StethascopePrimary Care

Heart failure: practical tips for GPs

Mr Smith is an 82-year-old with mild exertional dyspnoea which is not significantly limiting his daily activities. There is no history of orthopnoea or paroxysmal nocturnal dyspnoea. His past history includes hypertension, diabetes mellitus and prostatism. His current drugs are bendroflumethiazide, felodipine, tamsulosin, metformin and aspirin. At his annual diabetes review, he is noted to have an irregular pulse and an ECG confirms atrial fibrillation. His blood pressure is 128/64, heart rate is 84bpm, JVP is not elevated, chest is clear, and he has no peripheral oedema. An echocardiogram shows mild LVSD, moderate biatrial dilatation and no important valvular lesions. What is the best approach to managing this patient? Check your answer in our new Step by step module on Managing heart failure in primary care. The module covers which drugs to prescribe and which to avoid, how to monitor symptoms, treatment options for refractory symptoms and when to refer. Other GP users are finding it very helpful:

“Easy to follow with helpful scenarios.”

“Excellent - up-to-date and very practical and relevant.”

You may also be interested in our other heart failure modules for GPs:
Step by step: a guide to diagnosing heart failure
Ask an expert: chronic heart failure
What's new in chronic heart failure

Hay fever management: your questions answered

Clinical problems submitted by GPs are answered by consultant allergist Dr Sophie Farooque in our Ask an expert module on Hay fever. The module includes practical tips on a stepwise approach to treating hay fever, advising patients on antihistamine choice, minimising side-effects of intranasal steroids, latest evidence on nasal saline irrigation and the role of oral steroids and immunotherapy. It has great reviews from other GPs:

“Sound advice here - will use this in clinic.”

“Addressed the practical issues that present in general practice.”

How would you manage this asthma patient?

Rachael, who is 43 years old, is taking high-dose inhaled corticosteroids, a long-acting beta agonist and montelukast for her asthma. She uses a short-acting beta agonist (SABA) as required. Despite her medication, her asthma control is very poor; she typically wakes up coughing three nights a week and uses her SABA inhaler twice a day. What is the most appropriate next step in management? Check your answer in our new module on Managing chronic asthma in adults in primary care, which highlights the practice-changing points from the latest update of the BTS/SIGN asthma guidelines. It also includes practical tips - with a video demonstration - to help you advise patients on good inhaler technique. The module has already been getting great reviews from other GP users:

“Highly recommended, Will definitely help me to manage and diagnose asthma much better.”

“Real world case-based scenarios. Very useful.”

You might also want to look at our latest modules covering other aspects of asthma care, all of which are fully up to date with the latest BTS/SIGN guidance:

Guideline Focus: Asthma diagnosis in children and adults

Acute asthma in adults: assessment and management

Management of acute asthma in children

Childhood fever: are you confident to spot the red flags?

Assessing a feverish child under the age of five years can be challenging. Most will have a self-limiting infection but it’s vital not to miss the cases caused by more serious infections such as meningitis or pneumonia. Our newly updated module on Fever in under fives will ensure you feel confident to use the NICE traffic light system to identify children who need emergency referral or urgent specialist input. We’ve also added a summary of the 2016 NICE sepsis recommendations for under-fives so that it’s clear what to do if your assessment of a feverish child leads you to suspect sepsis. Other GPs are finding the module very helpful:

“A must for all GPs, from registrars to old hands!”

“Excellent module for daily practice.”

How would you manage this patient with sciatica?

A 35 year old man presents with acute sciatica. He is otherwise healthy and you have no concerns about serious pathology. He has already tried ibuprofen and paracetamol but is still troubled by his leg pain. What is the most appropriate next step in management?

Check your answer in our new Guideline Focus module on Low back pain and sciatica. The module highlights the key practice-changing points for GPs from the recent NICE guideline on low back pain. It offers practical advice on identifying which patients with non-specific low back pain are at highest risk of chronic pain and disability, latest evidence on safe and effective analgesia, the role of exercise and who to refer for radiofrequency denervation and other specialist interventions. The module is proving very popular with other GPs:

“Excellent module - in particular the back screening tool and advice on what treatments not to use.”

“Short, concise and informative.”

What's the diagnosis?

Check your answer in our new Clinical Pointers module on Melanoma, which will improve your confidence in distinguishing the benign from the malignant when a patient presents with a pigmented skin lesion. The module covers the key differentials, clinical tools that can help you identify suspicious lesions, pitfalls to beware of and advice on when to refer. It’s already getting great reviews from other GPs:

“Very useful. Photos of lesions a big help.”

“I've done a postgrad clinical dermatology diploma and this module was just as informative on malignant melanoma. Well done.”

Practical tips on incidental raised liver enzymes

An incidental finding of abnormal LFTs is a common event in primary care and it can be difficult to know which patients need further investigation. Our two new Ask an expert modules on Alcohol-related liver disease and Non-alcoholic fatty liver disease (NAFLD) offer a practical evidence-based approach to the problem. Consultant hepatologist Dr Stuart McPherson gives answers to common clinical challenges submitted by GPs and the modules are already proving very popular with other users:

“Gives me more confidence in dealing with a very difficult and challenging area.”

“An extremely helpful module on how to approach abnormal LFTs. Will change my practice.”