Anorexia nervosa in adolescence: how easily can you identify this?

Anorexia nervosa in childhood and adolescence: recognition and initial management in primary care

Amy, a 13 year old girl, is brought in by her mother to see you. Amy’s mother explains her concern that Amy has been missing breakfast and not eating as much dinner as usual. She has been very focused on her competitive running, she has lost weight, and her clothes are a bit loose. Amy says she is not concerned about her weight, she just does not feel hungry sometimes, but admits she is keen to do well in an upcoming running competition and has been training harder than usual. 

On examination, you find that her observations are all within the normal range for her age. You note that she is slim but not cachectic, she is between the 9th and 25th centile for BMI for girls her age. She has no signs of dehydration.

How concerned should you be about Amy at this stage? What kind of investigations might be appropriate, and what “red flags” should you be looking out for? Should you speak to Amy on her own?

Check your answers in our new module on Anorexia nervosa in childhood and adolescence: recognition and initial management in primary care. This module guides you through Amy’s case, with advice on recognising anorexia nervosa, identifying red flags, and knowing when to refer.

GPs who have already taken this module have said:

“Very informative and easy to understand."

"Very clear protocol for how to investigate monitor and treat in primary care"

A dry chronic cough: what treatment options can you suggest?

You 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 colleagues at work, and she is desperate for you to do something to help control it. 

What treatment options are available in primary care for relieving a chronic cough that has no easily identifiable cause? Does any one option have a stronger evidence base than others? Which approach would you suggest trying first in this patient’s case?  

Check your answers in our recently updated module on chronic cough in primary care. The module covers common causes that can be easily addressed. It also outlines a pragmatic “trials of treatment” approach for patients in whom no obvious cause for the cough can be identified. Other GPs have given it great reviews:

“Informative, up to date, practical, relevant and realistic.”

“Great module, will be invaluable in consultations.”

Heart failure guideline changes: key points for GPs

What combination of drugs is now recommended by NICE as the first line option for a patient with a new diagnosis of heart failure with reduced ejection fraction? How should you adjust your approach to management when a patient’s renal function declines significantly after you titrate up their heart failure medications? What’s the role of NT-proBNP testing for diagnosis of suspected heart failure in a patient with a history of myocardial infarction?

These questions cover just some of the key practice changing points for GPs from the recent update of the NICE guideline on diagnosis and management of heart failure, and you can get up to speed with all the changes with our updated set of modules on this important primary care topic:

Ask an expert: Chronic heart failure
Consultant cardiologist Dr Abdallah Al-Mohammad advises on tricky clinical scenarios and queries submitted by GP users.
“An excellent module with a lot of practical day to day tips.”

Step by step: A guide to diagnosing heart failure
When to suspect the diagnosis, how to rule out important differentials, which tests to request and when to refer.
“So well explained.”

Step by step: A guide to managing heart failure in primary care
Drugs to prescribe and those to avoid, treatment options for patients with refractory symptoms, monitoring treatment and when to seek specialist advice.
“Great module with thought provoking cases.”

How long should this patient continue taking a bisphosphonate?

Clinical pointers OsteoporosisYou see Mary, who is 64 years old. She started taking alendronic acid for primary prevention of fragility fracture three months ago, when her FRAX 10-year risk score indicated that she was at high risk, and a DXA scan confirmed a diagnosis of osteoporosis. She is also taking vitamin D supplements. She has tried unsuccessfully to give up smoking, and has a strong family history of osteoporosis. She is here to review her medication and get the results of serum calcium blood tests, which are normal. She is not suffering from any concerning side effects, but wants to know whether she will need to take a bisphosphonate for the rest of her life.

What factors do you need to consider in weighing up the risks and benefits of long-term bisphosphonate treatment? How does this judgement vary for different bisphosphonates?

 Check your answers in our recently updated module Clinical pointers: Osteoporosis – prevention and management in primary care. The module offers practical tips on fracture risk assessment, indications for DXA scanning, the use of bone-sparing medication for primary and secondary prevention and how to ensure patients with osteoporosis are vitamin D and calcium replete. Other GPs are finding it very helpful:

“Great module, learned a lot of things doing this one.”

“A brilliant, informative module on a confusing topic.”

Tired all the time: how would you manage this patient?

A 56 year old woman comes to see you complaining of feeling tired all the time. She is otherwise well, and has no other symptoms of hypothyroidism. On examination she is clinically euthyroid, with no evidence of goitre. She does not take any drugs known to affect thyroid function. As her symptoms have persisted for some time, you request a set of screening investigations including thyroid function tests (TFTs). The results are as follows:

  • TSH: 8.1 mU/L (normal range 0.4 mU/L to 4.5 mU/L)
  • Free T4: 12.1 pmol/L (9.0 pmol/L to 25.0 pmol/L)
  • Free T3: 5.3 pmol/L (3.5 pmol/L to 7.8 pmol/L)

All of the other screening investigations are normal. How should you interpret these TFT results, and how should you manage this patient? Check your answers in our new Step by step module on Diagnosing thyroid dysfunction in primary care.  It will refresh your knowledge on when (and when not) to request thyroid function tests, the recommended primary care follow up for patients with subclinical hypothyroidism and hyperthyroidism, and how to identify and manage thyroid dysfunction in pregnancy. The module is already proving very popular with other GPs:

“Wow. One of the best modules I have ever read.”

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.”