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General Practice: A Structured Guide for Junior Doctors (Beginner to Advanced)

HOW TO USE THIS GUIDE

This guide follows the RCGP curriculum framework and draws on the Textbook of Family Medicine 9e (Rakel), Swanson's Family Medicine Review, Goldman-Cecil Medicine, Harrison's Principles, and Katzung's Pharmacology. It is organized into 8 modules, moving from foundational principles to advanced clinical practice. Work through them in order, or jump to what you need.

MODULE 1 - THE PHILOSOPHY AND FOUNDATIONS OF GENERAL PRACTICE

1.1 What Makes GP Different

General practice is the only specialty defined by relationship and continuity rather than organ system or technique. The core definition from the Textbook of Family Medicine:

"The family physician provides continuing, comprehensive care in a personalized manner to patients of all ages, regardless of the presence of disease or the nature of the presenting complaint. Family physicians accept responsibility for managing an individual's total health needs while maintaining an intimate, confidential relationship with the patient."

This has four pillars:

First contact - the patient's entry point into the healthcare system
Continuity - knowing the patient over years, through illness and health
Comprehensiveness - managing physical, psychological, and social problems
Coordination - orchestrating specialists, allied health, and community resources

1.2 The Biopsychosocial Model

GP does not treat diseases in isolation. Every presentation sits inside a triangle:

Biological: pathology, anatomy, physiology
Psychological: anxiety, depression, health beliefs, health literacy
Social: employment, housing, relationships, ethnicity, culture

A patient with chest pain may have musculoskeletal strain (biological) amplified by work stress (psychological) in someone recently made redundant (social). Treat all three or you will fail.

1.3 The Patient-Centered Medical Home (PCMH)

The modern GP practice is not just a clinic. It is a coordinated hub with:

A registered patient list
Proactive chronic disease review
Integrated mental health support
Links to pharmacy, physiotherapy, social prescribing
Accessible same-day urgent appointments

1.4 Evidence-Based Medicine in GP

You will constantly balance:

Pre-test probability (how likely is this disease in this patient at this age?)
Likelihood ratios of clinical signs and symptoms
NNT (number needed to treat) and NNH (number needed to harm) when prescribing
Guideline recommendations (NICE, RCGP, local formularies) vs. individual patient values

Key principle: Not all evidence applies to every patient. Guidelines are derived from trial populations that often exclude the elderly, pregnant, multimorbid, and those on multiple medications - the exact people you see every day.

MODULE 2 - THE GP CONSULTATION

This is the single most important skill in general practice. The consultation is where almost everything happens.

2.1 Consultation Models

You should know these and be able to use elements of each:

Model	Core Concept	Key Technique
Pendleton (1984)	Patient's ideas, concerns and expectations (ICE)	Elicit ICE before agenda-setting
Calgary-Cambridge	Structure + relationship in parallel	Signposting, chunking, checking
Neighbour (1987)	5 checkpoints: connect, summarize, handover, safety net, housekeeping	Safety-netting is mandatory
Stott & Davis	Every consultation has 4 potential areas: current problem, ongoing problems, preventive care, health promotion	Don't miss opportunistic prevention
Helman's Folk Model	Patient has a lay explanation for their illness	Understanding it reduces conflict

2.2 The Structure of a Good Consultation

Opening

Greet warmly, check name and DOB
Open question: "What brings you in today?" or "How can I help?"
Let the patient speak for at least 90 seconds uninterrupted (studies show doctors interrupt within 18 seconds on average - resist this)

Gathering Information

Elicit ICE: "What do you think might be causing this?" / "What worries you most?" / "What were you hoping I could do for you today?"
Take a focused history: SOCRATES for pain (Site, Onset, Character, Radiation, Associated features, Timing, Exacerbating/relieving factors, Severity)
Background: PMH, medications (including OTC and herbal), allergies, FH, SH (smoking, alcohol, occupation, relationships)
Red flag screen: specific to the presenting system

Examination

Targeted - not a full systems exam every visit
Communicate what you are doing, maintain dignity

Explanation and Planning

Chunk information: give a piece, check understanding, give the next piece
Use plain language - avoid jargon. "The tube carrying food to your stomach is inflamed" not "oesophagitis"
Shared decision-making: "Here are your options. What matters most to you?"
Written information where appropriate

Safety-netting (mandatory for every consultation)

Tell the patient specifically what to watch for
When to come back / who to call / when to go to A&E
Document your safety-net advice

Housekeeping

Emotional reset between patients - 30 seconds to decompress before the next room

2.3 Difficult Consultations

The heartsink patient (frequent attender, multiple unexplained symptoms)

Acknowledge the distress is real, even if pathology is unclear
Set a shared agenda at the start of each visit
Avoid dismissal; it escalates over-investigation and erodes trust

Breaking bad news - use SPIKES:

Setting (private, seated, tissues)
Perception (what do they already know?)
Invitation (how much do they want to know?)
Knowledge (give warning shot, then information clearly)
Empathy (respond to emotion before giving more information)
Strategy/Summary (what happens next)

Angry or distressed patient - CALM:

C: Consider the reason for anger (unmet need, previous bad experience, fear)
A: Acknowledge the emotion explicitly - "I can see you're really frustrated"
L: Listen without interruption
M: Move toward resolution together

Language barriers - use professional interpreters, not family members. Brief interpreter before the consultation.

MODULE 3 - CLINICAL REASONING IN PRIMARY CARE

3.1 The Nature of GP Presentations

Unlike hospital medicine, most GP presentations are undifferentiated. The same symptom (e.g., fatigue) may reflect:

Iron deficiency anaemia
Hypothyroidism
Depression
Heart failure
Obstructive sleep apnoea
Malignancy
Normal life stress

The skill is probabilistic reasoning - most presentations are benign and self-limiting. Your job is to identify the minority that are serious without over-investigating the majority.

3.2 The Illness Script Framework

For each condition, build a mental "illness script" with:

Enabling conditions (age, sex, risk factors)
Fault (pathophysiology in brief)
Consequences (signs, symptoms, investigations)

Example - Pulmonary Embolism:

Enabling: immobility, recent surgery, malignancy, OCP, pregnancy
Fault: thromboembolism obstructing pulmonary circulation
Consequences: pleuritic chest pain, dyspnoea, haemoptysis, tachycardia, O2 desaturation, raised D-dimer, CT-PA findings

3.3 Red Flags - You Must Know These Cold

A red flag is a feature that raises the probability of serious pathology enough to mandate urgent investigation or referral. By system:

Headache red flags (think intracranial emergency):

Thunderclap (worst headache of life) - SAH until proven otherwise
Progressive worsening over weeks
New headache >50 years
Headache with fever, neck stiffness, photophobia - meningitis/encephalitis
Headache with focal neurology or papilloedema - raised ICP
Headache after head injury

Back pain red flags (think cauda equina, malignancy, infection):

Bilateral sciatica or saddle anaesthesia
Bladder/bowel dysfunction
Age <20 or >55 at first presentation
History of malignancy
Night pain, weight loss, fever
Progressive neurological deficit

Dysphagia red flags: age >55, progressive, solid food difficulty, weight loss - refer urgently for endoscopy (upper GI cancer)

Rectal bleeding red flags: dark/altered blood, weight loss, change in bowel habit >6 weeks, age >50, iron deficiency anaemia - 2-week wait colorectal referral

Breast lump: any new discrete lump in woman >30 (or any age with family history) - 2-week wait breast referral

Cough red flags: haemoptysis, >3 weeks, weight loss, smoker - urgent CXR, consider 2-week wait lung referral

3.4 Diagnostic Tools in GP

The 2-week wait (2WW) / urgent suspected cancer pathway (UK) Know your local thresholds. In England, NICE NG12 guidance defines criteria for suspected cancer referrals by site.

Investigations to use wisely:

Full blood count (FBC): anaemia, infection, haematological malignancy
U&E: renal function, electrolytes - check before starting ACE inhibitors, NSAIDs, diuretics
LFTs: liver disease, monitor medication toxicity (methotrexate, statins)
TFTs: thyroid disease (hypothyroidism is common and mimics many conditions)
HbA1c: diabetes diagnosis and monitoring
eGFR/CKD staging: chronic kidney disease management
Urine dipstick + MSU: UTI, proteinuria
ECG: arrhythmia, ischaemia, hypertrophy
Spirometry: COPD and asthma
Point-of-care CRP: differentiating viral from bacterial infection

When NOT to investigate: Unnecessary investigations generate anxiety, incidentalomas, further unnecessary tests, and cost. Ask "what will I do differently with this result?" before ordering.

MODULE 4 - CHRONIC DISEASE MANAGEMENT (The Core of GP Work)

Over 60% of GP consultations involve at least one long-term condition. Mastering these is non-negotiable.

4.1 Hypertension

Diagnosis (NICE NG136):

Clinic BP ≥140/90 on two occasions
Confirm with ABPM (ambulatory monitoring) or HBPM (home monitoring) - this is mandatory before starting treatment in most cases
Stage 1: clinic 140-159/90-99, ABPM daytime 135-149/85-94
Stage 2: clinic ≥160/100, ABPM daytime ≥150/95
Severe: clinic ≥180/120 - treat same day

Target BP (in most patients):

<80 years: clinic <140/90
≥80 years: clinic <150/90
Diabetics: <130/80
CKD with proteinuria: <130/80

The treatment ladder (NICE AB/CD):

Step 1: ACE inhibitor (or ARB if ACE intolerant) for age <55 or diabetics; OR Ca-channel blocker for age ≥55 or Afro-Caribbean
Step 2: ACE inhibitor + CCB
Step 3: ACE inhibitor + CCB + thiazide-like diuretic (chlortalidone/indapamide)
Step 4 (resistant): check compliance, add spironolactone 25mg (if K+ <4.5), beta-blocker, or alpha-blocker

Annual review: BP, U&E (ACE inhibitor/ARB monitoring), eGFR, urine ACR, CVD risk (QRISK3)

4.2 Type 2 Diabetes

Diagnosis:

HbA1c ≥48 mmol/mol (6.5%) on two occasions (or once if symptomatic)
Fasting glucose ≥7.0 mmol/L
2-hour OGTT glucose ≥11.1 mmol/L

Targets (NICE NG28):

HbA1c: 48 mmol/mol (6.5%) if on diet alone or single non-hypoglycaemic agent; 53 mmol/mol (7.0%) if on drugs that can cause hypoglycaemia (sulfonylureas, insulin)
BP <140/80 (<130/80 if kidney, eye, or cerebrovascular disease)
Cholesterol: total <4.0, LDL <2.0 (or statin therapy per CVD risk)

The SIGN/NICE treatment algorithm:

Lifestyle + metformin (if eGFR >30, no contraindication)
Add SGLT-2 inhibitor (empagliflozin/dapagliflozin) - especially if CVD, heart failure, or CKD
OR add DPP-4 inhibitor (sitagliptin) - weight neutral, low hypo risk
OR add GLP-1 agonist (semaglutide/liraglutide) - especially if BMI >35
Intensify: add sulfonylurea (gliclazide) or insulin if targets not met

Annual diabetes review (the 9 care processes):

HbA1c
Blood pressure
Cholesterol
eGFR + urine ACR (nephropathy screening)
Foot examination (peripheral pulses, sensation, inspection)
BMI
Smoking status
Retinal screening (community-based digital photography programme)
Immunisations (flu + pneumococcal)

Sick day rules: advise patients to hold metformin, SGLT-2 inhibitors, and ACE inhibitors during acute illness/dehydration ("SADMAN" drugs)

4.3 Asthma

Diagnosis (NICE NG80):

Characteristic symptoms: wheeze, breathlessness, chest tightness, cough - variable, worse at night/exercise, improves with bronchodilators
Spirometry: FEV1/FVC <0.7 with ≥12% bronchodilator reversibility, or peak flow variability >20%
In children <5: clinical diagnosis (spirometry unreliable)

Treatment (stepwise - BTS/SIGN):

Step 1: SABA (salbutamol) as needed
Step 2: Add regular low-dose ICS (beclometasone 200-400 mcg/day)
Step 3: Add LABA (formoterol/salmeterol) - only with ICS (never alone)
Step 4: Increase ICS dose, consider LTRA (montelukast), refer to specialist
Step 5: Oral steroids, specialist biologics (anti-IL-5 for severe eosinophilic asthma)

Asthma action plan: every patient should have one - what to do when symptoms worsen

Asthma review: every 1-12 months depending on severity - check inhaler technique, adherence, triggers, ACQ/RCP "3 questions"

Acute exacerbation:

Moderate: PEF 50-75%, normal speech - SABA + prednisolone 40mg for 5 days
Severe: PEF 33-50%, unable to complete sentences - oxygen, nebulised SABA + ipratropium, IV magnesium, hospital
Life-threatening: PEF <33%, silent chest, cyanosis, SpO2 <92% - immediate 999/hospital

4.4 COPD

Diagnosis: spirometry post-bronchodilator FEV1/FVC <0.70, with compatible symptoms (chronic productive cough, dyspnoea) and exposure history (smoking, biomass fuel)

GOLD classification by FEV1:

GOLD 1 (mild): FEV1 ≥80% predicted
GOLD 2 (moderate): FEV1 50-79%
GOLD 3 (severe): FEV1 30-49%
GOLD 4 (very severe): FEV1 <30%

Treatment:

All: smoking cessation (single most effective intervention), flu vaccine, pneumococcal vaccine, pulmonary rehabilitation if MRC dyspnoea ≥3
Bronchodilators: SABA as needed, then LABA or LAMA (tiotropium), then dual bronchodilator
Add ICS only if FEV1 <50% AND frequent exacerbations (≥2/year)
Roflumilast: for severe COPD with chronic bronchitis and frequent exacerbations

Exacerbation: increased breathlessness, cough, sputum - trial of antibiotics (amoxicillin or doxycycline) + prednisolone 30mg for 5 days

4.5 Heart Failure

Diagnosis: combination of symptoms (dyspnoea, fatigue, ankle swelling), signs (elevated JVP, basal crackles, pitting oedema), and objective evidence (echocardiogram showing reduced EF <40% for HFrEF, or preserved EF ≥50% for HFpEF)

HFrEF management (NICE NG106):

First line: ACE inhibitor + beta-blocker (titrate up gradually)
Add mineralocorticoid receptor antagonist (spironolactone/eplerenone) if still symptomatic
SGLT-2 inhibitors (dapagliflozin/empagliflozin) - now first-line alongside ACE inhibitor + beta-blocker
Diuretics (furosemide) for symptom control
Consider ARNI (sacubitril/valsartan) in place of ACE inhibitor if still symptomatic

Monitoring: U&E and eGFR at start and after each dose change of ACE inhibitor/ARB/spironolactone. Monitor potassium closely.

4.6 Atrial Fibrillation

Causes: hypertension, heart failure, valvular disease, thyrotoxicosis, excessive alcohol, sepsis, PE

Stroke risk - CHA₂DS₂-VASc score:

C: CCF (1 point)
H: Hypertension (1)
A₂: Age ≥75 (2)
D: Diabetes (1)
S₂: prior Stroke/TIA (2)
V: Vascular disease (1)
A: Age 65-74 (1)
Sc: Sex category female (1)
Score ≥2 in men, ≥3 in women → anticoagulate with DOAC (apixaban, rivaroxaban, edoxaban, dabigatran). Warfarin is now second choice except in mechanical valve / rheumatic AF.

Bleeding risk - HAS-BLED (hypertension, abnormal renal/liver function, stroke history, bleeding history, labile INR, elderly >65, drugs/alcohol) - use to identify and correct modifiable bleeding risks, NOT to withhold anticoagulation if score ≥3.

Rate vs. rhythm control: most stable AF patients are managed with rate control (beta-blocker, diltiazem, or digoxin) and anticoagulation. Rhythm control (cardioversion, flecainide, amiodarone, ablation) for symptomatic AF or new onset <48 hours.

4.7 Depression and Anxiety

PHQ-9 (Patient Health Questionnaire-9) and GAD-7 are the standard screening tools in GP. PHQ-9 ≥10 suggests moderate depression; ≥20 suggests severe.

Stepped care model (NICE CG90/CG113):

Step 1: Watchful waiting (mild, <2 weeks), psychoeducation, self-help
Step 2: Guided self-help, CBT (online or group), lifestyle advice (exercise is evidence-based, NNT ~9)
Step 3: Medication (SSRI first-line: sertraline or citalopram) + individual CBT
Step 4: Crisis/complex: specialist MH team, combination therapy, lithium augmentation

Starting SSRIs:

Start low, go slow (sertraline 50mg, increase to 100-200mg)
Warn of initial worsening of anxiety (first 1-2 weeks)
Full antidepressant effect takes 4-6 weeks
Continue for minimum 6 months after remission (1-2 years if ≥2 episodes)
Review at 2 weeks, 4 weeks, then monthly

Suicide risk assessment: ask directly - "Are you having thoughts of harming yourself?" PATHOS mnemonic - Problems (>1 month), Alone (at time of attempt), Trouble (in past), Hopelessness, Serious attempt. SAFE-T framework for formal assessment.

MODULE 5 - PREVENTIVE CARE AND HEALTH PROMOTION

5.1 Primary vs. Secondary vs. Tertiary Prevention

Level	Target	Example
Primary	Healthy people - prevent disease	Vaccination, smoking cessation, statins in high-risk
Secondary	Asymptomatic disease - detect early	Cervical smear, bowel cancer screening, BP check
Tertiary	Established disease - prevent complications	Tight diabetic control, cardiac rehab post-MI

5.2 The UK NHS Screening Programmes (Must Know)

Programme	Age Range	Test	Frequency
Breast cancer	50-71	Mammography	Every 3 years
Cervical cancer	25-64	HPV test + cytology	25-49: 3-yearly; 50-64: 5-yearly
Bowel cancer	50-74	FIT (faecal immunochemical test)	Every 2 years
Diabetic eye	All diabetics	Retinal photography	Annually
AAA	Men at age 65	Abdominal USS	Once
Antenatal	All pregnant	Blood, USS, anomaly scan	Trimester-based
Newborn	Neonates	Bloodspot, hearing, physical	In first weeks of life

5.3 Smoking Cessation

Smoking remains the single largest avoidable cause of morbidity and premature death. Your role:

Ask at every opportunity
Brief advice (30 seconds) from a GP doubles quit rates vs. no advice
NRT (nicotine replacement therapy) + pharmacotherapy:
- Varenicline (Champix): most effective single agent (OR ~3 vs. placebo), causes nausea, watch for mood changes
- Bupropion: second-line, CI in seizure disorder and eating disorders
- NRT: patch + fast-acting (spray/lozenge) combination is better than patch alone
Refer to stop smoking service (most effective overall)

5.4 Alcohol

Use AUDIT-C (3 questions) to screen, then full AUDIT if positive.

Low risk: men/women ≤14 units/week
Increasing risk: 14-35 units/week (women), 14-50 units/week (men)
High risk: >35 (women), >50 (men)
Dependence: morning drinking, withdrawal symptoms (tremor, sweating, seizures), tolerance

Brief intervention (FRAMES): Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy - this alone reduces consumption in hazardous drinkers.

Dependent drinkers need supervised alcohol withdrawal (chlordiazepoxide/lorazepam regime + Pabrinex for thiamine).

5.5 Cardiovascular Risk and Statins

QRISK3 - the UK tool for calculating 10-year CVD risk. Accounts for age, sex, systolic BP, cholesterol, smoking, diabetes, BMI, ethnicity, deprivation, AF, CKD, family history, SLE, HIV, SMI, migraine, erectile dysfunction.

QRISK3 ≥10%: offer statin therapy (atorvastatin 20mg first-line for primary prevention)
Secondary prevention (established CVD, T1DM >40, CKD): atorvastatin 80mg regardless of baseline cholesterol

Monitoring: LFTs at baseline, 3 months, then 12 months. Repeat CK only if muscle symptoms. Target LDL-C <2.6 mmol/L (primary) or <1.8 mmol/L (secondary prevention).

5.6 Immunisations in Adults (UK Schedule, key ones)

Flu: annually for all 65+, pregnant, and those with chronic conditions (diabetes, asthma, COPD, heart/kidney/liver disease, immunosuppressed, BMI >40, carers)
Pneumococcal (PPV23): once for 65+, and for at-risk adults under 65
Shingles (Shingrix): 70-79 (2-dose course), routine offer
COVID-19 booster: annual for 65+ and vulnerable
HPV: catch-up to age 25 for those who missed school programme

MODULE 6 - ACUTE AND URGENT PRESENTATIONS IN GP

6.1 Triage and Safety

In a GP same-day urgent clinic your first questions are always:

Is this patient safe at home, or do they need hospital now?
What is the risk of rapid deterioration?
Can I manage this, or do I need to escalate?

NEWS2 (National Early Warning Score) can be used in GP for acutely unwell patients:

Respiratory rate, SpO2, systolic BP, pulse, consciousness (ACVPU), temperature
Score ≥5 or any single score of 3: urgent review and consider 999

6.2 Chest Pain

Cause	Key features	Action
STEMI/NSTEMI	Crushing central chest pain, radiation to arm/jaw, sweating, nausea	999, aspirin 300mg, sublingual GTN
PE	Pleuritic pain, dyspnoea, haemoptysis, risk factors	O2, LMWH, CT-PA, hospital
Aortic dissection	Tearing interscapular pain, unequal BPs, pulse deficit	999 immediately
Pneumothorax	Sudden onset, young thin male, absent breath sounds	CXR, chest drain if tension
Pericarditis	Pleuritic, relieved by leaning forward, friction rub	NSAIDs + colchicine
Oesophageal	Burning, related to meals, relieved by antacids	PPI, lifestyle
MSK	Reproduced by palpation	Reassurance, analgesia

Well's Score for PE: clinical sign of DVT (+3), PE most likely diagnosis (+3), HR >100 (+1.5), immobilisation/surgery in 4 weeks (+1.5), previous DVT/PE (+1.5), haemoptysis (+1), malignancy (+1). Score >4: high probability - CT-PA. ≤4: D-dimer; if negative, PE excluded.

6.3 Breathlessness

Acute severe asthma: see 4.3 above
Acute heart failure (pulmonary oedema): upright position, oxygen, IV furosemide, consider GTN
Pneumonia: CURB-65 scoring: Confusion (1), Urea >7 (1), Resp rate ≥30 (1), BP <90/60 (1), age ≥65 (1). Score 0-1: community treatment. Score ≥2: hospital.
COPD exacerbation: controlled O2 (target SpO2 88-92% in known hypercapnia), bronchodilators, steroids, antibiotics

6.4 The Acutely Confused Patient

Confusion = DELIRIUM until proven otherwise. Causes - "I WATCH DEATH":

I: Infectious (UTI, pneumonia, meningitis)
W: Withdrawal (alcohol, benzodiazepines)
A: Acute metabolic (Na, glucose, renal, liver failure)
T: Trauma
C: CNS pathology (stroke, SDH, encephalitis)
H: Hypoxia
D: Deficiencies (thiamine, B12)
E: Endocrine (hypoglycaemia, hypothyroid, Addisonian crisis)
A: Acute vascular (MI, PE)
T: Toxins/drugs (opiates, anticholinergics, steroids)
H: Heavy metals

4AT score for delirium screening in GP/community: Alertness, AMT-4 (abbreviated mental test), Attention (months backwards), Acute change. Score ≥4: likely delirium.

6.5 Fever and Infection

Sepsis recognition (Sepsis 6 in 60 minutes):

NEWS2 ≥5 + suspected infection = sepsis until proved otherwise
Sepsis 6: blood cultures, lactate, urine output (catheterise), IV antibiotics, IV fluids, oxygen

Common infection management in GP:

UTI (uncomplicated, women): nitrofurantoin 100mg MR BD for 5 days (first-line). Send MSU before treating if recurrent, pregnant, or male.
Community-acquired pneumonia (mild): amoxicillin 500mg TDS for 5 days (add doxycycline or azithromycin if atypical suspected)
Cellulitis (mild-moderate): co-amoxiclav or flucloxacillin. Mark border, elevate limb, review in 24-48 hours.
Tonsillitis: FeverPAIN or Centor score to guide antibiotic decision. Phenoxymethylpenicillin 500mg QDS if needed.
Otitis media: most self-resolves. Safety-net. Antibiotics if systemically unwell, <2 years, or bilateral.

MODULE 7 - COMMON CONDITIONS BY SYSTEM

7.1 Musculoskeletal

Low back pain (non-specific): affects 80% of adults at some point. Reassure (most resolves in 6 weeks), encourage activity, avoid bed rest. NSAIDs for analgesia. Refer physiotherapy. Avoid opioids unless short-term.

Osteoarthritis: weight loss, exercise, physiotherapy first. Analgesia: paracetamol → topical NSAID → oral NSAID + PPI → consider intra-articular steroid or hyaluronate. Refer for joint replacement when quality of life severely impaired.

Rheumatoid arthritis: symmetric small joint synovitis (MCPs, PIPs, wrists), morning stiffness >1 hour, positive RF and anti-CCP. Early aggressive DMARD therapy (methotrexate + folic acid) is key - "treat to target" remission. Monitor FBC + LFTs on methotrexate.

Gout: acute monoarthritis (1st MTP joint classic), hyperuricaemia, birefringent crystals on joint aspiration. Acute: NSAIDs or colchicine. Prophylaxis: allopurinol (start AFTER acute attack resolved, titrate to urate <360 μmol/L).

Temporal arteritis (GCA): age >50, temporal headache, jaw claudication, raised ESR/CRP. Start prednisolone 40-60mg immediately (same day) to prevent blindness - do not wait for biopsy results.

7.2 Gastrointestinal

GORD/Dyspepsia: heartburn, regurgitation, epigastric discomfort. H. pylori test-and-treat (urea breath test or stool antigen). PPI trial. Lifestyle: lose weight, raise bed head, avoid triggers, reduce alcohol.

Irritable bowel syndrome (IBS): Rome IV criteria - recurrent abdominal pain ≥1 day/week for 3 months, related to defecation or change in stool frequency/form. Exclude red flags, check FBC/CRP/TTG antibodies (coeliac). Management: dietary advice (low-FODMAP), antispasmodics (mebeverine, buscopan), loperamide for diarrhoea, laxatives for constipation, low-dose amitriptyline or CBT for refractory cases.

Coeliac disease: diarrhoea, bloating, weight loss, anaemia. Test with anti-tTG IgA (with total IgA - IgA deficiency causes false negative). Confirm with duodenal biopsy. Treatment: lifelong gluten-free diet.

Inflammatory bowel disease (IBD): Crohn's (transmural, anywhere GI tract, skip lesions, smoking worsens) vs. UC (mucosal, colon only, continuous from rectum). GP role: initial diagnosis, maintaining remission, monitoring for complications, coordinating with gastroenterology.

7.3 Mental Health

The mental state examination (MSE) in GP must be efficient:

Appearance and behaviour (self-neglect? agitation?)
Speech (rate, volume)
Mood and affect ("How has your mood been?")
Thoughts (negative cognitions, suicidal ideation)
Perceptions (auditory hallucinations - always ask if relevant)
Cognition (orientation, memory - use AMT-4 or MMSE)
Insight

Psychosis: early recognition is key. New onset psychotic symptoms → urgent same-day/next-day referral to Early Intervention in Psychosis (EIP) team. Do not start antipsychotics in GP unless specifically trained.

Dementia: cognitive decline affecting daily function. Common causes: Alzheimer's (60-70%), Lewy body, vascular, frontotemporal. GP assessment: full history including informant, MMSE or MoCA, blood tests (FBC, U&E, TFTs, B12, folate, glucose, calcium), consider CT head. Refer to memory clinic for confirmation. Post-diagnosis support, carer assessment, driving advice (DVLA notification), LPA.

ADHD in adults: inattention, hyperactivity, impulsivity present since childhood. Screen with ASRS tool. Diagnose and initiate in specialist setting. GP role: monitoring, prescribing methylphenidate/atomoxetine/lisdexamfetamine under shared care agreements.

7.4 Skin Conditions

Eczema: emollient as treatment and wash substitute, topical steroids (mildest effective potency), short courses. Wet wraps for severe cases. Avoid triggers.

Psoriasis: chronic plaque - use Psoriasis Area Severity Index (PASI). Mild: emollients + topical steroids + vitamin D analogues (calcipotriol). Moderate-severe: PUVA, methotrexate, biologics (via dermatology).

Acne: comedonal (topical retinoids), inflammatory (topical/oral antibiotics + benzoyl peroxide), severe nodular/scarring (oral isotretinoin - dermatology only, pregnancy prevention programme).

Skin cancer red flags - ABCDE:

Asymmetry
Border irregularity
Colour variation
Diameter >6mm
Evolution (change over time) Any concerning lesion: 2-week wait dermatology referral.

7.5 Women's Health

Contraception:

UKMEC (UK Medical Eligibility Criteria) - classifies conditions by suitability for each method
COCP: CI in migraine with aura, VTE risk, breast cancer, smoker >35, BP >160/100
POP (progesterone-only pill): safe in most situations; good for breastfeeding, migraine, older women
LARC (long-acting reversible contraception): most effective. IUD, IUS (Mirena - also treats menorrhagia), implant (Nexplanon), DMPA injection

Menorrhagia: heavy menstrual bleeding. First: IUS (Mirena) - most effective medical treatment. Then tranexamic acid (anti-fibrinolytic) or NSAIDs (luteal phase). Norethisterone for short-term. Refer if fibroid/pathology suspected.

Menopause: diagnose clinically in women >45 with symptoms (flushes, sweats, urogenital atrophy, mood changes, cognitive symptoms). Check FSH only if <45. HRT is first-line for vasomotor symptoms: oestrogen + progesterone (if intact uterus). Modern HRT has favourable risk profile; absolute breast cancer risk increase is small. Consider cardiovascular and bone benefit vs. risk in shared decision-making.

Antenatal care in GP: confirm pregnancy, calculate EDD, book midwife, folic acid 400mcg (5mg if high risk), avoid teratogens, check blood group + antibodies + rubella immunity + infections (hepatitis, syphilis, HIV, chlamydia), lifestyle advice.

MODULE 8 - PROFESSIONAL PRACTICE AND SYSTEMS

8.1 Prescribing Safety

The 7 rights of prescribing: right patient, right drug, right dose, right route, right time, right indication, right documentation.

High-risk drugs in GP (know the monitoring requirements):

Drug	Monitoring	Key risks
Methotrexate	FBC + LFTs every 2-3 months	Myelosuppression, hepatotoxicity, pneumonitis
Lithium	Serum Li, TFTs, U&E every 3-6 months	Narrow therapeutic index; toxicity with dehydration/NSAIDs
Warfarin	INR (frequency depends on stability)	Interactions with almost everything
ACE inhibitors/ARBs	U&E + eGFR 1-2 weeks after starting	Hyperkalaemia, renal deterioration (>30% eGFR drop = stop)
NSAIDs	BP, U&E, consider PPI co-prescription	GI bleed, renal failure, fluid retention, HTN
Amiodarone	TFTs, LFTs, CXR every 6 months	Thyroid (hypo and hyper), pulmonary toxicity, photosensitivity

Polypharmacy: patients on ≥5 drugs have high risk of adverse interactions, non-adherence, and falls. Annual medication review - use STOPP/START tool or Beers Criteria to identify inappropriate prescribing, particularly in elderly.

Deprescribing: as important as prescribing. Systematically review all medications - is each drug still indicated, monitored, and wanted by the patient?

8.2 Safeguarding

Every GP must know their local safeguarding procedures. Key principles:

Child safeguarding:

Types of abuse: physical, emotional, sexual, neglect
Signs: unexplained injuries, developmental regression, disclosure, parental behaviour
Any concern: discuss with named/designated safeguarding professional. Document meticulously.
Referral to Children's Social Care if child at risk of harm. You can refer without parental consent if this would put child at greater risk.

Adult safeguarding:

Any adult with care/support needs who is unable to protect themselves from harm or exploitation
Care Act 2014 (England): six principles - empowerment, prevention, proportionality, protection, partnership, accountability
Discuss with adult safeguarding team

Domestic violence (IRIS programme): ask directly, non-judgementally. "Do you feel safe at home?" Document in coded terms if patient requests. Safety planning.

8.3 Ethical and Legal Principles

Four pillars of medical ethics (Beauchamp & Childress):

Autonomy - patient's right to make their own decisions (informed consent)
Beneficence - acting in the patient's best interests
Non-maleficence - do no harm
Justice - fair distribution of resources

Confidentiality: information shared by patients is confidential, with exceptions:

Patient consent
Sharing within the healthcare team (proportional, necessary)
Statutory duty (notifiable diseases, court orders)
Serious risk of harm to third party (e.g., disclosure of domestic violence, child at risk)

Capacity (Mental Capacity Act 2005): presume capacity, assess per decision, per time. A patient has capacity if they can: understand, retain, weigh up, and communicate. If lacking capacity - act in best interests using least restrictive option.

Lasting Power of Attorney (LPA): patients should be encouraged to set up Health & Welfare LPA while they have capacity.

Advance Care Planning (ACP): especially for frail elderly and those with terminal illness. DNACPR discussions, RESPECT forms. These are not prescriptions for inaction - they guide care to align with patient wishes.

8.4 Communication with Colleagues and Referrals

Referral letters: SBAR framework works well:

Situation: who, what problem
Background: PMH, medications, relevant history
Assessment: your clinical impression
Recommendation: what you want (urgent/routine, specific question)

Handover: use SBAR for verbal handover. Home visits, out-of-hours, hospital discharge - every patient needs a clear handover.

Learning from errors: significant event analysis (SEA) is a GP-specific quality improvement tool. When something goes wrong (or nearly goes wrong), complete a SEA: what happened, why, what we will do differently. No-blame learning culture.

8.5 Managing Complexity and Multimorbidity

Most patients aged >65 have ≥2 long-term conditions. Single-disease guidelines become unmanageable and contradictory when stacked.

Principles for multimorbid patients:

What matters to the patient most? (may not be what matters to your QOF points)
Treatment burden: how many appointments, tablets, blood tests? Can this be simplified?
Frailty assessment: use Clinical Frailty Scale (1-9). Frail patients require modified targets and careful prescribing.
Single annual review combining all chronic disease reviews, rather than separate siloed appointments
Social prescribing: link worker referral for social isolation, housing, debt, bereavement - these are bigger determinants of health than most medications

SUMMARY: THE GP'S MENTAL TOOLKIT

When you see a patient	Think about
Every consultation	ICE, red flags, safety-net, documentation
Chronic disease review	Targets met? Monitoring up-to-date? Medication review?
Prescribing	Indication, dose, interactions, monitoring, review date
Acutely unwell	NEWS2, sepsis, referral threshold, escalation
Preventive opportunity	Screening due? Vaccines? Smoking/alcohol/weight? CVD risk?
Complex/frail patient	Multimorbidity, polypharmacy, frailty score, what matters to them
Any safeguarding concern	Document, discuss, refer if needed
Ethical dilemma	Four pillars, capacity, confidentiality, best interests

RECOMMENDED RESOURCES FOR ONGOING LEARNING

RCGP Curriculum Topic Guides (free, rcgp.org.uk) - the definitive syllabus
NICE Guidelines (nice.org.uk) - always check current guidance before managing a new condition
SIGN Guidelines - especially strong for Scottish/UK evidence base
BMJ Best Practice - excellent clinical decision support at point of care
Swanson's Family Medicine Review - problem-based, excellent for AKT preparation
Textbook of Family Medicine (Rakel) - comprehensive reference for practice
GPnotebook / GPIQ - quick reference in consultation
MDCalc - validated clinical scoring tools (QRISK3, CHA₂DS₂-VASc, CURB-65, PHQ-9, etc.)
e-Learning for Health (e-LfH) - free NHS e-learning modules including GP curriculum content

This guide covers the full arc of GP knowledge from foundational philosophy to advanced prescribing safety and complex multimorbidity. The next step is to go condition-by-condition in Module 4 and 7 and test yourself using the Swanson's Family Medicine Review question bank format. Ask me to go deeper on any section and I can provide a detailed breakdown.

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Top20 GP Clinical Scenarios

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What's inside (42 slides)

Slide type	Content
Title slide	Dark navy with aqua accents
Overview slide	All 20 scenarios listed at a glance with numbered chips
Per scenario: divider + content	2 slides per scenario = 40 scenario slides
Closing slide	6 key principles to remember

The 20 Scenarios covered

Chest Pain
Acute Breathlessness
Headache
Abdominal Pain
Back Pain
Fatigue & Tiredness
Hypertension Management
Type 2 Diabetes Review
Mental Health - Depression
Mental Health - Anxiety
UTI & Dysuria
Skin Rash - Eczema & Psoriasis
Knee Pain
Cough & Respiratory Symptoms
Dizziness & Vertigo
Palpitations & AF
The Paediatric Consultation
Women's Health
Elderly & Frailty Assessment
Medically Unexplained Symptoms

Design features

Colour-coded urgency badges: RED (high risk), ORANGE (important/complex), TEAL (common/chronic)
Three-column layout per scenario: Red Flags / Differential / Management
Navy/teal/aqua clinical palette - professional and readable
Numbered scenario chips on every slide for quick navigation

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