Top Tips
Recurrent Epistaxis
1. Consider the following in the history:
a. Spontaneous or provoked? Provoked tend to be anterior bleeds.
b. Where is bleeding sensation noted first? (If upright at time of onset, and felt in throat, suggests a posterior bleed site more likely.)
c. Heavy nose bleeds in child/adolescent (typically males), associated with nasal obstruction, could be juvenile nasal angiofibroma.
d. If history of menorrhagia/prolonged bleeding after dental extractions/FH of epistaxes, consider Von Willebrands Disease. Check FBC, LFT & Coagulation screen.
e. OTC or prescribed steroids directed onto septum? Cocaine?
f. Patient’s on anticoagulation medications.
2. On examination check:
a. Anaemia? (especially consider in the elderly with chronic history)
b. Hypertensive? (chronic untreated hypertension may predispose)
c. Anterior rhinoscopy with an auroscope:
i. Prominent vessels in Little’s Area?
ii. Evidence or history of digital trauma (shiny thickened mucosa similar to lichen simplex).
iii. Localised anterior crusting (likely Staph-related vestibulitis)
iv. Generalised crusting and inflammation (could indicate Wegener’s or Sarcoid)
v. Mucosal lesions (e.g. Papillomas/SCC)
vi. Septal deviation (causes drying of mucosa and propensity to bleed)
vii. Septal perforation (is most commonly a complication of septal surgery or trauma and often the posterior rim will desiccate and crust/bleed)
3. Treatment options:
a. Prominent vessels in Little’s Area: Cautery with silver nitrate.
b. No obvious cause: Try Naseptin cream (if patient is not allergic to peanuts) for up to 2 weeks.
c. Mucosal lesions & polyps: Refer for consideration of removal/biopsy.
d. Septal deviation: Petroleum jelly at night applied with cotton bud.
e. Septal perforation: Petroleum jelly at night. Where new and associated with crusting and inflammation, refer for biopsy.
f. Recurrent unilateral nose-bleeds with associated other nasosinus symptoms: Refer for exclusion of malignancy.
g. All persistent posterior bleeds should be referred.
h. Bottom Line: Persistent epistaxis with no obvious anterior cause or unresponsive to treatment, refer.
Peripheral Arterial Disease (PAD):
1. Diagnosis of PAD is secured with an ABPI <0.9.
2. Where doubt exists, the Edinburgh Claudication Questionnaire (see www.ncbi.nlm.nih.gov/pmc/articles/PMC2560464/), is highly specific (91%) and sensitive (99%).
3. Appropriate investigations include FBC, U&E, FLP, HbA1c (or FBS or RBS). If referring for possible intervention, LFT & clotting studies are really useful as they allow more rapid assessment and angiograms can be booked quicker...
4. Lifestyle treatment should address smoking, weight and promote progressive exercise.
5. Standard medication should include aspirin 75mg/day and Simvador 40mg/night.
6. Ensure hypertension and/or diabetes treatment are optimised.
7. Any AAA should be referred, unless there is a robust surveillance programme in the community.
8. Most patients are managed conservatively in Primary Care.
9. Smokers who just have claudication (not critical ischaemia) will rarely be offered intervention - they need to stop smoking first.
10. The following must be referred: -
a. AAA >4.5cm diameter on USS
b. Popliteal aneurysm
c. Critical limb ischaemia:
i. Rest or Night pain in toes or feet
ii. Ulceration of feet/toes
iii. Gangrene
iv. Uncontrolled pain
11. Progressive ischaemia (rest pain and tissue loss) over a period of weeks needs an urgent OPD rather than an acute admission.
12. If a patient has leg ulcers and would benefit from compression bandaging, as a rule of thumb if they have an easily palpable foot pulse their arterial circulation is adequate to tolerate compression.
13. The new Derbyshire-wide vascular service maintains Chesterfield locality patients receiving all their OPD, pre-op work up and extended post-op recovery in Chesterfield, as well as maintaining all the non-interventional inpatient care plus day-case angioplasty here as well. Essentially they just go to Derby for their arterial surgery (delivered by a Chesterfield surgeon) or complex angioplasty.
Red/Hot Legs
The dermatology department at CRHFT are running a series of multidisciplinary workshops on treating hot/red legs. It fits in nicely with our work on cellulitis and clearly there is potential for savings in reducing secondary care activity. Dr Ezughah has asked that we circulate details which are attached. Places are limited and open to primary and secondary care and as there's likely to be big demand practices should get in early.
Erectile Dysfunction
1. History, examination and investigations are directed to establish whether there are particular organic or psychosexual problems.
2. Drug therapy accounts for erectile dysfunction in approximately 25% of cases and is mostly reversible when the offending agent is stopped. It is important that a drug related effect is considered at the outset, thus avoiding unnecessary investigation and inappropriate use of specific therapies. Typical offending drugs include beta-blockers, thiazides, digoxin, spironolactone and anti-depressants – particularly SSRIs.
3. Appropriate investigations are LFT, testosterone and prolactin, TFT, HbA1c, U&E and lipid profile.
Nasal Polyposis
1. The aetiology of inflammatory polyps is unknown and they are not associated with allergic rhinitis. Although the conditions may co-exist, the incidence of allergic rhinitis is no higher in polyp patients than the rest of the population.
2. Hyposmia, rhinnorhoea and constant blockage are the cardinal symptoms. Rarely an antro-choanal polyp will “ball-valve”, i.e. blockage on exhalation, not inhalation.
3. Acute pain is not a feature of inflammatory nasal polyps. If a patient presents with facial and/or sinus pain, consider an acute sinusitis or underlying malignancy.
4. Always ask about any bleeding; this suggests this may not be a straightforward inflammatory polyp.
5. Polyps are generally grey/translucent, are not sensitive to touch, which is a discriminatory sign as the turbinates are sensitive to probing!
6. If the polyp appears to be unilateral, and there is no previous history of inflammatory polyps, then refer as this could be a non-inflammatory polyp such as an inverted papilloma, or even a frank malignancy.
7. If, however there is a past history of inflammatory polyps, or polyps are bilateral, then a trial of treatment is reasonable, with referral if no response, as most idiopathic inflammatory polyps are steroid responsive.
8. Bear in mind the association between asthma and nasal polyps. Treating nasal polyps adequately would allow better asthma control.
9. Consider a stepped approach to management:
a. Step 1: Regular use of a nasal steroid spray (a 3 month trial suggested).
b. Step 2: Betnesol nasal drops 2 tds each nostril for a month, in the “head hanging” position (proven to improve distribution to the target area, and reduce amount passing directly to the pharynx to be swallowed). Equivalent to 0.5mg of prednisolone per day.
c. Step 3: Oral prednisolone: Either,
i. 60mg o.d.x3/7, 40mg x3/7, 20mg x3/7, 10mg x3/7, to be followed by step 2, then step 1 as maintenance. Usual contraindications apply.
ii. 30mg o.d. x7/7 as some patients’ co-morbid medical conditions may be better suited to a shorter course.
d. Step 4: Referral for consideration of confirmation of diagnosis and/or surgery.
10. Steroid nasal spray should be continued indefinitely as this is proven to decrease recurrence.
Decongestant drops nor sprays will not shrink nasal polyps and prolonged use (for more than a week) can cause Rhinitis Medicamentosa, which leads to a dependency on decongestants, and constant feeling of blockage
Inguinal Hernia Referral
A very short summary of the guidelines for referral (or not) of inguinal hernia was included in the latest R&MMT newsletter. Dr Richard Bull has recently appraised the evidence base around inguinal hernia referral and has summarised the data in the attached article. Clinicians will find the information useful to share with patients when having discussions around the pros and cons of referral.
Ultrasound for Gynaecological problems
1. The clinical information on the referral will help the Radiology Department decide what modality of ultrasound:
a. Patients should be warned at the time of the request of the possibility of vaginal scan.
b. If the referrer knows of a reason why vaginal scan would be inappropriate this should be included on the request form.
2. USS indicated:
a. Missing IUCD.
b. Fibroid? USS identifies nature and origin of any lesion. Also clarifies presence or absence of ureteric compression.
c. Where women C/O the following on a persistent or frequent basis, particularly >12 times per month, and where serum CA125 is ≥35 IU/ml*:
i. Persistent abdominal distension
ii. Early satiety and/or loss of appetite
iii. Pelvic or abdominal pain
iv. Increased urinary urgency and/or frequency
v. Women over 50 with recent onset of IBS
d. Pelvic pain with CA125 <35IU/ml: May give cause, but often unhelpful if no other feature than pain.
e. PMB: Refer 2WW Gynaecology if endometrial thickness >4mm.
3. USS not indicated:
a. Pelvic mass (not obviously fibroids) or ascites: 2WW Gynaecology referral following *NICE CG 122; Ovarian Cancer, 27/04/2011.
b. Recurrence of gynaecological malignancy: CT or MRI are investigations of choice.
Rapid Access Chest Pain (RACP) Clinic
1. The RACP is designed to facilitate rapid diagnosis and assessment of patients with a possible diagnosis of new onset angina.
2. Angina is unlikely unless at least two of the following apply:
a. Constricting discomfort in the front of the chest, neck, shoulders jaw or arms
b. Precipitated by physical exertion or stress
c. Relieved by rest or GTN < 5 minutes.
3. The core component of the RACP assessment is the exercise tolerance test: for reasonable sensitivity and specificity the patient should complete at least the first two stages (6 minutes) of the Bruce protocol. In the second stage (the final 3 minutes) the treadmill travels at 2.5 mph at an incline of 12%. If a patient will not be able to undertake this for reasons other than limiting chest pain they should be referred to a cardiology clinic.
4. Indications:
a. New onset (within 6 months) chest pain suggestive of angina
5. Contraindications:
a. Established diagnosis of CHD
b. Acute chest pain at rest suggestive of unstable angina or myocardial infarction: Admit directly
c. Inability to exercise on treadmill
d. Arthritis
e. COPD
f. CVA
g. Limiting claudication
h. Uncontrolled BP >SBP 200/DBP >120
i. Patient known to have LBBB on ECG (exercise ECG uninterpretable for ischaemia)
6. Beta-Blockers decrease the sensitivity but increase the specificity of the exercise test. If a patient is already on a beta-blocker, do not change. If a patient is not on a betablocker and anti-anginal treatment is required before the RACP, please start regular oral asymmetric isosorbide mononitrate.
Insomnia
- Pay particular attention to lifestyle issues (including drugs and alcohol) and screen for anxiety and depression where appropriate.
- Hypnotics are rarely needed, but where use is made of these treatments, issue no more than for 2 weeks. Repeating this issue is rarely justified.
- Behavioural approaches (e.g. Sleep hygiene) are appropriate for chronic insomnia.
Infective Conjunctivitis
1. Infective conjunctivitis is usually viral, but can be bacterial (purulent meniscus in inferior recess). Onset is usually acute and symptoms usually include redness, grittiness > itching, smearing of vision with discharge (clearing on bathing and blinking) and sticky eyelids.
2. Symptoms normally clear by about 7 days in bacterial conjunctivitis.
3. Symptoms of viral conjunctivitis may take up to 3 weeks.
4. Antibiotics have no evidence based role in treatment but artificial tears, simple eye ointment or alternatives (OTC) can be used as an eye salve to reduce grittiness, and cool compresses can also help.
5. Counsel patients who wear contact lenses to refrain for the duration of infection.
6. Pain, photophobia or visual impairment should not be overlooked and should always provoke further assessment, including fluorescein staining for more serious causes. Be particularly vigilant for Acanthamoeba keratitis in those who wear contact lenses.
7. Measures to reduce spread of viral conjunctivitis such as frequent hand washing and not sharing towels are helpful