Clinical topic guides

These Topic Guides each explore part of the RCGP curriculum, Being a General Practitioner.

Each Topic Guide is intended to illustrate important aspects of everyday general practice, rather than provide a comprehensive overview of each clinical topic. It should therefore be considered in conjunction with other Topic Guides and educational resources.

They also contain tips and advice for learning, assessment and continuing professional development, including guidance on the knowledge relevant to this area of general practice.

Allergy and immunology

This Topic Guide will help you understand important issues relating to allergy and immunology by illustrating the key learning points with a case scenario and questions.

The role of the GP in the care of people with allergic disorders

  • The UK has one of the highest prevalence of asthma, rhinitis and eczema. Allergy-related conditions may present in a significant number of consultations. The GP has the lead role in identifying underlying allergic symptoms that can be difficult to distinguish from the range of normality or other illness
  • Anaphylaxis is a potentially life-threatening emergency which can often present in primary care. GPs have a role in not only managing emergencies, but supervising the ongoing management of risk factors and prescribing
  • Allergy is a multi-system disease. GPs need to understand how to take an allergy focused clinical history and understand the differentiation of different types by appropriate testing and referral. This includes recognising and recording of food and drug sensitivities

Emerging issues in allergy care

  • Despite the increasing prevalence of allergic and immune disorders, there is limited access to expertise and resources. This requires community-based services to take a wider role and develop integrated multidisciplinary pathways 
  • Allergies are the commonest chronic disorders in childhood and the prevalence has increased dramatically in the last 25 years 
  • Allergy management plans are being developed in association with other specialties such as paediatrics. Awareness is increasing in schools who may request them for students 
  • The role of immunotherapy for chronic allergic disorders 

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis 

Symptoms and signs

  • Anaphylaxis  
  • Angio-oedema
  • Atopy – asthma, eczema and hay fever  
  • Drug reactions  
  • GI symptoms for example diarrhoea
  • Urticaria and rashes

Common and important conditions

  • Anaphylaxis, including doses of adrenaline and resuscitation  
  • Autoimmune conditions in primary care 
  • Drug allergies and their mechanisms 
  • Food allergies, including milk allergy (types for example IgE vs. non-IgE mediated, presentation, primary care management and referral) 
  • Occupational allergies such as latex allergy and contact allergies such as hair dye, metals, plants
  • Pollen Food Syndrome  
  • Types of allergic reactions: immediate, delayed, possible mechanisms 
  • Venom allergy: referral and emergency management; the role of immunotherapy

Examinations and procedures

  • Administration of adrenaline 
  • Risk assessment and prescribing of adrenaline devices 
  • Effective administration of topical nasal steroids and inhaler devices

Investigations

  • Allergy: skin patch and prick testing, specific IgE testing (blood and skin prick), exclusion and reintroduction in suspected non-IgE disease 

Service issues

  • Commissioning should consider specific training programmes for primary care staff and ensure they have a specialist allergy service 
  • Extended hub and spoke models such as allergy & clinical immunology networks involving specialist nurses, health visitors, and dietitians in integrated referral pathways 
  • Pathways through Accident & Emergency departments and criteria for urgent referral to secondary or tertiary care 
  • Digital health and decision support software to enable remote consultation, and more accurate diagnosis and management 
  • Prescribing issues (for example adrenaline devices) and the extended role of the pharmacist
  • Patient safety measures (for example systems to document allergies in the patient record; Medic Alert bracelet)

Additional important content

  • Economic and psychosocial impact of food allergies on the individual and their wider social network. 

The role of the GP in the care of people with immune disorders

  • Increasing numbers of people with secondary immune deficiencies from chemotherapy and use of biologics may present to their GP 
  • GPs deliver preventive public health strategies through routine immunization and should expand provision of vaccination as new disease patterns emerge

Emerging issues in immune disorders

  • Immune manipulation is increasingly being used in a range of therapies (for example monoclonal antibodies)

Common and important conditions

  • Immune deficiency states (inherited, primary and acquired such as HIV, chemotherapy) as applicable to primary care particularly the different requirements for antibiotics 
  • Immunisation:
    • antibody test results used in guiding management of specific situations such as chickenpox in pregnancy, rubella immunisation, hepatitis B and C
    • routine primary childhood immunisation schedules, contraindications and adverse reactions; and  
    • for occupational medicine such as healthcare workers and Hepatitis B  
  • Needle stick injuries and risk of Hepatitis B and C, HIV
  • Skin manifestations of immune disease such as Kaposi’s sarcoma
  • Transplantation medicine as applicable to primary care particularly in management of organ transplants such as heart, lung, liver, kidney, cornea 
  • Indications and complications of transplantation for example immunosuppression and immunosuppressant drugs

Symptoms and signs

  • Recurrent infections – use of risk assessment check list to assess susceptibility 

Investigations

  • Immune disorders:  immunoglobulin levels including IgG, IgM serology, and complement

Case discussion

Leo, A 15-year-old boy presents with a history of redness and soreness around his mouth and vomiting after eating a peanut. His mother tells you he had ‘lactose intolerance’ in childhood but has grown out of it. He is previously well and is unsure whether he has any other history of specific reactions.  

He is known to be atopic with chronic eczema which has become an embarrassment and is stopping him from swimming. His hay fever is usually sufficiently controlled with occasional antihistamines, but he is getting worsening asthma in the hay fever season, and during exercise. 

His mother wonders whether you could refer him to a clinic for ‘allergy testing’. How would you respond?

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.  

                      Core Competence                  
                           Questions                    
Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
What are the personal challenges I face in caring for patients with a history of allergy? 

How do my personal beliefs about the impact of allergies on wellbeing influence the care that I provide? 

Do I listen without preconceived ideas to patients’ thoughts on allergies or intolerance even if unlikely to have any medical basis? 
Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for diversity. 
What are my attitudes towards people with allergies? 

If the patient had been 3 years old, or 30 years old, instead of 15, might that have changed my management? 

Do I empower the patients to self-manage and to have confidence in accessing information on their condition and using treatments appropriately? 
Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 
How do I ensure that I accurately assess the needs and health beliefs of a 15yr old in the presence of her mother? 

How do I respond to the inherent uncertainties in diagnosis and management? 

How do I seek to understand how the patient and family might feel about the risk of further events, the medications required and the fear of death from anaphylaxis  
Data gathering and interpretation  
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations.
What other questions should I ask to help me with my diagnosis?  

Do I know how to take an allergy history and understand the important key points to enable me to adequately assess risk and document symptoms in a way that accurately describes allergy?  

What investigations, if any, could I do in primary care? 

What is ‘allergy testing’? How can it be performed? 

Do I understand different indications for Skin Prick Testing, blood tests or patch test? 
Clinical Examination and Procedural Skills  
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills.
How would I clinically assess and manage a patient presenting with acute angio-oedema? 
Making decisions
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
How do I explore other factors which might influence her health beliefs about his management? 

How can I incorporate shared decision-making in my management? 

What options are available to me if I am unsure what to do? 
Clinical management  
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 
What management options might be considered? 

Do I know the right dose of adrenaline for age and can I discuss types of devices, needle length etc?  

How do I assess the need or urgency of referral? 

How can I empower patients and their carers to recognise symptoms of anaphylaxis if unintended allergen exposure occurs, and train them to use adrenaline devices if needed? 

How do I provide the patient / family with information on next steps in the management process and also with emergency management plans which they can share with school, college etc? 
Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation
In what ways might I know or find out whether a patient has an allergy (for example ask in consultation, Medic Alert bracelet)? 

How far am I aware of the nature of multi-systemic allergy including rhinitis and its associations with asthma, and food allergy with gastrointestinal, respiratory and skin symptoms? 
Working with colleagues and in teams 
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 
 Am I aware of the boundaries of primary care and the role of the specialist services?  

What do I know about allergy services in my area? To whom would I make a referral? 

How can I coordinate ongoing care with the specialist multi-disciplinary teams? 

What are the best ways of communicating with regionalised teams such as allergy services? 
Improving performance, learning and teaching  
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
What do I know about the evidence-based management of allergy and do I understand and implement key national guidelines? 

What are my personal educational needs that this scenario identifies and how will I address them? Who might be able to help me? 

In what ways can I assess and improve the care of patients with allergy through Quality Improvement or audit? 
Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills.
What systems does my practice have in place for recording patient allergies? 

What shared care arrangements would I expect to be in place for patients with severe allergies? 

What further support does the practice need to provide? 
Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 
How do I assess the psychological and social impact of diagnosis on QOL including school or nursery setting, social occasions, travel and fear of reactions?  

How do I balance health anxiety with actual health risk? 

What other aspects of health promotion need to be addressed? 
Community orientation  
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 
How common are clinically significant allergies in my practice population?  

What are the cultural differences in my patient population and how does this impact on management of allergy? 

What support can to be identified in my locality? 

What voluntary organisation might be able to offer support and resources? 

How to learn this area of practice

Work-based learning

General practice is a good place for you to learn how to manage immune and allergic disorders because of the wealth of clinical material. Patients will present with various symptoms, at varying stages in the natural history of their illness. Discussion with a trainer will aid specialty trainees in developing strategies to help in problem-solving. Supervised practice will also give trainees confidence.

In particular, the GP specialty trainee should be able to gain experience in the management of immune and allergic disorders as they present in the community (incidental, acute and chronic), including life-threatening emergencies. Primary care is also the best place to learn about holistic chronic disease management (for example Immunosuppressed patients, atopy, food allergies, occupational allergies).

The acute setting is the place for you to learn about the immediate management of life-threatening presentations; you will also learn about the interpretation of clinical findings, and the use of appropriate specialist investigations such as serology and allergy testing. Outpatient or clinic settings are ideal places for seeing concentrated groups of patients with immune problems.

GP Specialty Training programmes should offer you the opportunity to attend these clinics when working in other hospital posts and during your general practice-based placements.

Self-directed learning

There is a growing body of e-Learning to help you consolidate and build on the knowledge you have gained in the workplace. You can find an e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare.

Learning with other healthcare professionals

Chronic disease management in primary care is a multidisciplinary activity. As a specialty trainee it is important for you to gain an understanding of the diagnosis, management and follow-up of patients with immune and allergic disorders even when the clinical lead is taken by secondary care or a community clinical nurse specialist. It is also important to understand the role of specialist allergy services and when it is appropriate to access their expertise.

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Management of chickenpox contact in pregnancy 
  • Indications and contraindications to routine immunisation in an immunosuppressed child 
  • Management of urticaria

Clinical Skills Assessment (CSA)

  • A young woman is concerned that her lifestyle may have put her at risk of HIV and requests testing 
  • A parent requesting allergy testing for their child with eczema
  • A woman who works as a beautician with suspected contact dermatitis from cosmetic products

Workplace-based Assessment (WPBA) 

  • Consultation Observation Tool (COT) about having to explain anti-D immunisation to a pregnant patient who has not understood the hospital specialist’s explanation 
  • Audit of the practice data on the appropriateness of prescribing adrenaline devices for patients at risk of anaphylaxis  
  • Reflective learning log entry about safety advice for a parent of a child with severe peanut allergy 
  • CEPS about administration of seasonal flu immunisation 

Cardiovascular health

This Topic Guide will help you understand important issues relating to cardiovascular health by illustrating the key learning points with a case scenario and questions.

The role of the GP in cardiovascular health

As a GP, your role is to: 

  • Manage the risk factors for cardiovascular disease as an essential part of health promotion activity in primary care. You should be able to describe the key research findings that influence management of cardiovascular risk and disease. A large part of our work in primary care involves working with patients to engage them in making healthy life style choices, and limiting unhealthy behaviours 
  • Communicate the risk of cardiovascular disease clearly and effectively in a non-biased manner, and use disease registers and data-recording templates effectively for opportunistic and planned monitoring 
  • Manage cardiovascular emergencies in primary care 
  • Accurately diagnose and manage symptoms that may potentially be caused by cardiovascular conditions  
  • Monitor and manage the care of patients with long-term cardiovascular conditions such as hypertension, chronic heart failure or atrial fibrillation 
  • Be aware of the impact that cardiovascular disease may have on disability and fitness to work, as well as the legal obligations relating to driving. You should also be able to recognise the cultural significance attached to heart disease 
  • Be aware of the potential psychological and social impact of cardiovascular conditions 
  • Advise on cardiovascular screening, such as the UK Aortic Aneurysm screening programme. 

Emerging issues in cardiovascular health

Cardiovascular disease (CVD) causes more than a quarter of all deaths in the UK; coronary heart disease (CHD) is the UK's single biggest killer, and around 40,000 people die each year in the UK from stroke. There are also considerable variations in mortality throughout the UK: early deaths from CVD (before the age of 75) are most common in the north of England, central Scotland and the south of Wales, and lowest in the south of England. A very significant number of people are living with cardiovascular disease in the UK, affecting equal numbers of men and women. As the population ages and grows and with improving survival rates from cardiovascular events it is likely that the number of people affected by cardiovascular disease will rise. 

GPs are involved in coordinating and commissioning care to provide appropriate acute and chronic disease management for patients at all stages of cardiovascular disease.  You should be able to describe the key government policy documents that influence healthcare provision for cardiovascular problems. 

Other emerging issues in cardiovascular health:

For example: 

  • Defining and measuring overall cardiovascular health 
  • Assessing and communicating lifetime risk for cardiovascular disease 
  • Addressing depression as a risk factor for and associated condition of heart disease and stroke 
  • Examining cognitive impairment due to cardiovascular disease 
  • Improving the cardiovascular surveillance system. 

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic
  • The prevalence and incidence across all ages and any changes over time
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of ‘alarm’ or ‘red flag’ features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis 

Symptoms and signs 

  • Cardiac murmurs 
  • Chest pain (including factors suggestive of cardiac origin) 
  • Circulatory symptoms of ischaemia, thrombosis, chronic arterial and venous insufficiency 
  • Dyspnoea 
  • Oedema: peripheral and central 
  • Palpitations and arrhythmias 
  • Syncope, dizziness and collapse including non-cardiovascular causes 
  • Symptoms and signs of stroke/Transient Ischaemic Attack (TIA). 

Common and important conditions 

  • Acute cardiovascular problems including cardiac arrest, acute coronary syndrome, acute myocardial infarct, acute left ventricular failure, dissecting aneurysms, severe hypertension and life-threatening arrhythmias, cardiogenic shock, acute ischaemia of limbs and gut, TIA and stroke 
  • Arrhythmias including conduction defects such as atrial fibrillation and flutter, heart block, supraventricular tachycardia, ventricular rhythm abnormalities
  • Cardiovascular conditions for which anticoagulation may be relevant such as Atrial Fibrillation (AF), myocardial ischaemia, peripheral vascular disease and TIA/stroke (including heparin, thrombolysis indications, oral anticoagulation)
  • Cardiomyopathies: primary and acquired, including dilated, hypertrophic obstructive 
  • Cerebral disease for which cardiovascular risk factors are important e.g. stroke, vascular dementia (see also Topic Guide 4.17 Neurology) 
  • Circulation disorders including: 
    • arterial problems such as peripheral vascular disease, vasculitis, aneurysms (cerebral, aortic and peripheral); and
    • venous problems such as venous thromboembolism, pulmonary embolism, Raynaud’s disease, varicose veins, venous and arterial ulcers
  • Congenital heart disease such as coarctation of the aorta, Ventricular Septal Defect (VSD), Atrial Septal Defect (ASD), Patent Ductus Arteriosus (PDA) and presentation of these both in children and adults 
  • Coronary heart disease including complications such as mural thrombus, ventricular aneurysm, and rhythm disturbance 
  • Drug-induced heart disease (e.g. secondary to cancer treatment with chemotherapy/ radiotherapy, recreational drugs) 
  • Heart failure: acute and chronic including left ventricular dysfunction, right heart failure, and cor pulmonale 
  • Hypertension: essential (and its classification into stages), secondary, and malignant 
  • Infections such as viral myocarditis, infective endocarditis, pericarditis, rheumatic fever and complications 
  • Complications and malfunction of pacemakers relevant to primary care
  • Pulmonary hypertension: primary and secondary to underlying causes such as fibrotic lung disease and recurrent pulmonary emboli 
  • Risk factors for coronary heart disease and other thromboembolic diseases such as lipid disorders, diabetes, hypertension 
  • Valvular problems such as mitral, tricuspid, pulmonary and aortic stenosis and regurgitation. 

Examinations and procedures 

  • Cardiovascular system examination 
  • Blood pressure monitoring 
  • Pulse oximetry 
  • Use of emergency equipment, including defibrillator, and oxygen delivery
  • Emergency cardio-pulmonary resuscitation

Investigations 

  • Knowledge and application of current risk assessment tools such as CHADSVASC and HASBLED for atrial fibrillation, QRISK/ASSIGN for Coronary Heart Disease
  • Relevant blood investigations such as cardiac enzymes, natriuretic peptides, or D-dimer
  • Secondary care interventions such as coronary angiography and stents, perfusion scanning, and CT scans 
  • Specific cardiac investigations including home and ambulatory BP monitoring, electrocardiogram (ECG), exercise ECG, 24 hour and event monitoring ECGs, echocardiography, venous dopplers and Ankle Brachial Pressure Index (ABPI) measurement

Service issues

  • Cardiovascular health screening, including abdominal aortic aneurysm screening, blood pressure, cholesterol and glucose checks 
  • Local service provision for cardiovascular healthcare 
  • Disease registers and data-recording templates for opportunistic and planned monitoring of cardiovascular problems to ensure continuity of care between different healthcare providers 
  • Effective and appropriate acute and chronic disease management – including medication, prevention, rehabilitation and palliative care for those with end-stage cardiac failure
  • Recognition of the social determinants of health in relation to cardiovascular disease 
  • Current population trends in the prevalence of risk factors and cardiovascular disease in the community 
  • Cardiovascular rehabilitation after a stroke or cardiac event 
  • Appropriate support services nationally and locally (for example, smoking cessation and weight loss) 
  • Safe prescribing, including indications for and monitoring of commonly used drugs such as antihypertensive drugs, anticoagulants and statins
  • Management of polypharmacy, which is common in patients with cardiovascular problems. 

Case discussion

Mr Black is a 58-year-old bus driver who presents to your clinic with a history of central chest pain radiating to the left arm. This occurs on exertion and is relieved by rest. It started about one month ago and has not got any worse. 

He has no history of hypertension, diabetes or hyperlipidaemia that you are aware of, but he rarely visits the practice. He smokes. There is no family history of ischaemic heart disease, but his mother developed diabetes from the age of 65. 

On examination, he is comfortable. His blood pressure is 155/95 with a pulse rate of 85 b.p.m. and regular. His BMI is 32 kg/m². 

[Example adapted from C. Heneghan in Cardiovascular Disease in Primary Care - a guide for GPs, RCGP Publications, 2010.]  

Questions 

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.  

                       Core Competence           
                      Questions                   

Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 

 

 

How important is it for me to model healthy living for my patients?

What actions can I take to help promote an organisational culture in which the health of the members is valued and supported?  

How well am I balancing work and life?  

Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 

 

 

How might cardiovascular disease prevention vary in different cultures and sexes? 

Should overweight smokers be offered open access to treatment if they do not lose weight or stop smoking? 

Communication and consultation
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 

 

 

 

 
How would I go about explaining cardiovascular risk to this patient? 

How could I influence a change in Mr Black’s lifestyle? 

How would I explore this patient’s ideas, concerns and expectations? 

 

Data gathering and interpretation
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 

 

 

What additional information do I need? 

If I have access to same day ECG, how confident am I at interpreting it? 

Would blood tests be useful? Which ones?  
Clinical Examination and Procedural Skills 
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills.  
How well can I assess and manage a patient presenting with acute breathlessness due to LVF? 

Making decisions
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 

 

 

What is my differential diagnosis? 

What drug treatment might I suggest for Mr Black? 

How does the prevalence of cardiovascular disease vary within the UK population?  

Clinical management
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 

 

 

What are the national guidelines for diagnosis and longer-term treatment in this case? 

What would be the key features of my safety-netting conversation with Mr Black? 

What advice would I give him about smoking cessation? 

Managing medical complexity  
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 

 

 

How would I manage his multiple risk factors at this initial consultation? 

What can I do to help manage the risk in this patient? 

What are the criteria for referral to secondary care and what would I include in my referral letter? 

Am I familiar with the DVLA guidance on fitness to drive? 

Working with colleagues and in teams  

 

 

 

This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

How might other members of the practice team be involved in the care of this patient? 

What rapid access clinics are available locally? 
Improving performance, learning and teaching
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
How do I keep up to date with developments in cardiovascular health?  

What learning opportunities does this case present for me?  

What quality improvement could I consider for patients with Ischaemic Heart Disease at my practice? 
Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
How do I record cardiovascular risk on my IT system? 

What Read code might I use for this patient?  

What computerised resources might I use in the consultation with Mr Black?  

Practising holistically, safeguarding and promoting health
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

 

 

 

How do I take my patients’ occupations into account when assessing, managing and advising them? 

What are his home circumstances? What would I advise him about having sex? What about driving and fitness to fly? 

What patient information resources are available? 

What are the social and psychological impacts of Mr Black's cardiovascular problems on his friends and dependants? 

How would I address the cultural significance of the heart as a seat of emotions? 
Community orientation
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 
What community resources are available for cardiovascular disease prevention in my area? 

Are there any important characteristics of the local community that might impact on patient care, particularly the epidemiological, social, economic, and ethnic features? 

How to learn this area of practice

Work-based learning 

General practice is an excellent place for you to learn how to manage cardiovascular problems. Patients will present with a wide range of symptoms, and at varying stages in the natural history of their illness. Critical, professional discussions with your trainer will help specialty trainees to develop problem-solving skills. Supervised practice will also give trainees confidence.  

In particular, the GP specialty trainee should be able to learn about risk factor management and gain experience in the management of cardiovascular problems as they present (acute and chronic), including emergencies. Primary care is also the best place to learn about cardiovascular chronic disease management (including angina, heart failure, hypertension, post-myocardial infarction (MI), peripheral vascular disease and stroke).  

The acute hospital setting is a good place to learn about management of cardiovascular emergencies including acute coronary syndrome (ACS), MI, stroke and aortic aneurysms. This could be in a variety of secondary care placements including cardiology, emergency medicine or general medicine. Some GP specialty training programmes have placements of varying lengths with cardiologists; here, you may also get the opportunity to become familiar with the invasive management of cardiovascular problems: angioplasty, coronary artery bypass grafts, transplantation, other forms of vascular surgery (carotid endarterectomy, vascular bypass), many of which you are likely to have to discuss with your patients in primary care during your career.  

Cardiovascular care is increasingly delivered via specialist community clinics where trainees may have the opportunity to observe the investigation and management of common cardiovascular problems and familiarise themselves with local care pathways. Outpatient or clinic settings are ideal places for seeing concentrated groups of patients with cardiovascular problems. They also provide you with opportunities to learn about secondary care investigation of cardiovascular problems (exercise tests, radionucleotide scans, MRI/CT, carotid dopplers, angiography and echocardiography).   

Self-directed learning 

You can find e-Learning module(s) relevant to this Topic Guide at e-Learning for Healthcare

Many postgraduate deaneries provide courses on cardiovascular problems. Other providers include universities and the Royal College of General Practitioners. There is a growing e-Learning resource to help you consolidate and build on the knowledge you have gained in the workplace. This includes NHS Evidence Search which provides access to information on a wide variety of topics including chest pain, stroke, hypertension, chronic kidney disease, deep vein thrombosis etc. You can learn about patients’ experiences of living with cardiovascular problems, from early symptoms to diagnosis and management, through the wide range of multimedia clips at Healthtalk

Learning with other healthcare professionals 

Chronic disease management in primary care is a multidisciplinary activity. As a specialty trainee it is important for you to attend nurse-led cardiovascular disease annual review assessments in practice and gain an understanding of the follow-up of hypertensive patients in the practice’s clinics that are often led and delivered by a practice nurse. It is also important to understand the role of district nurses in the assessment and management of leg ulcers or ankle oedema by attending their clinics or home visits. You should also take the opportunity to observe cardiovascular rehabilitation programmes led by physiotherapists. 

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT) 

  • Interpreting ECG tracings 
  • Adverse drug effects of anti-hypertensives 
  • Genetics of familial hypercholesterolaemia

Clinical Skills Assessment (CSA) 

  • Man is concerned that he may have heart disease having experienced chest pain when he exercises at the gym 
  • Woman with well-controlled heart failure has increasing exertional dyspnoea over the past fortnight 
  • Father is concerned about sudden death in young athletes and requests a routine ECG for his 12-year-old son who has joined a running club.

Workplace-based Assessment (WPBA) 

  • Learning log reflecting on having to explain a pacemaker to a patient who has not understood the consultant’s explanation 
  • Log entry about the logistics and value of the practice coronary heart disease clinic
  • Consultation Observation Tool (COT) about advice for a man requesting a calcium score after a private medical examination when you are unsure about the evidence for this 
  • CEPS about performing CPR on a collapsed patient. 

Dermatology

This Topic Guide will help you understand important issues relating to dermatology by illustrating the key learning points with a case scenario and questions.

The role of the GP in dermatology

As a GP, your role is to: 

  • Diagnose, treat and advise on common skin conditions efficiently 
  • Recognise the importance of the psychosocial impact of skin problems 
  • Prescribe appropriately and safely  
  • Appreciate the complexity of care that is needed with some skin problems 
  • Share management with secondary care where needed

Emerging issues in dermatology

  • The effect of an ageing population and increased exposure to sun damage in an older population 
  • The increased prevalence of aesthetic surgery  
  • Biological treatments for chronic skin conditions

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care:  

  • The natural history of the untreated condition including whether it is acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic, environmental and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of ‘alarm’ or ‘red flag’ features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis 

Symptoms and signs 

These include: 

  • Birthmarks 
  • Blisters 
  • Dry skin and scaling 
  • Erythema 
  • Hair loss and hirsutism 
  • Hyperhidrosis 
  • Hyper-, hypo- and depigmentation 
  • Lichenification 
  • Nail dystrophies 
  • Pruritus 
  • Purpura, petechiae 
  • Pustules, boils 
  • Rashes and eruptions 
  • Scaly and itchy scalp 
  • Skin lesions, including dermal and subcutaneous lesions 
  • Ulceration including leg ulcers and pressure sores 

Common and important conditions 

  • Acne rosacea, rhinophyma, perioral dermatitis 
  • Acne vulgaris including indications and side effects of isotretinoin 
  • Blistering diseases including pemphigoid, pemphigus, porphyria 
  • Dermatological emergencies such as Stevens-Johnson syndrome, toxic epidermal necrolysis, erythroderma and staphylococcal scalded skin syndrome 
  • Eczema: infantile, childhood, atopic, seborrhoeic, contact allergic, irritant (including occupational), discoid 
  • Hair disorders including alopecia, hirsutism, fungal infection, infestations including lice 
  • Hidradenitis suppurativa 
  • Hypopigmentation (for example, Vitiligo) and hyperpigmentation (for example, acanthosis nigricans) 
  • Infections: viral (for example, warts, molluscum contagiosum, herpes simplex and zoster), bacterial (for example, staphylococcal + MRSA, streptococcal), fungal (for example, skin, nails), spirochaetal (for example, Lyme disease, syphilis), TB, infestations (for examples, scabies, lice), travel-acquired (for example, leishmaniasis)
  • Lichen simplex, lichen planus, granuloma annulare, lichen sclerosus, morphoea 
  • Light sensitive disorders such as polymorphic light eruption, porphyria, drug reactions 
  • Light treatments such as UVB, PUVA 
  • Pityriasis rosea and Pityriasis versicolor 
  • Pruritus either generalised or localized, including underlying non-dermatological causes (for example, thyroid disease, iron-deficiency, pregnancy etc.) 
  • Psoriasis: plaque, guttate, flexural, scalp, nails, pustular and erythrodermic. Associated morbidity; physical such as cardiovascular disease and psychological such as depression 
  • Seborrhoeic keratosis 
  • Skin manifestations of psychiatric conditions such as dermatitis artefacta, trichotillomania 
  • Skin manifestations of internal disease including pyoderma gangrenosum, systemic lupus erythematosus (SLE), discoid lupus erythematosus (DLE), necrobiosis lipoidica, erythema nodosum, erythema multiforme, dermatitis herpetiformis, dermatomyositis, vitamin and mineral deficiencies such as scurvy 
  • Skin tumours including: 
    • benign lesions (for example, pigmented naevi, dermatofibroma, cysts)
    • malignant lesions (for example, malignant melanoma, squamous cell carcinoma, basal cell carcinoma, mycosis fungoides, Kaposi’s sarcoma, metastatic tumours); and 
    • lesions with malignant potential (for example, solar keratoses, Bowen’s disease, cutaneous horns and keratoacanthomas) 
  • Ulcers and their causes – for example, arterial, venous, neuropathic, pressure, vasculitic, malignant 
  • Urticaria, angio-oedema and allergic skin reactions including adverse drug reactions 
  • Wounds (for example, burns and scalds), scar formation and complications

Examinations and procedures 

  • Common terminology used to describe skin signs and rashes (for example, macule, papule) 
  • Examination of the rest of the skin, nails, scalp, hair, and systems such as joints, where appropriate (for example, psoriasis) 
  • The need to recognise skin conditions across a range of skin types

Investigations 

  • Skin and nail sampling, immunological tests including patch and prick testing, biopsy, photography and dermoscopy 
  • Relevant blood tests for underlying causes of skin conditions (for example, lupus, thyroid disease)

Service issues 

  • Dermoscopy: indications, availability in practice, when to refer  
  • Waiting times for local specialist services 
  • Role of and access to other health professionals (for example, dermatology specialist nurses, tissue viability nurses, podiatrists)

Case discussion

Jane Smith is 36 years old. She is a teacher and lives with her long-term partner. They have two daughters, aged ten and eight. She suffers from psoriasis, has borderline hypertension and a high BMI (31 kg/m2).  She smokes 20 cigarettes a day as does her partner. As you are the whole family’s GP, you are aware that their relationship has been unhappy from time to time.   

She has tried steroid creams of varying potency and more recently she has been using a vitamin D analogue ointment but finds this quite ‘irritant’ and so has abandoned it. She has previously had light therapy but tells you that a further course would be very inconvenient as she works all week.   

You ask her how having psoriasis makes her feel and she bursts into tears. ‘No one has ever asked me that before,’ she says. Jane feels that her psoriasis looks awful and she is conscious that she leaves a trail of skin scales wherever she goes. She refuses to take her daughters swimming and is so unhappy about exposing her body that she cannot get undressed in front of her partner. They have not made love for years. Recently she struggled to hide her tears when her daughter said, ‘Why do you never wear pretty skirts like my friend Kirsty’s mum?’ 

Questions 

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive. 

                      Core Competence             
                  Questions                              
Fitness to practise  
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
How do my own values and experiences influence my attitudes to treating skin problems?  

How hard should I work to help Jane if she seems unmotivated? 
Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for diversity.
How can I balance my patients’ needs with the availability of commissioned services? 

How can I maintain confidentiality between members of the same family who are all patients at the surgery? 
Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 
What further questions would I ask to explore Jane’s ideas, concerns and expectations? 

How might I help Jane to develop her own motivation to lose weight or stop smoking? 
Data gathering and interpretation  
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 
What tools could I use to measure severity (e.g. DLQI / PDI)? 

Given the increased cardiovascular (CV) risk in patients with psoriasis, what tests/examinations could I perform to get an objective idea of her overall CV risk (e.g. Qrisk2)?  

How would I explain this risk to Jane in a way which she could understand easily? 
Clinical Examination and Procedural Skills
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills.
What other body systems would I examine in this case, and what would I be looking for? 
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
 Am I confident I can diagnose psoriasis and distinguish it from other common skin conditions?  

Am I confident that I would know when to step up or step down treatment? 
Clinical management 
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 
What topical treatments might I prescribe for the various affected areas? 

How would I approach discussions about the inheritance of psoriasis? 
Managing medical complexity  
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 
Should I consider referring her for consideration of oral second-line therapies (e.g. methotrexate / ciclosporin)? 

If so, what advice would I give prior to referral (noting that she is a smoker and has borderline hypertension)? 

If her treatment is going to be topical, how is she going to treat her back and other hard to reach places? 
Working with colleagues and in teams
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

What resources might be available in the primary health care team to help me manage this patient?  

Are there any other members of the team who could help? 

Are there any services I could signpost Jane to which might offer help with her relationship? 

Improving performance, learning and teaching  
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
How could I design a quality improvement project in my surgery around psoriasis? 

What advice would I give regarding the use of topical steroids in psoriasis? 
Organisational management and leadership 
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
 What advice might I give about a pre-payment prescription? 

How can I record the distribution of her psoriatic plaques on the computer software? 
Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 
Jane is a smoker. Should I use this opportunity to discuss this with her? 

What is the additional risk of chronic, moderate or severe psoriasis accelerating atherosclerosis? How will I discuss CVS risk factors? 

What might be the potential differences between my agenda as the doctor, and Jane’s agenda as the patient? 
Community orientation  
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 
Do we provide sufficient support in the community for lifelong dermatological conditions? 

When I look around my environment, what things do I see that promote or discourage good skin health? 

What are the attitudes of society to people with skin conditions?  

How to learn this area of practice

Work-based learning 

Skin diseases are common, and many are chronic. They will therefore form a large part of your work as a GP. The patient is likely to be an expert on their own skin and can often tell you a lot about their condition. It can be helpful to develop a ‘longitudinal consultation’ by inviting the patient to come back to discuss their skin problem.  

It is very easy to fall into the trap of dismissing many skin diseases as trivial (acne, for example), but patients often tell us that they have difficulty raising the issue of their skin problem, even with a health professional.  The truth is that it can have a considerable impact on their lives and their psychosocial wellbeing. Recognising this and treating the condition well and sensitively makes an enormous difference. 

Consider discussing with practice members referrals that are made to dermatology specialists by yourself and your colleagues to establish what exactly you and your patients are hoping to achieve from the referral. Review your referral again after the patient has been seen to decide whether the same benefit might have been achieved from resources available in primary care. 

Consider arranging a Patient Satisfaction Questionnaire (PSQ) for patients with eczema or psoriasis in order to review your delivery of care. An annual Dermatology Life Quality Index (DLQI) assessment takes less than a minute to complete and would demonstrate to your patient that you are interested in the possible detrimental effect of their disease on their quality of life.  

Also consider regularly auditing your patients who are on repeat prescriptions for psoriasis treatments. Have you considered whether they might have psoriatic arthritis, that they have previously dismissed as ‘wear and tear’? 

Attending community-based and GPwSI clinics can provide valuable learning opportunities. You can also reflect on each case and ask yourself: ‘Why was referral deemed necessary and what value-added input has the specialist provided?’ 

Self-directed learning 

Dermatology is high on the learning needs of most GP specialist trainees. As a result, you will find that talks on the subject are regularly included in many continuing education programmes. The Primary Care Dermatology Society’s (PCDS) mission is to educate and disseminate high standards of dermatology in the community. They run a regular series of ‘Essential Dermatology’ days up and down the country, as well as educational events on minor surgery and dermoscopy (i.e. skin surface microscopy for increasing the accuracy in diagnosing both pigmented and non-pigmented lesions). Other excellent resources and leaflets are available on the British Association of Dermatologists website (www.bad.org.uk ). DermNet NZ is an excellent source for pictures and information on a wide range of skin problems (www.dermnetnz.org ).  

At the time of writing, Cancer Research UK have developed a skin cancer tool kit with multiple images of suspected lesions and links to resources (www.cancerresearchuk.org). 

Learning with other healthcare professionals

Experienced GPs will have seen a lot of skin disease, so ask them for their thoughts. Our nursing colleagues too are a reservoir of knowledge. As well as dermatology nurse specialists, health visitors and district nurses also have valuable dermatological knowledge. 

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Recognition of a malignant skin lesion from photographs 
  • Management of psoriasis 
  • Differential diagnosis of alopecia 

Clinical Skills Assessment (CSA)

  • A woman who has patchy hair loss and was advised to attend by her hairdresser (patient will provide photograph) 
  • A man with dark skin has dry itchy skin with areas that have become darker and roughened (patient will provide photograph) 
  • A waiter with excessive sweating on palms and axillae affecting his work

Workplace-based Assessment (WPBA)

  • Consultation Observation Tool (COT) about a teenager with moderately severe acne 
  • COT about a mother whose baby has widespread infantile eczema 
  • Audio COT with a woman who has a rash which she thinks looks like Lyme disease following a weekend camping

Ear, nose and throat, speech and hearing

This Topic Guide will help you understand important issues relating to ear, nose, throat and mouth problems by illustrating the key learning points with a case scenario and questions.

The role of the GP in the care of people with ENT and mouth problems

As a GP, your role is to: 

  • Identify symptoms that fall within the range of normal or are caused by self-limiting conditions.
  • Know the epidemiology and understand how to recognise oral, head and neck cancers including the risk factors, and identify unhealthy behaviour as well as being able to refer appropriately 
  • Offering smoking cessation advice and treatment 
  • Ensure that a patient's hearing impairment or deafness does not prejudice the information communicated or your attitude as a doctor towards the patient, and be able to communicate effectively 
  • Promote the benefits of early intervention to ensure people who need hearing aids get the most out of them 
  • Perform effective assessment including conducting or interpreting more detailed tests (for example, audiological tests, the Dix–Hallpike test) and treatment including procedures (for example, nasal cautery and ear wax removal) where indicated 
  • Demonstrate empathy and compassion towards patients with ENT symptoms that may prove difficult to manage for example, tinnitus, facial pain, unsteadiness, hearing loss. 

Emerging issues in the care of people with ENT and mouth problems

  • Guidelines for appropriate management are now widely available but not always used 
  • Management of patient expectations of the role of antibiotics and using an evidence-based approach to antibiotic prescribing  
  • Head and neck cancer rates are increasing, and outcomes depend on early diagnosis 
  • High levels of undiagnosed hearing loss; many more people could benefit from hearing aids than are currently doing so 
  • E-cigarettes are being increasingly used to aid smoking cessation. Ongoing research into the safety of e-cigarettes and their use for smoking cessation is underway. As a GP you should be aware of the latest evidence and guidance on e-cigarettes, and smoking cessation more generally, and use your clinical judgement on an individual patient basis 

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socioeconomic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis 

Symptoms and signs 

  • Symptoms within the normal range which require no treatment, such as small neck lymph nodes in healthy children and ‘geographic tongue’ 
  • Cough 
  • Deafness and the differentiation of types of hearing loss, including sudden hearing loss 
  • Dental symptoms relevant to general medical practice 
  • Disturbance of smell and taste 
  • Earache and discharge 
  • Epistaxis 
  • Facial dysfunction: sensory and motor 
  • Facial pain 
  • Head and neck lumps 
  • Hoarseness 
  • Jaw pain 
  • Rhinitis and nasal obstruction 
  • Salivation problems including swelling and obstruction of glands, excessive and reduced salivation 
  • Sore throat and mouth 
  • Sore tongue and changes in taste 
  • Tinnitus 
  • Vertigo and dizziness 
  • Snoring and sleep apnoea

Common and important conditions 

  • Aesthetic and reconstructive surgery and botulinum toxin therapies  
  • Congenital abnormalities (for example, cleft palate/lip, absent pinna, neck lumps) 
  • Cranial nerve disorders such as Ramsay-Hunt syndrome, Bell's palsy, trigeminal neuralgia, ototoxicity secondary to drugs 
  • Dental problems presenting in general medical practice (such as abscesses); dental disease due to underlying medical causes (such as anorexia, xerostomia, drug-induced) 
  • Disorders of the salivary glands such as infection (for example, mumps), salivary duct stones, connective tissue diseases (for example, Sjögren's syndrome), tumours (for example, adenoma, lymphoma) 
  • Ear disorders: earache and discharge including otitis externa, otitis media with and without effusion, perforation of the ear drum, barotrauma, cholesteatoma, mastoiditis, disorders affecting the skin of the pinna such as infection, eczema, psoriasis, solar damage and malignancy and affecting the cartilage such as injuries and polychondritis 
  • Emergency treatments such as tracheotomy  
  • Epidemiology of rarer but potentially serious conditions such as oral, head and neck cancer, taking into account risk factors, and unhealthy behaviour  
  • Head and neck malignancies including laryngeal, nasopharyngeal, sinuses, salivary glands, tongue, lips and oral cavity, tonsillar including lymphomas, unidentified malignancies presenting with lymphadenopathy 
  • Hearing aids and cochlear implants, tinnitus maskers 
  • Hearing problems including deafness such as occupational, presbyacusis, otosclerosis, tinnitus and associated speech or language disorders  
  • Increasing incidence of hearing loss in certain groups, such as people with learning disability or dementia 
  • Nasal problems including perennial and allergic rhinitis, postnasal drip, adverse drug effect, polyps and other causes of nasal obstruction, epistaxis, trauma, foreign bodies, septal deviation 
  • Oral problems including pain (for example, ulceration, lichen planus), infections (for example, gingivitis, herpes simplex, candidiasis), pre-malignant conditions (for example, leukoplakia), malignancies (including tonsils, tongue, lips and buccal mucosa) 
  • Sinus problems including acute and chronic infection, polyps, allergic rhinosinusitis, barotrauma 
  • Throat problems such as infections, globus, pharyngeal pouch or gastroesophageal reflux causing a cough 
  • Tracheotomy management in primary care 
  • Vertigo: central (for example, brainstem stroke) and peripheral (for example, benign paroxysmal positional vertigo, vestibular neuronitis, Ménière's disease, acoustic neuroma).  Factors differentiating vertigo from dizziness and lightheadedness
  • Vocal disorders such as hoarseness, dysphonia, aphonia and underlying causes (for example, vocal cord nodules, laryngeal nerve palsy). Associations with smoking, occupation and environmental factors. 

Examinations and procedures

  • Otoscopic appearances of the normal and abnormal ear 
  • Tests of hearing such as tympanometry, audiometry, tuning fork tests including Weber's and Rinne's, neonatal and childhood screening tests 
  • Detailed tests where indicated (for example, audiological tests and the Dix–Hallpike test to help diagnose benign paroxysmal positional vertigo (BPPV)) 
  • Skills which can be used in primary care to effect a cure when indicated (for example, nasal cautery, ear wax removal and the Epley manoeuvre).

Investigations 

  • Audiology testing 
  • X ray, USS, CT and MRI scans  
  • Endoscopy 
  • Sleep studies

Service issues 

  • ENT, oral and facial symptoms may be manifestations of psychological distress, for example, globus pharyngeus, atypical facial pain, burning mouth syndrome 
  • National paediatric screening programme for hearing loss. Effects of ENT pathology on developmental delay, for example, 'glue ear' can impair a child's learning 
  • Pathology in other systems may lead to ENT-related symptoms. Examples include gastro-oesophageal reflux disease (GORD) and cerebrovascular accident (CVA). Systemic disease such as haematological, dermatological and gastrointestinal problems may present with oral symptoms, for example, glossitis caused by iron deficiency anaemia 
  • Referral criteria and pathways for patients with dental or gingival problems to their general dental practitioner or local community dental services. Access to specialist services in oral medicine or oral and maxillofacial surgery for patients with oral disease  
  • The impact of hearing loss on quality of life, the relationship between hearing loss and other long-term conditions (for example, dementia) and community and cultural attitudes to deafness. 
  • The need to equip the primary care working environment to ensure people who are deaf or have hearing loss, or speech impairment, can contact and access GP services in an accessible way and communicate effectively in waiting areas and consultation rooms 
  • Community-specific aspects of oromucosal disease related to lifestyle (for example, chewing paan, tobacco, betel nut, khat/qat, or reverse smoking). Smoking cessation services
  • Influence of socio-economic status (especially vulnerable populations such as the homeless) on rates of head and neck malignancy 
  • Highly specialised and regionally based services such as the provision of cochlear implants 
  • Relevant local and national guidelines, including fast track referral guidance for suspected cancer. 

Case discussion

Mark Johnson is a 25-year-old trainee solicitor who presents with persistent nasal obstruction, runny nose, watery eyes and regular sneezing. The problem is perennial and has been getting worse for years. He also has asthma. He has moved into a flat and has adopted a cat. The use of steroid sprays and antihistamines only marginally improves things and he tells you he is 'fed up with his symptoms' and says, 'something has to be done'. He requests an immediate referral to a specialist. Your examination reveals some form of swelling in the nose, more noticeable on the right than the left. 

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive. 

                       Core Competence        
                       Questions                
Fitness to practise  
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
How do I feel when a patient says, 'something has to be done'? 

Why is this patient presenting now? 

What do I think his ideas, concerns and expectations might be? 
Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for diversity. 
When should I refer? 

Would my decision to refer change if the patient had private health insurance? 
Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 
How do I feel about his demand for referral? How will I manage those feelings in the consultation? 

How might I deal with his frustrations and anger? 
Data gathering and interpretation 
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 
How can I determine if Mark has been compliant with treatment? 

How effective is allergy testing (PRIST, RAST or skin tests)? 

What triggers his symptoms? 
Clinical Examination and Procedural Skills 
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 
How do I determine whether the swellings in the nose are nasal turbinates or polyps or part of the normal nasal cycle?  
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
How could the history help to determine the cause of his symptoms?  
Clinical management  
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 
What are the options available in managing this patient in general practice? 

What is the optimal treatment (drug and dosage)? 

What are the current guidelines for reducing exposure to house dust mite?  
Managing medical complexity  
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 
How might Mark's asthma and nasal symptoms be linked? 
Working with colleagues and in teams  
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 
Who else might I involve in the management of this patient? 

If I refer him, what key features should go in the referral letter? 

Where can I direct Mark to further information about his condition? 
Improving performance, learning and teaching
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
Do I have sufficient knowledge of nasal anatomy to allow me to detect any abnormality? If not, how could I improve my knowledge?  

What is the evidence for effectiveness of common ENT treatments? 

What other resources do I need in my area? 
Organisational management and leadership 
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
How would I know from my IT system whether Mark has had a recent asthma review?  

What recall systems are in place? 

How can I check how frequently Mark has been getting any repeat medications? 
Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 
How might these symptoms affect Mark's ability to work and study, and his social life? 

What would I advise if he asks whether the cat could be contributing to his symptoms? 
Community orientation 
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 
What are the resource issues relating to providing care for allergies in the NHS? 

How to learn this area of practice

Work-based learning

As a GP specialty trainee, you will find the frequency of ENT-related symptoms in primary care makes this the ideal environment for you to learn the basics of history-taking and examination (including identifying what is 'normal'). It is not uncommon for a clinician (GP or other healthcare professional) to have developed additional expertise in ENT and working alongside such an individual can be very beneficial. Local ENT departments are usually very willing to have trainees sitting in outpatient clinics and taking time to arrange a regular session in such a clinic will provide you with invaluable experience. The experience will be enhanced if you can see patients initially and then discuss examination findings and potential management with your supervising colleague. The extensive use of endoscopes and microscopes will greatly facilitate your understanding of ENT pathology. In both scenarios always ask for feedback on cases and look to use structured assessment tools (available online) to document your learning. Make the most of opportunities to observe and discuss common conditions such as hearing loss with an audiologist or hearing therapist. 

The frequency of common oral-related symptoms in primary care and the limited undergraduate training in this area make it worth your while attending specialist clinics in oral medicine and oral and maxillofacial surgery. In these clinics you will learn how to examine the mouth, recognise and provide initial management of common oral conditions and appreciate the presenting features of oral cancer and pre-cancerous lesions.  

Self-directed learning 

You can find an e-Learning module relevant to this Topic Guide at e-Learning for Healthcare (e-lfh.org.uk ) 

It is not uncommon to come across friends and relatives with ENT conditions and this can give you an insight into the impact on quality of life of what may be regarded as 'trivial conditions'. Examples include general upper respiratory tract infections, allergic and non-allergic rhinitis, snoring and deafness. Indeed, as a primary care physician it is essential that you understand the effect of a significant hearing loss on an individual's way of life. It is also important that you understand its isolating effect and appreciate the statement that 'blindness separates an individual from objects; deafness separates an individual from people'. 

Learning with other healthcare professionals

As a GP trainee, gaining experience in other medical specialities will give you insight into dealing with common ENT and oral problems. In particular: 

  • Paediatrics – many children have ENT-related conditions which affect their general well-being and may compromise their education 
  • Medicine of the elderly – deafness and balance disorders are common 
  • Immunology – it is not uncommon for systemic allergy to present with symptoms and signs in the ear, nose, oral cavity or throat 
  • Dermatology – skin conditions affecting the face and scalp, and otitis externa, may present to skin specialists 
  • Respiratory medicine – it is important to understand that both the upper and the lower airway often need to be treated together 
  • Oral medicine and oral and maxillofacial surgery – understand that oral signs and symptoms may be a manifestation of underlying systemic disease 
  • Gastroenterology – gastro-oesophageal reflux disease causing coughing 
  • Hospital audiology clinics and hearing therapists
  • Hearing loss clinics in the high street – these increase access to a range of services.  

During your training, spending time with nurses who have ENT experience can be very rewarding. Dental surgeons also have training and experience in managing common oral conditions as well as dental disease, and their opinion is often helpful. 

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Recognition of oral cancer 
  • Natural history of glue ear in children 
  • Diagnosis of salivary gland swelling

Clinical Skills Assessment (CSA)

  • Older woman has severe shooting pains in her left lower jaw 
  • Hearing-impaired man has troublesome tinnitus interfering with his sleep and concentration 
  • Middle-aged woman has sudden-onset disabling rotational dizziness. Examination expected. 

Workplace-based Assessment (WPBA)

  • Log entry about the referral criteria for a child with recurrent tonsillitis and the evidence for tonsillectomy as an intervention 
  • Clinical Examination and Procedural Skills (CEPS) on examining a patient with unilateral deafness and the interpretation of the results 
  • Consultation Observation Tool (COT) about a singer with persistent hoarseness. 

Eyes and vision

This Topic Guide will help you understand important issues relating to eyes and vision by illustrating the key learning points with a case scenario and questions.

The role of the GP in the care of people with eye and vision problems

As a GP your role is to: 

  • Understand how visual loss and impairment is a significant cause of physical and psychosocial morbidity, which is a barrier to accessing healthcare. This can be overcome by appropriate rehabilitation for the visually impaired 
  • Co-ordinate access to community and secondary care services 
  • Undertake opportunistic health screening, ensuring that patients have regular eye tests and are referred appropriately and in a timely manner 
  • Recognise how sight loss can interfere with mobility and lead to social isolation and difficulty in communication (such as use of telephones or computers), as well as the impact of poor eye health on loss of confidence, mental health, activities of daily living, independent living and ability to work 
  • Take a focused history, examine, diagnose and treat common eye conditions and know when to refer to specialist care. 

Emerging issues in the care of people with eye and vision problems

Eye disease impacts significantly on GP consultations and has wider social and economic consequences. Treating eye problems and effective screening is having an impact on the numbers of those with sight loss but there is much more to be done.  

Caring for those with sight loss goes beyond knowing which referral pathway should be used. GPs need to know how to access rehabilitation low vision aid services, how to access help to continue to live independently, and how to make general practices and written information accessible for those with poor vision. 

Sight loss occurs in conjunction with other complications of multiple morbidity and can make other aspects of care (such as being able to take medication safely) more complicated. People who cannot see may lose their non-verbal communication skills, and this should not affect or prejudice your interactions with or attitude to them. Visual loss is a significant cause of physical and psychosocial morbidity, which can act as a barrier to accessing healthcare. Rehabilitation can help promote independence and reduce social problems as well as enable access to healthcare. 

In the UK, the prevalence of sight loss due to cataract, macular degeneration, glaucoma and diabetic retinopathy is increasing as the population ages. Difficulties with reading small print, cooking, mobility, taking medication and recognising faces may be missed unless a careful history is taken. Visual acuity, contrast sensitivity and visual fields may be affected. 

Knowledge and skills guide

Knowledge and skills guide 

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis 

Symptoms and signs 

  • Colour blindness, changes in colour vision 
  • Diplopia, squint and amblyopia 
  • Discharge from the eye 
  • Dry eyes 
  • Entropion/ectropion 
  • Epiphora 
  • Eyelid swellings 
  • Falls 
  • Orbital swellings 
  • Red eye: painful and painless 
  • Visual disturbance: complete/partial loss of vision, distorted vision, floaters, flashes 
  • Visual field disturbance

Investigations 

  • Performing and interpreting fundoscopy, visual acuity tests and results, red reflex testing, visual field tests, Amsler charts 
  • Interpreting tonometry, optician reports, and tests of colour vision 
  • Examining eyes for foreign bodies, and corneal staining with fluorescein 
  • Key blood tests (for example, for giant cell arteritis)

Common / important conditions 

  • Cataracts – congenital, acquired such as drug induced 
  • Colour blindness 
  • Congenital, neonatal and childhood eye problems, such as prematurity, congenital cataract, vitamin A deficiency 
  • Conjunctivitis including infectious causes (bacterial, viral, parasitic and chlamydial), and allergic causes  
  • Contact lens use including infections such as acanthamoeba, corneal damage 
  • Diabetic eye disease 
  • Disorders of tears and tear ducts such as dacrocystitis, sicca syndrome, epiphora, dry eyes
  • Disorders of the pupil such as Horner's syndrome, Holmes-Adie 
  • Dual sensory impairment and loss (vision and hearing) 
  • Episcleritis, corneal or dendritic ulcers, pterygium, pinguecula, corneal injury and erosions 
  • Eye trauma including penetrating trauma, corneal abrasions, chemical burns, contusions, hyphaema 
  • Eyelid problems such as blepharitis, ectropion, entropion, chalazion, Meibomian cysts, and styes 
  • Genetic eye problems such as retinoblastoma, retinitis pigmentosa 
  • Glaucoma – acute, closed angle and chronic open angle 
  • Intracranial pathology affecting vision 
  • Keratitis including association with other diseases such as rosacea, thyroid disease 
  • Keratoconus 
  • Loss of vision or visual disturbance; differential diagnoses and appropriate management including timescale of urgency 
  • Macular degeneration – age-related (wet and dry), drusen 
  • Malignancy such as retinoblastoma, lymphoma, melanoma 
  • Ophthalmic herpes zoster 
  • Ophthalmic manifestations of infections such as syphilis, TB, toxocariasis, toxoplasmosis 
  • Optic neuritis and neuropathy 
  • Orbital infections such as cellulitis, tumours 
  • Red eye – differential diagnoses and appropriate management including timescale of urgency 
  • Refractive error including myopia, hypermetropia, astigmatism 
  • Retinal problems including:  
    • atrophy
    • detachment
    • haemorrhage, exudates, blood vessel changes associated with systemic diseases, such as hypertension, diabetes, haematological diseases thromboses or emboli
    • tumours such as melanoma, neuroblastoma; and 
    • vascular lesions  
  • Squint – childhood and acquired due to nerve palsy, amblyopia, blepharospasm
  • Subconjunctival haemorrhage 
  • Systemic diseases with associated eye symptoms/signs, such as hypertension, diabetes, raised intracranial pressure, multiple sclerosis, sleep apnoea, giant cell arteritis 
  • The effect of stroke and migraine on vision 
  • Thyroid eye disease 
  • Uveitis including knowledge of underlying associations for example, inflammatory bowel disease, connective tissue diseases 
  • Vitreous detachment

Service issues 

  • Appropriate and cost-effective prescribing (for example, eye drops and biological therapies)  
  • Benefits of certification of visual impairments and how this enables access to benefits, and local authority assessment of need 
  • The level of visual deficit required before certification of visual impairment can be issued 
  • Guide dogs for the blind 
  • Liaison with other agencies and reminder systems to ensure appropriate follow up of eye conditions 
  • Local NHS guidance on funding for certain treatments (for example, cataract surgery) 
  • Relevant policies and legislation (including disability) 
  • Restrictions on driving and employment, including DVLA (Driver and Vehicle Licensing Authority) guidance for visual acuity 
  • Services available to those with vision problems; from acute hospital to community optician, support from charities and the third sector 
  • Types of low vision aids available (for example, large print, audio, magnifiers, long cane, or braille).  

Case discussion

It’s Monday morning and your second patient is Mr Khan, who is 75 years old. He was last seen six months ago regarding his problems with sleeping. He has lived alone since his wife died suddenly from a stroke three years earlier.   

Mr Khan is accompanied by his daughter, whom you have not met before. She tells you that her dad has asked her to come along as he is a bit upset since his visit to his optometrist last week. He states, ‘It was not the girl I usually see at the optician. This man flashed a lot of lights in my eyes then said I had a major problem with my vision and should come to see you about going to the hospital. What’s worse is that he said I shouldn’t drive my car.’ His daughter adds, ‘Dad was so upset he didn’t even ask what was wrong. His car is his lifeline. I went back with him to the optician and they told me he probably has something called ‘ARMD’ – he wrote it down for me.’   

He has no relevant previous history, he is not taking any medication and comes in regularly for his ‘flu jab and health checks with the nurse. He had noticed his vision was deteriorating but assumed this was because he needed new glasses; that was why he went for an eye check. He says, ‘I don’t go out at night any more as I can’t see well enough. I also noticed a funny thing – I can see the television better when I look from the side rather than from the front.’   

The optometrist noted a marked loss of visual acuity since his last eye examination and feels that this is likely to be due to age-related macular degeneration. You advise Mr Khan that you will refer him to the local eye department and print off some information regarding eye charities in large print, which he can read while he awaits his appointment.  

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.  

 

                           Core Competence        
 Questions
Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients.

How do I feel about telling Mr Khan that he must not drive his car? 

 

 

Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for diversity. 
What would I do if he drives the car against my advice? 

Communication and consultation
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters.

 

 

How can I explore the psychological impact of visual loss in the consultation with Mr Khan?  

How would I explain the likely outcome of his condition?  

What do I think might be the obstacles to Mr Khan having regular eye tests? How would I explore all those issues?                                             
Data gathering and interpretation 
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 
What lifestyle factors would I record in the notes? 

Clinical Examination and Procedural Skills
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills.

 

 

Why should I use a pin hole when assessing visual acuity? 

When is an Amsler grid useful in assessing a patient? 

How confident do I feel performing fundoscopy? How could I improve my clinical examination skills in this area? 
Making decisions
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
What other blinding eye conditions present with gradual onset? 
Clinical management  
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 
Which of my patients are entitled to free eye tests under the NHS?  

How easy is it to arrange for my patients to receive an eye test at home? 
Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 

What co-morbidities are common with sight loss? 

What are the risk factors for age-related macular degeneration (ARMD/AMD) and how common is it? 

What role has his bereavement played in this scenario? 

Working with colleagues and in teams
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

 

How urgent is this hospital referral? 

What role does an optician play in caring for patients with eye conditions? How can I collaborate with local opticians to provide a better service for my patients? Can I read the GOS (General Ophthalmic Services) letter from the optician and understand what the different terms mean? 

Improving performance, learning and teaching
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 

 

What are the current issues around treating age-related macular degeneration? 

How do I keep myself updated about ophthalmological conditions? 

How confident am I at using an ophthalmoscope? 
Organisational management and leadership 
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 
How should I ensure that my patients are not ‘lost to follow-up?’ 

What does the practice provide to support visually impaired patients? 

Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

How will I manage the psychological impact of sight loss in Mr Khan? 

Why do I think Mr Khan did not seek help earlier for the problems with his vision? 

What do I know about Mr Khan’s living accommodation? Will he need additional support at home? 

Community orientation 
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 

 

 

What social benefits and services might be available to this patient and his carers if he is certified visually impaired? 

Where do I find the DVLA rules on sight impairment and who is required to inform the DVLA?  

What other health professionals in the community could help in managing his vision problems?  

How to learn this area of practice

Work-based learning 

In general practice you can learn how to manage eye problems within the limited time and resources available. You should also take the opportunity to find out about other agencies, both statutory and voluntary, that provide support for patients with chronic eye disorders in the community. 

As a GP specialty trainee, you should try, if possible, to attend some secondary care-based ophthalmology clinics and/or eye emergency units, to learn about both acute and chronic conditions and how to conduct a thorough eye assessment. It would also be useful for you to attend an operating session to gain an understanding of cataract surgery, perhaps by accompanying a patient on his or her journey. 

Self-directed learning 

You can find an e-Learning module(s) relevant to this topic guide at Learning for Healthcare (e-lfh.org.uk)   

Royal National Institute of Blind People (RNIB) has an excellent web site www.rnib.org.uk with GP related resources. There is a helpful At a Glance downloadable booklet with DVLA guidelines on the current medical standards for fitness to drive www.dft.gov.uk/dvla/medical/ataglance.aspx and the Royal College of Ophthalmologists has a range of patient information booklets on common eye conditions at www.rcophth.ac.uk 

Learning with other healthcare professionals 

Optometrists are key members of the primary healthcare team and are increasingly involved in working in partnership with GPs in the management of diabetic patients and in screening for glaucoma and other eye problems. Meeting with them provides an excellent opportunity for discussing the impact of chronic eye problems, and issues of screening and prevention. As a GP trainee you should attend your local optometrist to gain a better understanding of their skills and their contribution to primary care teams. 

Structured learning 

Specific workshops may be run by local hospitals or RCGP Faculty, for example.

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT) 

  • Recognition of serious eye disease in a photograph 
  • Interpretation of visual field charts 
  • Management of glaucoma

Clinical Skills Assessment (CSA) 

  • Elderly man has a rapid deterioration in vision over the past month. Examination expected (Snellen charts supplied).  
  • Gardener has troublesome allergic conjunctivitis and hay fever despite using over-the-counter eye drops and antihistamine tablets.  
  • A schoolteacher presents with a painful eye and blurred vision. Examination (photo provided) suggests uveitis 

Workplace-based Assessment (WPBA) 

  • Log entry reflecting on the local optician who frequently requests hospital referrals for patients
  • Log entry about a tutorial on the ‘acute red eye’ and your subsequent management of the next three patients with this symptom 
  • Consultation Observation Tool (COT) about an elderly woman who has watering eyes. 

Gastroenterology

This Topic Guide will help you understand important issues relating to gastroenterology by illustrating the key learning points with a case scenario and questions.

The role of the GP in gastrointestinal health

As a GP, your role is to: 

  • Diagnose, investigate and manage digestive symptoms using history, examination, monitoring and referral where appropriate. Take into account how digestive symptoms can often be multiple and imprecise 
  • Communicate effectively and consider the social and psychological impact of digestive problems including the potential difficulties for some patients to discuss digestive symptoms due to embarrassment and / or social stigma 
  • Intervene urgently when patients present with emergencies related to digestive health 
  • Coordinate care with other organisations and professionals (including community nurses, pharmacists, drug and alcohol centres, secondary care and voluntary services) leading to effective and appropriate acute and chronic digestive disease management 
  • Offer advice and support to patients, relatives and carers regarding prevention, prescribing, monitoring and self-management (for example, lifestyle interventions including diet, weight loss, alcohol and drugs, stress reduction and primary cancer and liver disease prevention). 

Emerging issues in gastroenterology

Prevention and early treatment of colorectal cancer are priorities for the Department of Health. A national programme of screening for colorectal cancer is in place. Primary care has an important role regarding cancer risks and referrals, even though recruitment of patients and follow-up for screening are centrally co-ordinated.  

GPs should be aware of the increasing incidence of liver morbidity and mortality and the role of primary care in preventing liver disease, as well as new treatment approaches for patients with hepatitis and non-alcoholic fatty liver disease. 

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis 

Symptoms and signs

Many conditions such as liver disease are often asymptomatic in their early stages. Symptoms and signs include: 

  • Abdominal masses and swellings including ascites and organ enlargement such as splenomegaly and hepatomegaly 
  • Abdominal pain including the differential diagnoses from non-gastrointestinal causes (for example, gynaecological or urological) 
  • Bloating 
  • Bowel issues including constipation, diarrhoea, changes in habit, tenesmus and faecal incontinence  
  • Chest pain 
  • Cough 
  • Disturbance of smell and taste 
  • Dyspepsia, heartburn 
  • Dysphagia 
  • Hiccups 
  • Inflammation (for example, eyes, joint) 
  • Jaundice 
  • Mouth ulceration, erythroplakia, leukoplakia, salivary problems  
  • Nausea and vomiting including non-gastrointestinal causes 
  • Pruritus 
  • Rectal bleeding including melaena 
  • Regurgitation 
  • Vomiting including haematemesis 
  • Unexplained weight loss and anorexia 
  • Weight gain including obesity

Common and important conditions

  • Dyspepsia, gastro-oesophageal reflux disease (GORD), and Irritable Bowel disease (IBS) are common conditions, affecting a significant proportion of the population 
  • Chronic abdominal conditions: inflammatory bowel disease, diverticular disease, coeliac disease and irritable bowel syndrome  
  • Acute abdominal conditions: appendicitis, acute obstruction and perforation, diverticulitis, Meckel's diverticulum, ischaemia, volvulus, intussusception, gastric and duodenal ulcer, pancreatitis, cholecystitis, biliary colic, empyema and renal colic 
  • Medication effects: analgesics (codeine, NSAIDs, paracetamol), antibiotics (nausea, risk of c. difficile), proton pump inhibitors (potential masking of symptoms) 
  • Post-operative complications 
  • Hernias: inguinal, femoral, diaphragmatic, hiatus, incisional
  • Functional disorders: non-ulcer dyspepsia, irritable bowel syndrome, abdominal pain in children. 

Upper GI conditions 

  • Gastrointestinal haemorrhage including oesophageal varices, Mallory-Weiss syndrome, telangiectasia, angiodysplasia, Peutz-Jeghers syndrome  
  • Gastro-oesophageal reflux disease, non-ulcer dyspepsia, peptic ulcer disease, H. pylori, hiatus hernia 
  • Oesophageal conditions including achalasia, malignancy, benign stricture, Barrett's oesophagus, globus

Lower GI conditions 

  • Constipation: primary and secondary to other systemic diseases such as hypothyroidism, drug-induced, hypercalcaemia 
  • Diarrhoea 
  • Gastrointestinal infection including:  
    • toxins such as C. difficile and E coli
    • bacterial causes such as salmonella, campylobacter, amoebic dysentery
    • viral causes such as rotavirus, norovirus; and 
    • parasitic causes such as Giardia lamblia 
      (Note Sexually Transmitted Infections can also cause symptoms) 
  • Gastrointestinal malignancies including oesophageal, gastric, pancreatic, colorectal, carcinoid, lymphoma  
  • Inflammatory bowel disease such as Crohn's disease, ulcerative colitis 
  • Malabsorption including coeliac disease, lactose intolerance, secondary to pancreatic insufficiency such as chronic pancreatitis, cystic fibrosis, bacterial overgrowth
  • Rectal problems including anal fissure, haemorrhoids, perianal haematoma, ischio-rectal abscesses, fistulae, prolapse, polyps, malignancy

Liver, gallbladder and pancreatic disease 

  • Abnormal liver function tests: assessment, investigation and consideration of underlying reasons such as: 
    • drug-induced: alcohol, medications (paracetamol, antibiotics), chemicals
    • infection: viral hepatitis, leptospirosis, hydatid disease
    • malignancy: primary and metastatic
    • cirrhosis (for example, from alcohol, fatty liver/ non-alcoholic fatty liver disease); and 
    • autoimmune disease: primary biliary cirrhosis, chronic active hepatitis, α-1 antitrypsin deficiency, Wilson's disease, haemolysis 
  • Secondary effects of liver diseases such as ascites, portal hypertension, hepatic failure 
  • Gallbladder disease: gallstones, cholecystitis, cholangitis, biliary colic, empyema, malignancy 
  • Pancreatic disease: acute pancreatitis, chronic pancreatitis, malabsorption, malignancy including islet cell tumours

Nutrition 

  • Dietary management of disease, inadequate or excessive intake  
  • Impact of diet on health (for example, risk of cancer from high red meat intake) and dietary approaches to healthy living and prevention of disease  
  • Disorders of weight: obesity and weight loss including non-nutritional causes such as cancer, thyroid disease and other endocrine conditions 
  • Nutritional problems: vitamin and mineral deficiencies or excess, supplementary nutrition such as dietary, PEG and parenteral feeding  
  • Complications and management of stomas

Examinations and procedures

The sensitive nature of GI symptoms and some GI examinations – importance of putting the patient at ease and providing an environment where abdominal and rectal examinations are performed with dignity and, where appropriate, under chaperoned conditions. 

Investigations 

  • Stool tests including culture results and faecal calprotectin 
  • Tests of liver function, including interpretation of immunological results and markers of disease including cirrhosis and malignancy
  • Endoscopy, ultrasound and other scans (for example, transient elastography), interpretation of relevant tests such as those for Helicobacter pylori infection, coeliac disease  
  • Secondary care interventions such as laparoscopic surgery, ERCP, radiological investigations (including contrast and CT scans) 
  • Screening programmes for colorectal cancer such as stool tests (for example, occult blood / fecal immunochemical test), endoscopy and the evidence base

Service issues 

  • High prevalence of GI symptoms in the community and the implications for primary care 
  • Importance of assessing major risk factors and encouraging early lifestyle interventions to reduce the risk of liver disease 
  • Availability and appropriate use of direct-access endoscopy and imaging for primary care practitioners 
  • Community-based services in areas such as drug and alcohol rehabilitation (both of which are implicated in gastrointestinal and liver disease) 
  • Increasing demand for weight loss surgery, and its potential long term effects 
  • Public health implications of the national bowel cancer screening programme and the role of primary care in provision and in dealing with symptoms amongst screening invitees

Additional important content

  • Appropriate tailoring of treatment to cater for the patient's GI function and preferences
  • Side effects of common medicines including analgesics, antibiotics and proton pump inhibitors 
  • Drug and alcohol misuse: range of associated gastrointestinal and liver problems, complex issues, ways these impact on digestive disorders and the management problems they are associated with (see also RCGP Topic Guide Alcohol and Substance Misuse) 
  • Impact of social and cultural diversity, and the important role of health beliefs relating to diet, nutrition and the presentation of gastrointestinal disorders. Ensure that the practice is not biased against recognising these

Case discussion

Beverley is a 62-year-old librarian with a history of osteoarthritis in her knees. She has not been eating or sleeping well, and presents with intermittent constipation, bloating, epigastric discomfort, tiredness and 5kg weight loss in the last 6 months. 

She presented last year with some rectal bleeding which was attributed to haemorrhoids by another GP. It settled with conservative treatment. She takes a non-steroidal anti-inflammatory drug (NSAID) for her arthritis and has a vegetarian diet. 

Her marriage is under strain since her husband lost his job and increased his alcohol consumption. She is stressed at work due to a difficult new supervisor and she would like to retire but cannot due to their financial situation. 

As part of the screening programme, she has been invited to undertake a faecal occult blood test (FOBT); the first was negative 2 years ago and she declined doing another. You do not find anything on abdominal or rectal examination and you request blood tests which show mild anaemia and low Vitamin D. 

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.

                       Core Competence            
                     Questions                        

Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 

 

 

 

How does Beverley's presentation make me feel and why?  

How would I take account of this in my management of the situation? 

How might my practice be different if I had past experience of a close relative or friend with a similar presentation? 

Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 

 

 

 

How would I deal with my concerns about the husband?  

What ethical principles do I know that might help me with this case?  

How might my approach be different if the patient was a different sex, had a different culture or religion? 

Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 

 

 

 

How can I acknowledge the wide range of psychosocial issues in the history?  

What techniques would I use to work flexibly and efficiently within the allotted time? 

How might I explain my examination findings and the investigations to the patient? 

Data gathering and interpretation  
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 

 

 

 

What are the differential diagnoses? 

What investigations might I request? How do I manage the risk of a possible serious illness if the test results were normal? 

How sensitive and specific are the bowel screening programmes? 

Clinical Examination and Procedural Skills
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 

 

 

What is the significance of a normal abdominal and rectal examination? Do I feel reassured by this? 

What other elements of the history and examination would I wish to explore in this case? 

Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 

 

 

 

What is my strategy for investigating this combination of symptoms and factual information (for example, weight loss, anaemia, weakness/fatigue, psychological issues)?  

How much should the patient's priorities influence this? 

How could the consultation encourage a shared decision-making process? 

Clinical management
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 

 

What are my next steps?  

When should I refer or investigate with a colonoscopy? 

What advice would you give regarding her medications?

Managing medical complexity  
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 

 

 

How will I address Beverley's current concerns while being diligent in investigating her for serious illness? 

How can I involve Beverley in thinking about planning the different strands of her care?  

What are the possible supportive organisations and potential referral routes in this case? 

Working with colleagues and in teams  
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

 

 

 

What are the referral guidelines for 2 weeks suspected cancer referrals? What information should be included in any referral letter? 

Who else in the team might be appropriate to involve in thinking more about Beverley's current concerns?  

How can colleagues be effectively engaged to ensure good patient care?  

Improving performance, learning and teaching
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity.   

 

 

 

What can be identified as areas of personal educational need? 

What sources of information can I identify to ensure I am up to date with the investigation of lower GI symptoms? 

What areas could be explored further for potential improvement at the practice level? 

Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 

 

 

How does my practice record and follow up patients who have not attended for the bowel screening programme? 

What can my practice do to improve the uptake of screening programmes? 

What's the most appropriate way to record the multiple aspects of this patient's presenting complaint?  

Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

 

How could Beverley's wider concerns influence her presentation? 

What other aspects of her social and cultural background would I like to enquire about? 

How could you support Beverley with self-management? 

Community orientation 
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 

 

 

 

How do people respond to invitations for FOBT screening? What influences this?  

What negative influences or barriers might exist in the community that could exacerbate problems for Beverley and her family? 

What community services might be available to help Beverley and her family? 

How to learn this area of practice

Work-based learning

There is a high prevalence of gastrointestinal symptoms in the community and one of the fascinating challenges is to interpret these symptoms and identify those patients with problems which warrant further and/or urgent investigation. As a GP trainee it may be possible for you to spend time in community-based endoscopy facilities – these are sometimes led by primary care doctors with an interest in gastrointestinal disease.  

You should ideally spend time in outpatient clinics, in both general and specialised areas – for example, hepatitis management, liver disorders, endoscopy clinics etc. There is a very broad spectrum of activity in which you could potentially get involved and the opportunities will depend to some extent on what is available locally.  You should also take the opportunity to discuss screening programmes with patients in eligible age groups and check on their understanding of the screening process and how it relates to symptom-based diagnosis. 

Self-directed learning 

You will find many case-based discussions within GP speciality training programmes on gastrointestinal disorders. These cases are often challenging because patients with gastrointestinal diseases often follow unpredictable diagnostic journeys.  

Learning with other healthcare professionals 

Trainees should take the opportunity of discussing gastrointestinal disorders with practice nurses and nurses in the hospital environment.  Some practices have community nurses dealing specifically with drug and alcohol problems and it would be helpful to spend time discussing gastrointestinal disorders in relation to intravenous drug use and excessive alcohol consumption. It would also be helpful to accompany patients in investigations such as helicobacter breath testing and endoscopic procedures. 

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Investigation of rectal bleeding in different patient scenarios
  • Drug therapies for inflammatory bowel disease 
  • Interpretation of liver function tests

Clinical Skills Assessment (CSA) 

  • Obese man has a cough which is worse overnight and first thing in the morning. Examination expected 
  • Young woman complains of recurrent abdominal pain and bloating 
  • Elderly woman asks for an explanation and advice after a hospital outpatient attendance. The consultant's letter (provided) gives a diagnosis of diverticular disease.

Workplace-based Assessment (WPBA) 

  • Case discussion about a man who continues to have upper abdominal pain following a recent cholecystectomy 
  • Log entry about a referral for a woman with dysphagia through the urgent cancer pathway  
  • Quality Improvement Project (QIP) looking at how effective your GP practice is at suggesting suitable interventions to patients who may potentially be at risk of liver disease.

Genomic medicine

This Topic Guide will help you understand important issues relating to genomics in primary care by illustrating the key learning points with a case scenario and questions.

The role of the GP in genomic medicine

The term 'Genomic Medicine' is increasingly used in health services. Whilst Genetics focuses on the DNA coding for single functional genes, Genomics is the study of the entirety of an individual’s DNA, recognising the role of non-protein-coding DNA and the complex interactions between multiple genes and the environment. Genomic medicine involves using genomic information about an individual as part of their clinical care (for example, for diagnostic or therapeutic decision-making). The term encompasses both Genetics and Genomics. 

As a GP your role is to: 

  • Take and consider family histories in order to identify families with, or at risk of, genetic conditions (including autosomal and X-linked disorders) and familial clusters of common conditions such as cancer, cardiovascular disease and diabetes 
  • Identify patients and families who would benefit from being referred to appropriate specialist services 
  • Manage the day-to-day care of patients with genetic conditions, even if the patient is under specialist care  
  • Coordinate care across services, including transitions from paediatric to adult services 
  • Communicate information about genetics and genomics, including discussing results from antenatal and new-born screening programmes 
  • Understand how genomic information is used within the context of routine clinical practice

Emerging issues in genomic medicine

  • Advances in technology can now make human and pathogen DNA sequencing speedy and affordable. This genomic information may be used in the diagnosis and tailored management of a range of conditions from cancer to tuberculosis, and in tailored prescribing decisions. The term 'Precision Medicine' describes the use of genomic information alongside other individual and environmental factors to refine disease prediction, prevention and treatment. 
  • Information about genetic susceptibility to common complex conditions (conditions with a multi-factorial inheritance pattern, such as ischaemic heart disease and cancer) is likely to offer additional information about risk, which will aid stratification into risk categories or disease sub-types and inform clinical management. 
  • Such clinical advances will have implications for service planning, in particular: how genomic information can contribute to managing common complex conditions, how medical management may be personalised through the stratified use of medicines (pharmacogenomics), how resources should be allocated, and the ethics of obtaining, storing, sharing and using genomic information. 
  • As access to genomic testing increases—either through research programmes, as part of clinical care, or by direct-to-consumer testing from commercial companies—patients and their relatives will turn to their GP for discussion and advice, and GPs must be aware of the implications of this. 

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition, including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring, and end-of-life care 
  • Patient information and education including self-care 
  • Prognosis 

Common and important conditions

Variations in the human genome may have no effect, predispose to common complex diseases, or result in genetic conditions. Many of these conditions (for example, cystic fibrosis, Huntington’s Disease) are individually rare, but as a group share common principles in terms of diagnosis, management, and supporting patients and their families. As a GP you should understand the following: 

  • Autosomal dominant conditions (for example, familial hypercholesterolaemia, polycystic kidney disease, Huntington's Disease, thrombophilias) 
  • Chromosomal disorders (for example, Down syndrome, trisomy 18, Turner syndrome, Klinefelter syndrome) 
  • Autosomal recessive conditions (for example, cystic fibrosis, hereditary haemochromatosis, haemoglobinopathies)  
  • X-linked disorders (for example, Fragile X Syndrome (see also RCGP Topic Guide Neurodevelopmental disorders, intellectual and social disabilities), Duchenne and Becker Muscular Dystrophy, haemophilia).

Common complex diseases follow a multi-factorial inheritance pattern, for example, ischaemic heart disease, hypertension, diabetes, cancer, obesity. A proportion of patients with a common complex disease demonstrate familial clustering of the condition or have an autosomal dominant condition that confers high risk, for example, BRCA1 pathogenic variant in breast cancer, Lynch syndrome or familial hypercholesterolaemia in Ischaemic Heart Disease. 

Symptoms, signs and modes of presentation

Many variations in the genome are asymptomatic. In patients who have, or are at risk of developing, a genetic condition, consider the following: 

  • Clinical suggestion of inherited disease (for example, multiple family members affected at a younger age) 
  • Genetic 'red flags' (for example, recurrent miscarriage, developmental delay in conjunction with other morbidities) 
  • Predisposition to common diseases (such as coronary artery disease or cancer) 
  • Symptoms and signs of specific conditions (see 'Common and important conditions' above) 
  • Symptom complexes and multisystem involvement 
  • Variability of symptoms and signs between family members for some genetic conditions, particularly some autosomal dominant conditions (such as neurofibromatosis type 1) as a result of variation in penetrance and expression. 

Assessing genetic risk

  • How to take a family history (relevant questions, interpretation, how to draw a pedigree) 
  • Basic inheritance patterns (autosomal dominant and recessive, X-linked, mitochondrial, multifactorial) 
  • Principles of assessing genetic risk, including: 
    • principles of risk estimates for family members of patients with single gene disorders
    • principles of recurrence risks for simple chromosome anomalies (for example, trisomies)
    • information from susceptibility variants in common complex conditions (for example, as used in direct-to-consumer testing)
    • conversations around risk in the context of antenatal screening; and  
    • online risk assessment tools, as they become available 
  • Other factors contributing to genetic risk (for example, ethnicity, effects of consanguineous marriage)

Investigations

  • Genetic and genomic tests (diagnostic, predictive, carrier testing) and their limitations 
  • Diagnostic tests in primary care (for example, cholesterol, ultrasound for polycystic kidney disease, testing for hereditary haemochromatosis)  
  • Carrier testing for families with autosomal recessive conditions such as sickle cell, thalassaemia or cystic fibrosis 
  • Antenatal and new-born screening programmes (for example, Down syndrome, cystic fibrosis, sickle cell and thalassaemia)

Service issues

  • Systems to follow up patients who have, or are at risk of having, a genetic condition and have chosen to undergo regular surveillance (for example, imaging for breast cancer and adult polycystic kidney disease or endoscopy for colon cancer) 
  • Coordination of care with other professionals 
  • Information and supporting resources: 
    • Eligibility and referral pathways for genetic and genomic testing 
    • Local and national guidelines (for example, for a family history of certain cancers) 
    • Services and support available for those with an inherited condition  
  • Organisation of genetics and genomics medicine services

Additional important content

  •  Genomic nomenclature (for example, what is meant by non-coding DNA, susceptibility variant, pathogenic variant and variant of unknown significance (VUS)) 
  • Difficulties in determining the exact genomic cause of a condition (for example, a learning disability) 
  • Heterogeneity in genetic diseases  
  • Skills in communicating genetic and genomic information  
  • Skills and techniques for non-directive, non-judgemental discussion about genetic conditions, taking into account an individual's ethnic, cultural and religious context 
  • Spectrum of risk-reducing measures, from lifestyle modification to targeted treatments for certain conditions (for example, mastectomy and/or oophorectomy for BRCA1/2 mutation carriers, colectomy for adenomatous polyposis coli (APC) mutation carriers, statin use for familial hypercholesterolaemia, venesection for haemochromatosis, losartan for patients with Marfan syndrome) 
  • Reproductive options available to those with a known genetic condition (including: having no children, adoption, gamete donation, prenatal diagnosis, neonatal screening or testing) 
  • Emotional, psychological and social impact of a genetic diagnosis on a patient and his/her family 
  • Clinical and ethical implications for family members of an affected individual, depending on the mode of inheritance of a condition (autosomal dominant, recessive and X-linked single-gene inheritance; de novo and inherited chromosomal anomalies; mitochondrial inheritance and somatic mutation) 
  • Ethical issues surrounding:  
    • Confidentiality and non-disclosure of genetic information within families (particularly when information received from or about one individual can be used in a predictive manner for another family member in the same practice)
    • Genetic testing (for example, testing in children, pre-symptomatic testing) 
    • The 'right not to know' 
    • The use of information (for example, for insurance or employment issues) 
  • Pharmacogenomics: the role of genomic information in prescribing.

Case discussion

Emily, a healthy 37-year-old woman, presents to you with concerns about developing cancer because her mother was diagnosed with breast cancer at the age of 38 and died at the age of 40. Emily’s maternal grandmother had also died from cancer in her late 40s, and her cousin, Lisa, who is 42 years old, has recently been diagnosed with ovarian cancer.  

You refer Emily to the local clinical genetics service where Emily sees a genetic counsellor who explains that the family pattern could be consistent with one of the family cancer syndromes. The genetic counsellor explained that it would be helpful to find out more information from her cousin Lisa. On further discussion with her family Emily finds out that Lisa had had a genetic test at the time of her ovarian cancer diagnosis, which showed a BRCA 1 pathogenic variant.  

Emily sees the genetics service again to discuss the possibility of being tested to see if she had also inherited the pathogenic variant. She is considering IVF with her partner Susie and wants to know if the genetic testing may be helpful in informing decisions in this regard. 

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive. 

                          Core Competence          
               Questions                      
Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
How do my own views influence the way I communicate information about genetic and genomic tests and results, in particular those that may impact on the wider family? 

What are the limits of my competence in this case? 

Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 

 

 

What potential ethical dilemmas could such a case present, and how would I address them? 

What are my thoughts and feelings about private companies offering genetic tests for the general public? 

Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 

 

 

 

How can I communicate the risks of common patterns of genetic inheritance in simple language?  

What do I need to consider when communicating information relating to a genetic disorder? 

What are the implications of a genetic diagnosis in one individual for the management of other family members who may ask for a consultation? 

Data gathering and interpretation  
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 

 

 

 

What tools are available to GPs for recognising and stratifying patients who may have an inherited predisposition to developing cancers?  

How can I recognise individuals or families at the greatest risk of having genetic conditions?  

What clinical information does my local specialist genetics service require prior to referral? 
Clinical Examination and Procedural Skills
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 
Are there any clinical examinations I would wish to perform in this case? Would the findings affect my decision to refer (and to whom)? 
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
What are the best ways of taking, recording and interpreting a genetic family history? 

When am I likely to refer patients to secondary care? 

Clinical management  
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 

 

What guidelines exist to guide my management of people with genetic conditions? How do I access them?  

Do I know when and where to seek advice on genetic and genomic issues? 

Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 

 

 

 

What roles could the GP play in managing complexity in this case?  

What other sources of advice and support are available to GPs? 

What role will pharmacogenomics play in current and future prescribing practice? 

If Emily is found not to have inherited the BRCA1 gene, does this mean she will not develop breast or ovarian cancer?  

Working with colleagues and in teams  
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

 

How can GPs work with local genetics departments to facilitate a seamless two-way transfer of information?  

How can the practice work as a team to ensure that patients with an identified predisposition to cancer or other genetic conditions are not lost to follow-up? 

Maintaining performance, learning and teaching  
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, participating in commissioning*, quality improvement and research activity. 

 

 

 

How can I ensure that information for my patients about the availability of genetic or genomic tests and targeted management is up to date? 

How do I keep myself updated about new developments in genetics and genomics?  

Where can I access quick and reliable information about any query regarding a genetic disorder or genomic tests? 

Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 

 

 

 

What codes within my electronic medical record system can I use to record a family history of cancers or any other genetic disorder? 

What systems are in place to record that someone has had a genomic test? 

What systems are in place to follow up patients who have, or are at risk of, a genetic disorder and have chosen to undergo regular surveillance? 

Practising holistically and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

 

 

How might a patient's cultural and religious background, and beliefs concerning genetics/genomics and inheritance, impact on the consultation? 

What range of feelings might a person have after finding out they have, or have not, inherited a predisposition to a condition? 

What population screening programmes should Emily continue to participate in? 

Community orientation 
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 

 

 

 

How would the views of the local community towards genetics, genomics and screening impact on the ways in which the family are likely to take up services? 

How might the makeup of the local population affect the prevalence of genetic conditions and attitudes towards genetic disease?  

Where are my local genetic or genomic departments and are there any agreed local protocols for referrals? 

How to learn this area of practice

Work-based learning

Many skills required to manage families with genetic conditions are part of the core skills of a GP. Primary care is a good setting for you to learn about genomic medicine because of the family-based focus and opportunities for staged counselling. Learning opportunities during consultations include: how to recognise conditions with a genetic component; how to appropriately manage genetic implications for the individual and family, particularly where there are ethical, social and legal issues; and when and how to refer patients to specialist services. As many common conditions seen in general practice – including cancer, diabetes and heart disease – are multifactorial with a genetic component, managing them can also help develop awareness of how genomics affects disease. 

GP trainees with a particular interest in genomic medicine may also wish to take the opportunity to learn from consultant geneticists and genetic counsellors working in regional specialist genetics services. This should include developing your understanding of the genetic counselling process, diagnosis and management of genetic conditions, and reproductive options including prenatal diagnosis for at-risk couples. 

Self directed learning

The Health Education England (HEE) Genomics Education Programme website has a number of resources to support the integration of genomics into clinical practice, including information about taking and drawing a family history, core concepts in genomics, genetic conditions, and genomic terminology. 

The British Society for Genetic Medicine website contains links to Regional Genetics Centres (RCGs), which often have information on referral pathways and criteria.  

You can find an e-Learning module(s) relevant to this Topic Guide at e-Learning for Healthcare.  

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT)

  • Interpretation of a genogram  
  • Recognising the presentation of common genetic conditions in primary care 
  • Consent, capacity and confidentiality of genetic testing 

Clinical Skills Assessment (CSA) 

  • Woman with one affected sibling requests genetic screening for breast cancer 
  • Woman attends for pre-conceptual advice because her nephew has Duchenne muscular dystrophy 
  • Neurology letter (provided): 'symptoms suggest cerebellar ataxia, with autosomal recessive inheritance'. Patient attends to discuss the implications of her own probable diagnosis for her children. 

Workplace-based Assessment (WPBA)

  • Audio Consultation Observation Tool (Audio COT) with a parent discussing the chances of passing his thalassemia-associated variant (trait) to his children 
  • Log entry about communicating with an adult patient who has Down syndrome 
  • Log entry about a mother who is finding it hard to cope with her child having cystic fibrosis

 


Gynaecology and breast

This Topic Guide will help you understand important issues relating to gynaecology and breast health by illustrating the key learning points with a case scenario and questions.

The role of the GP in gynaecology and breast health

As a GP, your role is to: 

  • Acknowledge that many gynaecological conditions women experience adversely affect their physical, psychological and social well-being and work with women to manage these impacts 
  • Understand that some women may find it difficult to discuss intimate health issues, for many reasons. Women may prefer to see a female GP to discuss gynaecological and breast problems 
  • Endeavour to adopt a 'woman-centred life course' approach, using current contact opportunities occurring over a woman's life (for example, HPV immunisation, cervical screening, contraceptive consultations, pregnancy, menopause) for health promotion and potential interventions  
  • Promote health in this area including breast and cervical screening 
  • Understand that breast cancer is now the commonest cancer in the UK. Many patients are now surviving breast cancer and undergoing long term treatment and surveillance, often living with the mental and physical consequences of treatment. The GP must be alert to the possibility of local or distant recurrence many years after original treatment 
  • Recognise that ovarian cancer remains a less common cancer with a relatively poor detection rate, often presenting late. Alertness to non-specific symptoms that could be consistent with ovarian cancer is crucial to earlier diagnosis.   
  • Be aware that men may also experience breast disorders. 

Emerging issues in gynaecology and breast health

  • GPs need to be aware of the changing landscape in the management of the menopause. In particular, identifying and managing premature ovarian insufficiency and avoiding over-medicalising women dealing with a normal menopause, whilst at the same time, being sensitive to the distress that many women experience and the range of evidence-based treatments and support available for those who require it 
  • Identification and reporting on Female Genital Mutilation has now become mandatory in primary and secondary care 
  • There are changes emerging in mammography provision. The age at entry to the screening programme is lowering, and this will have implications for new diagnoses
  • Some conditions such as endometriosis and polycystic ovarian syndrome (PCOS) need to be managed as long term conditions, often in primary care. 

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socioeconomic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis

Symptoms and signs

Breast 

  • Breast development and abnormalities of development  
  • Breast lumps (men and women) 
  • Breast skin changes 
  • Gynaecomastia 
  • Mastalgia 
  • Nipple discharge

Pelvic  

  • Bleeding symptoms: 
    • Menstrual bleeding problems such as amenorrhoea, oligomenorrhoea, polymenorrhoea, heavy menstrual bleeding 
    • Non-menstrual vaginal bleeding including intermenstrual and post-coital bleeding 
    • Postmenopausal bleeding 
  • Other pelvic symptoms and signs: 
    • Continence problems (urinary and faecal) 
    • Pelvic and abdominal masses 
    • Pelvic and abdominal pain 
    • Vaginal discharge and vaginal dryness 
    • Vaginal swellings and prolapse symptoms
    • Vulval pain, lump, irritation, ulceration, pigmentation, leucoplakia and other vulval skin lesions. 

Other 

  • Menopause and peri-menopause physical and psychological symptoms including bleeding disturbances, hot flushes, night sweats, urogenital symptoms 
  • Non-specific symptoms that could be consistent with ovarian cancer such as abdominal distension, ascites, bloating, early satiety, new onset IBS symptoms in women over 50, urinary symptoms, weight loss  
  • Pre-menstrual syndrome

[Urinary symptoms such as dysuria and haematuria are covered in RCGP Topic Guide Kidney and Urology. Sexual health symptoms are covered in the Sexual Health Topic Guide. Symptoms relating to pregnancy and reproductive health are covered in the Maternity and Reproductive Health Topic Guide.] 

Common and important conditions 

Breast

  • Benign breast conditions including eczema, infection (mastitis, breast abscess), lumps (for example, cysts, fibroadenoma) and mastalgia 
  • Breastfeeding, including common problems 
  • Malignant breast conditions including DCIS, invasive ductal and lobular carcinomas, Paget's disease of the nipple and secondary malignancy such as lymphoma, including awareness of treatment (surgery, radiotherapy, hormonal) and its complications 
  • Surgery for breast reconstruction, breast enlargement and breast reduction 

Pelvic  

  • Bleeding problems (which may have pelvic or extra-pelvic cause): 
    • Amenorrhoea (primary and secondary), oligomenorrhoea, polymenorrhoea, irregular menstrual cycles and anovulatory cycles 
    • Intermenstrual bleeding 
    • Medication induced bleeding problems (including secondary to hormonal contraceptives) 
    • Menstrual problems including heavy menstrual bleeding, dysmenorrhoea (primary and secondary), dysfunctional uterine bleeding 
    • Post-coital bleeding 
    • Post-menopausal bleeding 
  • Pelvic pain 
  • Ovarian: 
    • Benign ovarian swellings including ovarian cysts, dermoid 
    • Ovarian cancer including adenocarcinoma and teratoma 
    • Polycystic ovary syndrome: gynaecological aspects and associated metabolic disorders such as insulin resistance and obesity, and symptoms such as acne and hirsutism 
  • Uterine: 
    • Endometrial polyps, hyperplasia and cancer 
    • Endometriosis and adenomyosis 
    • Fibroids 
    • Prolapse including cystocele and rectocele 
  • Cervical: 
    • Cancer, cervical intraepithelial neoplasia (CIN), dysplasia, ectropion and polyps 
  • Vulvovaginal: 
    • Female genital mutilation (FGM) (including legal aspects) and cosmetic genital surgery 
    • Malignancy including vulval intraepithelial neoplasia (VIN), melanoma 
    • Skin disorders such as lichen sclerosus, psoriasis, intertrigo, pigmented lesions, genital warts 
    • Vaginal discharge including infectious causes such as candida, bacterial vaginosis and sexually transmitted infections (please refer also to Topic Guide Sexual Health) 
    • Vulval pain with causes such as atrophic changes, Bartholin's problems, dysesthesia, vulvodynia.  
  • (Urinary conditions including incontinence are covered in the Kidney and Urology topic guide) 

Fertility 

  •  Infertility and subfertility – causes and investigations: 
    • Male factors including impaired sperm production and delivery (for example, drug induced, cystic fibrosis) 
    • Female factors including ovulatory disorders, tubal disorders, uterine disorders and genetic causes 
  • Principles of assisted conception with knowledge of associated investigations 
  • Recurrent miscarriage

Other

  • Premenstrual disorders including premenstrual syndrome and premenstrual dysphoric disorder 
  • Menopause: 
    • Normal and abnormal menopause and peri-menopause including premature ovarian insufficiency 
    • Post-menopausal bleeding 
    • Systemic symptoms such as skin changes, hot flushes, psychological symptoms 
    • Treatment options including hormone replacement therapy (HRT) – systemic and local methods 
    • Urogenital aspects including atrophic vaginitis  
    • Wider health issues associated with menopause including increased cardiovascular risk and osteoporosis 

(Sexually transmitted infection, Pelvic Inflammatory Disease, dyspareunia, pregnancy (including miscarriage and ectopic pregnancy) are covered in the RCGP Topic Guides on Sexual Health and Maternity and Reproductive Health. Urinary problems are covered in the Topic Guide Kidney and Urology). 

Examinations and procedures 

  • Abdominal assessment for ascites, distension and masses 
  • Bimanual pelvic examination 
  • Breast examination 
  • Cervical cytology sampling 
  • Obtaining informed consent for breast examination, vaginal examination and speculum examination, including use of chaperones where appropriate 
  • Speculum examination including appropriate choice of size 
  • Vaginal and endocervical swabs  
  • Vulval examination 

Investigations

  • Breast imaging (including mammography, MRI and ultrasound) 
  • Common secondary care gynaecological investigations including colposcopy, hysteroscopy and laparoscopy 
  • Investigations within primary care such as blood tests (CA125, full blood count, hormone profile) cervical smears, clinician taken vaginal and cervical swabs, patient taken swabs, vaginal pH testing 
  • Primary care investigation of female subfertility including blood tests and ultrasound 
  • Semen analysis 
  • Ultrasound – abdominal and pelvic ultrasound including trans-vaginal scans

Service issues 

  • Emotional and organisational support structures and techniques to deal with the psychosocial aspects of women's health (for example, in relation to menopause, and breast and gynaecological cancer) 
  • HPV vaccination programme 
  • Local service provision and pathways for suspected malignancy including one-stop clinics 
  • Practical and legal aspects around FGM including reporting mechanisms, safeguarding concerns and protecting girls at risk of FGM 
  • Safeguarding issues that may present through gynaecological concerns

Other important content 

  • After-care of women who have had gynaecological or breast surgery and radiotherapy including 'late effects' of treatment and risk of cancer recurrence 
  • Gynaecological issues in transgender patients.Transgender issues are covered more fully in Sexual  health and Equality Diversity and Inclusion Topic Guides
  • The physiological and hormonal changes of the menstrual cycle  
  • Genetic mutations related to breast and gynaecological malignancy including BRCA and indications for referral for genetic counselling 
  • Screening programmes for cervical and breast cancer – including practicalities, benefits, risks, interpretation of results, non-participation. Awareness of controversies around possible screening for ovarian cancer

Case discussion

Jackie, who is 48 years old and a smoker, comes to see you. She is unemployed and brings her four-year-old granddaughter, Kylie, who she is caring for whilst Kylie's mother is in prison for drug-related offences. Jackie is exhausted, which she puts down to lack of sleep through worry, travel to the prison to visit her daughter and looking after Kylie. 

Owing to the chaotic family situation, Jackie has not paid much attention to her own health and has been ignoring some pinkish vaginal discharge. Now, however, she has irregular vaginal bleeding, which is becoming more frequent.  She has not had a cervical screening test for over 15 years and on examination you find an irregular, ulcerated area on the cervix. You explain your findings and agree with Jackie that you will refer her under the two-week rule to a gynaecologist.  

Jackie is diagnosed with a stage 1b cervical squamous carcinoma. She has a hysterectomy and subsequent chemoradiotherapy. The hospital admission, post-operative recovery period and subsequent daily outpatient visits for radiotherapy make it even more difficult for her to look after Kylie. Jackie is not keen on any further help at home as she fears social services will 'take Kylie away' but she agrees that you could ask the health visitors to see what support they can offer.  

Questions 

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive. 

                            Core Competence         
                     Questions                  
Fitness to practise  
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 
How do I feel when a patient's neglect of their own health may have contributed to a condition? For example, in this case Jackie is a smoker and has not attended for cervical screening?  

Maintaining an ethical approach 
This addresses the importance of practising ethically, with integrity and a respect for diversity. 

 

 

What ethical dilemmas does this case present?  

What tensions do I see between the scientific, political and patient-centred aspects of cervical screening? 

What safeguarding concerns are raised by this scenario? 

Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 

 

 

 

How effective am I at respecting the views of patients who are reluctant to accept help involving social services and other agencies? 

How good am I at explaining the risks and benefits of a screening test to my patients? What about explaining the results of abnormal smear tests to a patient? 

What communication strategies can I employ to 'break bad news' in a situation such as this? 

Data gathering and interpretation
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 

 

 

What are the risk factors in Jackie's history that might suggest a diagnosis of malignancy? 

What factors (for example, patient, doctor, clinical findings, guidelines) would influence which further investigations to perform and how urgently in a woman presenting with vaginal bleeding? 
Clinical Examination and Procedural Skills
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 
How confident am I in carrying out a speculum examination and a smear test, and being able to differentiate between a healthy cervix, common minor changes or serious pathologies? 

What other examinations and procedures could I consider performing in general practice? 
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice.
If her cervix had been normal, what would have been my next step? 

How do I make decisions about whether a child is safe? 

Clinical management 
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 

 

 

Do I know the 'red flag' symptoms that require urgent referral under the 'two-week rule' for gynaecological problems? 

Abnormal cervical cytology and cervical cancer are often related to sexually transmitted HPV – how do I explore the risk of other STIs, including HIV, in this case? 
Managing medical complexity  
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 
How can I balance on-going health promotion and advice-giving at a time of serious illness?  

What steps would I take to understand the impact of this illness on the patient's family? 

Working with colleagues and in teams  
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 

 

 

 

What are the local arrangements for administering the HPV vaccine to girls?  

What systems are in place to identify vulnerable families in the practice where I work? 

Do I have a good awareness of other agencies that might be helpful in this case? In particular, how might we be able to support Jackie as she cares for Kylie? 
Improving performance, learning and teaching  
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 
What is my plan for maintaining and updating my knowledge base in women's health?  

How do I ensure that my cervical smear taking skills are adequate?  

Organisational management and leadership 
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 

 

What is the protocol in my practice for calling, recalling and following up patients who attend and DNA for smears? 

How does the practice record the family relationships? What are the potential safeguarding issues related to record keeping in this family?   

Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

 

As the GP for more than one generation of a family, how do I balance their health and social care needs? 

In patients who are diagnosed with cancer, how do I acknowledge their fears and concerns in the consultation?  

How could we increase cervical smear uptake? What are the barriers to increased uptake? 

Community orientation
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 

 

 

What relevant social care assistance and support groups are available to patients in my area?  

How do we deliver primary care services to 'chaotic' and marginalised groups in society? 

How does the 'inverse care law' apply? 

How to learn this area of practice

Work-based learning

The period of time spent training in general practice will help you better understand gynaecology and breast health. It is ideal for delivering training in screening, counselling and continuous care, and to reinforce the idea that good healthcare requires a balanced overview of all factors affecting the patient at any time. There is no substitute for clinical experience supported by a GP trainer and experienced members of the primary healthcare team. Many practices will have a lead for this area who may offer particular clinics such as 'Well Woman' which will give concentrated exposure to this field. 

Many GP specialty training programmes include placements in gynaecology and/or breast care. These placements give opportunities to become proficient in gynaecological and breast history taking and examination skills, as well as management of common gynaecological problems. Additionally, they may give opportunities to observe more specialised gynaecological investigations and treatments, including surgical procedures, which will facilitate you discussing these with patients in the future. 

Sexual health and reproductive health clinics are also excellent environments to gain a better understanding of gynaecological health concerns and to learn techniques for examination including passing a speculum and interpreting findings.  

GP specialty trainees should take the opportunity to attend outpatient clinics in specialties directly relevant to this area of health, for example, general and emergency gynaecology clinics, one-stop clinics for suspected cancer and breast clinics. During these placements you should refer to this curriculum statement, and the relevant cross-references, to guide you and help consolidate your specific knowledge and skills in the area of women's health in primary care. 

Self-directed learning

There are many online and clinical courses for GP specialty trainees on breast and gynaecological health issues to supplement their local programmes and to ensure that those GP trainees who have not passed through a hospital-based placement in breast surgery or gynaecology are made aware of current management of these problems. You can find e-Learning module(s) relevant to this topic guide at e-Learning for healthcare and at RCGP Learning.   

The RCGP Women's Health Library is a collection of educational resources and guidelines relevant to GPs and developed in collaboration with the Royal College of Obstetricians and Gynaecologists (RCOG) and Faculty of Sexual and Reproductive Healthcare (FSRH). In addition, the RCGP have a Menstrual Wellbeing toolkit.

The RCOG offers a diploma examination in this field DRCOG particularly aimed at GPs. Details are on their website.

Other useful online organisations providing resources in this area for professionals and patients include the Primary Care Women's Health Forum, The British Menopause Society and Menopause Matters

Learning with other healthcare professionals

Gynaecological and breast health problems, by their nature, are often exemplars of teamwork across agencies. Joint sessions with nursing colleagues provide you with multidisciplinary opportunities for learning about the wider aspects of these aspects of healthcare provision, in both primary and secondary care. You should also find it fruitful to consider and discuss the roles of the various individuals who represent the many professional and non-professional groups involved in these areas of healthcare. 

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT) 

  • Use and interpretation of CA125 
  • Diagnosis of the menopause 
  • Diagnosis of endometriosis

Clinical Skills Assessment (CSA) 

  • Woman has a breast lump (silicon model for the examination) 
  • Woman from Somalia with a history of female genital mutilation has concerns about family pressure to submit her daughter to the same 
  • Phone call: Young woman wants to discuss her cervical smear result which shows borderline dyskaryosis (HPV negative)

Workplace-based Assessment (WPBA) 

  • Observation of a pelvic examination for a woman with unexplained vaginal bleeding 
  • Consultation Observation Tool (COT) on an 80 year old patient who ends the consultation saying she is bleeding 
  • Case-based Discussion (CbD) about a private gynaecologist's request that you prescribe high-dose oestrogen preparations when you disagree with the consultant’s diagnosis and management plan
  • Statutory Clinical Observation and Procedural Skills (CEPS) assessment of female genital examination 

 


Haematology

This Topic Guide will help you understand important issues relating to haematology by illustrating the key learning points with a case scenario and questions.

The role of the GP in the care of people with haematological disorders

Many consultations in general practice involve haematological investigations. As a GP you should be able to: 

  • Identify symptoms that are within the range of normal or self-limiting illness and differentiate them from underlying pathology for example, anaemia 
  • Know the epidemiology of common disorders and understand how to recognise them 
  • Make an effective assessment, including conducting more detailed tests and referring appropriately

Emerging issues in the care of people with haematological disorders

  • Chronic haematological disorders are more prevalent due to the ageing population. The need to differentiate abnormalities due to the ageing process, or secondary to other co-morbidities, from blood disorders requiring specific medical intervention 
  • Evolving new agents for anticoagulation treatment and prophylaxis in primary care. Their appropriate use as an alternative to warfarin and the assessment of their potential benefit and risk 
  • Improving outcomes in treatment of haematological malignancies and the increasing use of ambulatory and shared care management plans between secondary care specialist teams and the community

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features 
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including self-care, initial, emergency and continuing care, chronic disease monitoring 
  • Patient information and education including self-care 
  • Prognosis

Symptoms and signs

  • 'B' symptoms of lymphoma 
  • Bleeding, bruising, petechiae and purpura  
  • Bone pain or pathological fractures 
  • DVT or PE 
  • Fatigue 
  • Hyperviscosity symptoms (headache, visual loss, acute thrombosis)  
  • Jaundice secondary to haemolysis  
  • Lymphadenopathy, splenomegaly and hepatomegaly  
  • Pallor and anaemia  
  • Recurrent infection  
  • Recurrent miscarriage 
  • Skin manifestations of haematological disease (for example, mycosis fungoides)  
  • Systemic manifestations of haematological disease (for example, sickling crisis)  
  • Weight loss

Common and important conditions

  • Anaemia and its causes including iron, folate and vitamin B12 deficiency, sideroblastic, haemolytic, chronic disease  
  • Anticoagulants: indications, initiation, management and reversal/withdrawal including heparin, warfarin, Direct Oral Anticoagulants such as dabigatran, drug interactions and contra-indications  
  • Clotting disorders including genetic causes such as haemophilia and von Willebrand's disease, infective causes such as meningococcal septicaemia and disseminated intravascular coagulation  
  • Common abnormalities of blood films and their management (for example, macrocytosis, microcytosis, spherocytosis, neutrophilia)  
  • Enlarged lymph nodes of any cause +/- splenomegaly, including infection and malignancy (both primary and secondary); management of a single enlarged lymph node
  • Enzyme diseases such as G6PD deficiency    
  • Gout associated with haematological malignancies and myelodysplasias  
  • Haematological malignancies such as acute and chronic leukaemias, lymphomas (including Hodgkin's, non-Hodgkin's lymphomas, gut and skin lymphomas), multiple myeloma  
  • Haemochromatosis 
  • Haemoglobinopathies such as thalassaemia, sickle cell disease  
  • Haemolytic diseases including management of rhesus negative women in pregnancy, autoimmune and transfusion haemolysis  
  • Lymphatic disorders such as primary lymphoedema  
  • Myelodysplasia and aplastic anaemia  
  • Myeloproliferative disorders such as polycythaemia rubra vera, thrombocytosis 
  • Neutropenia: primary and secondary including chemotherapy and drug-induced 
  • Pancytopenia and its causes 
  • Polycythaemia: primary and secondary such as to hypoxia, malignancy  
  • Purpura: recognition and causes such as drug-induced, Henoch-Schönlein  
  • Splenectomy including functional asplenia   
  • Thrombocytosis and thrombocytopaenia, including causes and associations, indications for referral

Examinations and procedures

  • Appropriately obtaining blood samples and requesting clearly selected and targeted tests with informed consent 
  • Use of near patient testing for anticoagulation

Investigations

  • Blood grouping such as ABO and rhesus status including antenatal blood disorders; safe transfusion practice  
  • Normal haematological parameters and interpretation of laboratory investigations such as full blood count, haematinics, monitoring of anticoagulants and investigation of coagulation disorders including thrombophilia and excessive bleeding, protein electrophoreses, immunoglobulins  
  • Other relevant primary care investigations (for example, x-rays, paraprotein urine testing in myeloma)  
  • Relevant secondary care investigations such as bone marrow, bone scans  
  • Antenatal screening for inherited haematological disorders (for example, thalassaemia, sickle cell)

Service issues

  • Common investigations/treatment pathways in secondary care and referral criteria for common conditions 
  • Cancer care reviews and follow-up, including safe prescribing, management of multi-morbidity, and recognising signs of disease progression 
  • Indications for urgent (or semi-urgent) referral to secondary care 
  • Pathology in other systems may lead to haematological manifestations 
  • Certain services are highly specialised and regionally based such as bone marrow transplant 

Additional important content

  • Conditions with higher prevalence in certain ethnic groups (for example, benign ethnic neutropenia, sickle cell anaemia) 
  • Ethical issues related to blood transfusion 
  • Psychosocial impact of living with a haematological condition 
  • Major side effects of chemotherapy

Case discussion

Mr Chan a 79-year-old man presents with joint pains suggestive of OA, low mood and tiredness. The symptoms have been present for the preceding 6 months and appear stable. He complains of a poor sleep pattern and loss of appetite which appear to be depressive in nature. He lives at home with his wife and is otherwise in good health and active.

As part of routine investigations, his FBC has been reported as showing a raised lymphocyte count and flow cytometry suggestive of B Cell Chronic Lymphocytic Leukaemia.  

Referral to haematology was advised and a diagnosis of Stage 0 CLL was confirmed, and no active intervention recommended other than regular monitoring of his white cell count.  

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.  

                                 Core Competence

              Questions       

Fitness to practise
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 

 

 

 

What are the personal challenges I face in caring for chronic disease in the elderly? 

How do my personal beliefs and attitudes influence the care that I provide? 

How do I balance my desire to give long term personalised care with the risk of fatigue and burnout? 

Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 

 

 

 

 

What factors influence the decision for active intervention in asymptomatic illness? 

How can I respect the autonomy of my patient in a scenario where decisions are based on technical clinical criteria? 

How do I ensure that timely access to care is equal to all? 

Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters

 

 

 

What are the challenges explaining a diagnosis of disease in the absence of directly attributable symptoms? 

How do I respond to the inherent uncertainties in future management? 

How do I explore other factors which might influence her health beliefs about active Rx? 

Data gathering and interpretation
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 

 

 

 

How will I monitor this patient in the medium and long term? 

What information would require a change in current management? 

How do I balance the need for regular monitoring against over-investigation? 

Clinical Examination and Procedural Skills
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills.

 

 

 

What might I have found on examination in this case? 

Without the blood test results, what might have been the differential diagnosis in this case? 

What clinical signs are the most sensitive and specific for haematological malignancy in primary care?  

Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 

 

 

How can I incorporate shared decision-making in my management? 

What options are available to me if I am unsure what to do? 

Clinical management
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 

 

 

What clinical symptoms and signs would be considered 'red flags'? 

What treatment options might be considered? 

How do I assess the need or urgency of referral? 
Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 
How does the diagnosis of CLL affect the assessment, diagnosis, and clinical management of other potential co-morbidities? 

What are the likely psychological and social consequences of the diagnosis of a long term but as yet 'untreated' disease? 

What are the most relevant uncertainties and risks? 
Working with colleagues and in teams
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development. 
How will I coordinate ongoing care with the specialist multi-disciplinary teams? 

What factors might enhance or hinder the continuity of care? 

What are the best ways of communicating with very specialised teams such as haemato-oncology? 

Improving performance, learning and teaching
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, participating in commissioning*, quality improvement and research activity. 

 

 

 

What do I know about the management of haematological malignancies? 

What are my personal educational needs that this scenario identifies? 

In what ways can I assess and improve the care of patients with indolent disease? 

Organisational management and leadership 
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care planning, using new technologies to access and deliver care and developing relevant business and financial management skills. 

 

 

What shared care arrangements would I expect to be in place for this patient? 

How do I arrange ongoing monitoring at appropriate intervals? 

What support does the practice need to provide? 

Practising holistically, safeguarding and promoting health 
This is about the physical, psychological, socioeconomic and cultural dimensions of health. It includes considering feelings as well as thoughts, encouraging health improvement, preventative medicine, self-management and care planning with patients and carers. 

 

 

 

How do I differentiate and balance the physical and psychosocial symptoms of patients with chronic stable illness? 

How do I balance health anxiety with actual health risk? 

What other aspects of health promotion need to be addressed? 

Community orientation
This is about involvement in the health of the local population. It includes understanding the need to build community engagement and resilience, family and community-based interventions, as well as the global and multi-cultural aspects of delivering evidence-based, sustainable healthcare. 

 

 

How common is this type of illness in my practice population? 

What support needs to be identified in my locality? 

What voluntary organisation might be able to offer support and resources? 

How to learn this area of practice

Work-based learning

Patients will present with various symptoms, at varying stages in the natural history of their illness. Discussion with a trainer will aid specialty trainees in developing strategies to help in problem-solving. Supervised practice will also give trainees confidence.  

In particular, the GP specialty trainee should be able to gain experience in the management of abnormal haematological findings as they present (incidental, acute and chronic), including emergencies. General practice is also the best place to learn about holistic chronic disease management (for example, anticoagulation, anaemias, indolent malignancies, sickle cell disease, haemophilia,). 

Most GP training programmes have placements of varying lengths in general medicine, and some placements specifically in haematology. The acute setting is the place for you to learn about the immediate management life threatening presentations. As a specialty trainee you will also learn about the interpretation of haematology lab results, and how to differentiate significant abnormal findings and those of a coincidental nature, and appropriate secondary care investigations such as bone marrow aspirate and trephine. Outpatient or clinic settings are ideal places for seeing concentrated groups of patients with haematological problems.  

Your GP specialty training programme should offer you the opportunity to attend haematology clinics when working in other hospital posts and you should also consider attending specialist clinics during your general practice-based placements. 

Self-directed learning 

There is a growing body of e-Learning to help you consolidate and build on the knowledge you have gained in the workplace.  You can find an e-Learning module(s) relevant to this topic guide at e-Learning for Healthcare ( e-lfh.org.uk ) 

Learning with other healthcare professionals

Chronic disease management in primary care is a multidisciplinary activity. As a specialty trainee it is important for you to gain an understanding of the follow-up of patients with haematological disorders even though the clinical lead is taken by secondary care or a community clinical nurse specialist. It is also important to understand the role of medical scientists and when it appropriate to access their expertise in evaluating laboratory results. 

Examples of how this area of practice may be tested in the MRCGP

Applied Knowledge Test (AKT) 

  • Appropriate use of different anticoagulant therapies 
  • Interpretation of haematinic results 
  • Differential diagnosis of lymphadenopathy

Clinical Skills Assessment (CSA) 

  • Woman was investigated for tiredness and lethargy and has macrocytic anaemia and hypercholesterolaemia 
  • Child has developed purpuric rash on her legs (photo supplied) and three days of mild abdominal and joint pains 
  • Teenager has had a persistent and worsening sore throat for five days and now has abdominal pain and lymphadenopathy

Workplace-based Assessment (WPBA) 

  • Case Discussion on the management of a patient with persistent thrombocytopenia who is otherwise well  
  • Audit of the practice data on the appropriateness and value of requests for 'routine' haematology laboratory tests  
  • Learning log about the care of an elderly man who lives alone and has just been diagnosed with chronic lymphocytic leukaemia
  • Clinical Examination and Procedural Skill (CEPS) based on a patient with widespread lymphadenopathy 

Infectious disease and travel health

This Topic Guide will help you understand important issues relating to infectious disease and travel health by illustrating the key learning points with a case scenario and questions.

The role of the GP in travel health and the care of people with infectious disease

As a GP your role is to: 

  • Diagnose and manage diseases of infectious origin commonly seen in UK general practice and in the prospective or returning traveller  
  • Recognise and appropriately refer rare but serious infectious diseases 
  • Take a thorough social history including country of birth and travel history, and know how this may affect differential diagnoses 
  • Encourage self-management of benign self-limiting illnesses 
  • Identify, assess, manage and communicate major risks, including risks associated with common or serious infectious diseases, travel, therapies, and immunisation 
  • Know how to access specialist input for people with acute or chronic infectious diseases 
  • Know where to find appropriate travel health information  
  • Recognise and manage medical emergencies (including life-threatening conditions such as sepsis) in patients with acute or chronic infectious diseases, including returning travellers

Emerging issues in travel health and infectious disease

In an increasingly globalised world, infectious diseases are not restricted to geographical borders. As a GP you should therefore understand the local and global epidemiology of major infectious agents and their disease associations. Antimicrobial resistance (AMR) is an urgent problem of global and local importance; as a GP you can help tackle this through appropriate prescribing of antibiotics and patient education, amongst other measures. Additionally, the increasing mobility of people, including displaced populations such as refugees, means that GPs will need to understand a wider spectrum of infectious diseases and the altered contexts in which they may present. However, you should not make the assumption that illness in a returning traveller is necessarily or solely related to travel. 

Service provision for travel health and infectious diseases can vary greatly, depending on where you work. As a GP you may not be contractually obliged to provide certain services, or they may be delivered by other team members (for example, practice nurses). Nonetheless, you should be competent in diagnosing and managing common and important conditions related to travel and infectious disease, while at the same time knowing what services are available within your practice and locality, and what your statutory responsibilities are in terms of providing care. You should be aware of advances in diagnosing and monitoring infectious disease, such as genome sequencing of pathogens in outbreak detection (for example, Salmonella) or in TB diagnosis. 

Patients may be entering the UK or going abroad against their will (for example, trafficking, forced marriage, FGM) or to participate in criminal activities, and you should be familiar with GMC guidance and the law around these issues.  

GPs have a wider leadership and advocacy role that includes promoting better health systems, services, and policies (for example, effective local and global responses to international health emergencies), antimicrobial stewardship, and addressing health inequalities. 

Knowledge and skills guide

For each problem or disease, consider the following areas within the general context of primary care: 

  • The natural history of the untreated condition, including whether acute or chronic 
  • The prevalence and incidence across all ages and any changes over time  
  • Typical and atypical presentations 
  • Recognition of normal variations throughout life 
  • Risk factors, including lifestyle, socio-economic and cultural factors 
  • Diagnostic features and differential diagnosis 
  • Recognition of 'alarm' or 'red flag' features  
  • Appropriate and relevant investigations 
  • Interpretation of test results 
  • Management including prophylaxis, self-care, initial, emergency and continuing care, chronic disease monitoring and end-of-life care 
  • Patient information and education including self-care 
  • Prognosis  

Symptoms and signs

Infectious diseases may be asymptomatic. Symptoms and signs may include (but are not limited to): 

  • Cardiac symptoms
  • Fatigue and non-specific symptoms 
  • Fever 
  • Gastrointestinal symptoms for example, diarrhoea, vomiting, abdominal pain
  • Genitourinary symptoms
  • Hepatosplenomegaly   
  • Joint pains 
  • Lymphadenopathy 
  • Neurological symptoms 
  • Pruritus 
  • Respiratory symptoms for example, cough, shortness of breath, haemoptysis 
  • Skin signs (including pathognomonic rashes) 
  • Weight loss

Common and important conditions

Many infectious diseases are multi-systemic, therefore many of the conditions listed below will also appear in several other RCGP Topic Guides (for example, Children and Young People, Neurology, Respiratory Health, Gastroenterology, Musculoskeletal Health, Dermatology, Urgent and Unscheduled Care). You should read the relevant section of each Topic Guide for further information.  

Common and important conditions include: 

  • Bone, joint and soft tissue infections (for example, septic arthritis, osteomyelitis, necrotising fasciitis)  
  • Cardiovascular infections (for example, endocarditis, rheumatic fever) 
  • Common and serious childhood infections (including viral, bacterial, fungal) (see RCGP Topic Guides on Children and young people and Dermatology) 
  • Common ENT infections (see RCGP Topic Guide Ear, Nose, Throat and Mouth Problems) 
  • Fever in the returning traveller and its potential causes (for example, malaria, dengue, typhoid/paratyphoid, chikungunya, viral haemorrhagic fevers) 
  • Gastrointestinal infections (for example, amoebiasis, amoebic dysentery, food poisoning (including causative organisms), giardiasis, hydatid disease, Travellers’ diarrhoea, typhoid) 
  • Genitourinary infections including sexually transmitted and urinary tract infections 
  • Healthcare-associated infections (HCAI) (for example, MRSA, Clostridium difficile)  
  • Helminth infections (for example, schistosomiasis, hookworm, strongyloides) 
  • Hepatitis of infectious origin  
  • Human Immunodeficiency Virus (HIV)/AIDS including prevention, testing, transmission (including mother-to-child transmission), therapies, prophylaxis, and associated diseases (such as pneumocystis jirovecii (formerly carinii), cryptococcus spp., cytomegalovirus, candida)  
  • Immune deficiency; infectious disease in the immune-compromised patient 
  • Malaria (including malarial prophylaxis) 
  • Multi-systemic infections for example, bacterial (for example, staphylococcal, streptococcal), viral (for example, Epstein Barr Virus), fungal, parasitic (for example,
  • toxoplasma, Chagas disease) 
  • Neurological infections (for example, meningitis, encephalitis)
  • Occupational infections and their management (for example, needle stick infections) 
  • Ocular infections (for example, conjunctivitis, ophthalmia neonatorum) 
  • Pandemics (for example, pandemic influenza) 
  • Post-operative infections  
  • Respiratory disease (for example, pneumonia, Legionnaires' disease, influenza) 
  • Sepsis and the deteriorating patient 
  • Skin infections (for example, bed bugs, cutaneous larva migrans, exanthemata, flea, louse, ringworm, scabies, threadworm, orf, leishmaniasis) 
  • Tick borne diseases including Lyme disease 
  • Trauma including injuries, animal bites and wounds 
  • Tuberculosis and its different manifestations  
  • Travel related conditions (for example, altitude related sickness, DVT, PE, motion sickness, sun/cold exposure, water activities) 
  • Vaccine preventable communicable diseases including cholera, diphtheria, Haemophilus influenzae B, hepatitis A, hepatitis B, Human Papilloma Virus, influenza, Japanese encephalitis, measles, meningitis ACWY, meningitis B, meningitis C, mumps, pertussis, pneumococcus, poliomyelitis, rabies, rotavirus, rubella, shingles, tetanus, tick-borne encephalitis, tuberculosis, typhoid, yellow fever 
  • Zoonotic diseases (for example, leptospirosis, brucellosis)

Examinations and procedures 

  • Features of common and important infectious diseases through relevant, focused systems examination 
  • Rashes related to, or pathognomonic of, specific infectious diseases (for example, meningococcal meningitis, erythema chronicum migrans, erythema multiforme, erythema nodosum, viral exanthemata) 
  • Assessment of an acutely unwell patient with possible infection (including signs of sepsis)

Investigations 

  • Use, limitations and interpretation of investigations such as serological testing, swabs, blood films, urine and stool microscopy and culture, near patient testing (for example, CRP) 
  • Colonisation versus infection 
  • Common laboratory tests for example, haematology (including significance of eosinophilia in travellers or those born outside the UK) and biochemistry (including normal parameters) 
  • Imaging such as chest X-ray 
  • Screening in asymptomatic patients (for example, chlamydia, HIV, TB)

Service issues 

  • Immunisation including: 
    • childhood immunisation schedules
    • immunisation in pregnancy, travellers, and other important situations for example, contact tracing
    • vaccinations available on the NHS; and
    • mandatory vaccinations for travel to certain areas
  • Translation services
  • Safe working practice in personal, clinical and organisational settings (including principles and practice of infection control) 
  • Safe and effective evidence-based prescribing including prophylaxis, drug interactions, appropriate use of antimicrobial therapy, and antimicrobial resistance
  • Statutory notification of diseases
  • Fitness to travel documentation
  • Contact tracing and treatment of contacts
  • NHS travel health service provision and the role of the independent sector
  • Systems of care for people with infectious disease (including primary and secondary care, specialist services, voluntary sector organisations, shared care arrangements, and multidisciplinary teams)
  • Local emergency response plans and emergency preparedness
  • UK's health protection agencies and other major local, national and international organisations involved in emergency planning for and control of outbreaks of infection
  • UK screening and reporting programmes that relate to infection
  • Key national policy documents influencing health care provision for patients with infectious diseases

Additional important content 

  • Modes of transmission, incubation periods, and periods of communicability of common and important infectious agents 
  • Diseases likely to affect prospective or returning travellers and those who were born or have lived outside the UK 
  • Diagnostic overshadowing (i.e. assuming that illness in returning travellers or those born outside the UK are solely related to travel) 
  • Health advice for travellers (including vaccination and other precautions, use of electronic resources, and signposting to appropriate services) 
  • Pre- and post-exposure prophylaxis 
  • Infectious diseases during pregnancy, birth, and breastfeeding, in elderly people, the immunosuppressed, and drug/alcohol users 
  • Travel health during pregnancy (including specific risks, fitness to fly certification) 
  • Risk-benefit conversations (for example, around screening and testing for infectious diseases, immunisation and specific vaccines, travel, and therapies) based on patient’s current and past health and individual circumstances 
  • Use of appropriate language in communicating the status of a deteriorating patient to other services (for example, ambulance) 
  • Health of refugees, asylum seekers, people born or lived outside the UK, victims of human trafficking 
  • Loss of innate immunity in immigrants and its impact on travel prophylaxis 
  • Psychosocial impact of infectious diseases on individuals and their wider social networks 
  • Relevant guidelines and legislation ( Civil Aviation Authority, NICE, SIGN, national patient safety initiatives, local antimicrobial guidelines) 
  • Ethical and legal considerations (for example, around confidentiality/disclosure, data protection, consent, immunisation, rights of migrants to healthcare, capacity and competence)

Case discussion

Alex, a 20-year-old university student, is planning to travel to South East Asia for two months. She visits you for travel advice as the nurse who runs the travel clinic is absent.  

She has no significant past medical history. Her only medication is the combined oral contraceptive pill (COCP) which she uses for contraception and dysmenorrhoea. Alex is concerned about her DVT risk when flying whilst on the COCP but is reluctant to stop it.  

You provide Alex with country-specific and general travel advice, such as the risk of infectious diseases, vaccinations needed, malaria prophylaxis, sun exposure and travel insurance. 

After six months, you see Alex as an emergency appointment. She returned to the UK three days ago and has been having diarrhoea and vomiting for five days. On further exploration, she also admits to having unprotected sexual intercourse with a fellow traveller over a month ago and is worried about sexually transmitted conditions.  

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your Educational Supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.  

                       Core Competence       
                  Questions          

Fitness to practise 
This concerns the development of professional values, behaviours and personal resilience and preparation for career-long development and revalidation. It includes having insight into when your own performance, conduct or health might put patients at risk, as well as taking action to protect patients. 

 

 

What are my beliefs and assumptions about infectious disease and its acquisition? How might they impact on my consultations with Alex? 

How do I take care of my own health? Are there any significant risks to my health at work, or risks to patients because of my health? How might these be addressed? 

Maintaining an ethical approach
This addresses the importance of practising ethically, with integrity and a respect for diversity. 

 

 

What ethical issues should I consider in relation to STI (including HIV) testing? 

What additional issues might arise if Alex says that she has a partner? 

Communication and consultation 
This is about communication with patients, the use of recognised consultation techniques, establishing patient partnerships, managing challenging consultations, third-party consulting and the use of interpreters. 

 

 

How might I optimise consultations involving sensitive issues, including when the patient does not speak English? 

How confident am I based on the consultation that Alex will come back to see me? What techniques could I use to improve rapport and build trust? 

Data gathering and interpretation 
This is about interpreting the patient's narrative, clinical record and biographical data. It also concerns the use of investigations. 

 

How confident am I in taking a sexual history and conducting a risk assessment?  

What further information do I need about Alex's travel plans in order to give advice about infectious diseases and vaccinations? 

Clinical Examination and Procedural Skills
This is about the adoption of an appropriate and proficient approach to clinical examination and procedural skills. 

 

 

 

What equipment does my surgery have for STI testing in women and men? 

What methods can be used to test for chlamydia? 

What factors should be taken into account regarding the timing of STI testing? 
Making decisions 
This is about having a conscious, structured approach to decision-making; within the consultation and in wider areas of practice. 
How can I decide which vaccinations to recommend to Alex? What resources can I use to assist me? 

What signs and symptoms would have influenced me to refer to secondary care when Alex presented with diarrhoea and vomiting? 

Clinical management 
This concerns the recognition and management of common medical conditions encountered in generalist medical care. It includes safe prescribing and medicines management approaches. 

 

 

What should I tell Alex about her risk of DVT? 

What investigations would have been appropriate to initiate when Alex presented as an emergency? 

What factors would have influenced me to prescribe antibiotics or anti-motility agents when Alex presented with gastroenteritis? 

Managing medical complexity
This is about aspects of care beyond managing straightforward problems. It includes multi-professional management of co-morbidity and poly-pharmacy, as well as uncertainty and risk. It also covers appropriate referral, planning and organising complex care, promoting recovery and rehabilitation. 

 

 

What factors would I have had to consider if Alex had been pregnant? 

If Alex had been born or grown up in South East Asia, would this have altered my travel advice? 

How would I arrange contact tracing for STIs? 

Working with colleagues and in teams 
This is about working effectively with other professionals to ensure good patient care. It includes sharing information with colleagues, effective service navigation, use of team skill mix, applying leadership, management and team-working skills in real-life practice, and demonstrating flexibility with regard to career development.

 

 

How are patients requiring travel advice or STI testing managed in my practice?  

What alternative options are there for STI testing in my locality? How can patients access these? 

Where can my patients receive travel vaccinations such as yellow fever if my practice does not offer it?   

Improving performance, learning and teaching  
This is about maintaining performance and effective CPD for oneself and others. This includes self-directed adult learning, leading clinical care and service development, quality improvement and research activity. 

 

 

What is the guidance on management of STIs in primary care? 

What is the guidance on management of diarrhoea and vomiting in a returning traveller? 

Where can I seek up-to-date travel advice?  

Organisational management and leadership
This is about the understanding of organisations and systems, the appropriate use of administration systems, effective record keeping and utilisation of IT for the benefit of patient care. It also includes structured care plann