StethascopePrimary Care

Facial lesions in a three year old: what’s the diagnosis?

Three year old Stewart is brought to your surgery with recurrent lesions on his face, especially around his mouth and nose. These start as red macules and then become vesicles or pustules before crusting over, but tend to recur. He has had at least five episodes in the last six months. He is otherwise well, is apyrexial today, and has no past medical history of note.

What is the diagnosis?

The first module in the series has been proving popular with GPs:

Check your answer in our new module Quick quiz: Rashes in children. It’s the second in our Quick quiz series, and is full of cases, images, and clinical tips, designed with mobile devices in mind. Perfect if you have some time spare on your commute.

The first module in the series has been proving popular with GPs: Quick quiz: Acute itchy rash

“Excellent module. Love the case-based approach with pictures - which is practical and memorable”

“What a fantastic module - like being given a private tutorial in dermatology. I learnt so much.”


Does this man need to take vitamin D supplements?

Mr Smith comes to see you asking for advice about dietary supplements. He and his wife, who are both in their mid-70s, are planning to spend the winter in Finland, visiting their daughter who lives there. They have done a lot of research on the internet and are worried about not getting enough sunlight exposure to keep their vitamin D levels topped up.

How would you advise them? Should you check their vitamin D levels? Do they need to take a supplement?

Check your answersin our popular Clinical pointers module on Vitamin D  deficiency in adults in primary care. It offers practical tips for GPs on how to recognise adults at risk of deficiency, when and how to investigate, and how to manage people diagnosed with vitamin D deficiency. Other GPs are finding it very helpful:

"Some excellent pointers I had not considered."

"A good snapshot of a changing landscape. Very helpful."

What step-up treatment does this asthma patient need?

You see Mia, a 28-year-old woman who was diagnosed with asthma two years ago. She is taking a short-acting beta agonist as required as well as regular twice-a-day use of a combination beclometasone/formoterol inhaler containing a low dose of the inhaled corticosteroid. She has had no improvement in her symptoms since starting the combination inhaler. You have rechecked her diagnosis, checked her inhaler technique and confirmed her concordance with treatment. You conclude that her asthma medication needs stepping up - what would be the most appropriate next step?

Check your answer- and find out how and why the BTS/SIGN and NICE guidelines would recommend different approaches for this patient - in our newly updated module on Managing chronic asthma in adults. You'll earn 2 hours of CPD credits as you work through patient cases that you might see in everyday primary care.

You might also want to take our other recently updated asthma modules to ensure you are up to speed on all aspects of diagnosis and management:

Guideline focus: Asthma diagnosis in adults and children
"Succinct but very useful for daily practice."

Ask an expert: Management of chronic asthma in children in primary care
"Excellent, clear, directive expert advice. Has cleared a lot of lingering doubts. I highly recommend this module."

Step by step: How to manage acute asthma in adults in primary care
"This module is an absolute must for every GP."

Step by step: How to manage acute asthma and wheezing in children in primary care
"An extraordinary, brilliant module, worth repeating more than one time."

How would you manage this 8-week-old baby?

Rob brings his 8-week-old son, Joshua, to your baby clinic. Joshua is partly formula fed as his mother has just gone back to work. She breastfeeds first thing in the morning and at night. Rob is concerned because Joshua seems unsettled during the day, and cries a lot during and after feeds. He is feeding every three hours and sometimes vomits quite large amounts when Rob puts him down for his sleep after a feed, and he always takes a long time to wind. His stools are normal.

How should you approach this scenario? What factors in the assessment would help distinguish between possible diagnoses?

Check your answers in our new Ask an expert module on Common problems in new babies in primary care. It will help you feel confident that you won’t miss anything serious, as well as providing much-needed reassurance on topics including: common rashes; feeding problems; constipation; jaundice; eye problems; sepsis; and heart murmur. Other GPs are already giving the module great reviews:

“I really liked this module. Concise and well presented information with extra links (super useful). A well needed refresher.”

“Very useful and covered most of the common neonatal issues a GP would see.”

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 what 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.”

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.”