alkalosis + suppressed PTH + excess CaCO₃; stop calcium + IV saline; resolves 48-72h.
Stage CKD as 'G by eGFR, A by ACR' - eGFR 42 = G3b, ACR 45 = A3. Diabetics with albuminuria (ACR ≥3 mg/mmol) belong on an ACEi/ARB, and a sustained eGFR <30 or ACR ≥70 mg/mmol warrants nephrology referral.
CKD anemia (Hb <100 + CKD 4-5 + low ferritin/TSAT) = IV iron FIRST (correct deficiency), then epoetin if Hb remains low - target Hb 100-120 g/L (NOT >130), ESAs ineffective without iron.
Hypertensive nephrosclerosis = chronic HTN + small kidneys + mild proteinuria; African ancestry highest risk (APOL1); aggressive BP control most important.
For counselling, emphasise that “CKD is a heart disease multiplier” - controlling BP, cholesterol, and albuminuria is as important as protecting the kidneys themselves.
“Analgesic kidneys = small, scarred, and papillae gone” - chronic NSAID exposure, papillary necrosis, sterile pyuria, and calcified papillae on imaging point strongly to analgesic nephropathy as the cause of CKD.
Respiratory
80 high-yield facts
Asthma-COPD overlap (ACO) - recognise the key clinical and investigative features (smoking history, persistent obstruction, atopy, reversibility >200 mL, eosinophils >300, raised FeNO) to guide appropriate ICS/LABA management.
HAP ≥48h post-admission → broad Gram-negative ± Pseudomonas cover; piperacillin-tazobactam IV is first-line per NICE NG139; add vancomycin only if MRSA risk factors are present; de-escalate at 48-72h on cultures.
Palliative breathlessness = Opioids (morphine) first-line (2.5-5mg 4-hourly regular); Reduces dyspnoea sensation; Safe - does NOT hasten death; Oxygen if SpO2 <90%; Fan + non-pharmacological adjunct; Anxiolytics if anxiety; Titrate to control; Improves quality.
Secondary PTX = Higher risk than primary; >2cm OR breathless = chest drain; Admit all secondary PTX; Target SpO2 88-92% in COPD; Aspiration less successful than primary; Consider surgery if persistent leak >5 days or recurrent.
Early COPD + basal emphysema + low AAT = confirm with phenotype/genotype; augmentation if PiZZ.
LTBI (positive IGRA + normal CXR + asymptomatic) in healthcare worker = treat with isoniazid 6 months or rifampicin + isoniazid 3 months.
Annual asthma review (NICE NG245 / BTS-SIGN 2024) = symptom control (ACT/RCP3), inhaler technique, adherence, triggers, action plan, exacerbation risk and step-down review; CXR only if atypical features or suspected alternative diagnosis.
SCLC limited stage → Disease within single RT port; Concurrent chemoRT (platinum-etoposide + 45Gy); 5-year survival 20-25%; PCI if response; Extensive stage: chemo + immunotherapy, survival 2-5%.
Prolonged antibiotics 3-6 weeks, percutaneous drainage if fails - recognise the key clinical and investigative features to guide appropriate management.
CURB-65: C-U-R-B-65; 0-1 outpatient; 2 consider admission; 3-5 inpatient ± ITU; IV co-amoxiclav + clarithromycin if severe.
Women's Health
80 high-yield facts
Sterilisation regret is highest in women under 30 (~20%). Counsel about LARC alternatives and vasectomy. No age restriction exists, but thorough informed consent is essential.
Chronic pelvic pain + dyspareunia + dyschezia with normal ultrasound = suspect endometriosis. Diagnostic laparoscopy is the gold standard.
Screening barriers are mainly psychosocial and practical, not knowledge-based. HPV self-sampling may transform uptake for non-responders.
Micronised progesterone (Utrogestan) = body-identical, lower breast cancer risk than synthetic progestogens. Cyclical in perimenopause, continuous in postmenopause.
Desogestrel = 12 hours. Traditional POP = 3 hours. Desogestrel is the most commonly prescribed POP in UK practice.
Bartholin's abscess → Word catheter or marsupialisation (not just I&D). Over 40 → biopsy to exclude carcinoma.
Switching contraceptive methods within the current method's effective window = no gap in protection, no additional precautions needed.
"Deprescribe = Stop drugs with no SHORT-term benefit!" Statins in <1 year life expectancy = inappropriate. Focus on quality of life!
Rockwood CFS is assessed at baseline (2 weeks pre-illness). CFS 5 = needs help with some ADLs but not fully dependent. It should not be used in isolation for treatment decisions.
Frail elderly + recurrent hypoglycaemia = relax HbA1c target (58-70). Stop/reduce sulfonylureas. Avoiding hypos is more important than tight control. Metformin contraindicated if eGFR <30.
"Vitamin D <25 = Loading dose 300,000 IU over 6-10 weeks!" Then 800 IU daily maintenance. Reduces falls by 20-30%!
Unwise decision ≠ lack of capacity! If they understand, retain, weigh, and communicate - they have capacity. You MUST respect their autonomous refusal, even if it kills them. That is the law.
CAM requires acute onset + inattention + (disorganised thinking OR altered consciousness). Inattention is the cardinal feature of delirium. The 4AT is an alternative screening tool.
STOPP/START = evidence-based tool for medication review in elderly. NSAIDs in CKD = highest immediate risk (AKI, GI bleed). Review all medications but prioritise by harm potential.
Elderly + "off legs" / new confusion / functional decline = assume infection until proven otherwise. Fever is often ABSENT in elderly sepsis. Full septic screen mandatory. CRP is more reliable than temperature.
"Frailty = ≥3 of WEEWS!" Weight loss, Exhaustion, wEakness, Walking slow, low phySical activity. Reversible with multicomponent interventions!
Dementia = must notify DVLA. Mild dementia may still drive (DVLA decides with annual review). Doctor should advise notification, can breach confidentiality if patient refuses. Group 2 licence always revoked.
Nurses can verify expected deaths in the community. The GP issues the MCCD. Refer to the coroner only if criteria are met (unknown cause, unnatural death, not seen within 28 days). Medical Examiner review is now standard.
An alcohol-responsive, symmetrical postural/action tremor with a family history and no bradykinesia is essential tremor; offer propranolol or primidone first-line when it impairs function.
Focal epilepsy = levetiracetam/lamotrigine first-line; avoid valproate in women; 12m seizure-free to drive.
Bell's = sudden LMN VII + forehead involved + no vesicles; pred 50mg ×10d <72h + eye care; 90% recovery.
Vestibular neuritis = acute vertigo + abnormal HIT + no hearing loss; rehab essential; avoid prolonged suppressants.
CSF neutrophils >1,000 plus low glucose <50% ratio equals bacterial meningitis - start ceftriaxone plus dexamethasone immediately, dexamethasone reduces complications.
First seizure recurrence risk 40-50%; AED reduces to 20-25% but no long-term prognosis benefit; decision individualized (driving, job); lamotrigine/levetiracetam first-line.
Paediatrics & Child Health
80 high-yield facts
MenB = 8 weeks, 16 weeks, 12 months. Give prophylactic paracetamol with each MenB dose - unique to this vaccine.
Molluscum in healthy children = reassure and wait. Self-resolves in 12-18 months. No treatment needed.
Bruising in a pre-mobile child = NAI until proven otherwise. Non-bony sites (trunk, upper arms, ears, neck) are suspicious. Different ages of bruising suggest repeated injury. Safeguarding action must not be delayed by investigations.
FeverPAIN 0-1 = no antibiotics, 2-3 = delayed prescription, 4-5 = immediate antibiotics. First-line = penicillin V.
8 weeks = 6-in-1 + rota + MenB. PCV starts at 12 weeks. MMR at 12 months. Hepatitis B was added to the 6-in-1 in 2017.
Egg allergy (even anaphylaxis) is NOT a contraindication to MMR. Minor illness without fever = vaccinate. Don't miss opportunities.
"TEN" - Trunk, Ears, Neck bruising = suspicious. Bruises on bony prominences in mobile children are usually accidental. Any bruise in a non-mobile baby is concerning.
Risk of significant harm = refer to children's social care immediately. Consent not needed. Document everything. Follow up in writing within 48 hours.
NHSP pathway: AOAE → repeat AOAE if unclear → AABR if still unclear → audiology referral. A single failed AOAE is common and does not confirm deafness.
ADHD = specialist diagnosis only, not GP. Symptoms must be in multiple settings. Refer to CAMHS/specialist service. GPs do not prescribe methylphenidate first-line.
Roseola = high fever for 3-5 days then rash as fever settles. The child looks well once the rash appears - reassure.
Fever ≥5 days + 4/5 features = Kawasaki disease. Urgent referral for echo and IVIG. Coronary artery aneurysm is the feared complication.
ENT
80 high-yield facts
Prevent swimmer's ear: dry ears after swimming, use acetic acid drops post-swim, avoid cotton buds. Custom swim plugs for frequent swimmers. Do not use prophylactic antibiotics.
Throat clearing + hoarseness + posterior laryngeal oedema without heartburn = laryngopharyngeal reflux. Treat with lifestyle changes + PPI twice daily for 3-6 months. Response is slow.
Presbyacusis = bilateral symmetrical sensorineural hearing loss. Refer for audiometry and hearing aids. Investigate asymmetric loss with MRI. Untreated hearing loss accelerates cognitive decline.
Acute sinusitis is usually viral - no antibiotics for the first 10 days. Treat with analgesia, saline irrigation, and short-term decongestant. Limit decongestant use to 7 days.
Post-viral anosmia = olfactory training (4 odours, twice daily, 3+ months). Most recover within 12 months. No role for oral steroids. Refer if persistent beyond 12 months.
Progressive dysphagia + weight loss = 2WW referral for suspected upper GI cancer. Dysphagia at any age warrants urgent investigation via NICE NG12. Never treat empirically.
Bilateral bony growths in ear canals + cold water exposure = exostoses (surfer's ear). Prevention with ear plugs. Surgery only for significant canal narrowing causing recurrent infections or hearing loss.
Cocaine nasal damage = cessation of cocaine is the priority. Vasoconstrictive ischaemia causes progressive destruction. Check ANCA (levamisole-related vasculitis). Surgery only after sustained abstinence.
Bilateral symmetrical vocal cord nodules = speech therapy first, not surgery. Junction of anterior 1/3 and posterior 2/3. Caused by vocal abuse. Surgery only if SLT fails after 6-12 months.
Hoarseness after thyroid surgery = recurrent laryngeal nerve palsy until proven otherwise. Monitor for 6-12 months as recovery is possible. Left RLN palsy with no surgical cause - exclude lung cancer.
Haematology & Oncology
80 high-yield facts
Rectal bleeding + change in bowel habit in ≥50 = 2WW referral. FIT test is for patients who don't meet 2WW criteria. Don't delay referral with trials of treatment. Always perform DRE.
IDA in men/postmenopausal women = GI investigation (OGD + colonoscopy) to exclude malignancy. Always check coeliac serology. Treat iron deficiency but ALWAYS investigate the cause.
Breast screening: ages 50-70, every 3 years, two-view mammography. Self-refer after 70. Higher-risk women have separate enhanced surveillance pathways. Informed consent is essential.
Haemophilia A = raised aPTT + low FVIII + normal vWF; factor VIII replacement; DDAVP for mild.
ITP = isolated plt <100, normal Hb/WCC; >30 observe; <30/bleeding → prednisolone 1mg/kg; IVIg if life-threatening.
Cancer VTE = LMWH first-line (not warfarin); lifelong if active malignancy; pancreatic highest risk; Trousseau = migratory thrombophlebitis.
Visible haematuria aged ≥45 = 2WW referral regardless of other symptoms, UTI, or anticoagulant use. Bladder cancer is the most common cause. Smoking is a major risk factor.
Abnormal DRE = 2WW referral regardless of PSA. Learn age-specific PSA thresholds. mpMRI is now first-line before biopsy. PSA should not be checked within 48 hours of ejaculation or 1 week of UTI.
Alcohol is the commonest cause of macrocytosis in the UK. If B12 and folate are normal, check TFTs, LFTs, reticulocyte count and medication history. Consider MDS in older patients with unexplained persistent macrocytosis (NICE CKS Anaemia; BSH 2014 macrocytic anaemia guideline).
Targeted lung health checks: current/ex-smokers aged 55-74 at high risk. Low-dose CT is the screening modality. Smoking cessation is offered alongside. The programme is being rolled out nationally.
Ophthalmology
62 high-yield facts
Gradual blurred vision + glare + loss of red reflex in an elderly patient = cataract. Refer when affecting quality of life. Surgery is highly effective.
Drusen + gradual central loss + no distortion = dry AMD. Advise Amsler grid monitoring, smoking cessation, and healthy diet. Urgent referral only if distortion develops (wet conversion).
Long-term steroids + posterior subcapsular cataract = steroid-induced. Affects near vision and glare early. Review steroid dose and refer for surgery. Cataracts do not reverse on stopping steroids.
Proptosis + painful restricted eye movements + fever + reduced vision = orbital cellulitis. Emergency admission for IV antibiotics and CT. Usually secondary to sinusitis. Life and sight-threatening emergency.
Ptosis + miosis + anhidrosis = Horner syndrome. In a smoker, urgently exclude Pancoast tumour. Third nerve palsy = complete ptosis + dilated pupil (opposite of Horner).
Reduced vision in one eye + structurally normal eye + cannot be corrected with glasses alone = amblyopia. Treat with glasses + patching. Most effective before age 7. Often associated with squint.
Purulent discharge in a neonate <28 days = ophthalmia neonatorum. Urgent swabs including Chlamydia PCR and Gram stain. Day 1-5 onset = think gonococcal (emergency). Day 5-14 = think chlamydial. Treat parents.
Irregular pupil + visible wound + iris prolapse = open globe injury. Shield (no pressure), tetanus, antibiotics, nil by mouth, emergency ophthalmology. Never remove foreign bodies or apply pressure in primary care.
Fluorescein stains corneal epithelial defects green under cobalt blue light. Use fluorescein strips in primary care for any eye trauma or suspected corneal pathology. It is diagnostic only - not an anaesthetic or treatment.
Medico-legal & Safeguarding
55 high-yield facts
Duty to raise concerns about patient safety. Escalate: local first → NHS England/CQC/GMC → Freedom to Speak Up Guardian. Protected by whistleblowing legislation. Do not wait for harm - act promptly.
Self-neglect is a safeguarding category under the Care Act 2014, even if the person has capacity. Multi-agency approach is key. Having capacity does not prevent a safeguarding referral.
Always assume capacity. An unwise decision does not equal incapacity. Capacity is decision-specific, not diagnosis-specific.
Document: the specific decision, impairment, functional test results, support provided, and conclusion. IQ and diagnosis alone do not determine capacity.
Notifiable diseases require mandatory reporting regardless of patient consent. TB must be notified within 3 days. The duty to notify is a statutory obligation on the diagnosing doctor.
Confidentiality is owed to each patient individually. Encourage the patient to disclose to partners. Use partner notification services. Only breach confidentiality as a last resort if serious risk exists.
Confidentiality persists after death. Release records to personal representatives under the Access to Health Records Act 1990, but only relevant information. Consider the deceased's known wishes.
Justified disclosure without consent: statutory obligation, court order, public interest (prevent serious harm), or best interests (lacking capacity). Family convenience is never sufficient justification.
Child death/serious harm + suspected abuse + multi-agency involvement = Child Safeguarding Practice Review (formerly SCR). Purpose is learning, not blame. Mandated by Working Together 2018.
Multiple unexplained presentations + normal investigations + symptoms only with one carer = consider FII. Do not confront the parent. Make a safeguarding referral. This is child abuse on a spectrum from exaggeration to induction.
NHS Organisation & Contracts
50 high-yield facts
Partnership agreements are not mandatory but essential. Without one, the Partnership Act 1890 applies by default. Cover: profit-sharing, responsibilities, exit terms, restrictive covenants. Use a specialist solicitor. Review regularly.
ICBs replaced CCGs in 2022. They are statutory NHS bodies that commission healthcare services locally. They sit within ICSs alongside Integrated Care Partnerships. Accountable to NHS England.
CQC = independent regulator of health and social care in England. Five key questions: safe, effective, caring, responsive, well-led. Rates services from outstanding to inadequate. Registration is mandatory.
NHS England directly commissions approximately 150 specialised services for rare/complex conditions. This ensures equitable access and quality. ICBs commission most other services locally. GPs refer into specialised pathways.
GMS = nationally negotiated, standard framework, open-ended. PMS = locally negotiated, flexible. APMS = any provider, time-limited. GMS is most common. Negotiated between NHSE and BMA/GPC.
Core = must provide (acute/chronic care, terminal care). Additional = default inclusion, can opt out (screening, vaccinations, contraception). Enhanced = separately commissioned (DES national, LES local).
QOF = voluntary pay-for-performance. Rewards achievement against clinical indicators. Lower/upper thresholds determine points. Exception reporting allows exclusion of inappropriate patients. Part of the GMS contract.
BMA model salaried contract: 30 days leave + bank holidays, study leave, sick pay, 3-month notice period. Salaried GPs are employees with employment rights. No profit share. Pay guided by NHSE minimum scale.
SEA = no-blame, structured learning from significant events. Covers both good and bad events. Must include action points and follow-up. Required for CQC, appraisal, and revalidation. Team-based process.
Revalidation every 5 years via GMC. Based on annual appraisals reviewed by the responsible officer. Evidence needed: CPD, audit, MSF, SEAs, complaints. Mandatory for all licensed doctors.
Public Health & Screening
48 high-yield facts
Lead-time bias = earlier diagnosis extends apparent survival without changing death. Overcome by measuring population mortality, not survival from diagnosis. RCTs comparing mortality are the gold standard for evaluating screening.
Case-control: start with outcome, look back at exposure. Uses odds ratio. Good for rare diseases. Cohort: start with exposure, follow forward. Uses relative risk. RCT: randomise to exposure. Gold standard for interventions.
AAA screening: men at 65, one-off ultrasound. <3cm = normal. 3-4.4cm = annual scan. 4.5-5.4cm = 3-monthly. ≥5.5cm = surgical referral. Women not routinely screened. Men >65 can self-refer.
Prevalence = existing cases/population (snapshot). Incidence = new cases/at-risk population per time period (rate). Prevalence ≈ incidence × duration. Long-duration diseases have high prevalence relative to incidence.
OR = (a×d)/(b×c) in a 2×2 table. Used in case-control studies. OR approximates RR when disease is rare. OR >1 = positive association. OR <1 = protective effect. OR = 1 means no association.
Adults: 150 min moderate or 75 min vigorous per week + strength training 2 days. Minimise sedentary time. Start gradually if inactive. Over-65s add balance exercises. Any activity is beneficial.
TB contact tracing: stone in the pond - closest contacts first, expand based on infectivity and yield. Screen with CXR + Mantoux/IGRA. Coordinated by TB specialist team. Under-5s prioritised. GP cooperates but doesn't lead.
Social determinants (income, education, housing, employment, environment) account for 30-55% of health outcomes. WHO Commission highlighted structural inequality as the root cause. GPs see this daily. Solutions require cross-sector action.
Learning Disability & Neurodevelopmental
40 high-yield facts
Autism = disability under Equality Act 2010. Entitled to workplace reasonable adjustments. Disclosure is voluntary. Access to Work scheme can fund adjustments. Many autistic people thrive in employment with appropriate support.
PBS is NICE-recommended as primary intervention for challenging behaviour in LD/autism. Understand the function of behaviour, adapt the environment, and teach alternative skills. Not punishment or medication-based. Addresses triggers proactively.
LD annual health check bloods: FBC, TFTs, HbA1c/fasting glucose, lipids. Plus BP, BMI, urinalysis, vision, hearing, dental, and mental health. Targets the higher disease burden in this population.
Autism adjustments: predictable scheduling, advance information, reduced sensory input, clear literal language, extra time, written summaries. Legal duty under Equality Act. Individualise adjustments - ask the patient what helps.
Sensory sensitivities in autism cause genuine distress and pain - never dismiss them. Stop, adjust the environment, allow regulation. Plan adjustments for future appointments. Never exclude from screening. Stimming is regulatory, not disruptive.
Masking = suppressing autistic traits to appear neurotypical. Causes burnout, anxiety, depression, and suicidality. More common in women. Contributes to late diagnosis. GPs should validate and support safe unmasking environments.
Shared care for ADHD: GP prescribes and monitors once stabilised. Monitor pulse, BP, weight every 6 months. Watch for side effects. Arrange annual specialist review. GP can contact specialist for advice.
Untreated ADHD increases substance misuse risk 2-3x. Treating ADHD reduces substance use. Not a contraindication - use long-acting formulations. Address both conditions simultaneously. Self-medication is common.
10-20% of Down syndrome patients have atlantoaxial instability. Assess before high-impact sports (trampolining, diving, gymnastics, rugby). Cervical X-rays: atlantodental interval >5mm is abnormal. Symptomatic AAI needs urgent neurosurgical referral.
Allergy & Immunology
38 high-yield facts
PID red flags = too frequent, too severe, too unusual, too prolonged infections + failure to thrive. Look at the overall pattern, not individual infections. Early referral to immunology is crucial.
Anaphylaxis action plans must prioritise IM adrenaline as first-line. Include photo, triggers, symptom recognition, auto-injector instructions, 999, and positioning guidance.
IgA deficiency is the commonest PID (~1 in 600). Usually asymptomatic. Key risk = anaphylaxis with blood products containing IgA. Medical alert card needed. Associated with coeliac and autoimmune disease.
Drug allergy records need: specific drug name, reaction description, allergy vs intolerance classification, severity, and date. Accurate records improve prescribing safety and stewardship.
Intranasal corticosteroids are first-line for moderate-severe allergic rhinitis. More effective than oral antihistamines. Regular use needed - takes 1-2 weeks to work. Technique matters.
SPT and specific IgE show sensitisation, not necessarily clinical allergy. Clinical history is paramount. Oral food challenge is the gold standard for confirmation. Stop antihistamines before SPT.
Consider immunotherapy referral for severe allergic rhinitis uncontrolled by optimal pharmacotherapy for 2-3 seasons. Only disease-modifying treatment. Available as SCIT or SLIT over 3-5 years.
Three tryptase samples: ASAP, 1-2 hours, and baseline at 24+ hours. A rise above individual baseline confirms anaphylaxis. Don't delay treatment for sampling.
Drug desensitisation = hospital-based, gradually increasing doses when essential drug has no alternative. Temporary tolerance only. Never attempt in primary care.
Seasonal symptoms May-July = grass pollen. Pale boggy turbinates = allergic inflammation. Grass is the commonest UK cause of hay fever. Perennial = house dust mite.
IBS Rome IV = pain + defecation-related + altered frequency/form + no red flags; low FODMAP (50-70%) + antispasmodics first-line; TCA/CBT if refractory (NICE CG61, irritable bowel syndrome in adults).
Chronic watery diarrhoea + normal colonoscopy = biopsy to diagnose microscopic colitis.
NAFLD = steatosis + metabolic syndrome; FIB-4 >2.67 → FibroScan/biopsy; weight loss 7-10% first-line; pioglitazone/vitamin E for NASH.
Diabetic gastroparesis - first-line is dietary modification plus tight glycaemic control; metoclopramide is a 5-day prokinetic per MHRA, with surgery as last resort.
Sigmoid Volvulus - recognise the key clinical and investigative features to guide appropriate management.
ischaemic colitis (elderly + sudden pain + bloody diarrhoea + splenic flexure thickening + no peritonitis) = conservative IV fluids and bowel rest; approximately 85% resolve; surgery only if gangrenous.
BSG 2020 - high-risk findings (≥2 premalignant polyps with ≥1 advanced, or ≥5 premalignant polyps) warrant a single surveillance colonoscopy at 3 years; everyone else returns to routine screening.
Severe CDI = WCC >15/Cr ↑>50%/severe colitis → vancomycin 125mg QDS ± IV metronidazole; fidaxomicin for recurrent; FMT 85-90%; surgery if fulminant.
Confusion + asterixis + cirrhosis = HE; grade with West Haven; lactulose 15-30 mL TDS to 2-3 soft stools/day, add rifaximin 550 mg BD if recurrent (NICE TA337); always hunt the precipitant (sepsis, GI bleed, constipation); do not restrict dietary protein.
Persistent coeliac symptoms despite diet = dietary review first to exclude inadvertent gluten.
Upper GI bleed + Glasgow-Blatchford score 0-1 = LOW RISK. Safe for outpatient management with endoscopy within 24 hours.
PBC = AMA-M2 positive (95%) + cholestatic ALP + middle-aged women; UDCA 13-15mg/kg first-line; Response at 1 year (ALP less than 1.5× ULN); Obeticholic acid second-line; Transplant if bilirubin greater than 100/decompensation.
Watery diarrhoea with a normal endoscopy but a thickened collagen band on biopsy is collagenous colitis - treat with budesonide 9 mg daily and review causative drugs (BSG guidelines on microscopic colitis, 2021).
Los Angeles grade C/D esophagitis (severe erosive disease) = high-dose PPI twice daily 8-12 weeks - heals 90-95%, then maintenance once daily.
Chronic fissure = posterior midline + sentinel tag + >6w; topical GTN/diltiazem 6-8w (50-60%); sphincterotomy if fails (95%, incontinence risk).
NHS Bowel Cancer Screening = FIT every 2 years, ages 50-74; positive screening FIT → colonoscopy; symptomatic patients use NICE NG12 / DG30 FIT pathway (≥10 µg Hb/g).
Uncomplicated GERD = lifestyle + PPI 4w (omeprazole 20mg, >80% respond); no OGD if no alarm features; step down to lowest dose; fundoplication if refractory.
Severe CDI (WCC >15, creatinine ↑>50%, T >38.5) = oral vancomycin 125 mg QDS 10 days; fidaxomicin for recurrence; FMT after ≥2 episodes; soap-and-water hand hygiene (NICE NG199 2021; TA805).
PiZZ AATD - for liver, supportive care and transplantation if decompensated; IV AAT augmentation helps lungs but NOT liver; always stop alcohol and screen relatives.
Achalasia = Absent peristalsis + incomplete LES relaxation (IRP >15); HRM gold standard; Pneumatic dilatation (70-90%) or Heller myotomy (85-95%); Type II best prognosis; Perforation risk 2-3%; Botulinum temporary.
BAM = chronic watery diarrhoea + terminal ileum disease + SeHCAT <15%; colesevelam/cholestyramine with meals (70-80%); Type 1 (ileal), Type 2 (idiopathic), Type 3 (secondary).
H. pylori = PPI BD + amoxicillin 1g BD + clarithromycin 500mg BD × 7d; confirm UBT ≥4w post-Rx; if fails → bismuth quadruple 14d.
UC = continuous from rectum, superficial, crypt abscesses, no granulomas. Crohn's = skip lesions, transmural, granulomas, terminal ileum involvement.
Hepatic adenoma >5cm (OCP use + incidental finding) = stop OCP + surgical resection - rupture risk 30-50%, malignant transformation 5-10%, regression possible if <5cm after stopping hormones.
In chronic constipation, screen for hypothyroidism (and check calcium, glucose and FBC); hyperthyroidism, Addison's disease and coeliac disease cause diarrhoea, not constipation.
BAM = Chronic watery diarrhea + SeHCAT <15%; Colesevelam 625mg BD first-line (better tolerated); Response 70-80%; Post-cholecystectomy common (Type 3); Take with meals.
Collagenous colitis (chronic watery diarrhea + normal colonoscopy + collagen band >10 μm + NSAID use) = stop NSAIDs + oral budesonide 9mg - induces remission 80%, relapse common after stopping.
Chronic fissure failed medical → lateral sphincterotomy (gold standard 90-95%, incontinence 10%) OR botox (60-80%, no incontinence); posterior 90%, lateral → IBD/malignancy.
Intestinal TB = terminal ileum + transverse ulcers + caseating granulomas + central necrotic mesenteric nodes; treat with NICE NG33 standard 6-month regimen (2m RIPE → 4m RH) plus pyridoxine; surgery only for complications.
Autoimmune gastritis (anti-IF antibodies + atrophic gastritis body/fundus + low B12) = lifelong IM B12 injections plus endoscopic surveillance every 3-5 years - gastric cancer risk 3-6×.
Intestinal TB (ileocaecal + transverse ulcers + caseating granulomas + AFB) → 6-month standard regimen (2m RIPE → 4m RH) plus pyridoxine; surgery only for complications.
Hepatic adenoma = young women + OCPs + rupture 10-30% + malignancy 5-10%; stop OCPs (30-50% regress); resect if >5cm; avoid pregnancy until resected; β-catenin high malignancy.
A1AT deficiency liver disease (PiZZ + PAS-positive globules + cirrhosis) = avoid hepatotoxins + HCC surveillance + consider transplantation - no specific medical therapy.
Paracetamol ALF King's = pH <7.3 OR (INR >6.5 + Cr >300 + Grade 3-4 HE), IV NAC even beyond 24h, transplant if criteria met (80% mortality without).
Erosive esophagitis + partial PPI response = double dose to twice daily (e.g., omeprazole 40mg BD) for 8-12 weeks - most patients respond.
Penicillin allergy + H. pylori = PPI + clarithromycin + metronidazole (NICE); always confirm eradication at least 4 weeks later.
Under-55 with uninvestigated dyspepsia and no alarm symptoms - H. pylori test-and-treat OR a 4-week full-dose PPI (NICE CG184, both first-line); urgent endoscopy only for alarm features or ≥55 with new unexplained symptoms.
is soluble fibre (ispaghula, oats) - beneficial in IBS versus insoluble fibre (wheat bran) - often harmful in IBS.
Hepatocellular equals high ALT/AST with a normal or near-normal ALP; cholestatic equals high ALP/GGT. Use the pattern (and the R factor) to direct investigation, as set out in the British Society of Gastroenterology guidelines on the management of abnormal liver blood tests (2017).
Porcelain gallbladder (gallbladder wall calcification + chronic cholecystitis) = prophylactic cholecystectomy if fit for surgery - eliminates low but real gallbladder cancer risk.
Colonoscopy with high-risk adenoma (≥10mm, high-grade dysplasia, villous, or ≥3 total) = repeat in 3 years - balances cancer prevention with procedural risks.
FD + H. pylori → triple therapy eradication (10% improve); PPI 4-8w (30-40%); prokinetics for PDS; TCA refractory; red flags: dysphagia/weight loss/age >55.
Corticosteroids started within 72 hours save lives in moderate-to-severe PJP.
Drug-sensitive pulmonary TB = RIPE x 2 months, then RI x 4 months (total 6 months). CNS/spinal TB = 9-12 months. Monitor LFTs monthly. DOT improves adherence!
Most traveller's diarrhoea is self-limiting (3-5 days). Oral rehydration + loperamide for mild cases. Antibiotics only for dysenteric, severe, or prolonged (>7 days) cases. If persistent, investigate for giardia and amoeba.
IVDU native-valve IE → S. aureus; flucloxacillin is the key anti-MSSA agent; vancomycin if MRSA/penicillin allergy; take 3 blood-culture sets before antibiotics.
Probe-to-bone suggests osteomyelitis - bone biopsy confirms it and identifies the causative organism for targeted antibiotics.
Immunocompromised + shingles = IV aciclovir, not oral therapy or observation; start within 72 hours where possible.
Offer chlamydia screening to all sexually active 15-24 year olds. Self-taken vulvovaginal swab is preferred. 70% of female infections are asymptomatic. NAAT is the gold standard test.
Oral thrush with ICS = nystatin + spacer use + mouth rinsing after inhaler. Fluconazole is second-line. In patients without risk factors, consider HIV testing. Persistent thrush may indicate immunosuppression or oesophageal involvement.
Positive EIA + TPPA + RPR (no treatment history) = active syphilis. RPR titre correlates with disease activity. IM benzathine penicillin is first-line. All syphilis cases must be managed via GUM for staging, treatment, and partner notification.
Opt-out HIV testing in areas with prevalence >2/1,000. Test all new registrants. Normalise testing to reduce stigma and late diagnosis. Late diagnosis = CD4 <350 = worse outcomes. Pre-test counselling is NOT required for routine testing.
PEP must start within 72 hours (ideally <24 hours) of exposure. 28-day course of antiretrovirals. Refer urgently to ED or sexual health clinic. PrEP is for ongoing pre-exposure prevention. Both are available via sexual health services.
Full STI screen = chlamydia + gonorrhoea NAAT, HIV + syphilis serology, ± hepatitis B/C. Window periods apply - may need repeat testing. HSV testing is only for symptomatic ulcers, not asymptomatic screening.
Use Eron classification for cellulitis severity. Class II = systemically unwell or comorbidities. Flucloxacillin 500mg QDS (not 250mg) is first-line. Mark the border. Review at 48-72 hours. Always consider DVT in the differential.
TARGET = Treat Antibiotics Responsibly, Guidance, Education, Tools. Developed by RCGP/PHE for primary care. Includes patient leaflets, audit tools, and consultation aids. 80% of antibiotics are prescribed in primary care - stewardship starts here.
CAP first-line = amoxicillin 500mg TDS for 5 days. Use CRB-65 for severity assessment. NICE recommends 5-day courses for most infections. Doxycycline or clarithromycin for penicillin allergy.
Herpes zoster at ANY age is an HIV indicator condition - offer HIV testing. Multiple indicator conditions exist. The aim is to reduce late diagnosis. Only verbal consent is needed - no formal pre-test counselling required for routine testing.
Encourage disclosure and offer support as first step. U=U (Undetectable = Untransmittable) is key - virally suppressed patients have negligible transmission risk. Confidentiality breach is a last resort, guided by GMC. Document all discussions carefully.
Screen with anti-HCV antibody first. If positive, confirm with HCV RNA PCR. Past IVDU is the main UK risk factor. DAAs cure >95% in 8-12 weeks. NHS target: hepatitis C elimination by 2030.
First-episode genital herpes - oral aciclovir 400 mg three times daily for 5 days plus supportive care (BASHH 2024); topical aciclovir is ineffective, and suppression is reserved for frequent recurrences (around 6 or more per year).
Long COVID with PESE = paced activity within the energy envelope (do not push through) plus MDT rehabilitation; avoid boom-bust cycles.
Fever + travel to a malaria-endemic area = malaria until proven otherwise - urgent thick and thin films plus RDT, repeat ×3 at 12-24-hour intervals if negative (UKHSA 2024); same-day hospital review; falciparum from West Africa can kill within hours and severe disease requires IV artesunate.
Most URTIs and sore throats are viral - antibiotics are not indicated. Use FeverPAIN/Centor scores for sore throat. Explain antibiotic harms. TARGET toolkit supports antibiotic stewardship conversations.
PID = empirical treatment without delay. IM ceftriaxone + oral doxycycline + oral metronidazole for 14 days. Cervical motion tenderness is the key sign. Contact trace last 6 months. Review at 72 hours.
EBV with splenomegaly = no contact sports for at least 3-4 weeks - splenic rupture risk is highest in the acute phase and is frequently spontaneous.
Painless indurated genital ulcer + reactive EIA/TPPA + positive RPR in an untreated patient = primary syphilis → benzathine benzylpenicillin 2.4 MU IM single dose (BASHH 2024); doxycycline 14 days if penicillin-allergic; always offer HIV testing, partner notification and warn of Jarisch-Herxheimer.
Chronic hepatitis B with HBV DNA >2,000 IU/mL + raised ALT + fibrosis ≥F2 = start tenofovir or entecavir indefinitely.
Uncomplicated lower UTI in non-pregnant woman = nitrofurantoin 100 mg MR BD × 3 days (NICE NG109); avoid if eGFR <45; reserve quinolones for complicated infection per MHRA restrictions.
PEP = start <72h (ideally <4h); Truvada + raltegravir × 28d; reduces transmission 81%; repeat HIV 4-6w/12w/6m.
Returning traveller from South Asia + fever + relative bradycardia + rose spots = typhoid → azithromycin (or IV ceftriaxone if severe); notifiable disease (UKHSA).
ALA = fever + RUQ + solitary right lobe + positive serology; metronidazole then luminal agent; aspiration rarely needed; cure >95%.
Chronic HBV treat if DNA >2000 + ↑ALT + fibrosis ≥F2; tenofovir or entecavir (indefinite); 6-monthly HCC surveillance.
PCP = HIV CD4 <200 + subacute dyspnea + dry cough + bilateral interstitial infiltrates. Treat: High-dose co-trimoxazole 120mg/kg/day x 21 days + prednisolone if hypoxic (PaO₂ <9.3kPa). Steroids reduce mortality 50%!
Use empathy and explanation, not confrontation. Acknowledge experience, explain natural history, provide TARGET leaflets. Post-hoc attribution ("the antibiotics worked") is the main driver of expectation. Safety netting is essential.
Dengue = high fever + retro-orbital headache + myalgia + rash + thrombocytopenia after travel to endemic area. AVOID NSAIDs (bleeding risk). Supportive care only. Monitor for severe dengue. Transmitted by Aedes mosquitoes (day-biting).
Pre-travel consultation: risk assessment, vaccinations (routine + travel-specific), malaria prophylaxis, general health advice. Do NOT prescribe prophylactic antibiotics for the trip. Ideally consult 6-8 weeks before departure. Yellow fever certificate is mandatory for Kenya.
Fever + neutrophils <0.5 = neutropenic sepsis emergency - give IV piperacillin-tazobactam/meropenem within 1 hour, don't wait.
Hepatic hydatid cyst = albendazole + surgery/PAIR; never aspirate without chemotherapy cover (anaphylaxis/dissemination risk); "honeycomb" daughter cysts are characteristic.
Travel + chronic watery diarrhoea + steatorrhoea = giardiasis - metronidazole 400 mg TDS for 5-7 days (PHE/BNF), watch for transient lactose intolerance.
Scabies = night itch + web spaces + burrows; permethrin 5% ×2 (day 1 & 8); treat ALL contacts; itch persists 2-4w.
Suspected Ebola = isolate + notify PHE + full PPE + HCID unit; NO routine procedures; RT-PCR diagnostic.
First-episode genital herpes = oral aciclovir 400 mg TDS for 5 days (BASHH 2014); topical therapy is insufficient; offer suppression if ≥6 recurrences/year; HSV-2 recurs more often than HSV-1 genital infection.
Gonorrhoea first-line = IM ceftriaxone 1g single dose. Test of cure at 2 weeks. Contact trace last 3 months. Test for concurrent chlamydia, HIV, and syphilis. Ciprofloxacin resistance makes it unsuitable.
Acute sinusitis is usually viral and self-limiting (2-3 weeks). Intranasal corticosteroids are helpful if symptoms persist >10 days. Antibiotics only for severe, worsening, or persistent symptoms. 'Double sickening' (improvement then worsening) suggests bacterial superinfection.
Trismus + facial swelling + fever from dental infection = emergency admission. Risk of Ludwig's angina and airway compromise. Uncomplicated dental abscess = antibiotics + urgent dental referral. Definitive treatment is dental (drainage/extraction), not antibiotics alone.
Primary care prescribes 80% of UK antibiotics - GPs are key to AMR strategy. Even short courses increase resistance. Use narrow-spectrum, shortest duration. Trimethoprim resistance is ~30% - check local antibiograms.
Narrow-spectrum first principle: less microbiome disruption, less C. difficile risk, less resistance selection. Choose the narrowest effective agent. Reserve broad-spectrum for severe or resistant infections.
Needlestick from HIV-positive source = start PEP immediately (<1h ideal, <72h window); triple ART for 28 days; HIV testing at 6 weeks, 3, 6 months.
Fournier's gangrene = diabetic + rapid scrotal/perineal necrosis + crepitus; immediate debridement + pip-taz + clindamycin + sepsis-6; do not delay for imaging; mortality 20-40%.
PrEP = TDF/FTC daily for HIV-negative individuals at substantial risk. Confirm HIV-negative first. Review HIV/STIs and renal function 3-monthly.
Cryptococcal meningitis = induction IV amphotericin B + flucytosine for ≥2 weeks, then fluconazole; drain raised ICP with repeat LPs - pressure kills patients (BHIVA guidance).
PCP = dry cough + breathlessness + bilateral ground-glass on CXR in HIV with CD4 <200. Insidious onset over weeks. Treat with high-dose co-trimoxazole for 21 days. Add steroids if hypoxic. Prophylaxis when CD4 <200.
Severe AS + anaemia + troponin rise + minor CAD = Type 2 MI - treat trigger, NOT PCI!
HFrEF + sinus rhythm + HR ≥70 bpm on max beta-blocker = add ivabradine. Target heart rate <60 bpm for optimal outcomes in heart failure.
Subclavian steal + VBI + arm claudication + inter-arm BP gap >20 mmHg → angioplasty/stenting first-line; antiplatelet plus risk-factor modification if asymptomatic.
Post-MI with LVEF ≤35% = wait 40 days minimum, ideally 3 months on optimal medical therapy before ICD. Don't implant early - let LV remodelling stabilize first.
Hydroxychloroquine cardiomyopathy = hypertrophy plus conduction disease after chronic use - stop the drug immediately, as recovery is possible if caught early (per BNF/MHRA cardiotoxicity guidance).
ACE inhibitor + beta-blocker are both first-line for HFrEF - titrate to maximum tolerated doses. Add MRA if still symptomatic. SGLT2 inhibitors are now recommended for all HFrEF. Monitor U&E closely.
Never diagnose hypertension on clinic readings alone (unless ≥180/120). ABPM is gold standard - mean daytime ≥135/85 = stage 1, ≥150/95 = stage 2. White coat hypertension is common and should not be treated.
Varicose veins with skin changes, ulceration, bleeding, or significant symptoms = refer to vascular service. Compression stockings are NOT definitive treatment. Skin changes indicate chronic venous insufficiency requiring intervention.
For cancer-associated thrombosis, use a DOAC (apixaban or edoxaban) or LMWH; avoid DOACs where there is luminal GI or genitourinary cancer because of mucosal bleeding risk (NICE NG158, CARAVAGGIO).
Routine compression stockings do not prevent post-thrombotic syndrome (SOX trial); advise activity, leg elevation and weight control, reserving stockings for symptom relief (NICE NG158).
For unprovoked proximal VTE (NICE NG158), extended anticoagulation is supported after weighing recurrence risk (male sex, proximal clot, positive post-treatment D-dimer) against bleeding risk.
Match the monitor to symptom frequency - a 24-hour Holter for daily or several-times-weekly palpitations, a 7-14 day event recorder for weekly-to-monthly episodes, and an implantable loop recorder for rare events.
Any new adult murmur warrants echocardiography - clinical examination alone cannot reliably distinguish innocent from pathological murmurs, and early identification of valve disease improves prognosis.
Post-MI persistent ST elevation + dyskinetic apex + VT = LV aneurysm - surgery removes arrhythmia substrate and improves haemodynamics!
CIED infection + positive blood cultures = complete system extraction mandatory. Never leave infected hardware in situ - treatment failure and mortality risk.
Hypertension + diabetes or CKD = start ACE-I/ARB regardless of age or ethnicity! For uncomplicated HTN: <55 = ACE-I; ≥55 or Black = CCB.
Type A dissection + pericardial effusion = EMERGENCY SURGERY within hours - AVOID pericardiocentesis; mortality is 1-2%/hour untreated.
PPCM = heart failure within 5 months postpartum with no other cause - treat with standard heart failure therapy PLUS bromocriptine (stop breastfeeding); around half of women recover LV function and future pregnancy carries a high recurrence risk.
Athlete's heart = bradycardia + LVH voltage + dilated LV cavity + wall thickness ≤13 mm + normal diastolic function. Do not confuse with HCM - no sport restriction needed when echo is reassuring.
In trained athletes - sinus bradycardia, PR <400 ms, incomplete RBBB, early repolarisation and isolated voltage LVH = physiological adaptation; no further investigation needed.
Beta-blocker OR CCB is first-line for angina (NICE CG126). Both are equally effective - choice depends on comorbidities. All angina patients need aspirin + statin + ACE-i + GTN spray. Avoid combining diltiazem/verapamil with beta-blockers.
Heart failure monitoring = U&E (especially potassium), clinical fluid assessment, and medication optimisation. NT-proBNP is for diagnosis, not routine monitoring. Repeat echo only for clinical change, not routinely.
SGLT2 inhibitors (dapagliflozin TA679, empagliflozin TA773) cut HF hospitalisation and CV death in HFrEF regardless of diabetes - add them to an ACEi/ARB, beta-blocker and MRA, do not substitute.
Per the AHA scientific statement on cocaine-associated chest pain (endorsed in BNF/Resus Council practice), give a benzodiazepine + aspirin + GTN and arrange primary PCI for STEMI; avoid beta-blockers because of unopposed alpha vasoconstriction.
First-line work-up of palpitations in primary care is a 12-lead ECG plus TFTs, FBC and U&Es; arrange ambulatory monitoring if the ECG is normal but symptoms persist.
The RCEM-supported THINK AORTA campaign highlights that sudden tearing chest or back pain with an inter-arm systolic BP difference (>20 mmHg) and a hypertension history should prompt urgent 999 referral for CT aortography - mortality rises roughly 1-2% per hour, so do not delay and do not give aspirin.
Heart failure + warm peripheries + bounding pulses = high-output failure - find the shunt or systemic cause.
AF with heart failure = beta-blocker first-line for rate control. Avoid rate-limiting CCBs (diltiazem/verapamil) in HFrEF - they worsen failure.
Mobitz I = progressive PR + narrow QRS = benign, no pacing. Mobitz II = fixed PR + dropped beats + wide QRS = PACING!
Symptomatic paroxysmal AF + failed antiarrhythmics + young + normal heart = catheter ablation (PVI). First-line in selected patients per 2020 ESC guidelines.
NICE NG196 - anticoagulate all men with AF and CHA₂DS₂-VASc ≥2 (≥3 women); DOAC first-line (apixaban preferred profile per ARISTOTLE); assess bleeding risk with ORBIT; aspirin has no role in AF stroke prevention.
Resistant HTN + hypokalaemia = screen for primary hyperaldosteronism with ARR; most common secondary cause of resistant HTN.
HTN 230/135 + encephalopathy + AKI = EMERGENCY - IV labetalol, reduce BP 10-20% first hour NOT normalize!
CHA₂DS₂-VASc ≥2 (male) or ≥3 (female) = anticoagulate with DOAC or warfarin. DOACs are first choice unless contraindicated (mechanical valve, severe renal impairment).
Digoxin level 3.2 + regular 45 bpm + no P waves + atropine response = junctional rhythm from digoxin toxicity - STOP digoxin, NOT permanent pacemaker!
Post-ACS = atorvastatin 80mg (or rosuvastatin 20-40mg) for LIFE! Target LDL <1.4 mmol/L. Add ezetimibe if target not met.
Group 2 (HGV) driver + single unexplained syncope + normal cardiac workup = at least 3 months off + DVLA notification by the patient (DVLA Assessing Fitness to Drive).
NSTEMI risk stratification = GRACE score. Intermediate risk (109-140) = angiography within 72 hours; high risk (>140) = within 24 hours!
Advanced HF + 15% weight loss + persistent oedema = cardiac cachexia - assess for transplant, prognosis poor!
Postural hypotension in HF on GDMT → reduce diuretics first (check for overdiuresis); don't stop beta-blockers/ACE inhibitors unless absolutely necessary.
In CKD, high-sensitivity troponin often chronically elevated; acute MI requires significant delta (>20%) plus clinical/ECG/imaging evidence.
Stable angina investigation = CTCA first-line per NICE 2016! ETT is outdated. If CTCA shows disease → functional test or invasive angio.
Symptomatic WPW = catheter ablation (curative). Don't use AV-nodal blockers if AF develops in WPW!
Match monitoring duration to symptom frequency: daily = Holter, weekly = event recorder, monthly = ILR. Sudden-onset/offset regular palpitations suggest SVT. Normal resting ECG with no pre-excitation is reassuring but does not exclude paroxysmal arrhythmia.
Acute severe HF congestion → IV furosemide bolus + infusion; oral diuretics inadequate due to gut oedema reducing absorption.
HFrEF symptomatic despite ACE-i/BB/MRA/SGLT2i = consider switching ACE-i to ARNI (after 36-hour washout). ARNI superior to ACE-i in reducing mortality.
FH = tendon xanthomata + LDL >6.5 mmol/L - start maximum statin immediately and refer for specialist management. Early treatment can prevent premature MI and death.
ACE inhibitor cough = switch to ARB. ARB cough incidence <5% (much lower than ACE-i). Never stop RAAS blockade in HFrEF without replacing it.
Statin-intolerant patient post-MI = add ezetimibe. Simple, effective, affordable, and proven to reduce events. Ezetimibe should be considered in ALL patients not reaching LDL targets on statins.
HFpEF management = treat symptoms with diuretics + aggressively manage ALL comorbidities (HTN, AF, obesity, sleep apnea). SGLT2i emerging as beneficial!
Recent stroke makes PCI the only option for STEMI reperfusion - transfer time <120 minutes is acceptable.
Asymptomatic WPW + competitive athlete = EP study to stratify SCD risk - ablate if high-risk pathway!
Munchausen = deliberate symptom fabrication + sick role motivation + peregrination + pseudologia fantastica. Distinguish from malingering (external gain) and somatisation (genuine symptoms).
Dissociative amnesia = loss of personal identity/autobiographical memory after psychological trauma + normal neurology. Fugue = amnesia + purposeful travel. Not organic (preserved general knowledge).
Cyclothymia = chronic subthreshold mood swings for ≥2 years, never meeting criteria for mania or depression, no 2-month symptom-free period. 15-50% progress to bipolar disorder.
Opioid substitution therapy (methadone/buprenorphine) = gold standard for opioid dependence. Reduces mortality, injecting, and crime. Buprenorphine = safer in overdose (partial agonist).
Section 136 = police remove from public place to place of safety, up to 24 hours. Section 135 = warrant for private premises. Health-based place of safety preferred over police custody.
Sertraline is the preferred first-line SSRI - fewest drug interactions, good evidence base, and lower QTc risk than citalopram. Review at 2-4 weeks.
After two failed antidepressant trials, consider SSRI + mirtazapine combination in primary care. Lithium augmentation is effective but usually specialist-initiated. Refer to psychiatry if combination therapy fails.
Social anxiety = fear of scrutiny/judgment + avoidance of social situations + functional impairment for ≥6 months. First-line = individual CBT designed for social anxiety. SSRI if CBT inadequate.
Adjustment disorder = identifiable stressor + disproportionate emotional response + retained enjoyment capacity + subthreshold for depression. Usually self-limiting. Supportive management, not antidepressants.
Always check ferritin in RLS - supplement if <75 µg/L. Iron replacement may resolve symptoms. Trial for 3 months before considering dopamine agonists or gabapentinoids. Diagnose clinically using the four essential criteria.
Whooley questions = two screening questions for depression at antenatal booking. "Down/depressed/hopeless?" and "Little interest/pleasure?" If positive, ask about need for help. Further assess with clinical interview ± PHQ-9.
Sertraline is the preferred antidepressant during breastfeeding - lowest transfer into breast milk, most data. Do not advise stopping breastfeeding for antidepressants. Balance benefits of treating depression against small medication exposure risk.
Lithium monitoring: levels every 3 months, renal and thyroid every 6 months, calcium annually. Target 0.6-0.8 mmol/L (maintenance). Common interactions: NSAIDs, ACE inhibitors, thiazides. Dehydration increases toxicity risk.
Community detox: chlordiazepoxide reducing regimen over 7-10 days with supervision. Inpatient if: seizure history, DT history, >30 units daily, or unsafe home. Never stop alcohol abruptly in dependence - risk of seizures and DTs.
AST:ALT ratio >2 + raised GGT + raised MCV suggests alcohol-related liver disease. FibroScan is the non-invasive investigation for liver fibrosis assessment. Offer to those drinking hazardously for >10 years. Low platelets may indicate portal hypertension.
Never prescribe methadone without verifying with the specialist service. Methadone overdose is fatal - long half-life causes accumulation. GPs should only prescribe under shared care agreements with specialist supervision. Drowsiness may indicate toxicity or concurrent substance use.
Standard DBT has 4 components: individual therapy + group skills training + telephone coaching + therapist consultation team. Runs ~12 months. Four skill modules: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness. Strongest evidence for reducing self-harm in EUPD.
Section 2 = assessment, 28 days, diagnosis unclear. Section 3 = treatment, 6 months, diagnosis established. Both need 2 medical recommendations + AMHP application. Section 2 for first presentations, Section 3 for known patients refusing treatment.
Section 5(2) = doctor's holding power for voluntary inpatients, up to 72 hours, one doctor needed. Only for patients already admitted. Temporary measure pending full MHA assessment. Section 5(4) = nurse holding power, 6 hours.
DoLS = legal authority to deprive incapacitated people of liberty in care homes/hospitals. Part of MCA, not MHA. Requires 6 assessments. Care home applies to local authority. Liberty Protection Safeguards (LPS) will eventually replace DoLS.
AChEIs for mild-moderate Alzheimer's. Baseline ECG (bradycardia risk). Start low, titrate up. Common side effects: GI (nausea, diarrhoea). Caution in asthma and peptic ulcer disease. Memantine for moderate-severe or AChEI intolerance.
50% of adult ADHD has comorbid anxiety. SSRIs (sertraline) can be safely added to stimulants. Atomoxetine is an alternative that may help both. Don't assume anxiety resolves with ADHD treatment alone. Don't prescribe benzodiazepines.
FINISH symptoms within days of stopping a short half-life SSRI = discontinuation syndrome (NICE NG222/MHRA); restart and taper hyperbolically over weeks-months; fluoxetine is safest to discontinue.
Learning disability ≠ lacks capacity. Presume capacity (MCA principle 1). Assess for the specific decision with appropriate communication support. Take all practicable steps to help decision-making. Parents cannot consent for adults - even with LD.
"Refeeding = Start LOW calories, Go SLOW, Replace phosphate/K+/Mg²+!" Thiamine first, then feed cautiously. Monitor ECG + electrolytes daily.
Chronic insomnia first-line = CBT-I + sleep hygiene. Hypnotics only short-term (2-4 weeks) if non-pharmacological measures fail. Melatonin MR licensed for over-55s. Address caffeine, screens, and irregular schedules.
First-rank symptoms are positive psychotic features (hallucinations, delusions, thought disorder, passivity); flat affect is a negative symptom and is NOT first-rank.
OCD first-line is CBT with ERP per NICE CG31 - high-dose SSRIs if medication is needed; antipsychotics are augmentation, not first-line.
"SSRI nausea = EARLY and TRANSIENT!" Sexual dysfunction = persistent. Serotonin syndrome = triad (neuromuscular + autonomic + mental state).
Puerperal psychosis = psychiatric emergency, onset within 2 weeks of delivery. Admit to mother and baby unit urgently. Both mother and baby at risk. 25-50% recurrence risk in future pregnancies. Often related to bipolar disorder.
Illness anxiety disorder = fear of disease despite minimal symptoms and normal investigations; NICE CG113 management = CBT ± SSRI with single-GP continuity and scheduled appointments; differs from somatic symptom disorder (bodily symptom focus) and OCD (ego-dystonic intrusions).
ME/CFS: post-exertional malaise is the cardinal feature. NICE 2021 removed graded exercise therapy - it can cause harm. Manage with energy management/pacing, specialist referral, and symptom support. CBT for emotional impact, not cure.
MAOI + tyramine-rich food = hypertensive crisis. Key foods: aged cheese, cured meats, red wine, Marmite. Treat with phentolamine.
Depression = "Low mood OR anhedonia + ≥4 symptoms for ≥2 weeks!" Early morning wakening = biological depression feature.
Clozapine: mandatory FBC monitoring - weekly for 18 weeks, fortnightly for 1 year, then monthly. 1% agranulocytosis risk. Fever + sore throat on clozapine = urgent FBC. Also monitor for constipation (ileus risk) and myocarditis.
Cannabis + family history of psychosis = significantly elevated risk. High-potency ("skunk"), daily use, and adolescent onset are key risk factors. Monitor for prodromal symptoms. Amotivational syndrome is common with chronic use.
Fraser guidelines = specific criteria for contraception in under-16s. Gillick competence = general principle of child's capacity to consent. Child can consent but cannot refuse life-saving treatment against parents' wishes.
Refeeding syndrome hallmark = hypophosphataemia after refeeding a malnourished patient. Prevent: start low, go slow (10-20 kcal/kg/day) + prophylactic thiamine + monitor electrolytes daily.
"Acute dystonia = Muscle spasm within HOURS/DAYS!" IM procyclidine = rapid reversal. Tardive dyskinesia = late, irreversible.
BPD = abandonment fear + unstable relationships + mood lability over hours + self-harm; DBT first-line (NICE CG78); mood shifts hours (BPD) vs days-weeks (bipolar).
Clozapine = mandatory FBC monitoring for agranulocytosis (weekly for 18 weeks, then fortnightly to 1 year, then monthly); fever or sore throat on clozapine = check FBC urgently. (BNF clozapine monograph; NICE NG178 psychosis and schizophrenia.)
assume capacity; unwise ≠ incapacity; dementia ≠ incapacity; a capacitous adult can refuse life-saving treatment.
FEP = low-dose atypical antipsychotic first-line + early intervention team. Clozapine = third-line only after 2 failed trials.
Schizoaffective = psychotic + mood symptoms equally prominent and simultaneous. If mood dominates → psychotic depression. If psychosis dominates → schizophrenia.
Vascular dementia = stepwise decline + vascular risk factors + focal neurology + MRI evidence. Prevention of further strokes is the main treatment.
Patients can self-refer to NHS Talking Therapies (formerly IAPT) - no GP referral needed. Offers Step 2 and Step 3 interventions. Step up to high-intensity CBT if low-intensity treatment fails.
"Delirium = Acute + Fluctuating + Inattention + Medical illness!" Treat cause, supportive care, minimize medications.
Olanzapine and clozapine = highest metabolic risk (weight gain, diabetes, dyslipidaemia). Monitor metabolic parameters regularly. Aripiprazole = lowest metabolic risk. Consider switching if metabolic syndrome develops.
Continue antidepressants for at least 6 months after remission (first episode) or 2+ years if recurrent depression. Taper gradually when stopping - never abruptly.
BMI <15 + bradycardia + hypotension in anorexia = urgent referral (MARSIPAN criteria). Risk of cardiac arrhythmia, refeeding syndrome, and death. Check BMI, pulse, BP, ECG, and electrolytes in all suspected eating disorders.
Wernicke's triad: confusion + ophthalmoplegia + ataxia (but complete triad only in 16%). Emergency IV thiamine (Pabrinex) required - oral is inadequate. Give thiamine BEFORE glucose. Untreated → Korsakoff's (irreversible).
Pre-stimulant assessment: baseline BP, heart rate, cardiac history, and family history of sudden cardiac death. ECG not routinely required but often performed. Refer to cardiology if family history of sudden death under 40. Stimulants can increase BP and heart rate.
IMCA mandatory for serious medical treatment when the incapacitated person has nobody appropriate to consult. Also for accommodation moves and adult protection. IMCA represents the patient's interests but doesn't make the final decision. Statutory requirement under MCA.
Carers have a legal right to needs assessment (Care Act 2014). Offer respite care, Alzheimer's Society, Admiral Nurses, and carer support groups. Assess carer's own mental health. Discuss LPA and future planning. Carers are partners in care.
Mild depression = low-intensity interventions first (guided self-help, computerised CBT, exercise). Don't prescribe antidepressants for mild depression unless persistent or previous moderate-severe history.
CBT = first-line for depression and anxiety disorders (NICE). Targets negative thoughts and behaviours. 12-20 sessions. Also effective for OCD (with ERP), PTSD (trauma-focused), and bulimia.
Panic disorder = recurrent panic attacks + anticipatory anxiety + avoidance. First-line treatment is CBT. SSRI (sertraline) if CBT declined. Never prescribe benzodiazepines long-term for panic disorder.
Health anxiety = preoccupation with serious illness + reassurance-seeking + body checking despite normal investigations. First-line = CBT for health anxiety. Avoid repeated investigations as they reinforce the anxiety cycle.
SSRIs + NSAIDs = significantly increased GI bleeding risk. Always co-prescribe a PPI if both are necessary. Consider paracetamol as safer first-line analgesia. Also applies to SSRIs + aspirin or anticoagulants.
Partial response at 4 weeks on starting dose = titrate upward. Sertraline: start 50mg, increase in 50mg steps, maximum 200mg. Don't switch until adequate trial at adequate dose (6-8 weeks at optimised dose).
Z-drugs maximum 2-4 weeks only. After prolonged use, plan gradual withdrawal - never stop abruptly. Implement CBT-I alongside dose reduction. Never switch to a benzodiazepine as a solution to Z-drug dependence.
Specific plan + preparatory acts + mental illness + medication non-adherence = imminent suicide risk. Refer to crisis team for same-day assessment. Don't manage high-risk suicidality alone in primary care. Consider Mental Health Act assessment if refusing all help.
EPDS score ≥10 = possible depression, needs GP assessment. Always address question 10 (self-harm) urgently regardless of total score. EPDS screens, it does not diagnose. Use at 4-6 weeks and 3-4 months postnatally.
Perinatal OCD = ego-dystonic intrusive thoughts about harm to baby + distress + avoidance. NOT a safeguarding concern. Mother is horrified, not intending harm. Treat with CBT/SSRI. Never separate mother and baby for OCD alone.
radioiodine I-131
Subacute thyroiditis = painful tender goitre + viral prodrome + suppressed TSH with low radioiodine uptake + high ESR/CRP; NSAIDs first-line, prednisolone if severe (NICE CKS / BTA 2016); propranolol for symptoms; never carbimazole (destructive, not synthetic).
Acromegaly + macroadenoma + chiasmal compression = urgent transsphenoidal surgery; medical therapy for residual disease.
DKA = glucose >11 + ketones >3 + pH <7.3. Treat with FLUIDS FIRST, then fixed-rate IV insulin (0.1 units/kg/h)!
PCOS = Rotterdam 2/3; COC + metformin + 5-10% weight loss; letrozole first-line for ovulation induction (ESHRE 2023, PPCOS II); screen for T2DM and endometrial hyperplasia if prolonged amenorrhoea.
The NICE NG28 annual diabetes review = HbA1c, BP, lipids, eGFR and urine ACR, 10 g monofilament foot check, retinal screening, BMI, mood and lifestyle review - routine coronary angiography is NOT part of it and is reserved for specific cardiac indications such as ACS or a positive stress test.
Neuropathic plantar ulcer with intact pulses and no infection - offload with a total contact cast and refer to the multidisciplinary diabetic foot service (NICE NG19).
Confirmed primary aldosteronism → adrenal vein sampling to lateralise before adrenalectomy; spironolactone if bilateral (Endocrine Society 2016 / NICE NG136).
Prolactinoma - amenorrhoea + galactorrhoea + prolactin >2000 mU/L + pituitary adenoma on MRI; cabergoline first-line; surgery only if medical therapy fails (Society for Endocrinology UK).
T-score ≤−2.5 with high FRAX = alendronic acid 70 mg weekly + calcium and vitamin D (NICE TA464/NOGG); take fasting, upright, 30 minutes before food.
Treat subclinical hypothyroidism when TSH ≥10 twice, or TSH 4-10 with symptoms (especially anti-TPO positive) - start levothyroxine 25-50 µg (NICE NG145).
Per NICE NG145, treat subclinical hypothyroidism if TSH >10 (twice) or TSH 5.5-10 with symptoms/positive anti-TPO/CV risk; start levothyroxine 25-50 mcg with 6-weekly TSH titration.
GDM = OGTT fasting ≥5.6 or 2h ≥7.8; diet first-line; metformin if uncontrolled; IOL 38-39wk if on meds; post-partum OGTT 6-12wk; 50% T2DM in 10yr.
NICE NG246 - lifestyle underpins every tier of obesity management; drugs (TA875) and surgery are escalations, never substitutes.
HHS - glucose 55 (>30), osm 385 (>320), dehydration 8-12L, Na 155, ketones 0.4 (vs DKA >3), pH 7.38 normal (vs DKA <7.3), GCS 11, IV saline 1 L/hour (PRIORITY) THEN insulin 0.05 units/kg/hour AFTER 1-2L (lower than DKA), K replacement if <5.5, dextrose when <15, Na hourly (avoid >10/24h), LMWH, mortality 10-20%.
Macroprolactinoma + chiasmal compression - cabergoline first-line (BNF/NICE CKS); surgery only for resistance, intolerance, or apoplexy; monitor prolactin, MRI, and visual fields.
Primary hyperparathyroidism - ↑Ca + inappropriately normal/↑PTH diagnostic, parathyroidectomy curative (indications: symptomatic, Ca >2.85, osteoporosis, age <50, eGFR <60), post-op monitor hungry bone syndrome.
APS-2 = Addison + thyroid ± T1DM; hydrocortisone 15-25mg divided + fludrocortisone; sick day rules (double/triple); IM 100mg pen at home; MedicAlert bracelet.
Obese, metformin-intolerant T2DM → GLP-1 agonist (weight loss + CV benefit) meeting the NG28 BMI ≥35 criterion.
Raised calcium + inappropriately raised PTH + low phosphate = primary hyperparathyroidism; offer parathyroidectomy when symptomatic or when NICE NG132 criteria are met (cinacalcet only if surgery is declined or unsuitable).
HHS (extreme hyperglycemia >30 + hyperosmolality >320 + NO ketosis + type 2 diabetes + elderly) = 0.9% saline FIRST (1L/h initially, then slower) - more severe dehydration than DKA, LOW-dose insulin AFTER fluids, thromboprophylaxis essential, mortality 10-20%.
Acromegaly (elevated IGF-1 + GH fails to suppress with OGTT + pituitary adenoma) = transsphenoidal surgery first-line - cure 70% for macroadenomas, somatostatin analogues if surgery unsuccessful.
Fragility fracture + postmenopausal + glucocorticoids ≥7.5 mg ≥3 months → start alendronate 70 mg weekly with calcium and vitamin D (NICE TA464; NOGG 2021).
GDM - OGTT fasting ≥5.6 or 2h ≥7.8, lifestyle first, metformin if unmet, insulin if inadequate, OGTT 6-12w postpartum.
Vitamin D toxicity - ↑Ca + ↑PO4 (vs PHPT ↓PO4) + ↓PTH + 25-OH vitamin D >375, stop supplements + IV saline + bisphosphonates if severe + prednisolone if refractory.
IV saline + fixed-rate insulin 0.1u/kg/h + K+ replacement + glucose when <14; bicarbonate contraindicated; continue insulin until ketones <0.3; SC insulin before stopping IV.
Acromegaly - ↑ IGF-1 + failed GH suppression <1 on OGTT, trans-sphenoidal surgery first-line (70-80% micro, 50-60% macro), somatostatin analogues if residual.
Sheehan's = PPH → failure to lactate + amenorrhoea + panhypopituitarism; low prolactin is the hallmark; hydrocortisone BEFORE thyroxine (Society for Endocrinology 2016).
Symptomatic vitamin D deficiency = loading colecalciferol totalling ~300,000 units over 6-10 weeks (e.g. 20,000 units twice weekly for 7 weeks), then maintenance 800-2000 units daily; check adherence and ongoing sun exposure.
NICE CKS - load with colecalciferol ~300,000 IU total over 6-10 weeks, then maintain; never give bisphosphonates in untreated vitamin D deficiency.
Confirmed primary aldosteronism + surgical candidate → AVS before adrenalectomy (Endocrine Society 2016); CT alone is not reliable enough to lateralise.
Prolactinoma (hyperprolactinemia + pituitary microadenoma + amenorrhea/galactorrhea) = cabergoline first-line - normalizes prolactin 90%, shrinks tumor 80%, restores fertility, surgery only if drug-intolerant/resistant.
Severe hypomagnesaemia → tetany + torsades + refractory hypoK/hypoCa; give IV MgSO4 2 g first; correct Mg before Ca; PPIs and alcohol are common UK causes (MHRA 2012).
Consider GLP-1 receptor agonist BEFORE insulin - particularly if BMI ≥35 or weight management is important. If insulin needed: continue metformin, start NPH bedtime or basal analogue. Review sulfonylurea dose when starting insulin. SGLT2 inhibitor can be continued.
Adrenal crisis = hydrocortisone 100mg IM immediately + 999 + IV fluids + glucose. Do NOT delay treatment. Sick day rules: double dose when ill, IM kit if vomiting. All patients need steroid emergency card and medical alert jewellery.
All palpable thyroid nodules need ultrasound assessment. ~5% are malignant. U3-U5 nodules need FNAC. Features of concern: rapid growth, hoarseness, fixation, lymphadenopathy. Suppressed TSH = consider nuclear scan first.
Subclinical hypothyroidism: TSH >10 = treat. TSH 4-10 = treat if symptomatic or TPO+. Start levothyroxine 25-50mcg, recheck at 6-8 weeks. Target TSH 0.4-2.5. Take on empty stomach, separate from calcium/iron.
SADMANS: Stop SGLT2i, ACEi, Diuretics, Metformin, ARBs, NSAIDs during dehydrating illness. Never stop insulin. Monitor glucose frequently. Seek help if glucose >20 or unable to keep fluids down for 6 hours.
In type 2 diabetes with established cardiovascular disease, add an SGLT2 inhibitor with proven cardiovascular benefit (empagliflozin or dapagliflozin) per NICE NG28 - cardiorenal protection demonstrated in EMPA-REG OUTCOME and DECLARE-TIMI 58.
Metformin is first-line for T2DM - start low, titrate slowly. Target HbA1c 48 mmol/mol on metformin alone. If GI intolerant, try MR preparation. No hypoglycaemia risk as monotherapy. SGLT2 inhibitors preferred as second-line if CVD/CKD risk.
Thyroid nodule with suspicious US features (hypoechoic, solid, irregular, microcalcifications) = FNAC for cytology. BTA U3-U5 nodules >1cm need FNA!
No fertility wish in PCOS → COCP first-line; metformin targets metabolic risk; reserve co-cyprindiol and spironolactone for refractory hyperandrogenism, with contraception essential for spironolactone.
Postmenopausal fragility fracture with T-score ≤ −2.5 → oral alendronate 70 mg weekly first-line per NICE NG224/TA464; co-prescribe calcium and vitamin D; review treatment duration at 5 years.
Hashimoto thyroiditis (hypothyroid symptoms + firm goiter + anti-TPO antibodies >1000 + high TSH/low T4) = most common cause hypothyroidism - levothyroxine lifelong, associated other autoimmune diseases, annual TFT monitoring.
Acromegaly work-up = IGF-1 first (age/sex-adjusted), then OGTT to confirm GH non-suppression, then MRI pituitary; random GH alone is unreliable.
PCOS not seeking fertility: lifestyle + COCP for cycles and acne. Endometrial protection needed if <4 periods/year. Metformin is second-line, not first. 5-10% weight loss improves all aspects. Clomifene is for fertility only.
Hyperpigmentation + postural hypotension + low Na⁺/high K⁺ = primary adrenal insufficiency (Addison's). Secondary = NO hyperpigmentation, normal K⁺. 9am cortisol then short Synacthen test for diagnosis. Associated with other autoimmune conditions.
Hypomagnesemia-induced hypocalcemia - recognise the key clinical and investigative features to guide appropriate management.
Sarcoidosis hypercalcemia (elevated 1,25-OH-D + suppressed PTH + hilar lymphadenopathy + vitamin D supplementation) = extrarenal granulomatous 1α-hydroxylase (substrate-driven, not PTH-regulated) - stop vitamin D, use steroids, distinguish from vitamin D intoxication (mild hypercalcemia, normal 1,25-OH-D).
(JBDS-IP 2023): DKA = 0.9% saline + FRIII 0.1 units/kg/h + potassium + add 10% glucose when CBG <14; never stop insulin until ketones <0.6, pH >7.3, bicarbonate >15.
In a diabetic foot ulcer, probe-to-bone or exposed bone means treat as osteomyelitis per NICE NG19 - do not manage as superficial infection alone.
Hot, swollen, painless foot + neuropathy = Charcot until proven otherwise. Refer within 24 hours. X-ray may be normal early - MRI is diagnostic. Non-weight-bearing is essential. Often misdiagnosed as cellulitis or gout.
Sheehan = PPH → panhypopituitarism; agalactia is the earliest sign; hydrocortisone first, levothyroxine after; empty sella on MRI; steroid card and sick-day rules (Soc Endo 2016; BTA 2023).
Addison's = hydrocortisone 15-25 mg/day in divided doses PLUS fludrocortisone 50-200 micrograms daily; sick-day rules, IM emergency kit and NHS steroid card are mandatory (Society for Endocrinology UK; NICE CKS).
Annual ACR screening for all diabetic patients. ACR ≥3 mg/mmol = confirm with 2 further samples. Confirmed = start ACE-i/ARB regardless of BP. SGLT2 inhibitors also renoprotective. Target BP <130/80 in diabetic nephropathy.
GDM = 50% lifetime T2DM risk. Annual fasting glucose or HbA1c screening lifelong (NICE NG3). Test pre-conception before future pregnancies. Breastfeeding and weight management reduce risk. Early pregnancy OGTT in subsequent pregnancies.
Rotterdam = any 2 of 3 (oligo-anovulation, hyperandrogenism, polycystic ovaries on USS) after excluding mimics; manage by presenting concern - lifestyle, COCP, metformin, letrozole for ovulation induction, endometrial protection (NICE CKS, 2018 international PCOS guideline).
Graves ophthalmopathy (proptosis + diplopia + CAS ≥3 + smoking) = IV methylprednisolone for moderate-to-severe active disease - smoking cessation ESSENTIAL (worsens 8-fold), selenium for mild, avoid radioiodine in active disease, maintain euthyroidism.
Type 1 diabetes = basal-bolus insulin (long-acting basal + rapid-acting with meals). Gold standard! Offers flexibility and physiological insulin replacement!
Klinefelter = tall, small firm testes, gynecomastia, azoospermia, low testosterone + HIGH LH/FSH. Confirm with karyotype (47,XXY). Commonest chromosomal cause of male infertility!
Macrosomic IDM + jitteriness + glucose <2.0 mmol/L → buccal dextrose gel + feed; IV dextrose only if severe or refractory.
Adult under 65 without IHD with confirmed overt hypothyroidism → start levothyroxine 50-100 micrograms daily; recheck TFTs at 6-8 weeks targeting TSH 0.5-2.5 mU/L; reserve 25 micrograms for elderly or cardiac disease.
Primary hyperaldosteronism = high aldosterone + low renin + resistant HTN + hypokalemia. Image adrenals then ADRENAL VEIN SAMPLING to confirm lateralization before surgery!
Symptomatic severe hyponatraemia (Na <125 + neurological signs) → 3% hypertonic saline; correct slowly to avoid osmotic demyelination.
Primary hyperparathyroidism with osteoporosis (T-score ≤-2.5) = parathyroidectomy. Surgery is curative in 95%!
PCOS with obesity = lifestyle modification + metformin FIRST (improves insulin resistance, fertility, reduces diabetes risk). Add COCP for cycle regulation and endometrial protection!
RCT randomisation controls confounding (known and unknown); observational cohorts remain vulnerable to confounding by indication despite adjustment.
Lower threshold = ↑sensitivity + ↓specificity; screening tests need high sensitivity; confirmatory tests need high specificity; ROC curve shows trade-off.
Per BNF and MHRA, simvastatin + clarithromycin is contraindicated. High-dose CYP3A4 statin + CYP3A4 inhibitor = rhabdomyolysis risk; switch to rosuvastatin/pravastatin if interactions are unavoidable.
Severe myopathy + CK >10× ULN + myoglobinuria + AKI = rhabdomyolysis - stop statin, IV fluids; high-dose simvastatin and CYP3A4 inhibitors are the dominant risk factors (BNF; MHRA; NICE NG181).
Clarithromycin + warfarin = CYP inhibition → warfarin accumulation → high INR; Always check interactions before prescribing.
Codeine → morphine via CYP2D6; PM = no analgesia, UM = toxicity (especially in breastfeeding); per MHRA, avoid codeine in children <12 and in post-tonsillectomy adolescents with OSA.
Per NICE, ACE inhibitor angioedema is a contraindication to rechallenge - document clearly in medical records.
Selection bias = non-representative sample; Berkson's (hospital), survival, healthy volunteer; prevent with random sampling; differs from information bias (measurement) and confounding (third variable).
AR = both parents carriers, 25% affected; CF = CFTR/sweat chloride >60; sickle cell = HbS/hydroxycarbamide; β-thal major = transfusion-dependent + iron chelation.
Incidence = new cases per time (risk); Prevalence = existing cases (burden); Prevalence = Incidence x Duration; improved survival increases prevalence.
PPV depends on prevalence; low prevalence → low PPV; sens 80%, spec 95%, prev 2% → PPV 24%; UK: cervical/breast/bowel/AAA/newborn.
Fragile X = most common inherited ID; X-linked dominant; CGG repeat expansion; males = ID + macro-orchidism; females = POI; premutation → FXTAS.
High sensitivity = good NPV (rules out); High specificity = good PPV (rules in).
Partial agonists have a ceiling effect - buprenorphine = 40-50% maximal response, lower respiratory depression than morphine, but precipitates withdrawal in opioid-dependent patients (NICE NG215, BNF).
Confounding = third variable associated with both exposure AND outcome (NOT causal pathway); randomisation = gold standard; multivariable regression adjusts; NOT intermediate.
Incidence = new cases per time (risk, aetiology); prevalence = existing cases at a point (burden, resource planning); Prevalence ≈ Incidence × duration; chronic disease → high prevalence despite modest incidence (Health Survey for England, OHID).
N-acetylcysteine (NAC) prevents hepatotoxicity - recognise the key clinical and investigative features to guide appropriate management.
CO poisoning = normal PaO₂ but tissue hypoxia; 100% O₂ immediately, HBO if severe; co-oximetry needed.
Sensitivity rules OUT disease when negative (SnNout); 95% sensitivity = misses 5%.
ACE inhibitor angioedema = bradykinin accumulation → angioedema; NO urticaria (non-histaminergic), antihistamines/adrenaline ineffective; treatment: stop ACE inhibitor, FFP, icatibant; ARBs 10% cross-reactivity; differs from HAE (C1-INH deficiency, low C4).
CYP2D6: codeine→morphine, tamoxifen→endoxifen; PM = no efficacy; UM = toxicity (codeine deaths in children); avoid fluoxetine/paroxetine with tamoxifen.
AR = absolute excess (10%−1% = 9%); ARP = 90% disease in exposed due to exposure; PAR% = population preventable fraction; RR = strength (10×); common exposures with modest RR have greatest public health impact.
NPV = probability negative = disease-free; depends on prevalence (↓prevalence → ↑NPV); high sensitivity → high NPV (SnNOut); d-dimer/troponin = high NPV rule-out tests; PPV/NPV both prevalence-dependent.
NNH = 1/ARI; lower = more harmful; balance NNT (benefit) vs NNH (harm); ideal = low NNT + high NNH.
Observer bias = expectations affect measurement; Hawthorne = behaviour change when observed; blinding prevents (single/double/triple); objective outcomes less susceptible.
Digoxin toxicity = yellow vision + bradycardia + ANY arrhythmia. Furosemide lowers K⁺ making toxicity worse! Digibind for severe cases (bradycardia <50, VT, high K⁺). NEVER pace digoxin toxicity - worsens VT risk!
Phase I = CYP450 oxidation (active/toxic metabolites); inducers ↓levels; inhibitors ↑levels; Phase II = conjugation (inactive, ↑excretion); glucuronidation most common; CYP3A4 metabolises ~50% drugs.
Neonates rely on sulfation (SULT mature at birth, UGT immature); paracetamol overdose → NAPQI → glutathione depletion → hepatic necrosis; treat with N-acetylcysteine per BNF.
AIP = porphobilinogen deaminase deficiency causing raised ALA/PBG and neurovisceral attacks; check urinary PBG, stop precipitants (e.g. the pill) and treat with IV carbohydrate and haemin. Always check drug safety against an up-to-date porphyria list (e.g. NAPOS/British Porphyria Association).
Type 1 RTA = can't acidify urine (pH >5.5) + stones + low K+; Type 2 = can acidify urine but loses HCO3-.
ACE inhibitor angioedema = "BRADYKININ buildup" NOT allergy! Antihistamines won't help. Stop drug, secure airway, icatibant if severe. Afro-Caribbeans at highest risk!
Distal (type 1) RTA cannot acidify urine, so urine pH stays >5.5 despite acidosis, with low potassium and stones; proximal (type 2) RTA can still acidify urine once the threshold is exceeded (UK Kidney Association; NICE CKS).
NNT = 1 / ARR; lower NNT means greater benefit; here NNT 25 over 5 years.
Type IV = delayed, T-cell, no antibody - Mantoux, contact dermatitis and granulomas are the archetypes.
Clarithromycin/erythromycin + simvastatin/atorvastatin = rhabdomyolysis risk; stop both, IV fluids; use azithromycin or pravastatin/rosuvastatin instead.
DRESS = delayed (2-8 weeks) drug reaction with rash, fever, eosinophilia, lymphadenopathy and organ involvement (especially hepatitis); commonest culprits are anticonvulsants (carbamazepine), allopurinol and sulfonamides.
Small drop-shaped papules post-sore throat in a young person = guttate psoriasis. Usually self-limiting. Check family history of psoriasis.
Scalp psoriasis extending beyond the hairline = use coal tar shampoo + calcipotriol/betamethasone scalp gel. Descale thick plaques first with overnight oil application.
Facial papules and pustules WITHOUT comedones + flushing + central facial distribution in middle age = rosacea, not acne. Avoid topical steroids.
Persistent, well-demarcated red scaly plaque on the lower leg unresponsive to TCS in an elderly patient = think Bowen's disease (SCC in situ). Pre-invasive - refer for treatment.
Shingles in patients ≥50 years = aciclovir 800mg x5/day for 7 days if within 72 hours of rash. Adequate analgesia is essential. PHN risk increases with age.
Annular plaque with raised leading edge and central clearing = tinea corporis. Treat with topical terbinafine. Avoid topical steroids (risk of tinea incognito).
Well-demarcated hypo/hyperpigmented patches with fine scale on young adult's trunk = pityriasis versicolor. Treat with ketoconazole shampoo as body wash. Pigment takes months to normalise.
Well-circumscribed non-scarring hair loss with exclamation mark hairs = alopecia areata. Single small patch = 80% spontaneous regrowth. Potent topical steroid can help. Check TFTs.
Diffuse hair shedding 2-3 months after a trigger (e.g., postpartum) = telogen effluvium. Self-limiting - regrows in 6-12 months. Check ferritin, TFTs, vitamin D.
Ram's horn nails (onychogryphosis) in elderly diabetic patients = refer to podiatry for safe, regular nail care. Do not assume fungal - send mycology if needed. Avoid DIY cutting in neuropathy.
ABPI = rest supine 20 minutes, highest ankle pressure ÷ highest brachial pressure. Measure both ankle arteries, both arms. Reassess every 3-6 months.
Tender shin nodules = erythema nodosum. First investigation = chest X-ray (sarcoidosis is the commonest cause). Also screen for streptococcal infection, TB, and IBD.
Annular, smooth, non-scaly ring of firm papules on the dorsum of the hand = granuloma annulare. No scaling (unlike tinea). Usually self-limiting. Reassure.
Infantile eczema first-line = regular emollients + mild TCS for flares. Do not change diet without evidence of food allergy. Encourage breastfeeding.
Pruritus ani is most commonly caused by irritant contact dermatitis from excessive hygiene (especially moist wipes). Stop wipes, simplify cleaning, apply barrier cream. Exclude threadworms and skin disease.
Itchy rash on sun-exposed skin (face spared) at start of spring that improves with continued exposure = PLE. Commonest photodermatosis. Gradual desensitisation helps.
Crazy paving dry skin in elderly + excessive bathing/soap = asteatotic eczema. Change bathing practice: less frequent, soap substitutes, pat dry, immediate generous emollient application.
In immunosuppressed patients: warts are more extensive and may transform, skin cancer risk is dramatically increased, and presentations are atypical. Low threshold for biopsy and dermatology referral.
Transplant recipients = 65-250x increased SCC risk. Lifelong sun protection and annual dermatology surveillance are essential. SCC:BCC ratio reversed. SCCs are more aggressive.
Papules around mouth, sparing vermillion border + steroid use = perioral dermatitis. Stop the steroid. Treat with topical metronidazole or oral tetracycline.
Multiple colours (black, red, blue, white) in a lesion = suspicious for melanoma. Uniform colour and regular pattern suggest benign. Refer suspicious lesions on 2WW.
Frequent handwashing + wet work = irritant hand dermatitis. Emollients, barrier creams, gloves for wet work. Consider patch testing if atypical or recalcitrant.
Moderate psoriasis + failed topical therapy + patient prefers non-systemic = refer for phototherapy. Narrowband UVB is first-line.
Face and eyelids = mild TCS only (hydrocortisone 1%), short courses. Potent steroids on the face risk atrophy, telangiectasia, and periorbital complications.
Sausage digit (dactylitis) + enthesitis + nail changes in a psoriasis patient = psoriatic arthritis. Refer to rheumatology urgently to prevent joint damage.
Firm brown nodule on the lower leg with positive dimple sign = dermatofibroma. Benign - reassure. Excision often unnecessary as scar may be worse than the lesion.
Sandpaper-textured scaly patches on sun-exposed skin = actinic keratoses. Pre-malignant - treat with 5-FU for field disease or cryotherapy for isolated lesions.
Truncal hypopigmented scaly macules + "spaghetti and meatballs" on KOH = pityriasis versicolor; first-line is topical ketoconazole 2% shampoo (NICE CKS); reserve oral itraconazole for extensive or recurrent disease.
First-line = topical metronidazole/azelaic acid; no comedones (distinguishes from acne); AVOID topical steroids; rhinophyma = CO2 laser.
Erosive oral lichen planus - first-line is a potent topical corticosteroid; it is a potentially malignant disorder, so monitor and re-biopsy persistent or non-healing lesions.
Rapidly growing dome-shaped nodule with central crater = keratoacanthoma, but cannot be clinically distinguished from SCC. Refer urgently for excision biopsy. Do not watch and wait.
Pityriasis rosea = herald patch then 'Christmas tree' rash; self-limiting over 6-12 weeks; reassurance only; exclude secondary syphilis if at risk.
Necrobiosis lipoidica = shiny atrophic shin plaques with palisading granulomas; 60-70% have diabetes; no reliably effective treatment; protect from trauma to prevent ulceration.
Palpable purpura + arthralgia + abdominal pain + nephritis with IgA on biopsy = IgA vasculitis (HSP); adults need careful renal follow-up.
Pale, slightly scaly patches on a child's cheeks, more noticeable after tanning = pityriasis alba. Common in atopic children. Self-limiting - reassure parents.
Purple, polygonal, flat-topped papules on flexor wrists with Wickham's striae = lichen planus. Check for oral involvement and hepatitis C serology.
Slapped cheeks then lace-like reticular rash in a well child = parvovirus B19. Not infectious once rash appears. Warn pregnant contacts.
Inflamed molluscum = beginning of the end (immune response). Reassure. Do not prescribe antibiotics unless signs of true secondary bacterial infection. Self-resolves in 12-18 months.
>5 spider naevi in the SVC distribution = suspect chronic liver disease. Due to hyperestrogenism. Combined with palmar erythema, gynaecomastia, and sparse body hair - points strongly to cirrhosis.
≥6 café-au-lait + freckling + neurofibromas = NF1. Lisch nodules support diagnosis. Refer for genetics and surveillance.
Mild-moderate plaque psoriasis first-line = vitamin D analogue + potent TCS combination (e.g., Dovobet). Use for up to 4 weeks, then maintain with vitamin D analogue alone.
Brown gaiter area staining = haemosiderin from chronic venous insufficiency. The triad of venous eczema, haemosiderin staining, and lipodermatosclerosis indicates CVI requiring compression therapy.
Steroid phobia causes undertreatment. Counsel on appropriate use, potency, and safety. Mild TCS used correctly is safe. Provide written patient information.
Severe psoriasis + psoriatic arthritis meeting NICE biologic thresholds → anti-TNF (e.g. adalimumab) treats both skin and joints (NICE TA350); screen for TB and hepatitis B/C before starting any biologic.
SPF 30+ broad-spectrum, applied generously, reapplied every 2 hours. Sunscreen alone is insufficient - combine with shade, clothing, and avoidance during peak hours. UV penetrates cloud.
BCC is locally invasive but metastasises in <0.1% - pearly rolled-edge nodule with telangiectasia on sun-exposed skin; 4 mm excision per BAD (2021) is first-line, with Mohs for facial H-zone, morphoeic, or recurrent lesions.
Infantile eczema - start with regular emollients plus a mild topical corticosteroid for flares (NICE CG57/CKS); avoid routine oral antihistamines, elimination diets, or systemic steroids as first-line.
A clear drug exanthem from co-trimoxazole in HIV - stop the drug and switch to dapsone or atovaquone; reserve desensitisation for when there is no alternative.
Post-streptococcal guttate psoriasis in adolescents often self-resolves; start with emollients, add a topical corticosteroid plus vitamin D analogue, and refer for narrowband UVB if widespread or persistent at 6-8 weeks.
Keloid extends beyond the wound margin (vs hypertrophic) - intralesional triamcinolone is first-line (BAD/NICE CKS); excision alone recurs in up to 100% and must be combined with adjuvant therapy.
Heliotrope rash + Gottron's papules + proximal weakness = dermatomyositis. Screen for underlying malignancy - 15-25% have occult cancer. Screen for 3 years.
Scar-like plaque with no history of trauma, expanding slowly on the face = morphoeic BCC. Easily missed. Needs specialist excision (often Mohs surgery).
Cellulitis Class I = oral flucloxacillin, leg elevation, mark the erythema margin, review at 48 hours. Admit if systemically unwell or failing oral therapy.
Sloughy wound without infection = hydrogel dressing for autolytic debridement. Slough ≠ infection - do not give antibiotics for slough alone. Use the TIME framework for wound assessment.
Intensely itchy grouped vesicles on extensor surfaces + granular IgA in the dermal papillae = dermatitis herpetiformis = coeliac disease; treat with a gluten-free diet ± dapsone.
Targetoid lesions with blistering + mucosal erosions + recent drug exposure = SJS. <10% BSA = SJS, >30% = TEN. Stop the drug and admit immediately.
Subcutaneous nodule with central punctum and recurrent infections = epidermoid cyst. Definitive treatment is excision when not inflamed. Incision alone = recurrence.
Waxy white plaque with lilac ring, bound-down skin, no Raynaud's = morphoea (localised scleroderma). Does NOT progress to systemic sclerosis. Usually self-limiting.
Shiny, yellowish-brown atrophic plaques on the shins with visible blood vessels = necrobiosis lipoidica. Strongly associated with diabetes (especially type 1). Ulceration is common.
Potent topical corticosteroids are first-line for localised cutaneous lichen planus (per BAD / Primary Care Dermatology Society guidance); reserve systemic ciclosporin or methotrexate for severe or refractory disease.
Eczema management = emollients first (generous amounts, multiple times daily), then step up to mild/moderate TCS. Always optimise emollient use before escalating treatment.
Post-operative pain + erythema + purulent discharge = SSI. Open the wound to drain pus, swab, and start flucloxacillin. Do not re-close an infected wound.
TEN = stop the drug immediately + emergency burns unit transfer. Lamotrigine is a classic cause. Do not delay for investigations.
Punched-out erosions on eczematous skin = eczema herpeticum. This is an emergency - admit for IV aciclovir. Do not delay for results.
Greasy yellow scale in nasolabial folds/eyebrows = seborrhoeic dermatitis. Treat with ketoconazole cream ± mild TCS. Think Malassezia.
Venous ulcer + ABPI ≥0.8 = graduated compression bandaging is the most important treatment. Without compression, venous ulcers will not heal. Simple dressings alone are insufficient.
RA = independent CV risk comparable to diabetes; statins and BP control are as important as DMARDs for long-term outcomes.
In young women, “rash, joints, kidneys, and dsDNA” point strongly towards SLE with renal involvement, warranting prompt specialist assessment.
GCA + vision loss → IV methylprednisolone 500-1000 mg immediately; biopsy within 7 days; aspirin 75 mg; slow taper; tocilizumab per NICE TA518 for relapse (BSR 2020).
Fibromyalgia = widespread pain + tender points + normal bloods; first-line (EULAR 2017 / NICE CKS) = education + graded exercise ± amitriptyline; steroids, DMARDs and long-term opioids are not indicated.
Normal capillaroscopy + no other symptoms = primary Raynaud's - benign, treat symptoms only.
Haemochromatosis = MCP 2nd/3rd + chondrocalcinosis + bronze diabetes; phlebotomy prevents organ damage but NOT arthropathy.
Drug-induced lupus (hydralazine, procainamide, isoniazid, minocycline) - stop the drug; anti-histone positive with negative anti-dsDNA, normal complement, and renal/CNS sparing distinguishes it from idiopathic SLE.
aPL positive + no events = aspirin prophylaxis - don't anticoagulate without thrombosis.
Post-infective reactive arthritis - NSAIDs first (NICE CKS), DMARDs only if arthritis persists beyond 6 months; antibiotics do not help sterile synovitis once the triggering organism has cleared.
OA = Heberden's/Bouchard's nodes + osteophytes - think degenerative, not inflammatory.
Acute gout → NSAID + PPI (or colchicine) first; never start allopurinol during a flare (NICE NG219).
Allopurinol = wait 2-4 weeks post-attack; start 100 mg, titrate to <360; colchicine 6-month prophylaxis; lifelong per BSR guideline.
RA classification = ≥6 points out of 10 - think joint involvement + serology + acute phase + duration.
Calcinosis = calcium deposits in soft tissues - think fingertips/extensor surfaces, part of CREST.
Saddle anaesthesia + bladder symptoms = emergency MRI for suspected cauda equina. Previous cancer with new back pain must be investigated urgently for metastatic spinal cord compression (MSCC). NICE NG59 mandates same-day assessment.
NSAIDs first-line for acute gout, colchicine or prednisolone as alternatives. Never start allopurinol during an acute flare. Review thiazide diuretics as a precipitant.
Allopurinol start low (100mg), titrate to urate target <360 μmol/L, with colchicine prophylaxis for ≥6 months. Treat to target, not to a fixed dose.
Tennis elbow is self-limiting in most cases. Eccentric exercises are the best evidence-based treatment. Steroid injections give short-term relief but worsen long-term outcomes. Avoid complete immobilisation.
Ottawa knee rules - X-ray if age ≥55, isolated patellar tenderness, fibular head tenderness, inability to flex to 90°, or inability to weight-bear 4 steps. Sensitivity for fracture is ~99%; this patient meets none and needs no X-ray.
serological flare - recognise the key clinical and investigative features to guide appropriate management.
Hydroxychloroquine >5 years = annual screening - visual fields + SD-OCT, not just fundoscopy.
Knee OA (NICE NG226) - exercise + weight loss + topical NSAID first-line; oral NSAID with PPI second-line; joint replacement only for refractory disease.
ReA = arthritis + conjunctivitis + urethritis after infection - Chlamydia is the classic genitourinary trigger; Salmonella, Shigella, Campylobacter and Yersinia are the enteric triggers.
Sulfasalazine = monitor FBC/LFTs frequently early - most side effects in first 3 months.
Azathioprine = test TPMT first - think prevent severe myelosuppression, not just monitor FBC.
Diffuse SSc + anti-Scl-70 = watch for lung and renal complications - worse prognosis than limited disease.
Fibromyalgia equals widespread pain with normal inflammatory markers and no synovitis; objective weakness, synovitis, erosions, or autoantibodies point instead to inflammatory rheumatic disease.
RA is an independent CV risk factor - assess and manage CV risk as part of regular (at least annual) review, and control inflammation with DMARDs (EULAR).
For AS, think “young, stiff, and better with movement” - chronic morning stiffness and improvement on exercise in a young adult male should always raise suspicion of inflammatory back pain rather than mechanical strain.
RA + steroids + postmenopausal = high fracture risk - screen and treat early.
Knee OA first-line drug = topical NSAID (NICE NG226); paracetamol is no longer routinely recommended.
For RA, think “long, slow mornings” - stiffness >60 minutes that eases with use, whereas OA mornings are short and joints worsen with prolonged activity.
RA pre-conception - stop methotrexate 3 months before; sulfasalazine can stay with 5 mg folic acid; do not stop all DMARDs 1 week before trying to conceive.
Primary Raynaud = bilateral + normal capillaries + ANA negative + no ulcers; lifestyle first; nifedipine if severe; <1% progress to secondary.
DIL = arthralgia + serositis + anti-histone+ + anti-dsDNA negative + normal complement + spares renal/CNS; stop drug → resolves 4-6wk.
OA exercise (NICE NG226) = local muscle strengthening + low-impact aerobic; benefits not harms joints; modify (don't stop) during flares; avoid sedentary deconditioning; exercise is a core treatment regardless of age or severity.
Inflammatory back pain (morning stiffness >30 min, improves with exercise) in a young adult - request MRI sacroiliac joints, not X-ray. Early diagnosis prevents structural damage with timely biologic therapy.
True locking (a mechanical block to extension) plus failed physiotherapy is the key red flag for meniscal surgery - distinguish it carefully from painful pseudo-locking.
Pop + rapid swelling + instability = ACL rupture until proven otherwise. Lachman test is more sensitive than anterior drawer. Haemarthrosis (rapid swelling) = ACL tear in ~75% of cases.
Reactive (Reiter) arthritis = post-infectious seronegative spondyloarthropathy → NSAIDs first-line; treat the trigger (BASHH Chlamydia); sulfasalazine/methotrexate if refractory (BSR).
High-risk APS with thrombosis = “warfarin for life” (INR 2-3), not DOACs, and certainly not aspirin alone, due to the significant risk of recurrent thrombotic events.
Widespread pain + tender points + normal tests = fibromyalgia - think central sensitisation, not inflammation.
For methotrexate, think “check bloods little and often” - at least fortnightly then monthly at initiation, never “set and forget” for a year.
PMR = “pain and stiffness, not weakness” in the shoulders/hips of the elderly, and responds beautifully and quickly to modest doses of prednisolone.
High-risk tumor lysis syndrome - use rasburicase (rapid urate reduction), not allopurinol (too slow).
Activated charcoal contraindicated if GCS <12 (aspiration risk) - intubate first or use N-acetylcysteine alone.
Carbimazole agranulocytosis - unpredictable immune-mediated (type B) reaction; fever and sore throat require immediate FBC and permanent drug cessation.
Metal-ligand complex formation - recognise the key clinical and investigative features to guide appropriate management.
Propranolol in Thyrotoxicosis: Dual Mechanism - recognise the key clinical and investigative features to guide appropriate management.
A sedating, anticholinergic tricyclic such as amitriptyline in an older person with dementia and falls is a classic STOPP violation - switch to mirtazapine or trazodone and review the indication for any long-term PPI (STOPP/START v2; NICE multimorbidity guidance NG56).
Prednisolone ≥7.5mg ≥3m = alendronate + calcium + vitD; rapid bone loss 5-15% yr1; minimise steroid dose.
Oral bisphosphonates = empty stomach + plain water + upright 30 minutes + wait 30 minutes before food!
Amphotericin B deoxycholate → preload 1 L 0.9% saline before every dose (AKI 80% → 30%); avoid concurrent nephrotoxins; switch to liposomal if renal dysfunction develops; replace K⁺ and Mg²⁺.
QTc >500 ms = high torsades risk - stop non-essential QT drugs and correct electrolytes.
the "30-30 rule" - 30 minutes before food, upright for 30 minutes.
LAST = stop the injection, start CPR, and give 20% lipid emulsion as first-line specific treatment (1.5 ml/kg bolus then 15 ml/kg/hour infusion); continue CPR for 60+ minutes; bupivacaine is the most cardiotoxic agent; avoid vasopressin (AAGBI/Resuscitation Council UK).
Spironolactone + ACE inhibitor in CKD - very high hyperkalemia risk; avoid if eGFR <30 or K⁺ >5.0.
Cross-reactivity follows the R1 side-chain, not the β-lactam ring - in true penicillin anaphylaxis, a non-β-lactam (macrolide or doxycycline) is safest, and consider de-labelling via NICE CG183.
steroids plus a glucose of 15-18 mmol/L with symptoms = start insulin; the glucose peak is typically in the afternoon/evening, so check capillary glucose before lunch and the evening meal.
With ACE inhibitor plus MRA hyperkalaemia and ECG changes, give calcium for cardioprotection and stop the MRA first - retain the prognostically vital ACE inhibitor (NICE NG106; RALES trial).
TB hepatotoxicity (NICE NG33; BTS) - stop ALL drugs if ALT >5× ULN or >3× ULN with jaundice/symptoms; cover infectious cases with non-hepatotoxic interim regimen; sequentially rechallenge ethambutol → rifampicin → isoniazid; usually omit pyrazinamide if it was the culprit.
Hyperkalemia with ECG changes equals cardiac emergency - IV calcium gluconate immediately stabilizes myocardium, then insulin-dextrose lowers potassium.
CK >5000 + dipstick blood-positive/RBC-negative; IV fluids 1-2L/h MOST important (output >300mL/h); avoid diuretics; AKI 30-50%; treat hyperkalaemia.
AKI plus eosinophilia plus sterile pyuria plus recent drug exposure equals AIN - stop drug immediately, consider biopsy and steroids.
STEC-HUS (bloody diarrhea prodrome + thrombocytopenia + MAHA + AKI + E. coli O157 + child) = supportive care only (fluids, dialysis, BP) - antibiotics WORSEN (increase Shiga toxin release), self-limiting, 90% recover, vs atypical HUS (no diarrhea, eculizumab).
Stage 3 AKI = creatinine ≥3× baseline OR urine <0.3 mL/kg/h for ≥24 h - fluid resuscitate, stop nephrotoxins, and refer early to nephrology per NICE NG148.
Hyperkalaemia + ECG changes = calcium first (stabilises heart), then shift K+ intracellularly.
Drug dosing in renal impairment (CKD stage 3b) - recognise the key clinical and investigative features to guide appropriate management.
CKD-MBD = control phosphate first, then vitamin D, then calcimimetics if PTH still high.
Loop diuretics = K+ and Mg2+ wasting - always check both electrolytes.
Diabetic CKD with uACR ≥3 - start ACEi/ARB (NICE NG203) plus SGLT2 inhibitor (TA775); BP target <130/80 with significant proteinuria; recheck U&Es at 1-2 weeks.
If creatinine plummets with fluids, think pre-renal; if it stalls despite good volume, suspect intrinsic renal injury such as ATN.
In AKI questions, “old patient + CKD + NSAID + dehydration” usually implies pre-renal physiology; fix the haemodynamics and stop the culprit drug, and creatinine falls quickly.
Euvolaemic hyponatraemia - measure urine osmolality next to separate SIADH (inappropriately concentrated urine) from polydipsia (maximally dilute urine).
Hyperkalaemia + metabolic acidosis + an acid urine (pH <5.5) = Type 4 RTA (hypoaldosteronism).
Uncomplicated lower UTI in a non-pregnant woman = nitrofurantoin 100 mg MR BD for 3 days first-line (NICE NG109); MSU only if uncertainty, recurrence, pregnancy or treatment failure; check eGFR (avoid nitrofurantoin if <45); safety-net for upper-tract features.
Lithium + polyuria + no desmopressin response = nephrogenic DI - kidney unresponsive to ADH.
Preeclampsia = BP + proteinuria after 20wk; HELLP = haemolysis + ↑liver + ↓platelets; MgSO₄ + delivery.
Uncomplicated lower UTI in non-pregnant women - nitrofurantoin 100 mg MR BD for 3 days first-line (NICE NG109; BNF); trimethoprim option C is the wrong duration (should be 3 days not 7); send MSU only if symptoms persist, recur, or are atypical (MHRA fluoroquinolone alerts).
Hypercalcaemia + polyuria + dilute urine = nephrogenic DI - treat hypercalcaemia to restore concentrating ability.
In exams, “nephritic child + recent sore throat + low C3, normal C4” = post-strep GN; management is largely supportive with monitoring of blood pressure and renal function.
CKD anaemia → check ferritin, TSAT, B12, folate; raised hepcidin makes oral iron unreliable in advanced CKD; nephrology should initiate IV iron ± ESA per NICE NG8.
CKD anaemia = ↓EPO → normocytic anaemia; correct iron first (ferritin >200, TSAT >20%); ESA target Hb 100-120 g/L (NEVER >130 g/L - ↑CV events per TREAT/CHOIR); treat coexisting hyperparathyroidism; avoid transfusion to preserve transplant options; per NICE NG8.
Na <125 mmol/L with seizures or reduced GCS → 3% saline 150 mL IV over 10-20 min (Society for Endocrinology / European hyponatraemia guideline); cap correction at 10 mmol/L per 24 h to prevent osmotic demyelination.
Hypercalcaemia malignancy = suppressed PTH + Ca²+ >3.0; IV saline then zoledronic acid; PTHrP 80%; poor prognosis.
DKD = ACEi + SGLT2i (most important addition); BP <130/80; HbA1c <53; finerenone if still progressing; retinopathy = nephropathy.
Diabetes plus CKD plus contrast equals high CIN risk - IV saline hydration 12 hours pre/post-contrast reduces risk 50%.
Rhabdo = CK >1000 + dipstick blood no RBCs; aggressive saline; alkalinise; avoid diuretics.
CKD with ACR <70 mg/mmol → BP target <140/90 mmHg; ACR ≥70 mg/mmol → <130/80 mmHg (NICE NG203). Offer an ACEi or ARB when ACR ≥3 mg/mmol for renoprotection.
KDIGO Stage 1 = ≥26 µmol/L rise in 48 h OR 1.5-1.9× baseline; 1.75× = Stage 1; hyperkalaemia ≥6.0 (or with ECG changes) mandates urgent admission per NICE NG148.
Urine K+ below 20 mmol/L suggests GI losses; above 20 mmol/L suggests renal losses - hypertension plus alkalosis points to hyperaldosteronism.
FMD = young woman + 'string of beads' on angiography; treat with balloon angioplasty without routine stenting.
Male UTI = always send MSU + 7-day course of trimethoprim 200 mg BD or nitrofurantoin 100 mg MR BD (NICE NG109); consider obstruction, prostatitis and recurrence; refer to urology if recurrent, persistent haematuria or suspected obstruction; avoid quinolones first-line (MHRA).
CKD + ACEi + NSAID = triple-whammy AKI risk - prefer paracetamol or topical NSAID; check U&E 1-2 weeks after any new systemic NSAID.
NICE NG97 first-line for bothersome male LUTS/BPH = a selective alpha-1 blocker (tamsulosin 400 mcg OD); add finasteride if prostate >30 g or PSA >1.4 ng/mL; reserve TURP for medical-therapy failure or complications.
Avoid systemic NSAIDs in CKD G3b+; use topical NSAIDs, physiotherapy, and weight management first (NICE NG203, NG226); reserve cautious short-course weak opioids for uncontrolled pain, mindful of NG193 guidance.
IgA nephropathy (synpharyngitic macroscopic haematuria + persistent microscopic haematuria + hypertension + mesangial IgA deposition) = ACE inhibitor/ARB first (target BP <130/80, proteinuria <1g/day) - corticosteroids ONLY if high-risk, 20-40% ESRD over 20 years.
CKD 3b A3 = REDUCE (NOT stop) metformin at eGFR 30-44 (MHRA/NICE NG28); add ACEi + SGLT2i; BP <130/80; atorvastatin 20 mg; very high CV risk.
AIN = AKI + recent drug (PPIs, NSAIDs, antibiotics, allopurinol) + sterile pyuria + white-cell casts; stop the drug (60% recover alone); prednisolone 0.5-1 mg/kg if severe/dialysis-dependent or no improvement in 3-7 days.
AIN = PPI/NSAID/antibiotic + AKI 2-8w + eosinophiluria + WBC casts; STOP drug (recovery 60-70%); steroids if no improvement 7d.
VCD = episodic inspiratory stridor with a flattened inspiratory flow-volume loop and normal PEF during attacks; first-line treatment is speech and language therapy with laryngeal breathing techniques, not escalation of asthma therapy.
Cryptogenic organizing pneumonia (COP) - recognise the key clinical and investigative features to guide appropriate management.
LTBI = Positive test + Asymptomatic + Normal CXR; Healthcare workers high-prevalence → treat; Prevents active TB (risk 5-10%).
CURB-65 score 2 equals moderate CAP - dual antibiotics (amoxicillin plus macrolide) cover typical and atypical pathogens.
Bronchiectasis with frequent exacerbations requiring prophylaxis - recognise the key clinical and investigative features to guide appropriate management.
Amiodarone toxicity = Insidious dyspnoea + Bilateral infiltrates after months-years therapy; Stop drug + prednisolone 40-60mg; Half-life 40-100 days (effects persist); Improvement slow (3-12 months); Mortality 10% if severe; Monitor all patients on amiodarone.
Smoking cessation = Most important COPD intervention; Combination NRT (patch + short-acting) for high dependence; Varenicline most effective single agent; Behavioral support essential; Pharmacotherapy doubles/triples quit rates; 12 weeks minimum.
SIADH (SCLC common) → Fluid restriction 500-800ml/24h first-line; Correct maximum 8-10mmol/L/day (osmotic demyelination risk); Hypertonic saline only if severe symptoms; Treat underlying cancer.
PAVM + HHT → Embolize if feeding vessel greater than 3mm; Prevents stroke (30%) and brain abscess (5-10%); Success 95-99%; Antibiotic prophylaxis for procedures.
Inhaler technique = Check at EVERY visit; Up to 70% patients incorrect technique; Correct technique before escalating therapy; Common errors: not exhaling first, not holding breath 10s; Consider spacer/different device; Dramatically improves control.
Peak flow = Twice daily (morning/evening) 2-4 weeks; Same meter; >80% personal best + <20% diurnal variation = good control; Action plan: Green >80%, Amber 60-80%, Red <60%; <60% = seek help urgently; Effort-dependent (technique important).
TB contact = IGRA preferred if BCG-vaccinated (TST less specific); Positive + normal CXR = latent TB; Treatment: 3HR or 6H (reduces active TB 60-90%); High-risk contacts prioritize; 10% lifetime progression risk untreated.
Young adult, dry cough, X-ray worse than examination = think Mycoplasma; no cell wall means penicillins fail - use macrolide or doxycycline per NICE NG138.
Pleural plaques = Benign marker; Do NOT cause symptoms; Do NOT progress to mesothelioma; No treatment; Diffuse thickening can restrict if extensive.
PAP (anti-GM-CSF positive) → Crazy-paving HRCT + milky BAL diagnostic; WLL first-line (improvement 80-90%, lasts 6-24 months); GM-CSF therapy alternative (response 50-60%); Steroids ineffective.
DPIs need a fast, forceful breath; MDIs need slow, steady breath. Always check technique before escalating therapy. MDI + spacer is ideal for elderly or those with coordination difficulties. Poor technique is the commonest cause of apparent treatment failure.
COPD diagnosis requires post-bronchodilator FEV1/FVC <0.70. GOLD 2 = FEV1 50-79%. Always check alpha-1 antitrypsin in young-onset COPD. CXR is needed to exclude other pathology, not to diagnose COPD.
Heart failure is the commonest cause of pleural effusion. Bilateral effusions in heart failure = optimise diuretics first, no aspiration needed unless atypical features. Unilateral, fever, or failure to respond = investigate further.
LTOT criteria: PaO₂ ≤7.3 kPa stable on air (or 7.3-8.0 with cor pulmonale/polycythaemia). Must use ≥15 hours/day. Smoking is an absolute contraindication. Target SpO₂ 88-92% in COPD. Assess with two ABGs 3 weeks apart.
Post-CAP follow-up CXR at 6 weeks (BTS CAP guideline) - radiological resolution lags clinical recovery; key purpose is to exclude underlying lung cancer in smokers/age >50; persistent abnormalities → CT thorax and 2-week-wait referral.
Same-lobe recurrent pneumonia with persistent shadowing on follow-up CXR in a smoker = urgent CT thorax and 2WW lung cancer referral (NICE NG12); do not just re-treat with antibiotics.
Spiculated margins + upper lobe + smoker = high suspicion; calcified, smooth and stable nodules are usually benign - follow the BTS pulmonary nodule pathway with Brock scoring.
Haemoptysis in a smoker aged 40 or over with weight loss = urgent CXR within 2 weeks (NICE NG12); have a low threshold for investigation and use safety-netting.
In suspected ACO, a history of atopy plus raised blood eosinophils (at least 300 cells/μL) is the strongest pointer to an asthmatic component and predicts inhaled corticosteroid responsiveness (NICE NG115).
HIV + TB symptoms + cavitation = start treatment immediately; don't wait for negative TST to exclude TB.
Pancoast tumor (superior sulcus tumor) - recognise the key clinical and investigative features to guide appropriate management.
Green sputum = bacterial infection in COPD exacerbations. Purulence is the key trigger for antibiotics - simple increased breathlessness alone does not need them!
ACO = Asthma + COPD features coexisting; ICS/LABA essential (never LAMA/LABA alone); Consider triple if inadequate; Eosinophils >300 support ICS; Significant reversibility (>12%, >200ml); More exacerbations than COPD alone; Smoking cessation critical.
A flow-volume loop with flattening of BOTH limbs indicates a fixed large airway obstruction (e.g. tracheal stenosis or goitre); inspiratory flattening alone suggests a variable extrathoracic lesion (such as vocal cord dysfunction) and expiratory flattening alone a variable intrathoracic lesion.
Lung cancer screening = LDCT (NOT X-ray); Criteria: age 55-74 + ≥30 pack-years; Reduces mortality 20%.
Provoked PE with a resolved transient major risk factor (eg recent surgery) = 3 months anticoagulation then stop; unprovoked PE = at least 3 months then reassess for extended/indefinite treatment.
RSV bronchiolitis is supportive care only - admit when SpO₂ is 92% or below, work of breathing is increased, or feeding is inadequate; no routine salbutamol or steroids.
Young never-smoker with lower-lobe emphysema = check AAT; autosomal recessive with co-dominant expression (PiMZ intermediate phenotype); liver and lung involvement is the giveaway.
Velcro crackles + clubbing + restrictive spirometry = suspect IPF. HRCT is the key diagnostic investigation. NEVER give steroids empirically - they worsen IPF. Antifibrotics (pirfenidone/nintedanib) are disease-modifying.
Trapped lung? Talc will not stick - put in a catheter quick! If the lung will not re-expand (no relief despite drainage), pleurodesis will fail. IPC lets patients drain at home.
LTOT = PaO2 ≤7.3 kPa stable on air (or 7.3-8.0 with cor pulmonale, polycythaemia, or pulmonary hypertension), ≥15 h/day, non-smoker; refer to HOS-AR per BTS 2015/NICE NG115; survival benefit shown in NOTT/MRC trials.
Long-term oxygen therapy (LTOT) in severe COPD - recognise the key clinical and investigative features to guide appropriate management.
LTOT in COPD requires PaO₂ ≤7.3 kPa (stable, twice, non-smoker); ≥15 h/day improves survival per MRC/NOTT trials; smoking is an absolute contraindication (BTS / NICE NG115).
Light's - exudate if ANY of protein ratio >0.5, LDH ratio >0.6, or pleural LDH >²⁄₃ ULN; sensitivity 98%; diuresis causes false exudates - use albumin gradient or pleural NT-proBNP to reclassify (BTS 2023).
Monday morning wheeze, weekend ease = occupational asthma until proven otherwise. If symptoms improve on holidays/weekends, think workplace exposure!
Alcoholic + red-currant jelly sputum + bulging fissure = Klebsiella kills! This is not your garden-variety pneumonia - it is a necrotizing beast with 50% mortality.
Tracheal deviation + absent breath sounds + hypotension + distended JVP = tension pneumothorax; needle decompression first, then chest drain - never wait for imaging.
Obesity hypoventilation syndrome (OHS) - recognise the key clinical and investigative features to guide appropriate management.
Potato nodes (BHL) alone = Stage I = watch and wait! Most resolve spontaneously. Only treat if symptomatic. Löfgren syndrome (erythema nodosum + arthralgia) has best prognosis of all.
Asthma in pregnancy - continue ICS/LABA, uncontrolled asthma greater risk - recognise the key clinical and investigative features to guide appropriate management.
Asbestos-related pleural plaques - recognise the key clinical and investigative features to guide appropriate management.
Tension PTX = Tracheal deviation + Hypotension + Distended veins; Needle 2nd ICS MCL; DO NOT wait for CXR; Positive pressure worsens.
Varenicline = Highest cessation rates (23-33% at 12 months); Best for highly dependent smokers; Combination with behavioral support essential; Safe in COPD/cardiovascular disease; Nausea most common side effect (30%, mild).
Uterus present = must add progestogen. Still having periods = sequential. Postmenopausal = continuous combined.
Cervical screening starts at 25 with primary HPV testing (cytology only if HPV-positive); HPV-negative women aged 25-49 in England are now recalled at 5 years, and 50-64 at 5 years.
Breast lump aged ≥30 = 2-week-wait referral. Don't delay with GP-arranged imaging.
Ketonuria + weight loss + can't keep fluids down = admit for IV fluids + thiamine. Don't forget thiamine.
NHS breast screening: ages 50-70, every 3 years. Over 70 can self-refer. High-risk family history may start earlier.
Prolapse management = PFMT + pessary + lifestyle. Surgery is not first-line. Address modifiable risk factors.
PCB = examine the cervix + STI screen. A normal smear doesn't mean you can skip examination.
HPV vaccination = 1 dose of Gardasil 9, age 12-13, boys and girls. Screening still required.
Baby blues = day 3-5, resolves by 2 weeks, very common. If it persists beyond 2 weeks, think postnatal depression.
Body-identical (regulated) HRT = safe, NHS-available, NICE-recommended. Compounded 'bioidentical' = unregulated, not recommended. Don't confuse the two terms.
HRT monitoring = clinical review, BP check, symptom assessment. No routine bloods needed. Standard NHS breast screening applies.
HPV-positive + inadequate cytology = repeat in 3 months. HPV-positive + normal cytology = repeat in 12 months. HPV-positive + abnormal cytology = colposcopy.
Female sterilisation fails in 1 in 200 - less effective than IUS, implant, or vasectomy. Always discuss LARC alternatives.
LAM = three criteria must ALL be met: baby <6 months + fully breastfeeding + amenorrhoeic. If any one fails, switch to another method.
Quick-start COCP = give levonorgestrel EC + start COCP same day + 7 days barrier + pregnancy test at 3 weeks. Delay 5 days if ulipristal used.
Low-lying placenta at 20 weeks = usually resolves. Rescan at 32 weeks. Advise urgent assessment if any vaginal bleeding occurs.
Treat gestational hypertension at ≥140/90 mmHg (NICE 2019). Target 135/85. Labetalol first-line. Monitor for pre-eclampsia progression.
GSM (vaginal atrophy) = topical vaginal oestrogen first-line. No progestogen needed. Safe long-term. Also treats recurrent UTIs.
PGAD = unwanted persistent genital arousal + distress. Always review medications (SSRIs/SNRIs are common triggers). Multifactorial assessment needed.
Persistent bloating or pelvic symptoms in women aged 50 years or older - check CA-125 first per NICE NG12; if ≥35 IU/mL, arrange ultrasound and maintain suspicion even if CA-125 is normal.
Sudden collapse + respiratory distress + DIC in peripartum = amniotic fluid embolism. High mortality. Immediate resuscitation and emergency transfer.
Under 13 + sexual activity = mandatory safeguarding referral (Sexual Offences Act 2003). Still provide contraception for harm reduction alongside the referral.
HG with >5% weight loss + ketonuria + dehydration = admit for IV fluids + antiemetics + thiamine. Always give thiamine to prevent Wernicke's.
PUL with βhCG below discriminatory level = repeat βhCG in 48 hours. IVF increases ectopic risk. Consider heterotopic pregnancy with IVF.
RVVC = induction (fluconazole × 3 doses over 7 days) then weekly maintenance for 6 months per BASHH. Always exclude diabetes and non-albicans species.
Migraine with aura = absolute contraindication to all combined hormonal methods. Implant, LNG-IUS, and copper IUD are all safe options.
Previous caesareans + low-lying placenta = high risk of placenta accreta. Risk increases with each CS. Delivery must be at a specialist centre with multidisciplinary planning.
Gestational sac in caesarean scar + empty uterus = CSEP. Urgent specialist referral. Risk of rupture and placenta accreta if unmanaged. Increasing with rising CS rates.
Present HRT breast cancer risk as absolute numbers - ~4 extra cases per 1000 women over 5 years for combined HRT. This enables genuine shared decision-making.
~1 in 4 screen-detected breast cancers may be overdiagnosed. Present both benefits (lives saved) and harms (overdiagnosis) for informed choice.
Decision aids in contraception improve knowledge, satisfaction, and concordance. They support shared decision-making without reducing uptake of effective methods.
LR+ = how many times more likely the finding is in disease vs no disease. LR+ >10 substantially increases post-test probability. Clinically powerful for ruling in diagnoses.
Postmenopausal bleeding = 2WW referral for suspected endometrial cancer. All PMB must be investigated. ~5-10% will have endometrial cancer.
All cancers discussed at MDT. Team includes surgeons, oncologists, radiologists, pathologists, and CNS. GP role is supportive care, continuity, and communication.
Postmenopausal woman + intact uterus + vasomotor symptoms → continuous combined HRT (NICE NG23). Sequential HRT for perimenopausal; oestrogen-only only after hysterectomy; transdermal preferred if VTE risk; Mirena IUS is an alternative progestogen.
FRAX first to assess fracture risk, then DEXA if intermediate risk. Don't jump to DEXA or treatment without initial risk stratification.
Menopause can be a workplace disability under the Equality Act. GPs should treat symptoms AND advocate for reasonable adjustments through supportive letters.
England = HPV primary screening. Age 25-49 every 3 years, age 50-64 every 5 years. HPV-negative = routine recall.
FGM in under-18 = mandatory police reporting (legal duty). Also safeguard via social care referral. FGM is illegal in the UK.
Pelvic organ prolapse first-line = supervised PFMT for 16 weeks. Pessary is second-line. Mesh surgery is restricted.
Continue azathioprine and mesalazine in pregnancy - disease flares are more dangerous than these medications. Methotrexate is absolutely contraindicated.
Known endometriosis = try naturally first with preconception care. Refer for fertility assessment after 6-12 months of trying, not immediately.
Severe depression in PCOS must be treated first - it impairs engagement with all other treatments. Take an integrated biopsychosocial approach.
Over 45 + typical symptoms = clinical diagnosis, no blood tests needed. Explain the rationale - patients understand when the reasoning is shared.
Unexplained recurrent miscarriage = 75% success rate next pregnancy. Supportive early pregnancy care improves outcomes. Offer progesterone based on PRISM trial evidence.
Breast + ovarian cancer in the same family = refer to genetics. NICE CG164 guides referral criteria. Test the affected relative first.
Lynch syndrome + completed family = discuss risk-reducing BSO and hysterectomy. Surveillance alone has limited evidence for mortality reduction.
Observational studies showing HRT cardiovascular benefit are subject to healthy user bias. RCTs did not confirm the benefit. Do not prescribe HRT solely for CVD prevention.
Guidelines inform, patients decide. EBM = evidence + expertise + patient preference. Prescribing an accepted second-line treatment is better than insisting on a refused first-line option.
Combined Down screening = 11+2 to 14+1 weeks (NT + bloods). Quadruple test = 14+2 to 20 weeks if missed. NIPT is offered for higher-risk results.
Barrel-shaped blue cervix + gestational sac in cervical canal = cervical ectopic. High haemorrhage risk. Urgent specialist management required.
Missed pills in Week 1 = danger zone. Think emergency contraception if intercourse occurred.
POI does not mean zero fertility - 5-10% may conceive spontaneously; donor egg IVF is the most effective assisted option.
Breech at 36 weeks in nulliparous = offer ECV. Success ~40% nulliparous, ~60% multiparous. If ECV fails, usually elective caesarean.
Postnatal anxiety = excessive worry about baby + hypervigilance + avoidance. As common as PND. CBT first-line; sertraline if moderate-severe.
Menorrhagia on anticoagulants = LNG-IUS first-line. Do not alter anticoagulation without specialist input. Treat anaemia concurrently.
Enzyme-inducing AEDs (carbamazepine, phenytoin, phenobarbital) reduce hormonal contraceptive efficacy. Copper IUD or LNG-IUS are preferred - unaffected by drug interactions.
Menorrhagia without contraception need → tranexamic acid first-line. With contraception need → Mirena first-line.
Amenorrhoea after uterine surgery + normal hormones + cyclical pain = Asherman syndrome. Hysteroscopy is diagnostic and therapeutic.
≥4 episodes/year = recurrent candidiasis. Treat with fluconazole induction (3 doses) then weekly maintenance for 6 months.
Transdermal HRT = no significant VTE increase (avoids first-pass effect). Oral HRT = increased VTE risk. Always use transdermal route for obese women.
Post-bariatric patients cannot tolerate standard OGTT. Use capillary glucose monitoring as an alternative. Never skip GDM screening - increased risk persists.
In pregnancy, count VTE risk factors systematically. SLE, obesity, steroids, and admission each count. ≥4 factors = antenatal LMWH throughout pregnancy plus 6 weeks postpartum.
Post-egg collection + abdominal distension + weight gain + oliguria = OHSS until proven otherwise. Refer urgently. VTE prophylaxis is essential.
Mass at introitus + absent fundus + PPH = uterine inversion. Attempt immediate manual replacement. Do NOT remove placenta. Call for emergency obstetric support.
Approximately 650-1000 women screened lifetime to prevent one cervical cancer death. Present absolute numbers to patients for meaningful informed consent.
BPSD = non-pharmacological first. Antipsychotics increase stroke and mortality risk. Only risperidone is licensed for BPSD. Always exclude pain, infection, and constipation as triggers.
Dementia diagnosis = patient must notify DVLA. Does not automatically mean stop driving. If patient refuses, GP can inform DVLA (GMC-sanctioned breach of confidentiality).
DLB = fluctuating cognition + visual hallucinations + parkinsonism. AVOID antipsychotics - severe sensitivity risk. Rivastigmine is the treatment of choice.
Bowel obstruction = AVOID prokinetics (metoclopramide, domperidone). Use cyclizine or levomepromazine. Add hyoscine butylbromide for colic and secretions. Consider dexamethasone to reduce oedema.
The LCP was replaced by individualised care plans (NICE NG31), not another pathway. Key principles: recognise dying, communicate, individualise, review regularly. Never use a generic pathway as a tick-box exercise.
New faecal incontinence in over-60s - exclude colorectal malignancy first. Assess sphincter tone, stool consistency, and contributing factors. Consider metformin as a cause of diarrhoea-related incontinence.
Hypoactive delirium is more common than hyperactive but frequently missed. Acute change + fluctuation = delirium, not dementia. Look for and treat precipitants: pain, infection, constipation, medications, dehydration.
Acute onset + fluctuating course = delirium until proven otherwise. Delirium is often superimposed on dementia. Always look for and treat the underlying cause - delirium is usually reversible.
Reablement is free, time-limited (up to 6 weeks), and goal-focused. 60% of patients need no ongoing care afterwards. It supports independence rather than creating dependency. Start rehabilitation early.
"Falls = FRIDS first!" Review meds BEFORE adding interventions. Benzodiazepines = highest fall risk - stop if possible!
Palliative care in heart failure runs in parallel with active treatment. Low-dose opioids for refractory breathlessness, continue diuretics, discuss ICD deactivation, and remember the trajectory is unpredictable.
"Delirium + Dementia = DSD!" Acute change from baseline = delirium until proven otherwise. Treat underlying cause!
"Pressure ulcer prevention = Mattress FIRST!" High-spec foam for Waterlow ≥15. Reposition every 2-4 hours, NOT hourly!
"CGA = Gold standard for frail elderly!" Multidimensional assessment + MDT management. Reduces mortality, institutionalization, functional decline!
"Stress incontinence = Leaks with COUGH/SNEEZE!" Urge = can't reach toilet in time. First-line = pelvic floor exercises!
Hypoactive delirium = quiet, withdrawn, sleepy - accounts for 50% of cases but most commonly missed. Worse prognosis than hyperactive. Screen with 4AT. Acute change from baseline is the key clue.
Cyclizine commonly precipitates in syringe drivers. Use water for injection, not saline. If incompatible, switch to levomepromazine which is compatible with most drugs.
Home death requires: GSF registration, anticipatory meds, equipment, 24-hour nursing access, OOH handover, and carer support. Early planning is key - don't wait until the final days.
DNACPR is a clinical decision based on futility - involve family in discussion but family do not veto; document on a ReSPECT form; DNACPR ≠ withholding of active treatment.
Anticipatory medications cover pain (morphine), nausea (cyclizine), agitation (midazolam), and secretions (hyoscine butylbromide). Prescribe SC PRN before they are needed. Oral route is unreliable at end of life.
MCA 2005 section 4 - the clinician decides best interests; family are consulted, not determinative; IMCA only if no appropriate family; Court of Protection for disputed or finely balanced decisions.
"Elder abuse = Interview ALONE + Safeguard!" Multiple bruises + carer control = high suspicion. Statutory duty to report!
Hydration in dying patients - assess individually, discuss benefits/burdens with family, provide excellent mouth care. Avoid routine IV fluids (may worsen secretions/oedema).
Elderly with CKD + peptic ulcer + warfarin = avoid oral NSAIDs and be cautious with opioids. Topical NSAIDs are safe and effective for localised OA (knee, hand). NICE recommends topical before oral.
"Anticholinergics in dementia = avoid when possible!" Check ACB score. Oxybutynin + amitriptyline = highest burden offenders!
"Post-stroke coughing with water = SALT assessment!" Never resume oral diet without formal swallow evaluation. Aspiration pneumonia = major stroke complication!
Avoid morphine in severe renal failure (eGFR <30) - M6G accumulates causing toxicity. Fentanyl and alfentanil are safe alternatives (inactive metabolites).
Prolonged grief disorder = intense yearning, avoidance and functional impairment persisting beyond 6-12 months after bereavement; the key distinguishing feature from depression is persistent yearning for the deceased.
"Hip fracture = Treat IMMEDIATELY!" Zoledronic acid IV = best compliance. CKD stage 3 safe if eGFR >35!
Urge incontinence first-line = bladder training for ≥6 weeks. Avoid oxybutynin in elderly (cognitive harm). If medication needed: solifenacin, tolterodine, or mirabegron preferred.
"Postural hypotension = Review MEDS first!" Alpha-blockers + CCBs = common causes. Stop before adding fludrocortisone!
Always co-prescribe laxatives with opioids. Use stimulant + softener combination (senna + docusate). Lactulose is a poor choice for opioid-induced constipation. Tolerance to constipation does NOT develop.
"Wearing-off = Give levodopa MORE FREQUENTLY!" Reduce dosing interval first, then add COMT/MAO-B inhibitor if needed.
Use 6CIT or GPCOG for initial GP cognitive screening - both are free and validated. MMSE is copyrighted. Positive screen = bloods then memory clinic referral.
Normal grief includes sensing the deceased's presence and hearing their voice - these are not psychotic symptoms. Differentiate from complicated grief (>6-12 months) and depression. Support, not medication, is first-line.
In severe frailty with dementia, calcium and vitamin D is the most practical bone protection. Consider life expectancy and frailty status when prescribing bisphosphonates.
Vitamin D <25 nmol/L = deficient. Treat with loading dose colecalciferol then maintenance. Housebound elderly patients are at very high risk of deficiency.
Delirium = acute onset + fluctuating + inattention + precipitant. Hypoactive (quiet) is commonest and most missed. Treat the cause, not the confusion.
Deprescribe preventive medications first in limited life expectancy: statins, bisphosphonates, anticoagulants for AF. Continue symptom-relief medications (diuretics, analgesics). Use the framework: is this drug still providing net benefit?
Use the NHS 7-steps framework for structured medication reviews. Start with what matters to the patient. STOPP/START is the European inappropriate prescribing tool (not Beers).
Stress incontinence = leakage on exertion/coughing. Urge = leakage with urgency. First-line for stress incontinence = supervised pelvic floor exercises for ≥3 months, NOT medication.
CGA is multidimensional (medical, psychological, functional, social) and interdisciplinary. It is evidence-based and reduces mortality and institutionalisation. Triggered by moderate-severe frailty identification.
Primary care incontinence assessment = bladder diary + dipstick + PVR + pelvic exam. Start conservative management before referral. Urodynamics are a specialist pre-surgical investigation.
Malignant ascites refractory to diuretics = therapeutic paracentesis. Diuretics are less effective than in cirrhotic ascites. Consider an indwelling drain for recurrent drainage.
eFI thresholds: <0.12 fit, 0.12-0.24 mild, 0.24-0.36 moderate, >0.36 severe frailty. Moderate-severe frailty should trigger comprehensive geriatric assessment.
Hospital-acquired deconditioning causes rapid functional decline in elderly patients. Early mobilisation, nutrition, and community rehabilitation are key to recovery.
In falls-related medication review, prioritise stopping benzodiazepines and alpha-blockers. Use STOPP/START criteria systematically. Nocturnal falls often involve sedation plus postural hypotension.
DNACPR can be completed in primary care. Based on patient wishes and/or clinical futility. Does not affect other treatments. ReSPECT is replacing traditional DNACPR forms nationally.
Nitrofurantoin is ineffective at eGFR <45 - inadequate urinary concentration. Always check eGFR before prescribing. Review all medications for renal dose adjustments in elderly patients.
MUST uses BMI + weight loss percentage + acute disease effect. Score ≥2 = high risk requiring dietetic referral and nutritional support. >10% weight loss in 3-6 months scores 2 regardless of BMI.
Dexamethasone 16 mg daily for raised ICP and cord compression; 2-4 mg for appetite. Give mornings, taper after >1 week.
Breakthrough morphine = 1/6 the daily total! Simple math: total daily dose ÷ 6 = PRN dose. Using >4 PRNs/day for 2 days? Time to increase the background dose!
Oral to SC morphine = divide by 2; oral to SC diamorphine = divide by 3; always prescribe breakthrough doses at one-sixth of the 24-hour SC dose.
Fragility fracture in women ≥75 = start bisphosphonate without DEXA. Alendronate first-line. eGFR <35 → switch to denosumab. Fracture Liaison Service for all fragility fractures.
Terminal agitation? Levomepromazine = sedation solution! Broad-spectrum: sedates AND treats delirium. Benzos alone may worsen confusion. Comfort is the goal, not hastening death.
Bowel obstruction? Cyclizine - yes! Metoclopramide - death wish! Prokinetics push against the blockage = perforation risk. Use cyclizine (slows gut down) + hyoscine butylbromide (reduces secretions).
Memory clinic assessment = formal cognitive testing + informant history + examination. Do not start cholinesterase inhibitors before specialist diagnosis. CT/MRI to exclude reversible causes.
Capacity is decision-specific and time-specific. Dementia ≠ automatic incapacity. Use the two-stage test. Next of kin ≠ automatic decision-maker without LPA.
Recognising dying is a clinical skill. Signs include: bedbound, semi-conscious, minimal intake, Cheyne-Stokes breathing, mottled peripheries, and anuria. Focus on comfort, stop non-essential treatments, and communicate with family.
New medications are a common and reversible cause of delirium. Codeine and opioids are high-risk in elderly patients. Use the PINCH ME mnemonic to systematically identify precipitants.
The Surprise Question identifies patients for the GSF register. Not just cancer - include organ failure, neurological disease, and dementia. Use the traffic light coding to guide care intensity.
Low-dose morphine is first-line for refractory breathlessness. Oxygen is not helpful if SpO2 is adequate. A handheld fan is a simple, effective intervention. Do not withhold opioids due to unfounded fears of respiratory depression.
Vertebral fracture in men - always exclude myeloma and metastatic disease before attributing to osteoporosis. Check bone profile, protein electrophoresis, and PSA.
LPA must be arranged while the person still has capacity. Two types: Health & Welfare, and Property & Finance. Once capacity is lost, the Court of Protection must be involved instead.
STOPP/START is a validated tool for medication review in elderly patients. Aspirin for primary prevention in over-65s should be stopped. Always review gastroprotection when the indication medication is removed.
NSAIDs are high-risk in elderly patients, especially with CKD and concurrent ACE inhibitors/ARBs/diuretics/SGLT2 inhibitors. Use topical NSAIDs or non-NSAID alternatives. The 'triple whammy' causes AKI.
Psychotropic drugs are the strongest medication-related risk factor for falls. Review all medications using FRID criteria in every falls assessment. Sedation + postural hypotension + impaired balance = falls.
Marie Curie night sits are invaluable for carer respite. Apply for NHS Continuing Healthcare Fast-Track for rapidly deteriorating patients. Support the carer to support the patient - carer burnout is the main reason home deaths fail.
HINTS: positive head impulse + horizontal nystagmus + no skew = peripheral (vestibular neuronitis); negative head impulse + vertical nystagmus = central (stroke → urgent MRI).
Femoral neuropathy = weak knee extension + absent knee jerk + saphenous sensory loss + normal hip abduction; post-hip surgery commonest; physio + knee brace.
Restless legs syndrome: urge to move legs + uncomfortable sensations + worse rest/evening + relieved by movement; check ferritin (replace if <75); ropinirole/pramipexole first-line; avoid antidopaminergics.
Radial nerve spiral groove = wrist drop + weak finger/thumb extension + preserved elbow extension + first dorsal web space; splint + physio; 70-90% recover 3m.
GCA + vision loss = pred 60mg immediately; don't wait for biopsy; prevent second eye; biopsy <7d.
Wernicke encephalopathy = confusion + ophthalmoplegia + ataxia in an at-risk patient; give high-potency IV thiamine (Pabrinex) immediately and always before glucose (NICE CKS 'Alcohol - problem drinking'; BNF).
Wearing-off plus dyskinesias equals motor complications from pulsatile levodopa - add COMT inhibitor to smooth delivery, reduce dose fluctuations.
Bacterial Meningitis (Pneumococcal) - recognise the key clinical and investigative features to guide appropriate management.
First seizure = urgent first seizure clinic within 2 weeks, no antiepileptics in primary care, and (for Group 1) usually 6 months off driving after a first unprovoked seizure per DVLA.
Todd paresis (post-ictal paralysis) requiring observation for spontaneous resolution - recognise the key clinical and investigative features to guide appropriate management.
Severe unilateral periorbital pain plus lacrimation plus restlessness plus nocturnal attacks equals cluster headache - 100% oxygen aborts attacks, verapamil prevents recurrence.
JME is a lifelong genetic generalised epilepsy; sodium valproate is most effective but is contraindicated in girls and women of childbearing potential, so offer levetiracetam first-line (NICE NG217).
MOH = chronic daily headache + overuse ≥10d/m (triptans) or ≥15d/m (analgesics); stop all acutes; prophylaxis AFTER detox.
Spinal epidural abscess = back pain + fever + progressive deficit; urgent MRI plus decompression within 24 h and 6 weeks IV antibiotics; *S. aureus* in ~50% (BSAC/IDSA guidance).
Wernicke's = confusion + ophthalmoplegia + ataxia. Suspect ANY confused alcohol-dependent patient. Treat IMMEDIATELY with IV Pabrinex 2-3 pairs TDS x 3-5 days. NEVER give glucose without thiamine. 80% untreated → irreversible Korsakoff!
CVT = headache + seizures + haemorrhagic infarct (non-arterial territory); anticoagulate EVEN with haemorrhage; 80-90% recover.
Cerebellar stroke: ataxia + dysarthria + nystagmus + headache/vomiting + PICA territory; monitor GCS (deterioration = brainstem compression); neurosurgical decompression if large (>3cm) or hydrocephalus; mortality 80% large infarcts untreated.
Multiple system atrophy differentiating from Parkinson disease by autonomic failure and poor levodopa response - recognise the key clinical and investigative features to guide appropriate management.
BPPV = brief positional vertigo + positive Dix-Hallpike (latent, fatiguing, rotatory geotropic nystagmus); treat with the Epley manoeuvre per NICE CKS; betahistine is for Ménière's, not BPPV.
Migraine ≥4 attacks/month = prophylaxis. First-line: topiramate 50mg BD OR propranolol 80-160mg daily. Trial 3 months. CGRP mAbs for refractory!
Essential tremor = bilateral action/postural tremor + NO resting tremor + NO parkinsonian signs + improves with alcohol. Treat if impairing: propranolol 40-320mg OR primidone 50-750mg!
Rapid dementia + myoclonus + ataxia + DWI cortical ribboning/basal ganglia hyperintensity + CSF 14-3-3/RT-QuIC = sporadic CJD; no cure; notify the UK National CJD Surveillance Unit.
Tarsal tunnel = plantar burning + worse night + Tinel behind medial malleolus + normal ankle strength; conservative first; surgery if refractory (60-80%).
HSV encephalitis requiring urgent aciclovir - recognise the key clinical and investigative features to guide appropriate management.
Cluster headache = SC sumatriptan or high-flow O₂ acutely + verapamil prophylaxis (ECG-monitored); steroids or GON block as short-term bridge.
CN VI palsy = horizontal diplopia + failure abduction + no ptosis/pupil changes; microvascular commonest (90% resolve 3-6m); raised ICP = false localising sign; MRI if atypical.
Episodic headache becoming daily on regular analgesics = medication overuse headache; stop the offending drug (expect transient worsening) and review prophylaxis.
MSA = parkinsonism (poor levodopa response) + autonomic failure + cerebellar/pyramidal signs; inspiratory stridor and 'hot cross bun' sign are key red flags (Gilman 2008 / NICE NG71); management is symptomatic and median survival is 6-10 years.
Postural orthostatic tachycardia syndrome requiring volume expansion and reconditioning - recognise the key clinical and investigative features to guide appropriate management.
GCA + any visual symptoms = immediate prednisolone 60 mg (or IV methylprednisolone); do not wait for biopsy or imaging (BSR 2020; NICE CKS).
Cerebral amyloid angiopathy with high rebleeding risk on anticoagulation - recognise the key clinical and investigative features to guide appropriate management.
GCA + vision loss = IV methylpred 1g ×3d immediately; don't wait for biopsy; prevent second eye; taper steroids 12-18m.
Bell's = acute LMN VII (forehead involved); pred 50mg ×10d <72h + eye protection; 90% recovery with steroids.
TN = electric shock seconds + V2/V3 + triggered by touch/chewing; carbamazepine first-line (NNT 2-3); MVD if refractory.
RLS = urge to move + worse rest + relieved movement + worse evening; check ferritin → iron if <75 (improves 60%); then dopamine agonist or gabapentin.
IIH = obese young woman + headache + papilloedema + visual obscurations + LP >25 + normal MRI/CSF; weight loss + acetazolamide; monitor vision.
Cluster headache = excruciating unilateral orbital pain + lacrimation/nasal congestion + restlessness + 15-180 min duration. Acute treatment: SC sumatriptan 6mg OR high-flow oxygen 12-15L/min (equally effective). Oral analgesics useless!
Stroke secondary prevention: clopidogrel 75mg daily (superior to aspirin) + atorvastatin 80mg + BP less than 130/80; dual antiplatelet (aspirin + clopidogrel) only 21 days if minor stroke/high-risk TIA; anticoagulation if AF.
Excessive sleepiness plus cataplexy plus sleep-onset REM equals narcolepsy type 1 - modafinil for sleepiness, sodium oxybate for cataplexy.
TLE = aura (fear/déjà vu/epigastric) + automatisms (lip-smacking, fumbling) + post-ictal confusion + hippocampal sclerosis; first-line is lamotrigine or levetiracetam (NICE NG217), with anterior temporal lobectomy for drug-resistant mesial temporal sclerosis.
Postural hypotension: BP drop ≥20mmHg systolic or ≥10mmHg diastolic within 3 minutes standing; non-pharmacological first-line (fluid/salt, compression stockings, head-up tilt sleeping); fludrocortisone/midodrine if needed; common Parkinson/diabetes.
Vestibular neuronitis = acute severe vertigo + horizontal nystagmus + NO hearing loss; prochlorperazine ≤3d; vestibular rehab; 95% recover 6m; vs labyrinthitis (hearing loss).
CTS = median nerve (thumb/index/middle) + worse at night + Phalen/Tinel positive; splint first → surgery if fails (90% cure).
Vestibular migraine requiring standard migraine prophylaxis - recognise the key clinical and investigative features to guide appropriate management.
IIH = obese young woman + papilloedema + normal MRI + LP >25 cmH₂O; acetazolamide + weight loss first-line; surgery if vision worsening (IIHTT, 2014).
Rapidly progressive dementia + myoclonus + ataxia + DWI cortical ribboning/basal ganglia + CSF 14-3-3 (or RT-QuIC positive) = sporadic CJD - uniformly fatal in 4-6 months, supportive care only; notify the UK National CJD Surveillance Unit.
Secondary trigeminal neuralgia from structural lesion requiring neurosurgical evaluation - recognise the key clinical and investigative features to guide appropriate management.
Thunderclap headache plus negative CT >6 hours requires LP for xanthochromia - CT misses 15-50% SAH after 6 hours.
Always check ferritin in restless legs syndrome - replace iron when ferritin <75 µg/L; gabapentin or pregabalin is now preferred to dopamine agonists for persistent symptoms (NICE CKS).
Migraine with aura - abort acute attacks with a triptan (sumatriptan), and the combined pill is UKMEC 4 and must be stopped (NICE CKS Migraine; FSRH UKMEC 2016).
Wernicke encephalopathy requiring urgent IV thiamine - recognise the key clinical and investigative features to guide appropriate management.
MMSE 10-26 mild-to-moderate Alzheimer disease → donepezil first-line per NICE TA217/NG97; add memantine for moderate-to-severe disease; always exclude reversible causes (B12, thyroid, syphilis) and notify the DVLA.
Classical trigeminal neuralgia requiring first-line anticonvulsant therapy - recognise the key clinical and investigative features to guide appropriate management.
Sydenham chorea = penicillin prophylaxis ≥5yr (longer if carditis); chorea self-limiting but cardiac damage progressive; serial echo monitoring.
Bilateral postural tremor plus family history plus alcohol responsiveness equals essential tremor - propranolol reduces tremor amplitude 50-70%.
Diabetic autonomic neuropathy = late microvascular complication; gastroparesis → optimise glycaemia + small low-fat meals + short-course metoclopramide or domperidone (mind MHRA cautions); always actively look for coexistent orthostatic hypotension, ED and neurogenic bladder.
Thunderclap + normal CT = mandatory LP at 12+h for xanthochromia; CT sensitivity declines with time.
MOH = chronic daily headache + acute-medication overuse - abrupt withdrawal plus simultaneous preventive therapy is the only effective treatment (NICE CKS Headache; SIGN 155).
Separation anxiety = worry about harm to attachment figures, not about school itself. CBT is first-line. Somatic symptoms on school days are a red flag.
Anorexia with bradycardia or BMI <15 in adolescents = urgent specialist referral. Check U&E for hypokalaemia. Family-based treatment is first-line.
Adolescent depression = fluoxetine (start 10mg) + psychological therapy. Fluoxetine is the only first-line SSRI in under-18s. Review weekly for first 4 weeks.
Short child + short parents + normal growth velocity = familial short stature. Crossing centiles downward is the red flag, not being on a low centile.
Most warts self-resolve within 2 years. If treating, salicylic acid is first-line. Cryotherapy is second-line. No swimming exclusion needed for verrucae.
Tinea capitis = systemic antifungal (griseofulvin 8-12 weeks). Topical alone is inadequate. Black dots = Trichophyton tonsurans (Wood's lamp negative).
Tongue-tie + breastfeeding problems + weight loss = refer for specialist feeding assessment and consider frenotomy. Asymptomatic tongue-tie does not need treatment.
Newborn SpO2 <95% or pre-/post-ductal difference >3% = urgent neonatal referral for echocardiography. <90% = immediate referral. Pulse oximetry screens for critical congenital heart disease.
Undescended at 6 months = refer for orchidopexy. Surgery by 12 months. Distinguish from retractile testes. Increased malignancy and infertility risk.
Squint beyond 2-3 months = ophthalmology referral. Corneal light reflex asymmetry confirms squint. Always check red reflex (leucocoria = urgent referral). Treat early to prevent amblyopia.
Behavioural regression + fearfulness + flinching + low self-esteem = consider emotional abuse. No physical injuries does not mean no abuse. Document and consider safeguarding referral.
Gillick-competent under-16s can consent to STI screening. Non-judgmental approach. Screen for safeguarding. Chlamydia NAAT ≥2 weeks post-exposure. Promote condom use.
Central pain migrating to RIF + anorexia + vomiting + peritoneal signs = appendicitis until proven otherwise. Emergency surgical referral. Do not delay for investigations. Give analgesia.
Combined test at 11-14 weeks = NT + β-hCG + PAPP-A. ≥1:150 risk → offer NIPT. Quadruple test if missed the window. NIPT is screening, not diagnostic.
Pallor + bruising + bone pain + hepatosplenomegaly in a child = suspect leukaemia. Urgent same-day FBC and blood film. Never dismiss as growing pains if examination is abnormal.
Global developmental delay (≥2 domains) requires systematic investigation: chromosomal microarray (highest yield), TFTs, CK, metabolic screen. Refer to community paediatrics alongside investigations.
Sudden behavioural change in a young child = consider life events first; NICE CG158 on antisocial behaviour and conduct disorders advises distinguishing situational or adjustment reactions from a diagnosable disorder.
Screen removal from the bedroom is the single most important intervention for behavioural insomnia. Blue light suppresses melatonin. Children need 9-12 hours sleep. Chronic sleep deprivation mimics ADHD.
For childhood overweight and obesity, NICE CG189 recommends a family-based multicomponent lifestyle programme (diet, activity, behaviour) - not restrictive dieting, drug therapy or surgery as the first-line approach.
Under 3s: smear of ≥1000 ppm fluoride toothpaste twice daily. Over 3s: pea-sized amount of 1350-1500 ppm. Spit, don't rinse. First dental visit by age 1. Dental decay is the top cause of child hospital admission.
Road traffic collisions are the leading cause of injury death in 15-19 year olds. Injury prevention should be age-specific. Injuries are the leading cause of death in children 1-18. Deprivation triples the risk.
Toddlers can drown in 5cm of water. Drowning is often silent. Never leave under-5s unsupervised near any water. Empty paddling pools after use. Fence or fill garden ponds. Swimming lessons do not prevent drowning.
Periumbilical pain + normal growth + normal investigations + no alarm features = functional abdominal pain. Positive diagnosis with clear explanation. CBT and hypnotherapy are evidence-based. Avoid unnecessary investigations.
Childhood migraine: shorter duration, may be bilateral, prominent nausea. Ibuprofen first-line for acute treatment. Propranolol or topiramate for prevention if ≥4/month. Normal examination + episodic + well between attacks = no imaging needed.
Costochondritis is the commonest cause of chest pain in children. <1% is cardiac. Red flags: exertional pain, syncope, family history of sudden death, palpitations. Reassure and treat with simple analgesia.
Steroid phobia is common and causes treatment failure. Hydrocortisone 1% is safe in children. Undertreating eczema causes more harm. Use FTU to guide quantity. Step up potency for flares, step down for maintenance.
Tachypnoea is the best sign of pneumonia in children. Oral amoxicillin is first-line (BTS). Admit if SpO2 <92%, severe distress, or unable to hydrate. Add macrolide for atypical pneumonia in older children.
Gram-positive diplococci = pneumococcus. Gram-negative diplococci = meningococcus. Bacterial CSF: high neutrophils, high protein, low glucose. Pneumococcal meningitis has higher mortality than meningococcal.
Clinical dehydration: irritable, sunken eyes, dry mucous membranes, reduced skin turgor, CRT 2-3 seconds. Treat with oral rehydration solution 50mL/kg over 4 hours. Severe dehydration (CRT >3s, anuria, altered consciousness) needs IV fluids.
Periumbilical pain → RIF + fever + guarding + rebound = appendicitis until proven otherwise. Pain before vomiting suggests surgical cause. Urgent surgical referral. Perforation risk is higher in young children.
Coronary artery aneurysms are the key complication of Kawasaki disease. Echocardiography at diagnosis, 2 weeks, and 6-8 weeks. 25% untreated, 5% treated develop aneurysms. Defer live vaccines for 11 months after IVIG.
Gowers' sign + calf pseudohypertrophy + proximal weakness in a young boy = suspect DMD. Check CK first (massively elevated). X-linked recessive - maternal family history. Refer for genetic testing. Steroids slow progression.
Transilluminates + can get above it + doesn't change with crying = non-communicating hydrocele. Most resolve by 12-24 months. Cannot get above it + changes with crying = suspect hernia (refer). Communicating hydrocele varies in size during the day.
Down syndrome surveillance: annual TFTs (hypothyroidism), 6-monthly hearing tests until age 5, ophthalmology by 18 months, echo at birth, specific growth charts, annual FBC. 50% have congenital heart disease. Use Down syndrome-specific growth charts.
MASH is a multi-agency team providing a single point of contact for safeguarding referrals. It combines information from police, health, education, and social care for comprehensive risk assessment. Any professional can refer. GPs should provide medical information when requested.
Start transition planning at age 13-14 (Year 9), not at 18. It should be gradual, person-centred, and developmentally appropriate. GP provides continuity. Teach self-management skills. Joint clinics help bridge paediatric and adult services.
No meconium by 48 hours + abdominal distension + bilious vomiting = think Hirschsprung. Rectal biopsy confirms. Associated with Down syndrome.
Gillick = all medical treatment consent for under-16s. Fraser = specifically contraception. Competence is decision-specific. A competent child can consent but may not be able to refuse life-saving treatment.
Rib hump on forward bend + pubertal girl = suspect structural scoliosis. Refer to orthopaedics. Pre-menarchal girls are at highest risk of progression. Painful scoliosis is a red flag.
Threadworms = treat ALL household members simultaneously with mebendazole plus hygiene measures. Repeat dose at 2 weeks.
Wheeze only with colds + well between episodes = episodic viral wheeze, not asthma. Most grow out of it by school age.
Buccal midazolam is first-line for prolonged seizures in the community. Dose: 5mg (1-4yr), 7.5mg (5-9yr), 10mg (≥10yr). Status epilepticus = seizure >5 minutes. Escalate if no response after 2 doses of benzodiazepine.
New polyuria/polydipsia plus weight loss plus vomiting plus Kussmaul breathing plus high glucose = DKA - emergency hospital transfer; IV fluids cautiously first, insulin after 1 hour of fluids, and watch for cerebral oedema.
Anaphylaxis = IM adrenaline first. Dose based on age: <6y 150mcg, 6-12y 300mcg, >12y 500mcg. Anterolateral thigh. Repeat every 5 minutes if needed.
Always prescribe TWO auto-injectors. Age 6-12 or >20kg = 300mcg device. Both must be carried at all times. Provide training and an action plan.
School refusal = holistic assessment first. Distinguish from truancy (emotional distress is the key). Address underlying mental health, bullying, and school factors.
Behavioural sleep problems in children: consistent routine + gradual withdrawal is first-line. Melatonin is for neurodevelopmental disorders, not typically developing children. Address parental sleep associations.
Growing pains = bilateral, evening/night, gone by morning, normal examination. Any unilateral pain, limp, or joint swelling = investigate, not growing pains.
Squint + reduced acuity in one eye = amblyopia. Urgent ophthalmology referral - treatment only effective during the critical period (up to age 7-8). Patching of the good eye is the mainstay of treatment. Never assume a child will "grow out of" a squint.
Episodic screaming + drawing up legs + redcurrant jelly stool + sausage-shaped mass = intussusception. Emergency admission. Air enema reduction.
Post-viral limp in 3-10 year old + low-grade fever + mildly raised bloods = transient synovitis. Use Kocher criteria to differentiate from septic arthritis.
Extensive untreated dental caries with failure to seek dental care = dental neglect. Explore barriers before making judgements. NHS dentistry is free for children. Consider whether dental neglect is part of a wider pattern of neglect.
Multiple neglect indicators = safeguarding referral to children's social care. Neglect is the commonest form of abuse. Poverty does not explain all findings. Document thoroughly.
Neonatal murmur in a well baby = non-urgent echo referral. Urgent if cyanosis, heart failure signs, or absent femoral pulses. All neonatal murmurs warrant echocardiographic assessment. Normal femoral pulses help exclude coarctation.
Mottled + prolonged CRT + lethargy + tachycardia + parental concern = sepsis until proven otherwise. IM antibiotics and 999. "Sepsis 6" within 1 hour. Trust parental instinct.
Allergic rhinitis first-line = non-sedating antihistamine + intranasal corticosteroid. Avoid intranasal decongestants beyond 7 days. Look for the atopic triad.
White pupil in a photograph = urgent ophthalmology referral to exclude retinoblastoma. Most present before age 3. 40% hereditary (bilateral, RB1 gene). Treatment: chemotherapy, focal therapy, or enucleation. >95% survival if detected early.
Child protection overrides confidentiality. Consent is NOT needed to share safeguarding concerns. Inform the parent unless doing so increases risk. "If in doubt, share."
Recurrent anterior epistaxis in children = Naseptin for 2 weeks + stop nose-picking. ENT cautery if refractory. Investigate if bleeding from multiple sites or family history of bleeding disorder.
First typical UTI under 6 months responding to treatment = renal ultrasound within 6 weeks only (NICE NG224 Table 4). DMSA and MCUG are for atypical or recurrent UTI.
Vaccine refusal = explore concerns, educate, document, offer to revisit. Never force or refuse care. Maintain the relationship.
Clusters of brief flexor spasms on waking + developmental regression in an infant = infantile spasms (West syndrome). Urgent EEG (hypsarrhythmia). Treat with vigabatrin (tuberous sclerosis) or prednisolone/ACTH. Delay worsens outcomes.
Migratory arthritis + carditis + erythema marginatum + raised ASO titre after sore throat = acute rheumatic fever. Jones criteria require evidence of streptococcal infection + ≥2 major or 1 major + 2 minor criteria. Long-term penicillin prophylaxis is essential.
Faecal impaction = Movicol disimpaction regimen first. Soiling means overflow, not behavioural. Treat for months, not days.
Delayed puberty + family history of late development + delayed bone age = constitutional delay. Most common cause in boys. Usually self-resolving.
Pale toddler + excessive cow's milk + poor diet = iron deficiency anaemia. Reduce milk to <400ml/day, give oral iron for 3 months, improve diet.
NICE NG143 - 'no response to social cues' or 'appears ill to a healthcare professional' = RED; age <3 months + fever ≥38°C = automatic red.
Painless neck lump in an adult smoker ≥3 weeks = urgent investigation. FNAC under ultrasound is first-line. Think metastatic SCC or lymphoma. Never trial antibiotics for unexplained persistent neck lumps.
Mild croup = single dose oral dexamethasone in primary care. No steam, no antibiotics. Safety-net parents about worsening stridor, recession, or drowsiness.
Neonate distressed during feeding, better when crying, catheter won't pass = bilateral choanal atresia. Neonatal emergency. Associated with CHARGE syndrome. Treat with oral airway then surgical repair.
CRSwNP: anosmia + bilateral polyps + asthma association. Samter's triad: asthma + polyps + aspirin sensitivity. Intranasal steroids first-line. Oral steroids for acute shrinkage. Refer for FESS if refractory.
Recurrent vertigo + migraine history + migrainous features + normal hearing = vestibular migraine. Most common cause of episodic vertigo. Differentiate from Meniere's by normal hearing and no ear fullness. Treat as migraine (prophylaxis + trigger management).
BTE/RIC hearing aids are best for patients with dexterity issues - larger, easier to handle. NHS hearing aids are free. Refer to audiology. CIC aids: discreet but hard to manage. BAHA for conductive/mixed loss. Cochlear implant for severe-profound SNHL.
Bilateral NHSP failure = urgent audiology referral for diagnostic ABR within 4 weeks. 1-2 per 1,000 have permanent hearing impairment. Early intervention (hearing aids by 3 months) improves outcomes dramatically. Family history of deafness is a major risk factor.
Bilateral gelatinous swelling of vocal cords + smoker + deepening voice = Reinke's oedema. Smoking cessation is essential. Treat GORD. Surgery for significant voice change. Must exclude carcinoma by biopsy if any suspicion.
Anterior rhinoscopy: assess septum, turbinates, nasal floor, discharge, and masses. Otoscope with large speculum works well in primary care. Decongesting spray before examination improves the view. Unilateral polyps/masses need urgent ENT assessment.
Lateral border of tongue is the most common site for oral SCC. Examine systematically including palpation. Oral ulcer >3 weeks = 2-week wait referral. Erythroplakia has higher malignant potential than leukoplakia. Smoking + alcohol are synergistic risk factors.
FeverPAIN: Fever, Purulence, Attend rapidly, Inflamed tonsils, No cough. Score 4-5 = likely streptococcal - consider antibiotics. 0-1 = no antibiotic. Penicillin V is first-line. Avoid amoxicillin if EBV suspected (causes rash).
Acute rhinosinusitis <10 days: no antibiotics (98% viral). Delayed antibiotics if >10 days without improvement. First-line: phenoxymethylpenicillin. Quinsy, epiglottitis, and mastoiditis always need antibiotics. Most ENT infections are viral and self-limiting.
CRSsNP first-line: intranasal corticosteroid + saline irrigation for ≥3 months. CT sinuses only after failed medical treatment. Do not use oral steroids for CRS without polyps. Macrolide antibiotics (low-dose, long-term) may be considered second-line for their anti-inflammatory properties.
Parotid mass + facial nerve palsy = malignancy until proven otherwise. Urgent investigation required. Adenoid cystic carcinoma is notorious for perineural invasion. Benign tumours do not cause facial palsy.
Witnessed choking + unilateral wheeze or reduced breath sounds = inhaled foreign body until proven otherwise. Same-day paediatric referral. Right bronchus more commonly affected. Asymptomatic interval does not exclude foreign body.
Vertical/direction-changing nystagmus + limb ataxia + dysarthria + vascular risk factors = central vertigo (stroke). Use HINTS exam. Peripheral vertigo: horizontal unidirectional nystagmus, no cerebellar signs. Central vertigo is a medical emergency.
Presbyacusis: gradual bilateral high-frequency SNHL in older adults. Refer to audiology for free NHS hearing aids. Untreated hearing loss increases risk of dementia, depression, and falls. Hearing aids significantly improve quality of life.
Persistent dizziness after vestibular neuritis = vestibular rehabilitation exercises. Stop vestibular sedatives after acute phase (they impair compensation). Avoidance worsens recovery. VRT is evidence-based and effective. Do not prescribe long-term prochlorperazine.
Recurrent anterior epistaxis in children = cautery to one side + Naseptin cream. Never cauterise both sides simultaneously. Investigate for bleeding disorders only if other signs present.
Bilateral nasal polyps = intranasal steroid drops + ENT referral. Unilateral polyp = exclude malignancy. Associated with asthma and aspirin sensitivity (Samter's triad).
Minor aphthous ulcers = topical steroids and chlorhexidine mouthwash. Check iron, B12, folate, and coeliac screen. Consider Behcet's if genital ulcers or eye symptoms.
Severe-profound bilateral SNHL with inadequate hearing aid benefit = refer for cochlear implant assessment. Earlier implantation gives better outcomes. NICE supports this pathway.
Sudden deafness in one ear = same-day GP assessment and same-day ENT referral if sensorineural. Steroids within 72 hours improve outcomes. Never assume wax without examining the patient.
Stridor at rest + accessory muscles + desaturation = critical upper airway obstruction. Call 999, high-flow O2, sit upright. Do not delay. Goitre compression is a known cause of tracheal obstruction.
Shoulder weakness + inability to shrug after neck dissection = accessory nerve (CN XI) injury. CN XI supplies SCM and trapezius. Modified radical neck dissection aims to preserve CN XI but injury still occurs. Physiotherapy is the mainstay of rehabilitation.
Hyperacusis = reduced tolerance to normal environmental sounds. Refer to audiology for desensitisation. Avoid overuse of ear protection as this worsens the condition.
Unilateral foul nasal discharge in a child = foreign body; try the parent's kiss first then forceps if visible and cooperative; refer urgently to ENT for button batteries, magnets, deep impaction or failed removal (NICE CKS).
Immediate antibiotics in AOM if: age <2 with bilateral disease, otorrhoea present, or systemically unwell. First-line = amoxicillin.
Previous perforation or recent middle ear infection = no irrigation. Refer for microsuction. Always check for irrigation contraindications before proceeding.
Most traumatic TM perforations heal spontaneously in 6-8 weeks. Keep dry, avoid nose-blowing. Urgent ENT only if vertigo, facial weakness, or sensorineural loss.
Antibiotics for sinusitis if symptoms persist >10 days, are severe, or patient is systemically unwell. First-line: amoxicillin for 5 days. Know the red flag complications.
Posterior epistaxis = elderly, anticoagulated, no visible anterior source, blood in pharynx. Pack and transfer to hospital. Never cauterise both sides of the septum simultaneously.
Clear unilateral watery discharge after head injury = CSF rhinorrhoea. Confirm with beta-2 transferrin (gold standard). Most resolve spontaneously. Persistent leaks need surgical repair.
Lateral pharyngeal wall swelling + external neck swelling + sepsis = parapharyngeal abscess. More dangerous than quinsy due to proximity to carotid vessels. Emergency admission for CT and drainage.
Neck lump ≥3 weeks, oral ulcer ≥3 weeks, hoarseness ≥3 weeks, or red/white oral patches = 2WW referral for suspected head and neck cancer (NICE NG12).
Midline neck lump moving with swallowing AND tongue protrusion = thyroglossal cyst. Treatment: Sistrunk procedure (includes central hyoid bone). Always confirm normal thyroid before surgery.
Post-auricular swelling with pinna displacement after AOM = acute mastoiditis until proven otherwise. This is an emergency requiring same-day hospital admission.
Young woman + family history + progressive conductive hearing loss + normal otoscopy + paracusis of Willis = otosclerosis. Treatment: hearing aids or stapedectomy.
Pit anterior to the tragus with recurrent infection = pre-auricular sinus. Refer to ENT for excision if recurrently infected. Consider hearing test and renal assessment if bilateral or associated anomalies.
Facial palsy + vesicles on ear + otalgia = Ramsay Hunt syndrome (VZV reactivation). Treat with aciclovir + prednisolone within 72 hours. Worse prognosis than Bell's palsy (50-70% full recovery). May also cause hearing loss, taste disturbance, and vertigo.
80% of children with Down syndrome develop OME. Regular 6-monthly hearing surveillance. Hearing aids often preferred over grommets. High prevalence of OSA. Narrow ear canals complicate examination and treatment.
Neck lump >3 weeks in an adult = 2-week wait referral. USS + FNA is the standard investigation for neck lumps. Submandibular gland tumours: 50% malignant (higher rate than parotid). Avoid incisional biopsy of salivary gland tumours. FNA is safe and accurate.
OSA in a commercial driver: must inform DVLA and stop driving until treated. Epworth ≥10 is abnormal. CPAP is gold standard for moderate-severe OSA. Weight loss is highly effective. GP can inform DVLA if patient refuses.
CRS management: intranasal steroids + saline irrigation for ≥3 months before CT or referral. CT is not first-line. Manage patient expectations with clear explanation. Red flags (unilateral, bloody) warrant earlier investigation. CRS is chronic and requires ongoing management.
Bilateral tinnitus with normal hearing and no red flags: reassure, refer to audiology for support, CBT for distress. No MRI needed if symmetrical. No effective drug treatment. Sleep support with background sound. MRI only for unilateral, pulsatile, or asymmetric features.
House-Brackmann grading: I = normal, VI = total paralysis. Grade IV: incomplete eye closure, no/minimal forehead movement, obvious asymmetry. Bell's palsy treatment: prednisolone within 72 hours. Protect the eye if closure is incomplete.
Persistent hoarseness in a young child + maternal genital warts = recurrent respiratory papillomatosis (HPV 6/11). Requires repeated surgical debulking. May remit at puberty. HPV vaccination may reduce future incidence.
Direct patients to condition-specific charities and NHS websites for reliable information. Meniere's Society, British Tinnitus Association, RNID are key ENT resources. Provide written/digital information at diagnosis. Avoid unmoderated social media. Follow up to address questions.
Most AOM in well children over 2 resolves spontaneously. Use analgesics and a delayed prescription. Immediate antibiotics if under 2 with bilateral AOM, otorrhoea, or systemically unwell.
Otitis externa first-line = topical acetic acid 2%. Escalate to antibiotic/steroid drops if no response. Oral antibiotics only if spreading infection or immunocompromised.
Hearing aid users - microsuction preferred over irrigation. Always soften wax with oil drops first. Know irrigation contraindications: perforation, grommets, previous surgery.
Unilateral tinnitus plus asymmetric hearing loss warrants MRI to exclude acoustic neuroma. Pulsatile tinnitus requires investigation for vascular cause. Bilateral symmetrical tinnitus is usually benign.
Acute persistent vertigo + no hearing loss + post-viral = vestibular neuritis. Short-term sedatives only, then vestibular rehabilitation exercises.
Non-allergic rhinitis = chronic nasal symptoms without itching/sneezing/eye symptoms, negative allergy tests, triggered by temperature and odours. Treat with intranasal steroids or ipratropium.
Periorbital swelling after sinusitis + proptosis + restricted eye movements = orbital cellulitis. Emergency admission. Distinguish from preseptal cellulitis (no eye movement restriction or proptosis).
Unilateral foul-smelling nasal discharge in a child = foreign body. Try the "mother's kiss" technique. Button batteries = emergency - remove immediately.
Chronic sinusitis (≥12 weeks) = intranasal steroids + saline irrigation for 8-12 weeks first. No sinus X-rays. Refer to ENT if medical treatment fails.
FeverPAIN 0-1 = no antibiotics; 2-3 = delayed prescription; 4-5 = delayed or immediate. First-line antibiotic = penicillin V.
Key tonsillectomy indications: recurrent tonsillitis (Paradise criteria), ≥2 episodes of quinsy, and obstructive sleep apnoea from tonsillar hypertrophy. A single quinsy is NOT sufficient.
Ear pain on descent + recent URTI = otitic barotrauma. Perforations usually heal spontaneously. Advise against flying with active colds. Valsalva and decongestants help prevent barotrauma.
Nasal congestion worsening after prolonged decongestant spray use = rhinitis medicamentosa. Stop the spray and substitute intranasal corticosteroid. Never use topical decongestants for more than 7 days.
Bilateral submandibular swelling + elevated tongue + drooling + dental origin = Ludwig's angina. Airway emergency. Usually from lower molar dental infections. Emergency admission and airway management.
Button battery in the nose = emergency. Remove within 2 hours. Causes liquefactive necrosis via electrical current. Immediate A&E transfer. Never irrigate or delay.
Painful swollen pinna after cartilage piercing = perichondritis. Think Pseudomonas - treat with ciprofloxacin, not flucloxacillin. Remove the piercing. Complications include cauliflower ear deformity.
Mealtime swelling under the jaw that subsides after eating = submandibular duct stone. 80-90% of salivary stones are submandibular. Bimanual palpation of the duct floor is key to diagnosis.
Screening decisions should be informed choices, not directives. Provide balanced information about benefits (mortality reduction) AND harms (overdiagnosis, false positives). Respect the patient's autonomous decision.
CLL = persistent mature lymphocytosis + smear cells on blood film. Most common adult leukaemia. Diagnosed by flow cytometry. Many patients initially managed with watch and wait.
moderate-to-severe cancer pain → start a strong opioid (NICE CG140); modified-release for background plus immediate-release breakthrough at one-sixth of the daily dose; always add a laxative and consider radiotherapy and bone-protective agents.
Emergency transfusion with unknown blood group = O Rh-negative red cells. Group O = universal red cell donor. Group AB = universal red cell recipient. Always use Rh-negative for women of childbearing age when group unknown.
HS triad = “Hereditary, Haemolysis, (pigment) Gallstones” with spherocytes on film and splenomegaly; splenectomy may reduce haemolysis in severe cases.
CRAB = symptomatic myeloma - hyperCalcaemia, Renal impairment, Anaemia, Bone lesions - a favourite exam acronym indicating the need for full myeloma therapy rather than observation alone.
Cirrhosis + arterial enhancement + portal venous washout = HCC on imaging - biopsy is not required; BCLC staging guides treatment.
Short history with anaemia, thrombocytopenia, high WCC and circulating blasts = acute leukaemia until proven otherwise - a haematological emergency.
Recurrent thrombosis + pregnancy loss + persistent antiphospholipid antibodies = APS; lifelong warfarin; aspirin plus LMWH in pregnancy.
Haemophilia = "X-linked, APTT prolonged ONLY, Haemarthroses!" A = VIII, B = IX (Christmas disease).
Thrombophilia testing should be done after completing anticoagulation, not during acute VTE. Anticoagulants and acute thrombosis affect results. Main indication: unprovoked VTE aged <50, recurrent VTE, or unusual site.
Microcytic + normal ferritin + low TIBC = ACD; treat inflammation; avoid iron (hepcidin blocks utilisation).
Use the 7-point checklist (score ≥3 = 2WW referral) or ABCDE criteria for melanoma assessment. Do not biopsy in primary care - refer to dermatology. Any changing mole warrants urgent assessment.
Dabigatran (direct thrombin inhibitor) is reversed by idarucizumab 5g IV; factor Xa inhibitors are reversed by andexanet alfa or PCC; dabigatran is the only DOAC meaningfully cleared by haemodialysis (BNF; MHRA).
AF + CHA₂DS₂-VASc ≥2 → anticoagulate (NICE NG196). DOAC first-line for non-valvular AF; warfarin for valvular AF. Aspirin NOT for AF stroke prevention.
Unexplained, persistent (>3-4 weeks), firm, fixed or progressively enlarging lymphadenopathy - especially with B symptoms - warrants an urgent suspected cancer (2-week-wait) referral under NICE NG12; do not delay with empirical antibiotics.
Smoker aged ≥40 + persistent cough + any other symptom = urgent CXR. Haemoptysis = direct 2WW referral. Normal CXR does not exclude lung cancer if clinical suspicion is high.
Painless jaundice + weight loss + new diabetes + Courvoisier's sign = pancreatic head cancer until proven otherwise; refer on the urgent suspected-cancer pathway (NICE NG85).
Cancer-associated VTE = DOAC or LMWH for >=6 months; avoid DOACs in GI/urological cancers due to mucosal bleeding risk; continue anticoagulation while cancer active (NICE NG158).
Hoarseness persisting ≥3 weeks = 2WW referral to ENT. Don't trial PPIs or antibiotics without visualising the larynx. Normal oropharynx does not exclude laryngeal pathology.
In lymph node pathology questions, “Reed-Sternberg = Hodgkin” - particularly in a young adult with B symptoms and mediastinal or cervical nodes.
In macrocytic anaemia, “B12 = Brain + Back cord” - neurological signs point strongly to B12 deficiency rather than folate lack.
IDA labs = “LOW ferritin, LOW saturation, HIGH transferrin”; ACD = “HIGH ferritin, LOW transferrin” - ferritin is the key discriminating marker in exam questions.
In stable patients, think “70 without cardiac disease, 80 with cardiac disease” as rough transfusion triggers, always integrating clinical symptoms rather than chasing a single number.
DIC labs = “everything low except D-dimer” - platelets and fibrinogen low, PT/APTT prolonged, D-dimer very high in the classic full-blown picture.
vWD = “platelet-type bleeding with normal platelet count” and low ristocetin cofactor, often in women with heavy menses; treatment includes desmopressin or vWF-containing concentrates for procedures or major bleeds.
In exam scenarios, “low platelets, normal film, otherwise well = ITP”, and the initial answer is almost always “start steroids (± IVIG if severe)”, not platelet transfusion alone.
Lower oesophageal cancer + GORD history = adenocarcinoma (Barrett's pathway). Upper/middle oesophagus + smoking/alcohol = squamous cell carcinoma.
Aplastic anaemia = “empty marrow, empty blood counts” - hypocellular marrow with fat, pancytopenia, and normal cell morphology but reduced numbers.
Persistent bloating + early satiety + urinary frequency = check CA-125. If ≥35 → ultrasound → 2WW if suspicious. Do not dismiss as IBS without excluding ovarian cancer. Safety netting is essential.
Fear of cancer recurrence is common and treatable. Refer to cancer-specific support (Macmillan, Maggie's). Cancer care review in primary care is part of the Recovery Package. Address psychological needs alongside physical follow-up.
PE Wells >4 = PE likely → start anticoagulation immediately, arrange CTPA. Do not wait for D-dimer. CTPA is the gold standard investigation. COC is a significant VTE risk factor.
HIT type 2 = >50% platelet drop 5-14 days after starting heparin + thrombosis. Stop ALL heparin. Start alternative anticoagulant. Do NOT use warfarin until platelets recover. It is prothrombotic, not a bleeding disorder.
Dysphagia at any age = 2WW referral for suspected upper GI cancer. Progressive solid-to-liquid dysphagia is mechanical until proven otherwise. Barrett's oesophagus is a risk factor for adenocarcinoma.
Blast cells + pancytopenia + rapid onset = suspected acute leukaemia = same-day emergency referral. Platelets <20 = high bleeding risk. Do not start steroids before haematology assessment - they interfere with diagnostic testing.
Microcytosis + normal ferritin + HbA2 >3.5% = beta-thal trait; test partner; no treatment needed.
Sickle patient with fever, chest pain, hypoxia and a new pulmonary infiltrate = ACS → urgent red-cell exchange targeting HbS <30% alongside oxygen, antibiotics and analgesia.
ET = persistent platelets >450 + JAK2/CALR/MPL+ + BCR-ABL negative. Symptomatic microvascular disease (erythromelalgia) or high IPSET score → hydroxycarbamide + aspirin. Always check vWF before aspirin if platelets >1500.
Unexplained weight loss >5% in over-40s = urgent investigation for cancer. CT CAP is the most informative initial investigation when there are no localising symptoms. Also screen for myeloma, diabetes, and thyroid disease.
tTG IgA is first-line for coeliac screening. Patient must be eating gluten for ≥6 weeks. Always check total IgA. Positive serology → duodenal biopsy. Never trial GFD before testing.
Persistent lymphocytosis >5 in adults, especially >50 years = consider CLL. Request blood film review as first step. Flow cytometry confirms diagnosis. Many early CLL patients need monitoring only, not treatment.
Hypercalcaemia of malignancy = IV saline first (rehydrate), then IV bisphosphonate. Bisphosphonates take 48-72 hours. Furosemide is NOT first-line. Corrected calcium >3.5 is a medical emergency.
Unexplained breast lump in women ≥30 = 2WW referral. Do not delay referral by ordering imaging in primary care. The breast clinic performs triple assessment.
B12 deficiency with neurological symptoms = IM hydroxocobalamin on alternate days until improvement. Never give folate without B12 replacement. Pernicious anaemia requires lifelong injections. Check intrinsic factor antibodies.
ACD = raised ferritin + low transferrin saturation + raised CRP. Ferritin is an acute-phase reactant - it is unreliable in inflammation. Use ferritin <30 (not <15) as the IDA threshold when CRP is raised.
Folate deficiency = folic acid 5mg daily for 4 months. Always check B12 before starting folate. Common causes: poor diet, coeliac disease, medications. Coeliac disease compliance should be assessed with tTG antibodies.
CKD anaemia develops at eGFR <30-45. Caused by reduced EPO production. Correct iron deficiency first, then ESAs if Hb <100. Target Hb 100-120 g/L - avoid over-correction.
Ferritin is unreliable in inflammation - always interpret alongside CRP. Low transferrin saturation (<16%) with raised ferritin + raised CRP = ACD ± IDA. Consider sTfR for clarification.
HPV primary screening: HPV negative = routine recall. HPV positive + normal cytology = repeat at 12 months. HPV positive + ANY abnormal cytology = colposcopy. Screening every 3 years (age 25-49) or 5 years (50-64).
Painless, persistent lymphadenopathy >2 cm for >6 weeks + B symptoms = 2WW referral. Supraclavicular lymphadenopathy at any size is always pathological in adults. B symptoms: night sweats, fever, weight loss.
CRAB = Calcium, Renal, Anaemia, Bone. Think myeloma with bone pain + anaemia + raised ESR + high calcium + renal impairment. Serum protein electrophoresis and free light chains are key tests.
Endometrial cancer is driven by unopposed oestrogen; obesity and tamoxifen are the two key sources in this scenario, and postmenopausal bleeding needs urgent investigation (NICE NG12).
Tobacco plus alcohol act synergistically in head and neck SCC; HPV is the key driver specifically in oropharyngeal cancer, and persistent hoarseness over 3 weeks warrants urgent referral (NICE NG12).
Apixaban 2.5 mg BD if any two of: age ≥80 years, weight ≤60 kg, creatinine ≥133 µmol/L; widest renal range of all DOACs (down to CrCl 15 mL/min with caution); always twice-daily dosing (BNF; apixaban SmPC; NICE NG196).
Positive FIT = colonoscopy within 2 weeks! Do not repeat FIT. Screening saves lives - 16% mortality reduction in colorectal cancer. Age 60-74 (soon 50-74) get screened biennially.
NHS cervical screening uses HPV primary testing from age 25 - every 3 years (25-49) and every 5 years (50-64), with reflex cytology triage if HPV is positive.
High-grade NMIBC = intravesical BCG (induction + maintenance) per NICE NG2. A single mitomycin C dose suits intermediate-risk disease; cystectomy is for muscle-invasive disease or BCG failure.
Prolonged PT + obstructive jaundice + steatorrhoea = vitamin K deficiency; IV vitamin K 24h; PCC if urgent.
Postmenopausal woman + raised CA-125 + complex ovarian mass = high RMI - proceed to CT staging before surgical planning (NICE NG12).
Haemophilia A = prolonged aPTT + haemarthroses + low FVIII; IV FVIII target 50-100% for joint bleeds; start prophylaxis to prevent arthropathy.
Cancer VTE = LMWH or DOAC (avoid DOACs in GI/urological cancers). Not warfarin. Continue anticoagulation while cancer is active. Duration is typically longer than non-cancer VTE.
MSCC = back pain + weakness + bladder symptoms in cancer patients = emergency. Give dexamethasone 16mg immediately. MRI whole spine urgently. Outcome depends on speed of treatment, so refer the same day.
Fixed mid-dilated pupil + rock-hard eye + nausea = AACG! Multi-drug attack! IV acetazolamide + topical timolol + apraclonidine + pilocarpine. Then laser iridotomy when IOP controlled. Hours count!
POAG is the 'silent thief of sight' - NICE NG81 (2022) recommends 360° SLT first-line with a topical prostaglandin analogue (latanoprost) as the first-line drug; laser iridotomy is for angle-closure, not open-angle glaucoma.
Pain + photophobia + small irregular pupil + perilimbal injection = anterior uveitis. Same-day ophthalmology referral. Never start topical steroids in primary care without specialist assessment.
Painless bright red patch + normal vision + no discharge = subconjunctival haemorrhage. Reassure and check BP and INR if anticoagulated. Resolves in 2-3 weeks.
Corneal abrasion = fluorescein uptake + pain + FB sensation. Treat with chloramphenicol ointment. Never prescribe topical anaesthetics for home use. No eye padding.
Sudden distortion + central vision loss in known dry AMD = conversion to wet AMD. Refer urgently within 1 week. Anti-VEGF injections are time-critical - delays worsen outcomes.
Sectoral redness + mild discomfort + blanches with phenylephrine = episcleritis (benign). Does NOT blanch + severe pain = scleritis (urgent referral).
Dendritic ulcer + reduced corneal sensation = herpes simplex keratitis. Treat with topical aciclovir. Topical steroids are CONTRAINDICATED - they cause catastrophic worsening.
Itchy eyes + atopy + seasonal = allergic conjunctivitis. First-line is topical antihistamine drops. Avoid topical steroids in primary care - risk of glaucoma and cataracts.
4-2-1 rule for severe NPDR! Haemorrhages in 4 quadrants, venous beading in 2 quadrants, OR IRMA in 1 quadrant = severe NPDR. 50% progress to proliferative within a year - refer within 4 weeks!
Pearly nodule + rolled edges + telangiectasia + eyelash loss on the eyelid = basal cell carcinoma. Urgent 2-week wait referral. Lash loss (madarosis) is a red flag for eyelid malignancy.
Severe eye pain + haloes + semi-dilated fixed pupil + hard eye + hazy cornea = acute angle-closure glaucoma. This is an emergency - treat and transfer immediately.
Raised IOP + optic disc cupping + visual field loss = POAG. Asymptomatic until late. Afro-Caribbean ethnicity and family history are major risk factors. First-line treatment is prostaglandin drops.
Chemical eye injury = IRRIGATE FIRST, ask questions later. At least 20-30 minutes with saline or water. Alkali is worse than acid (penetrates deeper). Do not delay for examination or visual acuity testing.
Pre-existing diabetes + pregnancy = screen at booking + 28 weeks (+ 16-20 weeks if retinopathy found). Pregnancy accelerates retinopathy. Tropicamide is safe in pregnancy. Gestational diabetes does NOT need eye screening.
Flashes + shower of floaters + curtain/shadow = retinal detachment until proven otherwise. Emergency same-day ophthalmology referral. Myopia is the key risk factor.
Young obese woman + headaches + bilateral disc swelling = IIH! Transient visual obscurations (<30 sec) are the giveaway. MRI + MRV to LP (opening pressure >25cmH2O). Treat with weight loss + acetazolamide!
GCA with any visual symptoms = prednisolone 60mg IMMEDIATELY. Never delay treatment for biopsy. Jaw claudication is highly specific. Biopsy within 2 weeks. Risk of permanent bilateral blindness.
Proptosis + painful restricted eye movements + fever + RAPD = orbital cellulitis. Emergency admission for IV antibiotics and CT. Do not manage with oral antibiotics in the community. Often secondary to sinusitis.
R2, R3, or M1 = refer to ophthalmology. R3 is urgent (within 2 weeks). R0 and R1 with M0 continue annual screening. Pre-proliferative changes indicate ischaemia and risk of neovascularisation.
Miosis, partial ptosis, and anhidrosis in a smoker with an apical lung lesion is Horner syndrome due to a Pancoast tumour until proven otherwise. NICE NG12 supports an urgent (2-week-wait) chest X-ray and respiratory referral for suspected lung cancer.
Child struggling with distance vision = likely myopia. Refer to optometrist for refraction. Free NHS eye tests for children. No need for direct ophthalmology referral for uncomplicated refractive error.
Painless firm lump within the tarsal plate for weeks = chalazion. Treat with warm compresses. Consider incision and curettage if persistent. Recurrent lesions in the elderly need biopsy to exclude carcinoma.
Blepharitis = chronic gritty eyes + crusted lid margins. First-line = warm compresses + lid cleaning. Chronic condition requiring ongoing maintenance. No cure, but good control with hygiene.
Transient monocular vision loss with complete recovery plus vascular risk factors equals amaurosis fugax - treat it as a TIA. Give aspirin 300 mg and refer for specialist assessment within 24 hours (NICE NG128; do not use the ABCD2 score).
Sudden painless vision loss + cherry-red spot + pale retina = CRAO. Emergency referral. Exclude GCA urgently. Treat as equivalent to stroke - full cardiovascular workup.
Constant squint at any age = urgent ophthalmology referral. Intermittent squint is only normal under 3 months. Always check the red reflex. GPs should not initiate patching without specialist assessment.
Watery sticky eye from birth + white eye + clear cornea = nasolacrimal duct obstruction. Conservative management with massage. 95% resolve by 12 months. Probing if persistent after 12 months.
AACG emergency treatment: pilocarpine (constrict pupil) + acetazolamide 500mg (reduce aqueous) + analgesia/antiemetics. NEVER use atropine or mydriatics. Arrange emergency transfer. Definitive = laser iridotomy.
Diabetic eye screening starts at age 12 for all diabetes types. Annual screening is standard. Extended intervals possible after two normal screens. Ensure all diabetic patients are registered.
Prolonged topical steroid drops without IOP monitoring = risk of steroid glaucoma. Never initiate or repeat-prescribe topical steroids without ophthalmology supervision. 30-40% of patients are steroid responders. Re-refer this patient urgently.
R2, R3, or M1 on diabetic eye screening = ophthalmology referral. R3 is urgent (2 weeks). R1 M0 can continue screening. Always manage the worst eye result.
Chloramphenicol drops are available OTC from pharmacies for bacterial conjunctivitis in over-2s. Drops four times daily + ointment at night for 5 days. Refer to GP if contact lens wearer, under 2, or not responding.
Sudden blurred vision + widespread haemorrhages in all quadrants + tortuous veins + disc oedema = CRVO. Urgent ophthalmology referral. Optimise cardiovascular risk factors. Monitor for neovascular complications.
Proptosis, painful ophthalmoplegia, and reduced visual acuity with fever distinguish orbital from preseptal cellulitis - this is a medical emergency requiring IV antibiotics and urgent ENT/ophthalmology input (NICE CKS: orbital cellulitis; RCOphth guidance).
In chemical eye injuries, irrigate first and ask questions later - alkali burns are worse than acid because they penetrate deeper via liquefactive necrosis.
For allergic conjunctivitis not controlled by an oral antihistamine, add a topical mast-cell stabiliser (sodium cromoglicate) as per NICE CKS - avoid initiating topical steroids in primary care.
Cherry-red spot at macula = CRAO (retinal stroke)! Pale ischaemic retina everywhere except fovea (choroidal blood shows through). Emergency: ocular massage + paracentesis within 90 minutes. But prognosis awful despite heroics.
Pain on movement + RAPD + normal disc = retrobulbar optic neuritis! Patient sees nothing, doctor sees nothing. Get MRI - abnormal brain MRI = 50% MS risk within 15 years!
Blood and thunder fundus = CRVO! Widespread haemorrhages + dilated tortuous veins in all 4 quadrants. Watch out for rubeosis iridis (neovascular glaucoma) at 2-4 months - the 100-day glaucoma!
HLA-B27 + red eye + photophobia = anterior uveitis! Young male with axial symptoms (ankylosing spondylitis)? Classic! Unilateral, recurrent, alternates eyes. Treat with steroids hourly + cycloplegics (prevent posterior synechiae)!
Deep boring pain, non-blanching violaceous sclera with phenylephrine, and an associated autoimmune disease point to scleritis; the phenylephrine blanch test reliably differentiates it from benign episcleritis.
Absent red reflex at newborn check = urgent ophthalmology referral within 2 weeks. Congenital cataracts need early surgery to prevent amblyopia. Always perform red reflex testing at newborn and 6-8 week checks.
Flashes, floaters, and a visual field curtain in a myopic patient is retinal detachment until proven otherwise - requires same-day ophthalmology referral for surgical repair (Royal College of Ophthalmologists retinal detachment guidance).
Entropion = inturning lid + lashes rubbing cornea. Definitive treatment is surgical correction. Use taping and lubricants while awaiting surgery. Untreated entropion risks corneal ulceration and sight loss.
White pupil reflex (leukocoria) in a child = urgent 2-week wait referral to exclude retinoblastoma. Always check the red reflex at newborn and 6-8 week checks. Early diagnosis saves lives and eyes.
Sudden painless profound vision loss + pale retina + cherry-red spot + attenuated arteries = CRAO. Always exclude GCA (check ESR/CRP). Treat as equivalent to stroke - full cardiovascular workup urgently.
Lid swelling + normal eye movements + no proptosis + normal vision = periorbital cellulitis. Oral co-amoxiclav if mild. If eye movements are painful or restricted, suspect orbital cellulitis - admit immediately.
Recurrent oral and genital ulcers with posterior uveitis and retinal vasculitis in a patient from the Silk Road region is Behçet disease; prompt systemic immunosuppression is needed to prevent blindness.
Bacterial conjunctivitis = mucopurulent discharge + normal vision + no photophobia. First-line is chloramphenicol drops. Always check visual acuity and exclude red flags (pain, photophobia, reduced vision).
Young woman + pain on eye movement + colour desaturation + RAPD = optic neuritis. Request MRI to assess MS risk. Refer to ophthalmology and neurology. ~50% develop MS within 15 years.
First seizure, Group 1 = 6 months off driving. Epilepsy, Group 1 = 12 months seizure-free. Group 2 = 5 years seizure-free off medication. Patient must notify DVLA; GP can disclose if they refuse.
Elective PCI, Group 1 = 1 week off driving, no DVLA notification needed. ACS, Group 1 = 4 weeks. CABG, Group 1 = 4 weeks. Group 2 restrictions are longer. Always check current DVLA guidance.
GP's role: advise, document, encourage DVLA notification. If refused, can disclose to DVLA in the public interest. Inform the patient of the disclosure. Document everything.
GPs provide one of two medical recommendations for Sections 2 and 3, as the doctor who knows the patient. Section 12 approval is not required for this role. Both examinations must be within 5 days of each other.
Apology ≠ admission of liability (Compensation Act 2006). Being open reduces litigation risk. Clinical negligence claims have a 3-year limitation period. Always involve your medical defence organisation early.
Never accept arrangements that tie funding to prescribing. Prescribe based on evidence and patient need. Declare all financial interests. GMC requires integrity and independence in prescribing decisions.
MCCD Part 1 = causal sequence leading to death (1a → 1b → 1c). Part 2 = contributing conditions. Never use "cardiac arrest" or "respiratory failure" as 1a. The issuing doctor must have attended within 28 days.
Duty of candour: be open, apologise, explain, and support when harm occurs. Apology ≠ admission of liability (Compensation Act 2006). Applies to all CQC-registered providers. Document everything.
CTOs allow conditional community discharge from Section 3. Can recall to hospital if conditions breached. Cannot force medication in the community. Lasts 6 months initially. Patient can appeal to tribunal.
FGM in an under-18 = mandatory police report within one month. FGM is a criminal offence with no cultural exceptions. Also make a safeguarding referral to children's social care. Report via 101.
ADRT refusing life-sustaining treatment needs: written, signed, witnessed, and a statement it applies even if life is at risk. ADRTs refuse treatment - they cannot demand it.
Group 2 + insulin: no severe hypos in 12 months, twice-daily monitoring, awareness of hypoglycaemia, annual specialist review. Group 2 licence renewed every 3 years. No longer an absolute bar.
Assess Gillick competence first. A competent under-16 can consent. In a genuine emergency, treat under necessity. Competent minors can consent but refusal may be overridden.
Child safety overrides confidentiality. Share information without consent if risk of significant harm. GDPR is not a barrier to safeguarding. Document your decision and reasoning.
OSA with sleepiness = stop driving and notify DVLA. Group 2: needs satisfactory CPAP compliance and specialist confirmation. Epworth score >10 or excessive sleepiness = unfit to drive until treated.
Health and welfare LPA only operates when the donor lacks capacity, must be registered with the OPG, and must specifically authorise life-sustaining treatment decisions if intended.
Subject Access Requests under UK GDPR: respond within 30 days, free of charge, in an accessible format. Redact third-party information. The patient's right to access their data is a legal right.
Court orders must be complied with - they override patient confidentiality. Verify authenticity, disclose only what is ordered, and inform the patient. Solicitors' letters are not court orders.
Bruising in a non-mobile baby = NAI until proven otherwise. "Those who don't cruise rarely bruise." Refer urgently for paediatric assessment and make a safeguarding referral. Document with body maps.
The practice safeguarding lead oversees policy, training, and internal coordination. They do not investigate or replace social care. CQC requires a named lead and evidence of training for all staff.
Section 136 = police power, public place, place of safety, up to 24 hours. Section 135 = magistrate's warrant for private premises. Place of safety should be health-based, not a police station.
Bolam test: not negligent if actions accord with responsible body of opinion. Bolitho adds: that opinion must withstand logical analysis. Negligence requires duty, breach, causation, and damage.
GMC duties: patient care first, treat as individuals, work in partnership, be honest and open, maintain trust. These are regulatory standards - breach can lead to fitness to practise proceedings.
Professional boundaries protect both patient and doctor. They apply to all relationships, not just sexual ones. Vulnerable patients are at particular risk. Recognise boundary drift early and seek peer support.
Mandatory SAR criteria: adult with care needs, death or serious harm, suspected abuse/neglect, and concerns about multi-agency working. Purpose is learning, not blame. Governed by Section 44, Care Act 2014.
High DASH score = refer to MARAC. MARAC coordinates multi-agency safety planning. Never recommend couples counselling in domestic abuse. Patient consent preferred but not required for referral.
The medical examiner scrutinises all non-coronial deaths before MCCD issue - for both burials and cremations. This replaced old cremation forms. Introduced following the Shipman Inquiry to improve death certification oversight.
Suspected suicide/overdose = refer to coroner. Do not issue MCCD. Advise not to disturb the scene. Police will attend. Suicide conclusions now use the balance of probabilities (Maughan, 2020).
Complaints within 12 months. Acknowledge within 3 working days. Local resolution first, then NHS England, then PHSO. No solicitor needed. Complaints should be used as learning opportunities.
IMCA is required for serious medical treatment or accommodation changes when the person lacks capacity AND has nobody appropriate to consult. They support, not decide.
Coercive control is a criminal offence under the Serious Crime Act 2015. No physical violence is needed. Recognise patterns of control, isolation, and restriction. Ask, document, and refer appropriately.
Group 1: 6/12 with correction in better eye + 120° horizontal visual field. Group 2: 6/7.5 in better eye. The number plate test at 20 metres is the practical standard.
Refer to coroner if: unknown cause, violent/unnatural death, not attended in last illness, during surgery, industrial disease, or custody death. Never guess the cause - refer when uncertain.
Two-stage test - diagnostic (impairment) then functional (understand, retain, weigh, communicate). Failure of any one functional element = lacks capacity for that decision.
Under-16s can consent if Gillick competent. For contraception, apply Fraser guidelines. Always consider safeguarding - document your assessment thoroughly.
Confidentiality can be breached for serious public safety risks. For drivers refusing to notify DVLA, exhaust persuasion first, then disclose to the DVLA directly. Document everything and inform the patient.
Safeguarding referral to local authority adult social care if: care and support needs + risk of abuse/neglect + unable to self-protect. Reasonable suspicion is sufficient - do not wait for proof. Do not alert the suspected abuser.
The Care Act 2014 defines 10 categories of abuse. Neglect by a carer combined with financial control = neglect and financial abuse. Refer to local authority safeguarding team.
NAI red flags: unusual locations, different ages, patterned marks, inconsistent history. Document meticulously with body maps. Accidental bruises = bony prominences in mobile children.
Expected community death: visit to verify, complete MCCD, advise family to register within 5 days. No ambulance or coroner needed if expected. GP must have attended within 28 days to issue MCCD.
New presentation, no previous history = Section 2 (assessment, 28 days). Known diagnosis, ongoing treatment needed = Section 3 (treatment, 6 months). Section 2 needs 2 doctors + AMHP application.
Caldicott Principles govern patient-identifiable data sharing. Key points: justify purpose, minimum necessary, need-to-know basis, and duty to share can be as important as duty to protect.
Key signs of modern slavery: control by another, no documents, malnourishment, inability to speak freely. Refer through the National Referral Mechanism. See the patient alone with an independent interpreter.
Register death within 5 days in England and Wales. A relative or person present at death can register. Registrar issues the green form for burial/cremation. Delayed if coroner involved.
MHA nearest relative follows a statutory hierarchy. Cohabitants of 6+ months rank second (after spouse). The nearest relative has power to apply for admission and to discharge. The patient cannot choose their nearest relative.
Modern access: triage all contacts, use multiple contact methods, match to right clinician (skill mix), same-day urgent access, maintain continuity. Total triage helps manage demand effectively.
PPGs = patients working with practices to improve services. Advisory, not decision-making. Should be representative of the population. GMS contract requirement. Demonstrate how feedback influences changes.
Shared care is voluntary. Requires formal protocol, GP competence, and adequate resources. GP can decline. Protocol must define: initiation, prescribing, monitoring, and referral-back criteria. Common for DMARDs, lithium, specialist drugs.
Discharge summaries need: diagnosis, treatment, medication changes with reasons, pending results, follow-up plan, and patient information. Should arrive within 24 hours. Poor summaries cause medication errors at care transitions.
EMIS Web and SystmOne are the main GP systems. Cloud-based EHRs supporting all clinical functions. Use SNOMED CT coding. Integrate with NHS digital services. CQC requires good record-keeping.
Portfolio careers combine clinical GP work with other roles (teaching, research, leadership, special interests). Reduce burnout, develop skills, aid retention. Promoted by RCGP. Not the same as locum work.
Regular clinical meetings are essential for clinical governance. Include all clinical staff, use no-blame culture, document actions, and follow up. CQC expects evidence of regular meetings. At least monthly frequency recommended.
Referral thresholds ensure appropriate conservative management before surgery. Evidence-based, promote equity and effectiveness. Do not replace clinical judgement. IFR available for exceptional cases.
QALY = 1 year in perfect health. Combines length + quality of life. NICE uses cost/QALY for decisions. Threshold £20,000-30,000/QALY. Measured using EQ-5D questionnaire. This drug = £24,000/QALY (cost-effective).
NICE TAs = legally mandated funding within 3 months. NICE guidelines = recommended but not mandated. TA decisions based on cost-effectiveness (cost per QALY). Threshold typically £20,000-£30,000/QALY.
e-RS enables electronic referral with patient choice of provider. Patients have a right to choose. Supports routine and urgent referrals. Advice and Guidance function allows pre-referral specialist advice.
Acknowledge within 3 working days. Investigate thoroughly. Written response addressing each point. Offer a meeting. Use complaints for learning. Escalation: practice → NHS England → PHSO.
GPST = 3 years minimum (18 months hospital + 18 months GP). Must pass MRCGP (AKT + CSA/RCA + WPBA). Leads to CCT. Salaried training with educational supervision. Some 4-year programmes available.
CQC five key questions: Safe, Effective, Caring, Responsive, Well-led. Not profitable. Rated outstanding to inadequate. Special measures for inadequate practices. Prepare evidence for each domain.
SCR contains medications, allergies, and adverse reactions. Accessible across NHS care settings. Enriched SCR adds more detail. Patients can opt out. NHS App gives patients access to their own records - complements SCR.
CPD should be reflective, varied, and relevant. Evidence presented at appraisal for revalidation. Quality of reflection matters more than hours. RCGP recommends 50 credits/year. Include diverse learning activities.
GMC process: triage → provisional enquiry → case examiner review (medical + lay). Outcomes: close, warn, undertakings, or refer to MPTS. Doctor has right to respond. Contact MDO at the earliest stage.
Place-based partnerships work at local level within ICSs. They integrate NHS, council, and community services for local populations. Key for addressing local health inequalities and delivering joined-up care at community level.
Global sum = largest income component for GMS practices. Capitation-based, adjusted by Carr-Hill formula (age, sex, morbidity, rurality, etc.). Other streams: QOF, enhanced services, premises, PCN. Covers core service delivery costs.
Audit cycle: set standards → collect data → compare → implement change → re-audit. The re-audit closes the loop. Audit measures against known standards; research generates new knowledge. No ethics approval usually needed.
Care navigation = trained receptionists signposting patients to the right service/clinician. Not diagnosing or prescribing. Follows agreed protocols. Maintains confidentiality. Improves access and efficiency.
Opportunity cost = what you give up when choosing one option. NHS has finite resources - every allocation has an opportunity cost. Commissioners must balance cost-effectiveness, equity, and population health benefit.
EPS sends prescriptions electronically to nominated pharmacy. No paper needed. Supports acute, repeat, and repeat dispensing. Now includes some controlled drugs. Reduces errors and fraud.
Responsible officer: evaluates fitness to practise, recommends revalidation to GMC, oversees appraisal. For GPs, usually appointed by NHS England. Makes one of four recommendations. Governs performers list and manages concerns.
PCNs = groups of practices, 30,000-50,000 patients. Funded through Network Contract DES. ARRS provides additional roles. Led by a Clinical Director. Practices retain independence.
FTP outcomes: no action, warning, undertakings, conditions, suspension, or erasure. MPTS conducts hearings. Doctor has right to legal representation and appeal. Responsible officer is informed. Contact your MDO immediately.
NHS England: sets strategy, allocates budgets to ICBs, commissions specialised services directly, manages primary care contracts, and holds ICBs to account. It oversees but does not directly manage practices.
Additional services (screening, vaccinations, maternity, contraception) can be opted out of with a corresponding funding reduction. Core services are mandatory. Enhanced services are voluntary. Notice to ICB required for opt-outs.
A&G = electronic specialist advice before referral, via e-RS. Reduces unnecessary referrals, improves primary care management. Response within days. Not for emergencies. Available across most specialties.
NICE guidelines: multidisciplinary committee, systematic evidence review, stakeholder consultation, transparent process. Takes 2-3 years. Not legally mandated but represent best practice. Inform QOF, commissioning, and CQC assessments.
Foundation Trusts have greater autonomy, local governance (governors and members), and more financial flexibility. NHS Trusts have less autonomy. Both provide NHS services. The distinction is narrowing over time.
42 ICSs in England. Two components: ICB (NHS commissioning body) and ICP (broader partnership). Purpose: improve health, reduce inequalities, enhance productivity. Established by Health and Care Act 2022.
DES = nationally specified, ICBs must commission, practices volunteer to provide. LES = locally specified and commissioned. Both are separately funded beyond core contract. Network Contract DES funds PCNs.
Verify performers list, GMC registration, DBS, indemnity, and safeguarding training. Practice retains vicarious liability. Use a locum agreement. Check appraisal status and GMC conditions.
ARRS funds specific additional roles through PCNs: pharmacists, social prescribers, physios, paramedics, physician associates, and others. Does not fund GPs, nurses, HCAs, or managers. Part of the Network Contract DES.
Traffic light system: Red = specialist only. Amber = GP with shared care protocol. Green = GP can prescribe freely. If discharged on a red drug, do not prescribe - refer back to specialist.
SNOMED CT is mandated for NHS GP coding, replacing Read codes. Comprehensive, hierarchical terminology. Essential for QOF, audit, research, and commissioning. Accurate coding underpins quality data and patient safety.
Burnout = emotional exhaustion + cynicism + reduced accomplishment. Support first: listen, signpost (GP Health Service, BMA), practical help. GMC referral only if patient safety risk. Prevention through workload management and team support.
GP Retention Scheme: reduced sessions (1-4/week) with financial support for GPs at risk of leaving. Maintains skills and registration. Other initiatives: fellowship programmes, mentoring, flexible working, GP Health Service.
CNSGP provides state-backed indemnity for NHS GP work since 2019. Run by NHS Resolution. Still need MDO cover for non-NHS work, GMC proceedings, complaints, and inquests. Covers GPs and practice clinical staff.
Dahlgren-Whitehead: concentric layers - individual → lifestyle → community → living/working conditions → socioeconomic/environmental. Health is multiply determined. Interventions needed at all levels, not just individual behaviour.
Air pollution (PM2.5, NO2) causes 28,000-36,000 UK deaths/year. Worsens respiratory and cardiovascular disease, causes lung cancer. Vulnerable groups most affected. GPs: advise on air quality forecasts and exposure reduction.
Asbestosis: progressive fibrosis from asbestos exposure. Refer to respiratory specialist. Advise on IIDB compensation. Report under RIDDOR. Monitor for mesothelioma and lung cancer. Occupational disease reporting is a legal duty.
Flu vaccine: 65+, pregnant women, chronic conditions, healthcare workers, carers, care home residents. Children 2-3 and primary school get nasal spray. Adults get injectable. Updated annually. September-March season.
Highest evidence: systematic reviews/meta-analyses of RCTs → RCTs → cohort → case-control → cross-sectional → case series → expert opinion. Quality matters within each level. Not all questions suit RCTs.
Overdiagnosis = real disease found by screening that would never have caused harm. Different from false positives. Leads to overtreatment. Major concern in prostate (PSA), breast, and thyroid screening. A genuine harm of screening programmes.
RR = risk in exposed ÷ risk in unexposed. RR of 10 = 10 times higher risk. Used in cohort studies and RCTs. RR=1 means no difference. Also calculate absolute risk difference and NNH for clinical relevance.
PPV depends heavily on prevalence. Low prevalence = low PPV = many false positives. Sensitivity and specificity are intrinsic to the test. This is why population screening produces many false positives in low-prevalence conditions.
NNS = total screened ÷ outcomes prevented. In this case 2,000. Helps communicate the scale of benefit. Balance NNS against harms. Large NNS = many screened for one to benefit. Similar concept to NNT.
MI: empathy, develop discrepancy, roll with resistance, support self-efficacy. Techniques: OARS (Open questions, Affirmations, Reflective listening, Summaries). Brief consultations are effective. Works across many health behaviours.
No national PSA screening programme. Informed choice available for men 50+ who request it. PSA has low specificity and risk of overdiagnosis. Discuss benefits and harms before testing. PCRMP guides GP discussions.
NNT = 1/ARR. ARR = control risk − treatment risk. NNT of 20 = treat 20 to prevent 1 stroke. More useful than relative measures. Report with timeframe. Lower NNT = more effective treatment.
Outbreak: 2+ linked cases or 1 rare/serious case. OCT led by UKHSA health protection team. Investigate, control, communicate, report. GP role: treat, notify, cooperate. Environmental health enforces control measures.
Screening = identifies higher risk in healthy populations (stratifies risk). Diagnostic = confirms/excludes disease in those with symptoms or positive screens. Screening prioritises sensitivity; diagnosis prioritises specificity.
From July 2025 (England) - cervical screening is 5-yearly for ages 25-64 if HPV-negative; HPV-positive results trigger more frequent (12-monthly) surveillance. HPV primary screening with reflex cytology underpins the pathway.
Breast screening: 50-71, mammography, every 3 years. Over-71s can self-refer. High-risk women screened earlier (possibly MRI). Age extension trial 47-73. Benefits must be balanced against overdiagnosis.
Diabetic eye screening: annual digital retinal photography, age 12+, all diabetes types. R0-R3 grading + M1 maculopathy. R2/R3/M1 = ophthalmology referral. Extended intervals possible if consistently R0.
Shingles vaccine: Shingrix (non-live), two doses, from age 65. >90% efficacy. Can be given to immunosuppressed patients (unlike old Zostavax). Previous shingles or Zostavax does not preclude vaccination.
Statistical significance: CI excludes null value (1 for RR/OR) and p<0.05. RR 0.75 = 25% relative reduction. CI gives range of plausible values. P-value = probability of result if null hypothesis true, not probability drug works.
RRR exaggerates perceived benefit. ARR and NNT are more clinically meaningful. This drug: RRR 50% sounds great, but ARR only 1%, NNT 100. Use absolute risk and natural frequencies for patient communication.
Stages: pre-contemplation → contemplation → preparation → action → maintenance. This patient is contemplating. Use motivational interviewing at this stage. Relapse is normal, not failure. Tailor approach to the patient's stage.
VBA for smoking: Ask, Advise (support + pharmacotherapy), Act (refer to stop smoking service). Takes 30 seconds. Effective even as brief advice. Best quit method = behavioural support + medication. NICE recommended.
Obesity: lifestyle first → pharmacotherapy (semaglutide, liraglutide, orlistat) → bariatric surgery (BMI ≥35 + comorbidity or ≥40). GLP-1 agonists achieve 10-15% weight loss. Surgery can induce T2DM remission. Tier 3 involvement pre-surgery.
Pandemic preparedness: business continuity plan covering workforce, IPC, remote consultations, vaccination capacity, and communication. COVID-19 lessons: digital infrastructure, flexibility, staff wellbeing, maintaining routine care. Practice-level planning complements national response.
Length-time bias: screening preferentially detects slow-growing tumours (longer detectable phase). Fast tumours present between screens. Screen-detected cancers appear to have better outcomes partly because of tumour biology, not just early detection.
NHS FASP offers all pregnant women the combined test (nuchal translucency plus PAPP-A and beta-hCG) at 11+2 to 14+1 weeks for Down's, Edwards' and Patau's syndromes, with the quadruple test as the later-booking alternative for Down's syndrome.
Inverse care law (Tudor Hart, 1971): good care varies inversely with need, worse with market forces. Deprived areas have fewer resources despite greater need. Policy responses: weighted funding, targeted recruitment, Core20PLUS5.
NHS newborn blood spot at day 5 = 9 conditions (SCD, CF, CHT, PKU, MCADD, MSUD, IVA, GA1, HCU). Early detection prevents irreversible harm. SCID screening is currently being piloted, not yet universal.
PPV23: single dose at 65+, also for at-risk adults. No routine booster (except asplenic patients every 5 years). At-risk + immunosuppressed may get PCV13 first then PPV23. Children receive PCV13 in the routine schedule.
Vaccine hesitancy: listen, explore specific concerns, provide tailored evidence, use motivational approach. Never coerce or dismiss. Build trust. Wakefield study was retracted and discredited. Offer further discussion opportunities.
Meningococcal meningitis = urgent notification within 24 hours. Notify on suspicion, not confirmation. Approximately 30 notifiable diseases. Report to proper officer (CCDC). Statutory obligation on the diagnosing clinician.
Cold chain means 2-8°C throughout - pharmaceutical fridge, continuous monitoring, twice-daily recording. A cold chain breach means quarantine the stock and seek advice from UKHSA.
Wilson-Jungner: important condition, latent stage, accepted treatment, suitable and acceptable test, understood natural history, treatment policy agreed, cost-balanced, continuous process. These remain the gold standard for evaluating screening.
Bowel screening: FIT test, ages 56-74, every 2 years. Single stool sample by post. Positive result → diagnostic colonoscopy. Threshold 120 μg/g. Over-75s can self-request. Bowel scope discontinued.
True contraindication = anaphylaxis to previous dose/component. Live vaccines contraindicated in immunosuppression and pregnancy. Minor illness, antibiotics, prematurity, and family history are NOT contraindications.
IMD: 7 domains (income, employment, education, health, crime, housing, environment). Ranks all LSOAs in England. Used for resource allocation and planning. Area-level measure - doesn't capture individual deprivation. Updated periodically.
Targeted lung health checks: LDCT for high-risk adults 55-74 (smokers/ex-smokers). Not universal screening. Evidence from NELSON/NLST trials. 20-24% mortality reduction. Rolling out nationally.
NHS Health Check: ages 40-74, every 5 years, not on existing disease registers. Assesses CVD risk using QRISK. Commissioned by local authorities. Includes BP, cholesterol, BMI, lifestyle assessment, dementia awareness (65-74).
People with LD are in priority vaccination groups. Proactive contact, accessible information, and reasonable adjustments improve uptake. Assess and support capacity. Never assume inability to consent based on disability alone.
In autistic patients with new mental health symptoms, always assess environmental factors first. Sensory overload and unpredictability are major drivers. Workplace adjustments may resolve symptoms. If medication needed, start SSRIs low and slow.
Best interests ≠ best medical outcome. Must consider wishes, feelings, beliefs, values, and views of relevant people. Least restrictive option. IMCA needed for serious treatment decisions if no family/friends to consult.
STOMP = don't use psychotropics for challenging behaviour without psychiatric diagnosis. Review all long-term psychotropics in LD patients. Taper gradually with specialist support. Non-pharmacological interventions first. 30,000+ people in England are overmedicated.
People with LD are 4-10x more likely to experience abuse. Document disclosures accurately. Assess safety and capacity. Follow local safeguarding adults procedures. Never contact the alleged perpetrator. Financial control is coercive control.
Always check drug interactions before prescribing to patients on AEDs. Macrolide antibiotics (clarithromycin, erythromycin) can elevate AED levels. People with LD may not report toxicity symptoms. Monitor and review when adding new medications.
Autistic patients often have increased medication sensitivity. Start low, go slow with psychotropic medications. Half the standard starting dose. Titrate gradually. Warn about side effects in concrete terms. Early review essential.
Environment changes are a major cause of behavioural disturbance in LD. Room moves, staff changes, and routine disruption cause significant distress. Address environmental causes before considering medication. Consistency and predictability are therapeutic.
Address the patient directly using their preferred communication method. Allow extra time. Use simple language, one question at a time. Observe non-verbal cues. The support worker facilitates - not replaces - the patient's voice.
People with LD are eligible for ALL cancer screening. Uptake is much lower. Key barriers: inaccessible information, lack of adjustments, and staff assumptions. GPs must proactively support access and follow up non-attenders.
Buccal midazolam is first-line rescue medication for prolonged seizures in the community. Given between gum and cheek. More dignified than rectal diazepam. Carers should be trained. Clear individualised care plan essential.
Capacity is decision-specific and time-specific. Two-stage test: diagnostic threshold then functional test (understand, retain, use/weigh, communicate). All practicable support must be given before concluding incapacity. LD ≠ automatic incapacity.
Always assess capacity decision-specifically. LD ≠ lack of capacity. Take all practicable steps to support understanding first. Carers cannot consent for adults. Follow MCA principles. Use Easy Read, desensitisation, and EMLA.
Health Action Plans must be accessible (Easy Read), person-centred, shared with patient and carers, include specific actions with responsibilities, and be updated regularly. They are key to reducing health inequalities in LD.
Reasonable adjustments remove barriers to access. They should be offered, not imposed. Never assume a person with LD cannot attend independently. Assess capacity individually. Adjustments should empower, not restrict.
Down syndrome + progressive cognitive/functional decline after 40 = suspect Alzheimer's dementia (APP gene on chromosome 21). Always exclude reversible causes first. Baseline assessments in early adulthood are crucial for comparison.
Hypothyroidism in Down syndrome: ~15-20% prevalence. Screen with annual TFTs. Symptoms overlap with Down syndrome features, so biochemical screening is essential. Autoimmune thyroiditis is the commonest cause.
LD Annual Health Check = comprehensive physical exam, medication review, mental health screening, sensory checks, bloods, screening status, vaccinations, and a Health Action Plan. Addresses significant health inequalities.
Pre-ADHD medication cardiovascular check: heart rate, BP, cardiac/family history, and cardiovascular exam. ECG only if concerns raised. Stimulants cause small HR and BP increases. Contraindicated in uncontrolled hypertension and structural heart disease.
Adult ADHD often presents with inattention, disorganisation, and internal restlessness rather than hyperactivity. More underdiagnosed in women. Symptoms must have been present since childhood. Screen for co-morbid anxiety and depression.
40-50% of Down syndrome babies have CHD. AVSD is the most common. ALL newborns with Down syndrome need echocardiography within 6 weeks. Lifelong cardiac follow-up for those with CHD.
Paroxysmal events in LD can be seizures, stereotypies, or non-epileptic - don't assume. Video-EEG is the gold standard. Smartphone video recordings from carers are invaluable. Misdiagnosis rate up to 25-30%. Specialist assessment is essential.
Disability hate crime is common and underreported in LD. GPs must recognise it, take it seriously, document it, and support reporting. It is NOT normal teasing. Enhanced sentencing applies. Consider safeguarding referral. Challenge normalisation of victimisation.
In Down syndrome, arrange regular audiology and vision checks plus annual thyroid function - hearing loss is common, easily missed, and correcting it protects development.
DVLA notification for ADHD is required only if symptoms or treatment significantly affect driving safety. Group 2 has stricter rules. Stimulants generally improve driving - untreated ADHD is the bigger hazard.
Autism diagnosis requires specialist multidisciplinary assessment (not GP diagnosis). Refer to local autism diagnostic service. No scan or blood test confirms autism. Can be diagnosed at any age. GPs recognise, refer, and manage co-morbidities.
Sexually active women with Down syndrome should be offered cervical screening with reasonable adjustments. Assess capacity individually - don't assume inability. Pre-appointment preparation and Easy Read information improve participation.
SUDEP risk is 3-5× higher in people with learning disability and epilepsy. Frequent generalised tonic-clonic seizures are the biggest risk factor.
Consider autism in adults presenting with chronic anxiety/depression plus lifelong social difficulties. Women are underdiagnosed due to masking. Employment and qualifications do not exclude autism. Explore developmental history.
6-monthly ADHD monitoring: check pulse, BP, weight. Confirm elevated BP with repeat readings. Discuss concerns with specialist. Weight loss is common - assess nutrition. Don't stop abruptly without specialist advice.
New behaviour change in LD = physical cause until proven otherwise. Pain is the most common missed cause. Head-to-toe examination essential. Do NOT prescribe psychotropics without excluding physical causes first. Use STOMP principles.
Always prescribe non-sedating antihistamines (cetirizine, loratadine, fexofenadine) for drivers and those needing alertness. Sedating antihistamines impair driving. DVLA implications are important to communicate.
Allergic rhinitis and asthma = united airway. 80% of asthmatics have rhinitis. Treating rhinitis improves asthma control. Always assess for both conditions together.
Wheals >24 hours + residual bruising + systemic symptoms = suspect urticarial vasculitis, not simple urticaria. Skin biopsy is diagnostic. Check complement levels and autoimmune screen.
CSU refractory to up-dosed antihistamines → refer for omalizumab (NICE TA339). UAS7 ≥16 = moderate-severe. Given as 4-weekly subcutaneous injections. Review response at 6 months.
6-8 URTIs per year is normal in young children, more in nursery-attenders. Investigate only if infections are too frequent, too severe, too unusual, or associated with poor growth/development.
Cetirizine and loratadine are first-choice antihistamines in pregnancy (best safety data). Intranasal steroids are also safe. Hydroxyzine is contraindicated. UKTIS provides pregnancy-specific drug safety guidance.
Introduce allergenic foods from around 6 months alongside breastfeeding. Early introduction may reduce allergy risk (LEAP/EAT studies). No benefit from maternal dietary restriction or hydrolysed formulas over breastfeeding.
Peanut is a legume, not a tree nut. Cross-reactivity ~25-40%. Don't blanket-restrict tree nuts - test individually. Specialist allergy assessment guides specific avoidance. Lupin has higher cross-reactivity.
GI symptoms alone are a side effect, not allergy. Up to 90% of 'penicillin allergy' labels are incorrect. De-labelling is an important antimicrobial stewardship intervention.
Key allergy history components: specific food, timing, symptom description, reproducibility, and atopic/family history. Focus on characterising the reaction to guide investigation and management.
Resus Council UK IM adrenaline - <6 months 100-150 mcg; 6 months-6 years 150 mcg; 6-12 years 300 mcg; ≥12 years 500 mcg. Always IM, anterolateral thigh, repeat at 5 minutes.
Minimum 6 hours observation post-anaphylaxis. Extend to 12+ hours for severe reactions, repeated adrenaline, or previous biphasic reactions.
Anaphylaxis during exercise after eating a specific food = FDEIA. Wheat is the commonest trigger. Avoid trigger food 4-6 hours pre-exercise. Carry two auto-injectors.
True local anaesthetic allergy is extremely rare. Most reactions are vasovagal or adrenaline-related. Refer for formal testing if genuine allergy suspected. Cross-reactivity between amide and ester types is negligible.
Breastfed infant with suspected CMPA - mother eliminates cow's milk from her diet for 2-4 weeks. Continue breastfeeding. Supplement calcium and vitamin D. Avoid soya under 6 months.
Recurrent bacterial infections + low IgG = investigate for CVID and HIV. Refer to immunology. Treatment is immunoglobulin replacement therapy. Check for bronchiectasis as a complication.
Adrenaline IS indicated for anaphylaxis in pregnancy - same dose (500mcg IM). Untreated anaphylaxis is more dangerous than adrenaline. Position in LEFT lateral tilt (not supine) to avoid aortocaval compression.
Mild-moderate topical corticosteroids are safe in pregnancy for eczema. Emollients remain the foundation. Untreated eczema causes more harm than appropriate treatment. Eczema flares are common in pregnancy (~50%).
Anaphylaxis = IM adrenaline first into the anterolateral thigh (500 micrograms adult dose of 1:1000); repeat every 5 minutes if needed - antihistamines and bronchodilators are adjuncts, not substitutes.
ALL patients with anaphylaxis need specialist allergy clinic referral (NICE CG134). GPs provide interim auto-injector prescriptions and avoidance advice while awaiting appointment.
Profuse vomiting 1-4 hours post-feed + pallor + lethargy + negative IgE testing = FPIES. Most common triggers: cow's milk, soya, grains. Can mimic sepsis in severe cases.
Chronic urticaria step-up: first increase non-sedating antihistamine up to 4x standard dose. This is off-label but guideline-recommended. Only refer for omalizumab if up-dosing fails.
Penicillin-cephalosporin cross-reactivity is ~1-2%. Highest with first-generation cephalosporins. Avoid cephalosporins in confirmed penicillin anaphylaxis without specialist input.
Asthma + nasal polyps + NSAID reaction = N-ERD (Samter's triad). Non-IgE, COX-1 mediated. All traditional NSAIDs contraindicated. COX-2 inhibitors usually safe.
Urticaria ≥6 weeks = chronic. Individual wheals <24 hours + no bruising = CSU (not vasculitis). Often autoimmune. Check TFTs. Most cases resolve within 2-5 years.
Recurrent non-pruritic angioedema + abdominal pain + family history + no urticaria + antihistamine-resistant = HAE. Check C4 as screening test. C1 inhibitor deficiency. Bradykinin-mediated.