Minor Illness in Primary Care

Question 1

What are the clinical features of tonsilitis?

Answer 1

Sore throat.
The throat may be erythematous.
Swollen tonsils +/- cervical lymphadenopathy.
There may be white exudate on the tonsils.

Question 2

What is the treatment for tonsilitis?

Answer 2

Penicillin V for 10 days - if penicillin allergic Clarithromycin.
Broader range: doxycycline, co-amoxiclav or clarithromycin.

Question 3

What are the clinical features and findings on examination of otitis media?

Answer 3

Ear pain.
Discharge - if the tympanic membrane ruptures/perforates.
A distinctly red, yellow, or cloudy tympanic membrane.
Moderate to severe bulging of the tympanic membrane, (negative light reflex), loss of normal landmarks, and an air-fluid level behind the tympanic membrane (indicates a middle ear effusion).

Question 4

What is the management of otitis media?

Answer 4

Usually resolves within 3-7 days.
Patients should be given antibiotics if they have a perforation.
First-line = amoxicillin 5-7 days (penicillin allergy: clarithromycin).
Not responding to antibiotics within 2 days = Co-amoxiclav.

Question 5

What are the clinical features of acute sinusitis?

Answer 5

Nasal blockage or discharge accompanied by facial pain/pressure, headache or a reduction in the sense of smell.

Question 6

What may be the examination findings of a patient with acute sinusitis?

Answer 6

Signs which support a diagnosis of acute sinusitis such as nasal inflammation, mucosal oedema, and purulent nasal discharge.

Question 7

When should you suspect a diagnosis of acute bacterial sinusitis?

Answer 7

Symptoms for more than 10 days
Discoloured or purulent nasal discharge (with unilateral predominance).
Severe local pain (with unilateral predominance).
A fever greater than 38°C.
A marked deterioration after an initial milder form of the illness (so-called ‘double-sickening’).
Elevated ESR/CRP (although the practicality of this criterion is limited).

Question 8

What is the management of acute sinusitis?

Answer 8

NICE guidelines:

• symptoms for less than 10 days = no antibiotics.
• no improvement after 10 days = 2 weeks of high-dose steroid nasal spray.
• no improvement after 10 days and suspected bacterial cause = consider delayed or immediate prescription of antibiotics.

First line = Penicillin V for 5 days (penicillin allergy clarithromycin or doxycycline).
No response within 2 days = Co-amoxiclav
Pregnancy = Erythromycin

Question 9

What are the clinical features of blepharitis?

Answer 9

Burning, itching, and/or crusting of the eyelids.
Symptoms are worse in the mornings.
Both eyes are affected.
Recurrent hordeolum (infection of the glands in the eye)
Contact lens intolerance.

Question 10

What is the management of blepharitis?

Answer 10

The eyelid can be cleansed by wetting a cloth or cotton bud with cleanser and gently wiping along the lid margins to clear any lid debris.
Eyelids should be cleaned twice daily initially, then once daily as symptoms improve.
In addition, a warm compress should be applied to closed eyelids for 5–10 minutes once or twice daily —
Eyelid hygiene should be continued even when symptoms are well controlled to minimise the number and severity of relapses.

Question 11

What are the clinical features of conjunctivitis?

Answer 11

Acute onset conjunctival erythema.
Discomfort which may be described as ‘grittiness’, ‘foreign body’ or ‘burning’ sensation.
Watering and discharge which may cause transient blurring of vision.

Question 12

What symptoms are suggestive of a bacterial cause of conjunctivitis?

Answer 12

Purulent or mucopurulent discharge with crusting of the lids which may be stuck together on waking.
Mild or no pruritus.
Pre-auricular lymphadenopathy with Neisseria Gonnorhoea infection.

Question 13

What symptoms are suggestive of a viral cause of conjunctivitis?

Answer 13

Mild to moderate erythema of the conjunctiva on eyelid eversion and lid oedema.
Petechial (pin-point) subconjunctival haemorrhages.
Pseudomembranes
Less discharge (usually watery) than bacterial conjunctivitis.
Mild to moderate pruritus.
Upper respiratory tract infection and pre-auricular lymphadenopathy.

Question 14

What STI infections can cause conjunctivitis?

Answer 14

Chlamydia
Gonorrhoea

Question 15

How should viral conjunctivitis be managed in primary care?

Answer 15

Reassure the person that most cases of acute, infectious conjunctivitis are self-limiting and do not require antimicrobial treatment — viral (non-herpetic) conjunctivitis usually resolves within one to two weeks without treatment.

Advise the person that symptoms may be eased with self-care measures such as:
Bathing/cleaning the eyelids with cotton wool soaked in sterile saline or boiled and cooled water to remove any discharge.
Cool compresses are applied gently around the eye area.
Use of lubricating agents or artificial tears.

Advise the patient that this is highly infectious and they should maintain good hand hygiene and avoid close contact with others.

Question 16

How should bacterial conjunctivitis be managed in primary care?

Answer 16

Self-limiting resolving within 5-7 days.
Treat with topical antibiotics if severe or circumstances require rapid resolution.
Options for topical antibiotics include:
Chloramphenicol 0.5% drops
Chloramphenicol 1% ointment
Fusidic acid 1% eye drops
Continue use until 48 hours after the infection has cleared.

Question 17

What are the red flags for eye infections?

Answer 17

Reduced visual acuity.
Moderate to severe pain.
Headache.
Photophobia (serious eye infection or possible meningitis)
Pain on pupillary constriction.
Loss of red reflex.

Question 18

What are the main features of treating conjunctivitis in primary care?

Answer 18

Reassuring the person that most cases are self-limiting.
Advising self-care measures such as bathing/cleaning the eyelids, cool compresses, lubricating drops or artificial tears, and avoidance of contact lenses.
Advising on appropriate infection control techniques.
Antibiotics if severe or unresolved bacterial infection.
Follow-up and appropriate safety-netting on red flag clinical features may indicate the need for urgent review.

Question 19

What are the clinical features of a stye?

Answer 19

An acute-onset painful, localized swelling (papule or furuncle) near the eyelid margin that develops over several days.
Unilateral.
The eye may water excessively (epiphora).

Question 20

What are the clinical features of the common cold?

Answer 20

Sore or irritated throat
Nasal irritation, congestion, nasal discharge (rhinorrhoea), and sneezing.
Cough
A hoarse voice can be caused by associated laryngitis.
General malaise.

Question 21

What are some less common clinical features of the common cold?

Answer 21

Fever — this is unusual in adults and is typically low-grade.
Headache and myalgia — are more often associated with influenza rather than the common cold.
Loss of taste and smell, eye irritability, and a feeling of pressure in the ears or sinuses (due to obstruction or mucosal swelling).

Question 22

What is the management in primary care for the common cold?

Answer 22

Adequate fluids
Adequate rest is advised

Question 23

What are the clinical features of bacterial vaginosis?

Answer 23

Approximately 50% of women with bacterial vaginosis (BV) are asymptomatic.
When symptoms are present, BV is characterized by a fishy-smelling, thin, grey/white homogeneous discharge that is not associated with itching or soreness.

Question 24

What additional questions should be asked when assessing for BV?

Answer 24

Duration
Severity
Exacerbating
Treatments tried
The presence of contributing factors, including the use of vaginal products, such as douches, deodorant, and vaginal washes, and the use of antiseptics, bubble baths, or shampoos in the bath.
Medical history (past and present).
Drug history, including the use of oral contraceptives.

Question 25

When can examination and investigation be omitted in women presenting with suspected BV?

Answer 25

The woman is at low risk of an STI.
The woman does not have symptoms of other conditions causing vaginal discharge.
Symptoms have not developed pre or post a gynaecological procedure.
The woman is not postnatal or post miscarriage.
The woman is not pre or post termination.
This is a first episode of suspected BV, or if recurrent, a previous episode of recognizably similar symptoms was previously diagnosed to be BV following examination.
The woman is not pregnant.

Question 26

What examination is carried out for suspected BV?

Answer 26

Palpate the abdomen to assess for tenderness or a mass.
Inspect the vulva for lesions, discharge, vulvitis, ulcers, and any other changes.
Perform a speculum examination.
BV is characterized by a thin, white/grey, homogeneous coating of the vaginal walls and vulva that has a fishy odour.

Question 27

What investigations are carried out for women with suspected BV?

Answer 27

pH test.
High vaginal swab (or low self-test vaginal swab)

Question 28

What is the management of BV in primary care for a woman that is not pregnant? What is the addition in pregnancy?

Answer 28

Asymptomatic = no treatment

Symptomatic = Advise that, where possible, she should reduce exposure to contributing factors.
Prescribe oral metronidazole 400 mg twice a day for 5 to 7 days.

If oral is not preferred or tolerated = Prescribe intravaginal metronidazole gel 0.75% once a day for 5 days or intravaginal clindamycin cream 2% once a day for 7 days.

Pregnant women should be tested again a month after initiation of treatment.

Question 29

What questions should be asked for a diagnosis of thrush?

Answer 29

Duration
Itching
Soreness or irritation
White, thick discharge with no odour.
Dyspareunia
Any risk factors for candidiasis.
Any risk factors for a sexually transmitted infection (STI), if appropriate.
Any treatments tried, including over-the-counter treatments.
Risk of pregnancy and contraceptive use.

Question 30

What symptoms would suggest an alternative diagnosis to thrush?

Answer 30

Foul-smelling discharge -> BV
Urinary frequency -> UTI or STI
Bleeding -> STI or Gynaecological cancer

Question 31

What findings may be present on an examination of the external genitalia in thrush?

Answer 31

Erythema — usually localized to the vagina and vulva, but may extend to the labia majora and perineum.
Vaginal fissuring and/or oedema.
Satellite lesions (rare; may indicate other fungal conditions or herpes simplex virus [HSV] infection), or vulval excoriation.

Question 32

What investigations can be carried out for thrush if, after history and examination, the diagnosis is still in doubt?

Answer 32

Consider a high vaginal swab (HVS) of vaginal secretions for microscopy first-line for suspected acute vulvovaginal candidiasis.
Arrange an HVS of vaginal secretions for culture for suspected recurrent vulvovaginal candidiasis.
This may identify Candida albicans, non-albicans Candida species, or an additional infection.
If there is a poor or partial response to maintenance therapy, request culture with full speciation and sensitivity testing.
Consider arranging a self-collected vaginal swab if the initial results are negative.
Consider vaginal pH testing of secretions, but this is not essential to make a diagnosis of Candida infection.
Consider a midstream sample of urine (MSU) — if a UTI is suspected.
Consider an HbA1c test — to exclude diabetes mellitus in severe or recurrent infection.
Consider a full blood count and serum ferritin level — to exclude iron deficiency anaemia.
Consider STI screening — if the woman is concerned or at risk, or if there are clinical features suggesting an STI.

Question 33

What is the management of thrush in primary care?

Answer 33

Conservative:
Use simple emollients as a soap substitute to wash and/or moisturize the vulval area.
Avoid contact with potentially irritant soap, shampoo, bubble bath, or shower gels, wipes, and daily or intermenstrual ‘feminine hygiene’ pad products.
Avoid vaginal douching.
Avoid wearing tight-fitting and/or non-absorbent clothing, which may irritate the area.
Avoid the use of complementary therapies such as the application of yoghurt, topical or oral probiotics, and tea tree or other essential oils.

Anti-fungal treatments:
Advise fluconazole 150 mg oral capsule as a single dose first-line.
Advise clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated. See the section on Oral fluconazole in Prescribing Information for more information on drug contraindications and cautions.
Advise that topical imidazole preparations may damage latex condoms and diaphragms.

Vulval symptoms:
Options include clotrimazole 1% or 2% cream applied 2–3 times a day.
Advise that oral fluconazole, intravaginal clotrimazole, and topical clotrimazole can be bought over-the-counter.

Question 34

What are the key questions when taking a history of a suspected chest infection?

Answer 34

Onset and duration of symptoms.
The type of cough (dry or productive).
Additional symptoms such as breathlessness, wheezing, pleuritic pain, and fever.
Smoking status.

Question 35

What score should be used to assess the severity of a chest infection in an older patient?

Answer 35

CURB-65
Confusion
Urea >9
RR > 30
BP <60/9
Over 65?

Question 36

What features suggest that a chest infection may be pneumonia?

Answer 36

Difficulty breathing.
Oxygen saturation less than 90%.
Raised heart rate.
Grunting; very severe chest indrawing.
Inability to drink.
Lethargy; reduced level of consciousness.

Question 37

What investigations can be carried out for a person with a chest infection?

Answer 37

Pulse oximetry - O2 sats
CRP - inflammation
FBC - markers of infection (WBC)
CXR - evidence of pneumonia (consolidation)

Question 38

How does the typical history of acute bronchitis vary from that of CAP?

Answer 38

Both = cough
Acute bronchitis:
May or may not have sputum, wheeze, or breathlessness.
Substernal or chest wall pain may be present when coughing.
Sometimes mild constitutional symptoms.
CAP:
Dyspnoea, sputum production, pleural pain, sweating, fever, shivers, aches, and pains

Question 39

How do the typical examination findings of acute bronchitis vary from that of CAP?

Answer 39

AB:
Mildly ill.
Wheeze is often present; rhonchi that improve with coughing may be present.
May have systemic features with or without a raised temperature.

CAP:
Moderately to severely ill.
Focal chest signs such as decreased or asymmetric breath sounds, bronchial breath sounds, dullness to percussion, course crepitations, and vocal fremitus.
Typically tachypnoea, tachycardia, dyspnoea
Temperature 38°C, or above
May be hypoxia
Confusion (uncommon, but may be seen in older people)

Question 40

How do the typical investigation findings of acute bronchitis vary from that of CAP?

Answer 40

AB: Chest X-ray normal
CAP: Chest X-ray abnormal (new infiltrate provides definitive diagnosis of pneumonia).

Question 41

What is the management of Acute Bronchitis in primary care? (not including antibiotics).

Answer 41

Self-care and conservative management (smoking cessation etc).
Safety net: if symptoms acutely worsen or do not improve in 3-4 weeks return.
Acute bronchitis is usually a self-limiting illness and the cough usually lasts about three to four weeks.

Question 42

When should immediate or backup antibiotic prescription be considered for acute bronchitis?

Answer 42

A pre-existing comorbid condition such as heart, lung, kidney, liver, or neuromuscular disease, immunosuppression, or cystic fibrosis.
Older than 65 years of age with two or more of the following, or older than 80 years with one or more of the following:
Hospital admission in the previous year.
Type 1 or type 2 diabetes mellitus.
History of congestive heart failure.
Current use of oral corticosteroids.

Question 43

What antibiotics should be offered for acute bronchitis in those aged 18+?

Answer 43

The first-line choice is oral doxycycline: 200 mg on the first day, then 100 mg once a day for 4 days (a 5-day course in total). (Not in pregnancy)
Alternative first choices are oral:
Amoxicillin (preferred in pregnant women) 500 mg three times a day for 5 days.
Clarithromycin 250 mg to 500 mg twice a day for 5 days.
Erythromycin (preferred in pregnant women) 250 mg to 500 mg four times a day or 500 mg to 1000 mg twice a day for 5 days.

Question 44

What antibiotics should be offered for acute bronchitis in those aged 12-17?

Answer 44

The first-line choice is oral amoxicillin (preferred in young women who are pregnant): 500 mg three times a day for 5 days.
Alternative first choices are oral:
Clarithromycin 250 mg to 500 mg twice a day for 5 days.
Erythromycin (preferred in young women who are pregnant) 250 mg to 500 mg four times a day or 500 mg to 1,000 mg twice a day for 5 days.
Doxycycline 200 mg on the first day, then 100 mg once a day for 4 days (5-day course in total). Note doxycycline should not be given to young women who are pregnant.

Question 45

When should adults with CAP be referred to hospital?

Answer 45

Symptoms and signs suggest a more serious illness or condition (for example cardiorespiratory failure or sepsis), or
Symptoms are not improving as expected with antibiotics.

Question 46

How should CAP be managed in primary care?

Answer 46

Self-care advice.
Antibiotics.

Question 47

What are the options for antibiotic treatment for patients with CAP in primary care?

Answer 47

Low severity:
The first choice oral antibiotic is amoxicillin 500 mg three times a day for 5 days (higher doses can be used — see the BNF).
Alternatively, if there is a penicillin allergy or amoxicillin is unsuitable (for example atypical pathogens are suspected) options are oral doxycycline (total course of 5 days), or oral clarithromycin twice a day for 5 days, or oral erythromycin (in pregnancy) four times a day for 5 days.

Moderate severity: Prescribe oral amoxicillin 500 mg three times a day for 5 days and (if atypical pathogens are suspected) oral clarithromycin twice a day for 5 days, or oral erythromycin (in pregnancy) four times a day for 5 days.
Alternatively, in penicillin allergy, oral doxycycline on the first day then once a day for 4 days (total course of 5 days), or oral clarithromycin twice a day for 5 days.

Child 12-17:
The first choice oral antibiotic is amoxicillin 500 mg three times a day for 5 days (higher doses can be used — see the BNF for children).
Alternative choices if there is a penicillin allergy or amoxicillin is unsuitable (for example atypical pathogens are suspected) are oral clarithromycin twice a day for 5 days, or oral erythromycin (in pregnancy) four times a day for 5 days or oral doxycycline 200mg on the first day, then 100mg once a day for 4 days (total course of 5 days).

Question 48

How should the course of CAP and the symptoms progress after treatment?

Answer 48

1 week — fever should have resolved.
4 weeks — chest pain and sputum production should have substantially reduced.
6 weeks — cough and breathlessness should have substantially reduced.
3 months — most symptoms should have resolved but fatigue might still be present.
6 months — symptoms should have fully resolved.

Question 49

What are the clinical features of a UTI?

Answer 49

Dysuria — discomfort, pain, burning, tingling or stinging associated with urination.
Frequency — passing urine more often than usual.
Urgency — a strong desire to empty the bladder, which may lead to urinary incontinence.
Changes in urine appearance or consistency:
Urine may appear cloudy to the naked eye, or change colour or odour.
Haematuria may present as red/brown discolouration of urine or as frank blood.
Nocturia — passing urine more often than usual at night.
Suprapubic discomfort/tenderness.

Question 50

How is a UTI (with no haematuria) managed in primary care (women)?

Answer 50

Simple analgesia
Fluid intake increase

First-line: Nitrofurantoin 100mg modified-release twice a day for 3 days (if eGFR ≥45ml/minute) or
Trimethoprim 200mg twice a day for 3 days (if there is a low risk of resistance).

Second-line: Nitrofurantoin 100mg modified-release twice a day for 3 days (if eGFR ≥45ml/minute and not used as first-choice) or
Pivmecillinam (penicillin) 400mg initial dose, then 200mg three times a day for a total of 3 days or
Fosfomycin 3g single dose sachet.

Question 51

How is a UTI (with visible or non-visible haematuria) managed in primary care (women)?

Answer 51

Refer depending on suspected cause:
Cancer -> 2-week wait referral
Kidney disease

Question 52

Which antibiotic for UTI treatment should be avoided in pregnant women in trimester 3?

Answer 52

Nitrofurantoin

Question 53

Which antibiotic for UTI treatment should be avoided in pregnant women in trimester 1?

Answer 53

Trimethoprim

Question 54

What is the management of UTIs in men, in primary care?

Answer 54

Trimethoprim 200 mg twice daily for 7 days.
Nitrofurantoin 100 mg modified-release twice daily (or if unavailable 50 mg four times daily) for 7 days.
Nitrofurantoin is not recommended for men with prostate involvement as it is unlikely to reach therapeutic levels in the prostate.

Question 55

What investigation should be carried out in men with suspected UTI?

Answer 55

Urine culture

Question 56

When should men with UTIs be referred for the 2-week wait?

Answer 56

Aged 45 years and over who have unexplained visible haematuria without urinary tract infection, or visible haematuria that persists or recurs after successful treatment of urinary tract infection.
Aged 60 years and over who have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.

Question 57

When should men with UTIs be referred to urology?

Answer 57

Have ongoing symptoms despite appropriate antibiotic treatment.
May have an underlying cause or risk factor for the UTI (such as suspected bladder outlet obstruction, or have a history of pyelonephritis, urinary calculi, or previous genitourinary tract surgery).
Have recurrent episodes of UTI (for example, two or more episodes in a 6-month period).

Question 58

What are the red flag symptoms for acute diarrhoea?

Answer 58

Blood in the stool.
Recent hospital treatment or antibiotic treatment.
Weight loss.
Evidence of dehydration.
Nocturnal symptoms (always pathological)

Question 59

What features of a history would suggest acute diarrhoea in association with infection?

Answer 59

Fever.
Vomiting.
Recent contact with a person with diarrhoea.
Exposure to possible sources of enteric infection (for example, having eaten meals out, or recent farm or petting zoo visits).
Travel abroad — increases the likelihood of infection. Ask about potential exposures such as raw milk or untreated water.
Being in a higher risk group such as food handlers, nursing home residents, and recently hospitalized people.

Question 60

What should be asked about in a history for acute diarrhoea?

Answer 60

Signs of infection - fever
Characteristics of the diarrhoea - consistency, colour, blood.
Medications.
Recent travel.
Stress and anxiety.
Abdominal pain.
Risk factors for immunosuppression.
Diet, alcohol, substance abuse.
Surgery + medical conditions.

Question 61

How would you assess for dehydration and what would be the findings in a person presenting with acute diarrhoea?

Answer 61

Pulse rate - increased.
Skin turgor - decreased.
Mucous membranes - dry.
Cap refill - delayed.
Urine output - decreased.
Blood pressure - hypotensive.

Question 62

What examinations can be performed for a patient presenting with acute diarrhoea and what are you assessing for?

Answer 62

Perform an abdominal examination to assess for pain or tenderness, distension, mass, increased or decreased bowel sounds, or liver enlargement.

Consider a rectal examination to assess for rectal tenderness, stool consistency, and for blood, mucus, and possible malignancy.

Question 63

What are the signs of mild dehydration?

Answer 63

Lassitude - lack of energy
Anorexia, nausea.
Light-headedness.
Postural hypotension.
Usually no signs.

Question 64

What are the signs of moderate dehydration?

Answer 64

Apathy/tiredness.
Dizziness.
Nausea/headache.
Muscle cramps.
Pinched face.
Dry tongue or sunken eyes.
Reduced skin elasticity.
Postural hypotension.
Tachycardia.
Oliguria.

Question 65

What are the signs of severe dehydration?

Answer 65

Profound apathy.
Weakness.
Confusion, leading to coma.
Shock.
Tachycardia.
Marked peripheral vasoconstriction.
Systolic blood pressure less than 90 mmHg.
Oliguria or anuria.

Question 66

What are the red flag symptoms for chronic diarrhoea?

Answer 66

Unexplained weight loss.
Unexplained rectal bleeding.
Persistent blood in the stool.
Abdominal mass.
Rectal mass.
Severe abdominal pain.
Iron deficiency anaemia.
Raised inflammatory markers (may indicate inflammatory bowel disease).
Nocturnal or continuous diarrhoea or both
Fever, tachycardia, hypotension, dehydration.

Question 67

How should chronic diarrhoea be investigated in primary care?

Answer 67

Full blood count — to detect anaemia.
Urea and electrolytes.
Liver function tests, including albumin level.
Calcium.
Vitamin B12 and red blood cell folate.
Iron status (ferritin).
Thyroid function tests.
ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein).
Testing for coeliac disease — immunoglobulin A (IgA), and IgA tissue transglutaminase (tTG), or IgA endomysial antibody (EMA).

Question 68

What antigen tests can be considered when investigating chronic diarrhoea?

Answer 68

Ca-125

Question 69

What tests should stool samples be sent for when investigating chronic diarrhoea?

Answer 69

C.diff
Faecal calprotectin

Question 70

When should a patient be referred to the cancer pathway for chronic diarrhoea?

Answer 70

They are aged 40 and over with unexplained weight loss and abdominal pain, or
They are aged 50 and over with unexplained rectal bleeding, or
They are aged 60 and over with iron deficiency anaemia or changes in their bowel habit, or tests show occult blood in their faeces.

Question 71

When should you suspect gastroenteritis?

Answer 71

Sudden-onset diarrhoea (change of stool consistency to loose or watery stools, usually at least three times in 24 hours); blood or mucus in the stool; faecal urgency.
Nausea or sudden onset of vomiting.
Fever or general malaise.
Abdominal pain or cramps.
Associated headache, myalgia, bloating, flatulence, weight loss, and malabsorption, depending on the underlying cause of infection.

Question 72

What should be asked for suspected gastroenteritis?

Answer 72

Symptoms such as diarrhoea (including blood, mucus, and/or pus), nausea, vomiting, abdominal pain, fever, and general malaise.
The onset, frequency, duration, and severity of symptoms.
Risk factors for developing dehydration, current fluid intake (including breastfeeding in children), food intake, and urinary output.
Any co-morbid conditions including history of immunosuppression.
Occupation.
Recent food intake.
Recent exposure to untreated or potentially contaminated water.
Contact with other affected individuals or outbreaks.
Recent foreign travel (which country and region visited).
Recent antibiotic or proton pump inhibitor treatment, or recent hospital admission.

Question 73

When must urgent hospital admission be arranged for a patient presenting with suspected gastroenteritis?

Answer 73

The person is systemically unwell and/or there are clinical features suggesting severe dehydration and/or progression to shock.
There is intractable vomiting or high-output diarrhoea.
There is a suspected serious complication, such as sepsis.

Question 74

How is gastroenteritis managed in primary care?

Answer 74

In healthy adults:
Encourage regular fluid intake.

In adults at increased risk of dehydration (such as the elderly, immunocompromised, those with co-morbid conditions or concurrent illness):
Advise on the use of oral rehydration salt (ORS) solution as supplemental fluid.

In adults with clinical features of dehydration who can safely be managed at home:
Advise to use ORS solution frequently and in small amounts to rehydrate the person.
After rehydration:
Gradually reintroduce the usual diet, advising that small, light, non-fatty, non-spicy meals may be better tolerated.

Question 75

When should anti-diarrhoeal drugs not be used?

Answer 75

Blood, mucus, and/or pus in the stools or high fever (suggesting possible dysentery).
Shigellosis or confirmed, probable, or suspected Shiga toxin-producing Escherichia coli 0157 (STEC) infection, following stool culture and sensitivity testing.

Question 76

What are the clinical features of dental abscesses?

Answer 76

Pain :
S - in the teeth/gums
Q - throbbing
I - intense (wakening)
T - sudden onset, worsens over a few hours.
A - hot and cold sensitivity, chewing/biting.
R - N/A
S - Unpleasant taste, Fever, malaise, trismus or dysphagia, lethargy and loss of appetite.
Trismus (inability to open the mouth)

Question 77

What are the findings on examination of the mouth for a dental abscess?

Answer 77

Facial swelling, with or without cellulitis.
Regional lymphadenopathy.
Altered tooth appearance: the affected tooth may be elevated, broken, or show signs of decay.
Gum swelling.
Purulent drainage
Palpation may reveal:
Tooth: increased mobility and tenderness.
Gum: tenderness, warmth, and a purulent exudate.

Question 78

When should a patient have an emergency admission to hospital for a dental abscess?

Answer 78

Signs of airway compromise.
Are unwell with a high temperature and cardio-respiratory compromise.
A rapidly progressing infection.
Significant mandibular, submandibular, or infraorbital swelling (or difficulty opening the eye).
‘Floor of mouth’ swelling.
A spreading facial infection or orbital cellulitis.
Neurological signs.
Dehydration.
Social factors that may compromise outpatient treatment.

Question 79

What advice should be given to patients with dental abscess that do not have immediate access to dental treatment?

Answer 79

Use a soft toothbrush to reduce discomfort.
Avoid flossing the tooth with the abscess.
Consume soft foods and try eating on the other side of the mouth to reduce discomfort and irritation to the abscess.
Avoid food or drink that may be too hot or cold.
Analgesia.

Question 80

What are the clinical features of haemorrhoids?

Answer 80

Bright red, painless rectal bleeding is the most common symptom of haemorrhoids.
Anal itching or irritation
A feeling of rectal fullness, discomfort, or tenesmus.
Soiling (due to mucus discharge or impaired continence) may also occur.

Question 81

When can haemorrhoids be painful?

Answer 81

Internal - if they prolapse and become strangulated.
External - if they develop thrombosis, large painful mass.

Question 82

What features may be found on examination of the perianal area in haemorrhoids?

Answer 82

The perineum may appear normal if there is a non-prolapsed internal haemorrhoid.
Local erythema and irritation.
If internal haemorrhoids have prolapsed, straining may cause them to appear at the anal verge, and bluish, soft bulging vessels covered by mucosa may be seen.
If external haemorrhoids are asymptomatic, a bluish bulging of the blood vessel beneath the skin may be seen.
An acutely thrombosed external haemorrhoid may present as a purplish, oedematous, tense, tender, subcutaneous perianal mass.

Question 83

What lifestyle advice should be given to people with haemorrhoids?

Answer 83

Advise on the importance of correct anal hygiene.
The anal region should be kept clean and dry to aid healing and reduce irritation and itching. Recommend careful perianal cleansing and to pat (rather than rub) the area dry.
Advise against ‘stool withholding’ and undue straining during bowel movements, both of which can worsen the condition.

Question 84

What analgesia should be avoided in haemorrhoid treatment?

Answer 84

Opioids - can cause constipation.

Question 85

What is the immunisation schedule for babies under 1?

Answer 85

8 weeks: 6 in 1 vaccine, rotavirus vaccine, and MenB
12 weeks: 6 in 1 vaccine, pneumococcal vaccine, and rotavirus.
16 weeks: 6 in 1 vaccine, MenB

Question 86

What is the immunisation schedule for children 1 to 15?

Answer 86

1 year: Hib/MenC, MMR, Pneumococcal vaccine and MenB
2 to 10 years: Flu vaccine (every year)
3 years 4 months: MMR, 4 in 1 pre-school booster.
12 to 13 years: HPV vaccine
14 years: 3 in 1 teenage booster, MenACWY

Question 87

What is the immunisation schedule for adults?

Answer 87

50 years: Flu vaccine (every year)
65 years: pneumococcal vaccine
70 years: shingles vaccine

Question 88

What is the immunisation for pregnant women?

Answer 88

During flu season: flu vaccine
From 16 weeks: whooping cough (pertussis) vaccine