Minor Illness

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Minor Illness

• Amy Tatham Freeda Bhatti

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Definition

• Any condition which is self limiting and does
  not prevent the patient from carrying out their
  normal functions for more than a short period of
  time.

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Why is it important?

• Around half of consultations in AE and 20 40
  of GP consultations are for minor illnesses
• 57 million GP consultations/yr OR accounts for
  over an hour a day for every GP
• In 90 of cases a prescription will be issued
  costing est 370 million/year

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Most common

• Backache
• Eczema
• Sore throat/Ear pain
• Heartburn
• Rhinitis
• Constipation
• Migraine
• Cough
• UTI
• Acne

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Quiz TIme

• Are you ready?

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Question 1

• What is this?
• It is normal for the foreskin to be attached to
  the head of the penis until what age?
• 1year
• 3years
• 5years
• Circumcision can be done on the NHS for religious
  and cultural reasons (true/false)

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Phimosis

• Foreskin is very tight and cannot be pulled back
  over the head of the penis
• Normally attached to the head of the penis until
  5yrs and is still attached in 60 of 6-9yr olds
• Consider referral if recurrent infections,
  ballooning, painful, poor stream
• Consider referral after 6 yrs
• Incidence of circumcision in the UK is 1/15 in
  boys under 15 yrs
• Not funded by NHS for religious/cultural reasons

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Question 2

• What is this?
• They are not present at birth (true/false)
• They usually leave a small scar (true/false)

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Strawberry Naevi/Capillary Haemangioma

• Collection of raised capillaries
• Not present at birth
• 1/20 babies develop them at few days/weeks of age
• Increased in females
• Usually stop growing at around 6/12 and begin to
  shrink and fade
• Usually gone by 7yrs
• If causing feeding/breathing/speech difficulties
  can be treated with laser/steroids

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Question 3

• What is this?
• What percentage are caused by viruses?
• 96
• 72
• 50
• Chloramphenicol is available OTC (true/false)

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Acute Infective Conjunctivitis

• Inflammation of the conjunctiva
• Usually lasts
• Symptoms itch, swelling of the eyelid, purulent
  discharge
• Exclude red flags
• 50 viral aetiology
• Difficult to clinically distinguish viral and
  bacterial cases
• Viral often occur with an URTI and may last
  couple of weeks
• Bacterial usually last 2-5days
• No evidence of benefit in treatment
• Consider treatment if prolonged (2weeks) or
  severe symptoms
• Advise on cleaning eyes/avoiding transmission
• Chloramphenicol is available OTC for people aged
  over 2yrs

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Question 4

• What is this rash?
• Is it contagious?
• How long does the rash typically last
• Upto 2 weeks
• Upto 2 months
• Upto 18 months

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Molluscum Contagiosum

• Pink or pearly white papules with central
  umbilication, upto 5mm diameter
• Caused by DNA virus of pox family
• Lesions can occur anywhere except palms of hands
  and soles of feet.
• Children trunk, flexures, anogenital
• Adults sexual contact may cause lesions in
  thighs, pubis, genitals, lower abdo
• Immunocompromised (HIV, steroids) atypical
  presentation
• Self limiting, usually resolves by 18months
• Infectious, avoid sharing towels/baths
• Can suggest trauma (by squeezing after bathing)
  or cryotherapy if appropriate
• If unsightly or persistent other treatments
  include topical 0.5 podophllyotoxin or imiquimod
  5 cream

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Question 5

• At what age should children be referred for
  orchidopexy?
• 6mths
• 1year
• 18mths of age
• There is still an increased risk of cancer and
  subfertility after surgery (true/false)
• Retractile testicles should fully descend by 3yrs
  of age (true/false)

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Cryptorchidism

• Failure of testicular descent
• Usually unilateral 80 (right 50, left 30),
  bilateral 20
• Increased in premature babies (20 incidence),
  compared to full term babies (2 incidence)
• Increased risk of cancer and subfertility
• Retractile testicles exaggerated cremasteric
  reflex, can be manipulated down
• Become less retractile with age, full descent may
  not occur until after puberty. No treatment
  required

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Question 6

• What do you notice about this mans head?
• Finasteride results in hair re-growth in a third
  of men (true/false)
• Finasteride is not available on the NHS
  (true/false)

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Male Pattern Baldness

• Hereditary
• Usually occurs in late 20s-30s
• Set pattern of hair loss
• Receding frontal hairline
• Thinning of hair at temples and crown
• Hair follicles become over sensitive to
  dihydrotestosterone (DHT), it makes hair
  follicles shrink
• Rx options
• Reassurance
• Finasteride
• Stops conversion of testosterone to DHT, takes
  4/12 for effect
• Some regrowth in 2/3rds of men
• Not available on NHS
• Minoxidil lotion
• ?how it works
• Slows balding in 50, 15 experience hair regrowth

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Question 7

• Sore throats are self limiting and improve within
  a week without treatment in
• 75
• 85
• 95
• Consultation rates for sore throats are
  approximately
• 1/10 patients per year
• 1/20 patients per year
• 1/40 patients per year

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Sore throat

• Independent of causative organism, self limiting
  and resolves in 7 days in 85 of patients
• Centor guidelines can help you decide who needs
  antibiotics.
• Patients unwell with tonsillitis who have ¾ of
  following are more at risk of infection with GpA
  ß-haemolytic strep and complications
• Tonsillar exudate
• Tender ant cervical LNs
• Absence of cough
• History of fever
• If unwell with ¾ of above risk of quinsy is
  160, compared to 1400 without
• Pen V antibiotic of choice. Consider delayed
  prescription
• People who receive antibiotics are more likely to
  present in future with minor illnesses

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Question 8

• In acute sinusitis there is evidence that
  decongestants help (true/false)
• In acute sinusitis antibiotics are of no benefit
  (true/false)

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Acute Sinusitis

• Usually occurs as secondary bacterial infection
  after a viral URTI
• Other causes
• allergic rhinitits, swimming, diving, high
  altitudes, dental infection, trauma
• Symptoms usually occurring a week after URTI
• pain on bending, maxillary pain, purulent
  rhinorrhoea, tooth pain
• Red flags
• Unilateral signs, bleeding, diplopia/proptosis,
  maxillary paraesthesia, orbital swelling,
  immunocompromised
• First line treatment
• Paracetamol, brufen /- codeine
• No evidence decongestants help
• If persistent symptoms 2/52
• Nasal steroid may be of small benefit (73 vs
  66)
• Antibiotics may be of small benefit 80 get
  better within 2/52 without treatment compared to
  90 with antibiotics
• If symptoms persist 12/52, red flags or frequent
  recurrent episodes refer to ENT

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Question 9

• What is the diagnosis?
• The herpes virus is thought to be the cause in
  the majority of cases (true/false)
• Name some differential diagnoses

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Bells Palsy

• Sudden onset facial paralysis, usually unilateral
• Increase incidence in 15-45yr olds
• 1/60 lifetime risk, GPs can expect to see 1 case
  every 2-3 yrs
• Cause used to be largely unknown, now thought
  predominantly due to herpes virus
• Usually LMN affects muscles of one side of face
• UMN affects lower half of face, eye spared
• Loss of taste anterior 2/3rds of tongue
• If patient presents within first 72hrs of
  symptoms can give prednisolone 25mg bd for 10/7,
  otherwise no treatment
• 85 recover fully within 9months

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Bells Palsy Differential Diagnoses

• Lyme disease bilateral, tick exposure, rash,
  arthralgia
• Otitis media examine ears, otalgia, hearing
  loss
• Ramsey Hunt rash, prodrome of pain
• Sarcoidosis if affecting parotid gland may be
  recurrent, usually bilateral
• Guillain-Barre Syndrome usually bilateral
• HIV bilateral lymphadenopathy
• Tumours cholesteatoma, parotid gland tumour,
  primary/secondary brain tumours
• MS consider in a young patient if unilateral,
  painless and resolves in a few weeks
• Stroke

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How do patients consulting with minor illnesses
make you feel?
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Bad Ok
Good

• Frustration as they take Can be used
  as A break btwn more
• up valuable time a pretext to a more
  demanding
• serious problem consultations
• Patient takes no
• responsibility for Rather see
  than Opportunity to alter
• illness miss an important health
  behaviour
• illness

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Why do patients with minor illness consult rather
than self care?
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Health seeking behaviour
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Patient Factors

• Demographics e.g age (elderly),socioeconomic
  group,religion
• Illness itself i.e perceived threat
• Health beliefs, poor education
• Previous experience
• Other events in patients life e.g
  bereavement,work stress (therefore not coping)
• Secondary gain prescription eg sick note

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Society Factors

• Media e.g health stories like the Swine Flu,
  medicalisation of normal, Jade Goody effect
  (P.S. Were not saying theyre not justified
• Jade Goody effect resulted in a dramatic uptake
  for smears good)
• Government
• - confusing on one hand keen to promote self
  care e.g by increasing availability OTC
  medicines but also promote policies so patients
  have easier access to GPs
• Society
• Different cultures eg Asian Eastern European
  may present more
• Certain groups eg Refugees ( often because of the
  hell theyve endured)
• The its free on the NHS society

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Doctor Factors

• Access greater the access, the more likely
  patients are likely to use/abuse
• Doctor Behaviour in the Consultation doctor may
  be too approachable encouraging people to drop in
  any time (that dr wont mind)
• Secondary gain some doctors subconciously
  encourage minor illnesses (easy consultations,
  adds relaxing time to their surgeries)
• Ineffective opportunistic health education/self
  care counselling
• Not defining boundaries
• Previous doctor behaviour eg someone who gave a
  patient abx for sore throat and thus they expect
  the same in the future

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How can we as GPs encourage patients to self
manage minor illness?
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• Access
• Consultation Behaviour
• - Chanign Our Attitude not encouraging
  simple consults
• - Giving information, educating pitching at
  the right level
• - Prescribing (or not)
• - Safety netting
• - Doctors acting in a similar way eg no abx for
  sore throats