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How would you manage this patient with raised LFTs?

Jill is a 75 year old with a BMI of 28 and a history of hypertension, for which she takes amlodipine. She does not drink alcohol and has no other significant past medical history. Three months ago, LFTs requested by the practice nurse during a routine health check came back showing a raised ALT level of 70 IU/L. Jill was advised to lose weight and increase her physical activity and to have repeat LFTs after three months. Those results have come back and her ALT remains elevated at 75 IU/L. You request a liver screen and the ultrasound shows fatty infiltration of the liver. The rest of the liver screen is negative. Her FIB-4 score is 1.52. What is the most appropriate next step?

Check your answer in our new Step by Step module on Investigating asymptomatic patients with abnormal liver function tests. It offers practical tips on interpreting LFTs and liver screen results as well as advice on which patients can be managed in primary care and who should be referred. The module is getting great reviews from other GPs:

“Excellent. Clear, practical, pragmatic - just want general practice wants.”

“Great module, really loved the flow charts!”

A quick neurological screen for a 10-minute consultation

examIt’s not feasible to carry out a full neurological examination in a 10-minute consultation - so it’s helpful to know which aspects of the exam are most important to check in which patients. Our new video module on a Quick neurological exam for primary care is full of practical tips. Consultant neurologist Dr Giles Elrington starts by demonstrating a 15-point neurological screen that can be completed in a few minutes. He then explains how to use the results of that screen, together with the presenting symptoms, to target specific diagnoses with more focused examinations - including for multiple sclerosis, Parkinson’s disease, sciatica, carpal tunnel syndrome, cervical radiculopathy, radial nerve dysfunction and foot drop. Other GPs are loving the module:

“Brilliant module. Simplicity is its hallmark. Will review it again and again as these are all common presentations in general practice.”

“This is just fantastic. I’ve watched it all twice now. Great tips for a GP eg. a quick screen to exclude peripheral neuropathy.”

What can you do for patients with unexplained chronic cough?

coughing womanYou see a 47 year old non-smoker who is suffering from a dry chronic cough that has been bothering her for several months - there are no red flags, her chest x-ray and spirometry results were normal and she is not taking any regular medication. She says the constant coughing is driving her mad and irritating her work colleagues and she is desperate for you to do something to help control it. What is the best next step?

Find the answer in our highly rated new module on dealing with patients who present with a Chronic cough in primary care. The module covers red flags to look out for and common causes that can be easily addressed. It also outlines a pragmatic “trials of treatment” approach for managing the significant number of patients in whom no obvious cause can be identified. Other GPs are finding it really helpful:

“One of the best overviews about a very common, often challenging, problem in our daily surgery.”

“Good pragmatic approach to a troublesome problem.”

How confident are you in diagnosing and managing fibromyalgia?

What clinical criteria does a patient need to satisfy before you can make a diagnosis of fibromyalgia - and what's the latest evidence on the most effective approach to managing this challenging condition? Check your answers in our popular Ask an Expert module on fibromyalgia diagnosis and management, in which GPSI Dr Adrian Dunbar answers questions submitted by GPs on the aspects they find trickiest in everyday practice. Other GPs are finding the module really helpful:

“Really well constructed module with links to useful resources that I was unaware of. Can see how this will influence my practice.”

“Really useful and GP focused update. I intend to use the patient resources.”

What’s the significance of this CA125 result?

A 72-year-old woman, who is in generally good health, comes to see you because she has been suffering vague abdominal discomfort for the past couple of months, together with new-onset urinary frequency. A mid-stream urine sample is normal to dipstick and culture. Abdominal palpation and internal examination are normal. You request a CA125 test and the result comes back as 25 IU/ml.
What should you do next?

Check your answer in our highly rated module on Recognising early symptoms of ovarian cancer. Identifying ovarian cancer at an early stage is vital to improving outcomes - whereas overall five-year survival rates in the UK stand at just 46%, this rises to 90% among women diagnosed when their cancer is stage I. Our module covers the combination and pattern of red flag symptoms that should alert you to the possibility of this important diagnosis, as well as the role of CA125 testing and ultrasound scanning. Other GPs are finding it very useful:

“Realistic clinical cases and scenarios. Excellent.”

“Really good module. I think we all dread missing an ovarian cancer.”

COPD - what's the next treatment option?

You are reviewing a 67-year-old man who has COPD. He is an ex-smoker; his FEV1 is 45% predicted. He is taking salbutamol when necessary and has become progressively more short of breath on exertion over the last few months. What should you do next in terms of his pharmacotherapy?

Check your answer in our highly rated module on Long-term management of COPD. You’ll update your knowledge on the role of drug and non-drug therapies in controlling symptoms and improving outcomes as you work through interactive patient scenarios. The module has been getting great reviews from other GP users:

“Especially liked all the case studies to check we could apply the theory/guidelines to patient care.”

You might also want to try our GP modules on other aspects of COPD:
Managing acute exacerbations of COPD in primary care
COPD: Diagnosis and assessment of severity

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

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.”