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Self Skin Exam

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1221. Neck pain - acute torticollis

adequate neck support, or carrying heavy unbalanced loads. Assessment of a person with acute torticollis should include: Taking a detailed medical history and conducting a physical examination to distinguish neuropathic pain from mechanical neck pain. Excluding red flags suggestive of a serious spinal or other abnormality, including compression of the spinal cord (myelopathy), cancer, severe trauma or skeletal injury, and vascular insufficiency. Identifying typical features of acute torticollis (...) . Sedentary lifestyle. Smoking. Trauma. Obesity. [ ; ; ; ] Prognosis What is the prognosis for people with neck pain? Most cases of acute neck pain resolve within 2 months. However, half of people continue to experience low grade symptoms or recurrences for more than a year. Acute torticollis is usually self-limiting, with symptoms resolving after 7–10 days. [ ; ; ] Diagnosis Diagnosis of neck pain - acute torticollis Assessment How should I assess someone with suspected acute torticollis? Acute

2018 NICE Clinical Knowledge Summaries

1222. Balanitis

be suspected if there is: Penile soreness and itch, odour, and possible dysuria, difficulty passing urine, and/or dyspareunia. Redness and swelling of the glans penis (and often the foreskin) with exudate; tightening of the foreskin or meatal stenosis; phimosis. Assessment of a person with suspected balanitis should include: Asking about hygiene practices; exposure to potential irritants, allergens and new drugs; trauma, skin conditions, sexual history, and history of immunosuppression. Examining (...) to severe or persistent infection. Examine the penile skin for of balanitis or its . Examine the genital area and extra-genital skin for specific clinical features suggesting an . In adult men, examine the genital area for signs of: or , and manage appropriately if suspected clinically. See the CKS topic on for more information. Do not routinely perform a sub-preputial swab to confirm the diagnosis, but consider swabbing for Candida sp. and bacterial culture and sensitivity if symptoms are severe

2018 NICE Clinical Knowledge Summaries

1223. Angina

information, see the section on . Provide information on how to use a short-acting sublingual nitrate and when to administer it. Assess the person's need for lifestyle advice to manage their . Explore and address issues according to the person's needs, which may include: Self-management skills such as pacing their activities and goal setting. Concerns about the impact of stress, anxiety, or depression on angina. Advice about physical exertion including . Advice about other activities (...) by family history, physical examination, or ECG). Further reasons to refer people to a cardiologist include: Doubt about the diagnosis. The presence of several risk factors or a strong family history. The person's preference for referral. Basis for recommendation Basis for recommendation These recommendations are based on the Scottish Intercollegiate Guidelines Network (SIGN) guideline Management of stable angina [ ], and the National Institute for Health and Care Excellence (NICE) guideline Stable

2018 NICE Clinical Knowledge Summaries

1224. Allergic rhinitis

, frequency, persistence, and location of symptoms. The severity and impact of symptoms. Housing conditions, pets, and occupation. Any drugs that may cause or aggravate symptoms. Any family history of atopy. Examination for signs and underlying causes of rhinitis, and/or associated conditions. Initial management of allergic rhinitis should include advice on: Sources of information and support. Possible use of nasal irrigation with saline. Allergen avoidance techniques if there is a specific identified (...) availability No changes in product availability since 1 July 2018. Goals and outcome measures Goals and outcome measures Goals Goals To support primary healthcare professionals to: Make an accurate diagnosis of allergic rhinitis. Offer appropriate management in primary care. Refer people with refractory symptoms to an immunology or ear, nose, and throat (ENT) specialist if appropriate, depending on clinical judgement. Provide self-management advice and information to parents and carers, if needed. Outcome

2018 NICE Clinical Knowledge Summaries

1225. Otitis externa

Otitis externa Otitis externa - NICE CKS Share Otitis externa: Summary Otitis externa is inflammation of the external ear canal and is classified as acute (lasting 3 weeks or less) or chronic (lasting longer than 3 months). Diffuse otitis externa is widespread inflammation of the skin and subdermis of the external ear canal. Localized otitis externa is an infection of a hair follicle that can progress to become a boil in the ear canal. Malignant otitis externa is spread of otitis externa (...) , hearing loss, and ear discharge). Managing any aggravating or precipitating factors (such as diabetes mellitus, dermatitis, or ear trauma). Offering paracetamol or ibuprofen for symptomatic relief (plus codeine for severe pain). Treating infection, usually with a topical preparation. Considering the need for investigations (such as taking an ear swab) — these are rarely useful, but may be necessary if symptoms are persistent or recurrent. Providing appropriate self-care advice to aid recovery

2018 NICE Clinical Knowledge Summaries

1226. Urinary tract infection (lower) - men

tract, skin and soft tissue). In men with symptoms suggestive of a UTI, confirm the diagnosis by urine culture and sensitivity, by arranging of a mid-steam urine (MSU) or catheter specimen of urine (CSU), to determine the infecting micro-organism. Obtain a urine sample for culture before starting empirical drug treatment. Only send a urine sample for culture in a man with an indwelling catheter if there are features of systemic infection. See the section on for more information. Do not use urine (...) frail who are incontinent, condom catheters may be an option. Clean-catch urine sample (CCU) — periurethral cleaning is recommended. The whole specimen is collected and an aliquot sent for examination. Catheter urine sample (CSU) — if the man has a long-term indwelling urinary catheter, drain and discard a few millilitres of urine from the catheter or sampling port, and then collect the urine sample, using an aseptic technique. Do not take the specimen from the collection bag, as this is more likely

2018 NICE Clinical Knowledge Summaries

1227. Breast cancer - managing FH

for recommendation Explaining the principles of breast awareness Evidence from a Cochrane systemtic review (search date: October 2007) did not suggest a beneficial effect of breast screening by either self-examination or clinical examination, but suggested increased harms in terms of increased numbers of benign lesions identified and an increased number of biopsies performed [ ]. However, there is a consensus among cancer geneticists supporting its use to help early detection in women who are at increased risk (...) ., Doyle,J.M., McDermott,E.W. and O'Higgins,N.J. ( 1997 ) Hereditary breast cancer. 84 ( 10 ), 1334 - 1339 . [ ] Kosters,J.P. and Gotsche,P.C. ( 2003 ) Regular self-examination or clinical examination for early detection of breast cancer (Cochrane Review). The Cochrane Library. John Wiley & Sons Ltd . [ ] Kotsopoulos,J., Lubinski,J., Lynch,H.T., et al. ( 2007 ) Age at first birth and the risk of breast cancer in BRCA1 and BRCA2 mutation carriers. Breast Cancer Research and Treatment. 105 ( 2 ), 221

2018 NICE Clinical Knowledge Summaries

1228. Diarrhoea - adult's assessment

, , , and . Prognosis What is the prognosis? Most infectious diarrhoea is of viral origin and is self-limiting, with nearly half of episodes lasting less than a day [ ]. It is thought that [ ]: Viral diarrhoea lasts around 2–3 days. Untreated bacterial diarrhoea has a duration of around 3–7 days. Protozoal diarrhoea can be present for weeks to months without treatment. The prognosis of chronic diarrhoea will depend on the underlying . Management Management : covers the primary care assessment, investigation (...) colitis. History of recent radiation treatment to the pelvis. Factors increasing the risk of immunosuppression (for example, human immunodeficiency virus infection, long term steroid use, or chemotherapy). Any surgery or medical conditions (for example, endocrine disease) accounting for the diarrhoea. Diet and use of alcohol or substances such as sorbitol. Assess for complications of diarrhoea, such as dehydration. Features indicating dehydration include increased pulse rate, reduced skin turgor

2018 NICE Clinical Knowledge Summaries

1229. Back pain - low (without radiculopathy)

due to work-related back disorders was 3.4 million. On average each person took 15.9 days off work as a result of back pain [ ]. Diagnosis Diagnosis of low back pain without radiculopathy Diagnosis How should I diagnose the cause of low back pain? Assess the person. Ask about the type of pain, duration of symptoms, aggravating and relieving factors, associated symptoms, radiation of pain, night pain. Examine the person. Observe gait, posture, skin and any bruising, skin changes, rashes, deformity (...) people can reasonably be expected to recover from an episode of acute non-specific back pain within a period of weeks. Provide information on self-help measures to relieve symptoms. Offer information leaflets on simple exercises that may help relieve symptoms, for example provided by the charity Backcare, which has a range of information leaflets available at . Local heat (ensuring that the skin is protected) may relieve pain and muscle spasm. Encourage the person to stay active, resume normal

2018 NICE Clinical Knowledge Summaries

1230. Feverish children - risk assessment

, to help guide whether hospital admission is needed. Consider arranging hospital admission if: An infant is younger than 3 months with a suspected urinary tract infection (UTI) and no alternative focus of infection, to obtain a reliable urine specimen and initiate treatment. See the CKS topic on for more information. The feverish illness has no obvious underlying cause, and the infant or child is unwell for longer than expected for a self-limiting illness. There is significant parental/carer anxiety (...) ) Red (high risk of serious illness) Colour Normal colour of skin, lips, and tongue. Pallor of skin, lips, or tongue reported by parent or carer. Pale, mottled, ashen, or blue skin, lips, or tongue. Activity Responding normally to social cues. Content and smiling. Stays awake or awakens quickly. Strong normal cry or not crying. Not responding normally to social cues. Waking only with prolonged stimulation. Decreased activity. Not smiling. No response to social cues. Appears ill to a healthcare

2018 NICE Clinical Knowledge Summaries

1231. Angio-oedema and anaphylaxis

or current allergies or autoimmune conditions. Any gastrointestinal symptoms (swelling of the lining of the intestinal tracts may cause gastrointestinal pain and cramps). (past or present). Examine the person. The clinical features of angio-oedema may vary slightly between the different . In general: The surface of the skin may appear normal or there may be weals or other rash. Skin swelling is less well defined than in urticaria and can affect the eyes, lips, genitalia, hands, and/or feet. The swellings (...) . Ensure that help is on its way as early advanced life support is essential. For people who do not require CPR: Examine the chest for signs of lower and upper airway obstruction. Check the pulse and blood pressure for signs of circulatory collapse. Check the skin and inside the mouth for urticaria and angio-oedema. Place the person in a comfortable position. People with airway and breathing problems may prefer to sit up as this will make breathing easier. Lying flat with or without leg elevation

2018 NICE Clinical Knowledge Summaries

1232. Food allergy

allergy should include: Asking about causal foods, symptoms, timing in relation to the suspected allergen exposure, any uneventful exposures, the reproducibility of symptoms, any co-factors which increase the likelihood of a reaction, any co-morbid atopic conditions, and any symptom response to dietary restrictions or food reintroduction. Examining for nutritional status, any signs of a clinical reaction or co-morbid conditions. Arranging for skin prick testing and/or serum-specific IgE allergy (...) family history of food allergy or atopic conditions, particularly in parents and siblings. Any symptom response to dietary restrictions or reintroduction of foods, and/or medications tried, such as oral antihistamines. Examine the person for: Nutritional status, including weight, length/height, and calculation of body mass index (BMI). Any of a clinical reaction. Any signs of co-morbid conditions such as asthma, atopic eczema, and/or allergic rhinitis. Arrange for skin prick testing and/or serum

2018 NICE Clinical Knowledge Summaries

1233. Bacterial vaginosis

history is not taken. Examination and investigations Expert opinion in the RCGP/BASHH guideline is that examination is not always needed in women with uncomplicated vaginal discharge. However [ ]: The prescriber should take a thorough history and not simply rely on the woman’s self-diagnosis. Women with recurrent symptoms or those who fail to improve should be examined and investigated. Certain conditions should prompt an appropriate examination and investigations first-line. PHE recommends that women (...) and not simply rely on the woman’s self-diagnosis. Women with recurrent symptoms or those who fail to improve should be examined and investigated. Certain conditions should prompt an appropriate examination and investigations first-line. Expert opinion in the CDC guideline [ ] and in review articles is that a good history and examination of the genitalia (where indicated) are essential in order to establish the correct diagnosis [ ; ; ; ]. High vaginal swabs The recommendations on when a high vaginal swab

2018 NICE Clinical Knowledge Summaries

1234. Nausea/vomiting in pregnancy

% of pre-pregnancy weight. Findings which may suggest an alternative diagnosis include: Onset of symptoms after 11 weeks of gestation. Abdominal pain or tenderness (more than mild epigastric tenderness after retching). Fever. Headache or abnormal neurological examination. Goitre. Complications are more likely in women with severe vomiting and include: Maternal — weight loss, dehydration, hyponatraemia, vitamin deficiencies, Mallory-Weiss tear or oesophageal rupture, increased risk of venous (...) and food intake, monitoring weight, checking for dehydration, testing the urine for ketones, and referring for pelvic ultrasound to assess for predisposing multiple or molar pregnancy. Offering appropriate self-care advice (for example rest, adequate fluid intake, and small frequent meals). Some women find ginger or acupressure helps symptoms. Considering the need for an oral anti-emetic if self-care advice fails and the woman has persistent symptoms. Hospital admission should be considered

2018 NICE Clinical Knowledge Summaries

1235. Bites - human and animal

tetanus and rabies infection risk. Scenario: Managing a human bite Scenario: Managing a human bite From age 1 month onwards. Assessment of a human bite How should I assess someone with a human bite? Document how and when the bite occurred. Who was bitten, and by whom. Whether the skin was broken or blood was involved. The nature of the bite (i.e. occlusal or clenched fist). Monitor vital signs if the bite is particularly traumatic, or sepsis is suspected. Examine the bite using gloves, bearing in mind (...) the metacarpophalangeal joints). Dog bites characteristically involve puncture wounds from the canine teeth which anchor the victim whilst the other teeth bite, shear, and tear the tissues causing structural damage. Cats have fine, sharp teeth and, despite having a weaker bite than dogs, inflict deep puncture wounds inoculated with saliva, and are capable of penetrating bone, joints, and tendons. Dog bites are the most common mammalian bite. Bacterial infection is a risk if there is a break in the skin. Infective

2018 NICE Clinical Knowledge Summaries

1236. Dyspepsia - proven functional

management How should I handle initial management? Assess for any alarm symptoms that may suggest a complication or other serious underlying pathology, and manage appropriately. See the CKS topic on for more information. Offer written information and advice on the symptoms, self-care, and management options for functional dyspepsia, such as the NHS patient information leaflets on and . Offer advice on lifestyle measures that may improve symptoms. Encourage the person to: Lose weight (...) strategies, consider referral for psychological therapies, and manage depression symptoms if needed. See the CKS topics on and for more information. Review the person's medication: Ask about any over-the-counter medication such as antacids and/or alginates that have been tried for symptom relief. Advise that self-treatment with an antacid and/or alginate may be used for short-term symptom control, but long-term, continuous use is not recommended. Consider reducing or stopping (if possible and appropriate

2018 NICE Clinical Knowledge Summaries

1237. Anaemia - iron deficiency

anaemia in premenopausal women. Other gynaecological causes include haemorrhage in childbirth. Increased requirement — physiological iron requirements are three times higher in pregnancy than they are in menstruating women, with increasing demand as pregnancy advances. Other causes — these include: blood donation, self-harm, haematuria (rare), nosebleeds (rare), medication. [ ; ; ; ] Prevalence How common is it? Iron deficiency is the most common cause of anaemia, affecting around 500 million people (...) — this in turn may affect the woman's interactions with the infant and may negatively impact behaviour and development. Infant iron deficiency in the first three months of life (by a variety of mechanisms). [ ; ; ; ] Diagnosis Diagnosis of iron deficiency anaemia Assessment How should I assess someone with suspected iron deficiency anaemia? Diagnosis of anaemia caused by iron deficiency is made through history, examination and . Take a detailed medical history, and ask about: of anaemia. If the anaemia

2018 NICE Clinical Knowledge Summaries

1238. Dermatitis - contact

, epoxy resin and the Compositae family of flowering plants — these appear to trigger chronic dermatitis, even after avoidance. Severe dermatitis at presentation. Delay in diagnosis. [ ; ; ; ; ] Complications What are the complications? Complications of contact dermatitis include: Reduced quality of life — functional impairment, discomfort and loss of sleep due to chronic contact dermatitis may threaten employment and personal and social relationships. Lowered self-esteem. Secondary skin infections (...) history of skin conditions or atopy. Examine the person, checking for: of contact dermatitis — the anatomical distribution may help in the identification of a likely irritant or allergen. Hands and arms are a common site of contact dermatitis often due to repeated exposure to water or detergents. Face — contact dermatitis of the face due to fragrances, hair dyes, skincare products, cosmetics, and nail varnish is common. Eyelids — the eyelids may be directly affected by cosmetics or contaminated

2018 NICE Clinical Knowledge Summaries

1239. Impetigo

including pre-existing skin conditions (such as eczema) or immunosuppression. Other risk factors for impetigo such as trauma to the skin (for example, abrasions or insect bites). Previous treatment including antimicrobial therapy. Systemic features such as fever. Examine the person looking for: of impetigo such as bullae or yellow exudate forming a crust. Features of systemic involvement such as lymphadenopathy or fever. Signs of to impetigo. Consider the need for investigations: Impetigo is usually (...) Impetigo Impetigo - NICE CKS Share Impetigo: Summary Impetigo is a common superficial bacterial infection of the skin. The two main clinical forms are non-bullous impetigo and bullous impetigo. Non-bullous impetigo is caused by Staphylococcus aureus , Streptococcus pyogenes or a combination of both and accounts for the majority of cases (about 70%). Bullous impetigo is caused by Staphylococcus aureus — bullae are fluid filled lesions which are usually more than 5mm in diameter. Impetigo caused

2018 NICE Clinical Knowledge Summaries

1240. Otitis media - acute

such as fever, crying, poor feeding, restlessness, cough, or rhinorrhoea. On examination the tympanic membrane is distinctly red, yellow, or cloudy and may be bulging. Pain and fever should be managed with paracetamol or ibuprofen. Many people with AOM will not need antibiotic treatment as symptoms usually resolve spontaneously within a few days. However, antibiotics are necessary in a number of situations, including for: People who are systemically very unwell. People who have symptoms and signs of a more (...) evidence. The following important changes have been made to the previous CKS guidance: In line with the National Institute for Health and Care Excellence guideline, Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care , immediate antibiotics are no longer routinely recommended for: All children younger than 6 months of age. Children aged between 6 months and 2 years of age in whom the diagnosis of AOM is reasonably certain. Children older than

2018 NICE Clinical Knowledge Summaries

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