Case 1: Elderly Patient With A Rash

• Understand how impetigo might present and what this rash looks like

  • Red itchy sores around the mouth and nose, but then you also get spots at more distant sites too → bursts → forms a honey coloured crust, which very quickly starts to spread.
  • There is also a more serious form of impetigo - bullous impetigo - might need to refer patient to hospital etc.
  • Differentials to look out for - eczema and psoriasis. Sometimes people manage it with OTC moisturisers etc, but then when a secondary infection happens they then present to their GP. Another thing to look out for is perioral dermatitis. This can be seen in people on steroids.

• Know how impetigo is treated and what advice to give to a patient with impetigo

  • Consider prescribing hydrogen peroxide 1% cream (apply two or three times daily for 5 days) for people who are not systemically unwell or at a high risk of complications.
  • If this is unsuitable, prescribe a short course (5 days) of a topical antibiotic, offer:
    • Fusidic acid 2% (apply three times a day for 5 days), or
    • Mupirocin 2% (apply three times a day for 5 days) if fusidic acid resistance is suspected or confirmed.
  • The length of course can be increased to 7 days if required based on clinical judgment, depending on the severity and number of lesions.
  • If topical treatments aren’t working then we can move to oral antibiotics such as flucloxacillin or if patient is penicillin resistant then clarithromycin etc.
  • Advise patient not to touch area, to avoid spread. Wash bedding, towels, etc at high temperatures to kill infection. Keep area clean and dry, and avoid close contact with vulnerable people and sports etc.

• Consider how patients with haematological problems might present to a GP

  • Split it up into white blood cells, red blood cells and platelets.

    • Platelets - bleeding that doesn’t really stop. Purpura (larger spots) and petechiae (pinpoint spots). Bruises. A common cause of low platelets in children is ITP.
    • White blood cells - recurrent infection
    • Red blood cells - anaemia. Tiredness and fatigue. Cardiovascular symptoms? Dizzyness, fainting, palpitations, chest pain and breathlessness if severely anaemic.

  • Malignancy - weight loss, night sweats, fever → B symptoms.

    • Someone that has persistent bone pain → worrying too… especially if it gets worse at night and wakes them up…
    • Enlarged spleen and liver
    • Lymphadenopathy - check neck, axillae, groin.

    If you pick these symptoms up, you want to refer the patient for a scan and a biopsy.

• Comment on consultation styles in practice

Case 2: A Teenager With Tiredness

• Consider how to assess and investigate anaemia in General Practice

  Patient presented with tiredness…

  • GP asked a range of questions to help narrow down the problem

    • Sleeping - could explain the tiredness
    • Periods - common cause of anaemia in young girls
    • Diet - iron deficiency - is she eating meat, leafy veg etc.
    • Some mental health screening
    • Weight loss → because… cancer

    In general, chronic health conditions make patients tired… patients who are on polypharmacy are also susceptible to feeling tired… pretty much any medication has this kind of side effect…

  On clinical examination…

  • Paleness
  • Koilonychia - spoonshaped nails
  • Conjuctival pallor
  • Angular chelitis

• Identify potential safeguarding issues in children

  If you were speaking to a child in practice and they admitted that their parents might occasionally beat them etc…

  • Check notes to see if there are any safeguarding concerns/social work involvement with them or their other siblings…
  • Speak to the school nurse
  • Phone child protection unit - they are always willing to help. They would arrange to investigate further.
  • There’s also a notification of concern form… a social worker would then look further into it.

  In these consultation, the GP asked the girl if she was sexually active, if she smokes and drinks etc.

• Be aware of health promotion for young people

  Important not to be judgemental. Just planting the seed.. we all wanna be singing from the same hymn sheet :)

• Understand the application of Gillick competence and the Fraser principles

  • Gillick competence - children under 16 can consent to treatment for themselves as long as they can understand, retain and repeat the information back to you.

  • Fraser guidelines - similar, but more to do with contraception and sexual health etc. You can prescribe contraceptions or STI treatments or refer them for termination as long as they can consent to it.

    • The age cutoff for if a child reports being sexually active is 12 or under, you must break confidentiality and refer them to child protection.

    Key aspects…

    • Encourage to inform parents
    • Understand, retain and repeat information
    • Treatment is in their best interests
    • Likely to continue having sexual intercourse