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Latest Updates - 'Pearls' from the Red Whale

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Supporting you throughout your CPD journey - one update at a time

Our regular updates or ‘Pearls’ are topical items relating to primary care. Each one is drawn from the latest research, clinically relevant to issues in general practice, and linked to an article in our handbook.

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Red Whale Pearls are copyright free so you can print off as many hard copies as you like and forward soft copies to your colleagues to your heart's content. All we ask is that you acknowledge us as the source.

Find our specialised Pearls for Primary Care Nurses here.

Varicella zoster and ibuprofen

12 Sep 2018

NICE Clinical Knowledge Summaries make clear recommendations that NSAIDs should be avoided for both pain relief and fever management in chickenpox. This is because of concerns identified in 3 studies of an association between NSAID use during an attack of chickenpox and an increased risk of necrotising soft tissue infections and invasive group A beta-haemolytic streptococcal infections. 

Gestational diabetes diagnostic criteria – NICE and now SIGN criteria are new … and are different!

05 Sep 2018

Oral glucose tolerance testing has a limited role because it is complex, expensive and less reproducible . Its main role is in pregnancy. Confusingly, NICE and SIGN have differing criteria for the diagnosis of gestational diabetes. NICE changed the threshold for diagnosis in 2015. The newer SIGN criteria (2017) are in line with recommendations that followed on from the HAPO study, and seem to be used internationally.

Vertigo: differential diagnosis

29 Aug 2018

It is Monday morning. You are already running late and it is only 9:30. Mrs Smith walks hesitantly down the corridor, slowly lowers herself into your consulting room chair and tells you that she is feeling dizzy. Your heart sinks. But maybe, after reading this, it won’t! 

There are many causes of dizziness, but if her ‘dizziness’ is true vertigo, think BPPV and vestibular migraine. 


22 Aug 2018

Imagine a clinical meeting in a surgery not too far away…The practice manager sheepishly asks, “Who is going to be the clinical lead for hyperkalaemia?” The ‘what’?, you think. No one raises their hand, so you volunteer and then wonder what you have let yourself in for! This relates to a recent NHS Patient Safety Alert which may be festering in your post-school holiday inbox. 

We reveal all …and, if you lost at raising-hand-roulette, we offer some help!

Novel psychoactive substances

15 Aug 2018

Do you know your khat from your black mambo? If not, have a read of this article. 

Novel psychoactive drugs, previously called ‘legal highs’ (although all are now illegal!), are widely used in some populations. There are over 500 recognised novel psychoactive drugs within four main categories, although there is some overlap between the categories.

Understanding new cancer treatments – immunotherapy

09 Aug 2018

PARP inhibitors, adoptive cell therapy, cytokine immunotherapy, vaccine immunotherapies, gene therapies… what are these all about? What do we in primary care need to know about new cancer treatments?

Annie has been having immunotherapy for metastatic melanoma. All the evidence suggests that her treatment has been remarkably effective, but she has been struggling with diarrhoea and was found to have colitis as a side-effect of her treatment. Her symptoms have been severe enough to need admission for IV fluids and treatment with steroids. 

Fever in returning travellers

02 Aug 2018

John, who had been travelling across central Africa, became unwell with a fever the day before returning home. Now home for more than 24h, the fever persists and he is feeling more unwell. What do you do? 

Always consider that this may be a highly transmissible infection, for example Ebola or another haemorrhagic fever, a severe strain of influenza or TB. If this is a possibility, seek appropriate support/advice, and take the necessary precautions to ensure patient safety while protecting others.

Chronic fatigue syndrome (CFS/ME): effective home treatment for teenagers

26 Jul 2018

In 2012, a Dutch study called FITNET randomised 135 teenagers to receive an internet-based intervention called FITNET (fatigue in teenagers internet) or usual care. It followed them up for 6m; the results were impressive, and were maintained 4y later: 

Outcome measure (after 6m)

FITNET group

Usual care




* Recovery (= full school attendance, no severe fatigue, normal physical functioning)

Faltering growth in children

17 Jul 2018

This issue may arise with parents who are concerned that their child is too small or too thin, or where the parents or health visitor pick up that a child is not growing as they should be. It may also come up in the ‘picky eater’ consultations. Weight loss in the first 3d of life is usually physiological and recovers by 3w. Breastfeeding support and advice should be offered. 

Lateral hip pain – not all hip pain is osteoarthritis!

12 Jul 2018

Greater trochanteric pain syndrome (which we used to call trochanteric bursitis – until it became apparent that it often doesn’t involve bursitis!) is the most common cause of lateral hip pain in primary care. It generally affects women aged between 40 and 60y. 


04 Jul 2018

Kwame has developed a number of very obvious hypopigmented patches in his otherwise flawless skin. He is troubled that they are so evident to others, but is also worried that they might represent some sort of serious underlying disease.

Pancreatic cancer

28 Jun 2018

Barry retired 2 months ago, having recently turned 63. He prepared well for retirement, and has started working with a number of organisations he wishes to support in a voluntary capacity. Barry readily says that being able to spend more time with his grandchildren is what he has been most looking forward to in retirement. He had not felt unwell, though retrospectively realises that he had lost some weight. So, when he rapidly developed painless jaundice, it was a huge shock to discover that he has pancreatic cancer. His life, hopes and plans have been turned upside down.


21 Jun 2018

Hirsutism is excess hair growth in women in an androgen-dependent distribution. It occurs as a result of increased androgen production or increased skin sensitivity to androgens. PCOS and idiopathic androgen excess are the most common causes. Baseline investigations should include plasma testosterone, free androgen index, TSH and prolactin, and, if clinical suspicion, 17-hydroxyprogesterone and 24h urinary cortisol. 


13 Jun 2018

Anna just does not feel right. She says she is tired no matter how much rest she gets. She feels short of breath and her heart races with even minimal exertion. She is certain that her hair is thinning. You run some initial blood tests and her TSH is undetectable. She has thyrotoxicosis.

In the UK, 80% of cases of thyrotoxicosis are caused by Graves’ disease. However, there are many other causes to consider, including multinodular goitre, thyroiditis and drug-induced thyrotoxicosis (amiodarone, lithium and a number of other drugs can cause thyrotoxicosis).

Bullous pemphigoid

06 Jun 2018

Bullous pemphigoid is a serious condition and not to be missed. Though rare, it is on the rise because it is a condition of old age – the mean age of onset is 80y. 

Though a self-limiting condition, it can last months or years. Possible triggers include trauma, furosemide, NSAIDs and antibiotics. Initially, there may be intensely itchy lesions which can mimic eczema. Tense blisters (bullae) appear on limbs and trunk – the underlying skin can be normal or inflamed. Lesions may be single or widespread. It is usually itchy. 

Managing the consequences of cancer treatment

22 May 2018

Nearly 80% of women diagnosed and treated for breast cancer will survive for 10 years or more. In primary care, they form a large proportion of our patients who live with cancer as a long-term condition. As part of the 2020 Cancer Plan, the majority of breast cancer patients will be discharged early for shared care follow-up in primary care. The exact model and funding of this is in development. 

However, the end of treatment is not the end of the impact of a breast cancer diagnosis.

Acute knee pain (traumatic)

22 May 2018

“I hurt my knee last night at football training. I didn’t want to wait for hours in A&E so I thought I would come to you this morning to check it out”, said Tariq as he hobbled into your consulting room on a pair of crutches.

The most common causes of acute knee pain in a primary care setting are minor ‘sprains and strains’ (42%) and acute on chronic flare of osteoarthritis (34%).

Ask WHY before HOW

16 May 2018

Demand is rising. There are real issues with the supply of GPs. The political momentum is towards larger and more integrated organisations: towards ‘working at scale’, whatever that means! Are you feeling under pressure to merge with another practice or to join a federation? Do you feel wary having heard stories like the following?

Thrombocytosis and cancer

09 May 2018

 “Reading page 259 has helped find three asymptomatic bowel cancers in the past 4 months. Truly astonishing. Perhaps change LEGO to BOGLE? Love the courses.”

This recent feedback from a delegate on our courses made our day! This is evidence being applied and making a real difference for our patients. So, what are elevated platelet counts and cancer all about? The short answer is, raised platelets in those over 40y are strongly predictive of a new cancer diagnosis in the next 12 months, and this includes colorectal cancer as well as the LEGO cancers.

HRT choosing preparations and bio-identical hormones

02 May 2018

In April, we introduced you to Chloe, a 49-year-old exhausted and at her wits’ end with menopausal symptoms. You have now established that she has had no bleeding at all for more than 12 months. She has not had a hysterectomy. She is not using a Mirena coil. She tells you that she and her partner have been using condoms for contraception for the past 3 years, so she has not taken any hormonal preparations.

Chloe’s BMI is 22 and her QRISK-2 score was 3.2% when assessed 2 years ago. She has never smoked. She has no personal nor family history of VTE, nor known thrombophilia. She has no family history of breast cancer. You have discussed the possible side-effects, monitoring, duration and stopping of HRT, and she is keen to start. So, now you need to agree which formulation of the many available options will be best for Chloe.


19 Apr 2018

Here are two real-life duty doctor scenarios I have experienced in the past few months:

“Hi Doc, I’ve just finished cycle 2 of my chemo and have this rash and my hands are peeling.” 

“The ward nurse said I should call because I have these dreadful mouth ulcers after chemo and nothing seems to be working.”

I don’t know about you, but if I see a patient having chemotherapy who is remotely unwell, I have a very low threshold for ‘phoning a friend’ at the hospital. And indeed, many patients have 24-hour access to a hospital helpline while they are having their chemo – if only it was so simple. 

Leg ulcers

18 Apr 2018

Leg ulcers are common. They can have a profound impact on a patient’s quality of life. They also have significant impact on clinical services. Up to 50% of leg ulcers and 30% of foot ulcers are not healed at 6m (that is a lot of treatment room or district nurse visits!).

Lots of questions may arise in diagnosing and managing leg ulcers: what is the aetiology, is compression appropriate, is there any infection present, is the ulcer healing at an appropriate rate, when should we refer to specialist services?

Insomnia management: something better than a drug?

10 Apr 2018

Do you find managing insomnia challenging? Managing patient expectations can be even trickier! We hope this PEARL helps us and our patients make decisions around this difficult issue.

In primary insomnia, Z-drugs and benzodiazepines do work better than placebo, BUT, the effect is not long lasting and there are significant concerns about side-effects. Key things to be aware of:

HRT: starting, stopping and troubleshooting

04 Apr 2018

HRT can be bewildering for patients…and for us! Oestrogen-only, sequential combined, continuous combined, gels, pills, patches, pessaries, and where does the IUS fit in?

Chloe, aged 49y, says she has finally come to you as she can no longer bear the hot flushes; they are troublesome at work and disturb her sleep, leaving her exhausted and at her wits end. She has read about HRT and wonders whether this would be helpful for her.

Chronic pain and opiates

22 Mar 2018

In recent days, the media has focused on the issue of opiate use and misuse. 

“NHS accused of fuelling rise in opioid addiction” was the headline following a BBC investigation. This has been picked up by other media outlets with headlines such as “Opioid prescriptions in England nearly doubled in 10 years”, and, more sensationally, “The Opioid Timebomb: How addiction to painkillers cost me my wife, my children, my home and my £150,000-a-year job.”