Primary care
Primary care
Primary care
This section offers learning modules with CPD credits and is aimed at healthcare professionals in primary care. It covers a range of topics that are relevant to frontline general practice, including initial presentations, common problems, red flags, infection, and pain management. This section also covers conditions ranging from mental health and cancer to diabetes, skin, gut, lung and cardiac conditions; and offers a monthly round-up of recent research that may impact clinical practice.
Dr Ravi Ramanathan
GP in London and clinical adviser to MIMS Learning
Guidance update: latest NICE guidelines on cardiovascular disease risk assessment and reduction
Module description
1 CPD hour
NICE has republished its guidance on cardiovascular disease (CVD) risk assessment and reduction (including lipid modification). As well as now recommending using QRISK3, rather than QRISK2, to assess the 10-year risk of CVD, NICE has revised its lipid-lowering targets for secondary prevention. This updated module, originally written by Dr Farooq Ahmad, outlines what the key changes are for primary care.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● When to, and when not to, use QRISK3 to assess the risk of CVD
● The components of a cardioprotective diet
● When to initiate statin therapy and at what intensity/dose
● Lipid-lowering targets for primary and secondary prevention
● How to achieve lipid-lowering targets
● How to monitor for and support people with statin-related muscle symptoms
Epidemiology
Cardiovascular disease (CVD) is an umbrella term for all diseases of the heart and circulatory system including coronary artery disease, peripheral artery disease, stroke, heart failure, atrial fibrillation, and cardiomyopathy.
Approximately 7 million people in the UK have CVD, with similar numbers of men and women affected.1 While the number of CVD-related deaths has substantially fallen over the last 40 years, CVD is still the second most common cause of death in men and women after cancer.2 It accounts for 27% of deaths in men and 24% of deaths in women.
Additionally, according to the British Heart Foundation, CVD costs the UK healthcare system about £9bn per year and costs the UK economy about £19bn per year.
CVD accounts for 27% of deaths in
men and 24% of deaths in women.
References
1. NICE. Cardiovascular disease: risk assessment and reduction, including lipid modification. NG238. Published December 2023
2. NICE CKS. CVD risk assessment and management. Revised May 2023.
QRISK3 versus QRISK2
NICE now recommends using QRISK3 (it previously recommended QRISK2) to assess the 10-year risk of CVD in people aged between 25 and 84 years without known disease. QRISK3 should also be used to assess the risk of CVD in people aged 25 to 84 with type 2 diabetes.
Compared with QRISK2, QRISK3 has additional risk factors and, therefore, may provide better risk prediction for certain groups. This includes:
People taking corticosteroids
People taking atypical antipsychotics
People with systemic lupus erythematosus
For people aged 85 years or older, age alone puts them at increased risk of CVD (particularly if they have raised blood pressure and/or smoke).
Age alone puts people aged 85 years or older at increased risk of CVD
(Image credit: Izusek/Getty Images)
Diet
NICE states that both people at high risk of CVD and those with established CVD should be encouraged to eat a cardioprotective diet. It states that:
Total fat intake should be ≤30% of the total energy intake
Saturated fat intake should be ≤7% of the total energy intake
Where possible, saturated fats should be replaced with mono-unsaturated and polyunsaturated fats
Total fat intake should be ≤30% of the total energy intake
Saturated fat intake should be ≤7% of the total energy intake
Where possible, saturated fats should be replaced with mono-unsaturated and polyunsaturated fats
For more information about weight management in primary care, read:
Obesity in adults and Espresso CPD: weight management enhanced service in general practice
For more information about weight management in primary care, read: Obesity in adults and Espresso CPD: weight management enhanced service in general practice
Guidance update: latest NICE guidelines on cardiovascular disease risk assessment and reduction
What is new in the republished NICE guidance on cardiovascular disease risk assessment and lipid modification? What are the lipid-lowering targets for secondary prevention? And, how should these targets be achieved? Find out in this revised module.
Guidance update: latest NICE guidelines on cardiovascular disease risk assessment and reduction
What is new in the republished NICE guidance on cardiovascular disease risk assessment and lipid modification? What are the lipid-lowering targets for secondary prevention? And, how should these targets be achieved? Find out in this revised module.
Transgender healthcare: why is it important?
Module description
1 CPD hour
Dr Amy Tulip and Dr Demi Thompson explore issues that transgender individuals face when accessing medical care, providing a definition of LGBTQ+ terminology, discussion of key Stonewall report statistics and insights from personal accounts of transgender individuals.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Define common LGBTQ+ terms
● Have an awareness of the key statistics relevant to transgender healthcare
● Understand the common challenges transgender people may face
● Gain insight into the personal experiences of trans individuals within healthcare
Introduction
In the UK, just under 1% of the population is transgender (trans).1 These are individuals who do not identify with the gender they were assigned at birth, and we will come to discuss the terminology in further depth shortly.
Transgender individuals face significant challenges when accessing healthcare and are known to have poorer health outcomes as a result.2 It is crucial that all health professionals have an understanding and awareness of these potential barriers to ensure we can make a positive difference to the lives of these individuals, wherever they may be on their transitioning journey.
In this way, healthcare professionals play a vital role in ensuring these patients feel respected and listened to, are treated without prejudice or discrimination and that, ultimately, they receive the specialist medical care they need. Specifically, GPs are often the first point of contact for patients questioning their gender identity, highlighting the importance of this initial interaction with the healthcare system.
This module will introduce you to:
1. LGBTQ+ terminology
2. Transgender statistics from the Stonewall report
3. Personal accounts and experiences of trans individuals
Just under 1% of the UK population is transgender
(Image credit: Jim Craigmyle/Getty Images)
References
1. Stonewall. Rainbow Britain Report (2022). 2022.
2. Radix A, Harris AB. Challenges in transgender health. Med 2021; 2(5): 472-475.
LGBTQ+ terminology
`LGBTQ+’ is an acronym for `lesbian, gay, bisexual, trans, and queer’. The additional `+’ stands for all the other identities not included.
A pronoun is the words we used to refer to people’s gender in conversation – for example ‘he’, ‘she’ or ‘they’. Use of the correct pronoun is important for transgender individuals and promotes their engagement with healthcare.
There is a wide spectrum of terminology used within the LGBTQ+ community, which can seem quite overwhelming and confusing when first approached.
However, as healthcare professionals, it is important that we have a basic understanding of what these terms mean, to ensure we can make sense of what our patients may be referring to. That being said, we can’t be expected to remember them all – it is always OK to ask a patient to clarify what they mean politely and respectfully rather than making assumptions.
The scroll to see the key terms within LGBTQ+ but are not an exhaustive list.3
It is always OK to ask a patient
what they mean politely and
respectfully, rather than making
assumptions.
References
3. Stonewall. List of LGBTQ+ terms. 2023. [Accessed 6 February 2024]
Definition of terms - people
A term to describe a person who doesn’t experience sexual attraction (some people may experience romantic attraction).
Umbrella term to describe a romantic and/or sexual attraction to more than one gender.
A term to describe an individual whose gender identity is the same as the sex they were assigned at birth.
A term used to describe a person who is born with reproductive anatomy that doesn’t fit with either ‘male’ or ‘female’.
A term to describe a person who does not identify exclusively with a binary gender (male or female).
A term to describe a person who does not identify with the gender they were assigned at birth.
An individual who is assigned female at birth but identifies and lives as a man.
An individual who is assigned male at birth but identifies and lives as a woman.
Definition of terms - gender
An individual’s innate feeling of what their gender is, what gender they identify with, which may or may not be the gender assigned at birth.
How a person outwardly expresses their gender within the context of society’s expectation of gender (for example, in the UK a female would wear a dress and high heels and a male would not).
When a person experiences distress or discomfort due to a mismatch between their sex assigned at birth and the gender they identify with.
A term to describe a person’s transition – can mean to undergo medical intervention, but also changing names, pronouns, dressing differently.
Legal document that enables trans people to be legally recognised in their affirmed gender and issued with a new birth certificate.
Individuals currently have to be over the age of 18 to apply.
Definition of terms - concepts
Homophobia
Fear or dislike of a person based on prejudiced beliefs or attitudes about gay, lesbian or bi people.
Questioning
Process of exploring your own sexual orientation.
Transitioning
The steps a trans person may take to live in the gender with which they identify.
Transphobia
The fear or dislike of someone based on the fact they are trans.
Transgender healthcare: why is it important?
Dr Amy Tulip and Dr Demi Thompson explore issues that transgender individuals face when accessing medical care, providing a definition of LGBTQ+ terminology, discussion of key Stonewall report statistics and insights from personal accounts of transgender individuals.
Transgender healthcare: why is it important?
Dr Amy Tulip and Dr Demi Thompson explore issues that transgender individuals face when accessing medical care, providing a definition of LGBTQ+ terminology, discussion of key Stonewall report statistics and insights from personal accounts of transgender individuals.
Dizziness – red flag symptoms
Module description
0.5 CPD hours
In this updated overview, Dr Suneeta Kochhar describes red flag symptoms associated with dizziness. Key learning points include possible causes, red flag symptoms, taking a comprehensive history, and matching symptoms to specific causes.
Educational objectives
After taking this module, you will be better able to:
● Take a comprehensive history from a patient with dizziness
● Recall red flag symptoms associated with dizziness
● Understand possible causes of dizziness
● Recognise symptoms associated with specific causes
Red flag symptoms
Ataxia
Focal neurologic deficit
Severe, continuous symptoms for >1 hour
Definition of dizziness
`Dizzy’ may describe light-headedness, feeling unsteady (gait disturbance) or vertigo. It may be associated with nausea and vomiting or difficulty with balance. In patients presenting with dizziness, it is important to clarify what this means.
Dizziness can be acute or chronic and is more likely to present with increasing age.
The vestibular system is important in balance, and comprises the vestibular nuclei in the brain stem and cerebellum, and the vestibular apparatus in the inner ear. Conditions affecting the vestibular system can therefore cause dizziness.
Dizziness may be acute or chronic, and more likely in older people
(Image credit: FG Trade/Getty Images)
Duration of vertigo
Duration - Seconds
Condition - BPPV
Duration - Minutes
Condition - TIA
Duration - Hours
Condition - Meniere’s
Duration - Days
Condition - Vestibular neuritis
Duration - Seconds
Condition - BPPV
Duration - Minutes
Condition - TIA
Duration - Hours
Condition - Meniere’s
Duration - Days
Condition - Vestibular neuritis
Dizziness – red flag symptoms
In this interactive module for GPs, paramedics, hospital doctors and GP trainees, Dr Suneeta Kochhar provides an updated overview of red flags symptoms associated with dizziness.
Dizziness – red flag symptoms
In this interactive module for GPs, paramedics, hospital doctors and GP trainees, Dr Suneeta Kochhar provides an updated overview of red flags symptoms associated with dizziness.
Best use of neuropathic pain medication
1 CPD hour
In this module for healthcare professionals with an interest in pain management, Dr Michael Serpell reviews the pharmacological treatment of neuropathic pain. He outlines the various options available, highlights national guidance for treatment and discusses the risks.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Discuss the various management options for neuropathic pain
● Describe contraindications for the use of neuropathic analgesics
● Understand when to reduce or discontinue pain medication
Reducing emissions from inhalers
0.5 CPD hours
In this learning module, Dr Pipin Singh provides tips for primary care on how to reduce emissions from inhaler use, while maintaining best practice in asthma management.
Educational objectives
After taking this module, GPs should be better able to:
● Understand the impact of inhalers on the NHS carbon footprint
● Be familiar with which inhalers offer a lower carbon footprint than MDIs
● Recognise the benefits of taking a team approach to make the transition to sustainable healthcare
Guidance update: NICE guidelines on thyroid disease
1 CPD hour
In this learning module for primary care professionals, Dr Sonya Jey outlines NICE recommendations on assessment, investigations and management of thyroid disease. Key learning points include what’s new in the guidance and areas of uncertainty. This module provides audit/quality improvement ideas and a case study.
Educational objectives
After taking this module, GPs and other healthcare professionals will be better able to:
● Follow recommendations on testing for thyroid disease
● Know what to prescribe, and what not to prescribe
● Manage subclinical hypo- or hyperthyroidism according to guidelines
Invasive Group A streptococcus
0.25 CPD hours
In this quick learning module, Dr Pipin Singh reminds healthcare professionals of the signs and symptoms of scarlet fever and invasive group A streptococcus infection, and relays management advice from the UK Health Security Agency.
Educational objectives
After reading this module, healthcare professionals should be better able to:
● Be aware of the symptoms of GAS and differential diagnoses
● Conduct an appropriate examination
● Order the right investigations
● Know when to refer patients
● Be aware of current advice on prescribing and notification
Best use of neuropathic pain medication
1 CPD hour
In this module for healthcare professionals with an interest in pain management, Dr Michael Serpell reviews the pharmacological treatment of neuropathic pain. He outlines the various options available, highlights national guidance for treatment and discusses the risks.
Educational objectives
After taking this activity healthcare professionals should be better able to:
● Discuss the various management options for neuropathic pain
● Describe contraindications for the use of neuropathic analgesics
● Understand when to reduce or discontinue pain medication
Reducing emissions from inhalers
0.5 CPD hours
In this learning module, Dr Pipin Singh provides tips for primary care on how to reduce emissions from inhaler use, while maintaining best practice in asthma management.
Educational objectives
After taking this module, GPs should be better able to:
● Understand the impact of inhalers on the NHS carbon footprint
● Be familiar with which inhalers offer a lower carbon footprint than MDIs
● Recognise the benefits of taking a team approach to make the transition to sustainable healthcare
Guidance update: NICE guidelines on thyroid disease
1 CPD hour
In this learning module for primary care professionals, Dr Sonya Jey outlines NICE recommendations on assessment, investigations and management of thyroid disease. Key learning points include what’s new in the guidance and areas of uncertainty. This module provides audit/quality improvement ideas and a case study.
Educational objectives
After taking this module, GPs and other healthcare professionals will be better able to:
● Follow recommendations on testing for thyroid disease
● Know what to prescribe, and what not to prescribe
● Manage subclinical hypo- or hyperthyroidism according to guidelines
Invasive Group A streptococcus
0.25 CPD hours
In this quick learning module, Dr Pipin Singh reminds healthcare professionals of the signs and symptoms of scarlet fever and invasive group A streptococcus infection, and relays management advice from the UK Health Security Agency.
Educational objectives
After reading this module, healthcare professionals should be better able to:
● Be aware of the symptoms of GAS and differential diagnoses
● Conduct an appropriate examination
● Order the right investigations
● Know when to refer patients
● Be aware of current advice on prescribing and notification
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