Sore throats and antibiotics

The majority of acute sore throats (including pharyngitis and tonsillitis) are self‑limiting and often triggered by a viral infection of the upper respiratory tract. The symptoms can last for around 1 week, but most people will get better within this time without antibiotics, regardless of cause (bacteria or virus).

If you are concerned it may be strep throat (and therefore benefit from antibiotics) use the FeverPAIN scoring system. This reduces antibiotic prescribing by 30%!

FeverPAIN criteria

  • Fever (during previous 24 hours)
  • Purulence (pus on tonsils)
  • Attend rapidly (within 3 days after onset of symptoms)
  • Severely Inflamed tonsils
  • No cough or coryza (inflammation of mucus membranes in the nose)

Each of the FeverPAIN criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause.

0 or 1 =13 to 18% likelihood of isolating streptococcus.

2 or 3 = 34 to 40% likelihood of isolating streptococcus.

4 or 5 =62 to 65% likelihood of isolating streptococcus. Treat these with penicillin (unless allergic) for a 5 to 7 day course ONLY (new evidence). Consider giving the same dosage twice a day rather than 4 times a day to improve compliance.



There is new guidance from the UK’s Faculty of Sexual and Reproductive Health with regards to taking the COCP. Please note this is accepted practice but is ‘off licence’ meaning the drug has not been formally approved for use in this way.

Most errors in taking the cocp occur in the pill free week. This pill free week is not necessary and should be shortened to 4 days.

Patients can now

  1. Run 2 or 3 packets together. This will give them regularity and regular menses. Only a 4 day break is needed.
  2. Continue running packets together until they get spotting. Then stop for 4 days.
  3. Continue running packets together whether there is spotting or not (like the POP).

Consider discussing this with your patients. It gives them more control and flexibility with their menses and reduces risk of pregnancy.



Medical quiz 1.

This is the first in a series of monthly quizzes to get both C.O and volunteer drs thinking. This is based on a real life patient I treated.

Feel free to post your comments.

Answers in 2 weeks.

Quiz 1.

73 year old patient with a long term history of osteoporosis and spinal stenosis presents with worsening pelvis pain and difficulty walking. She has no history of trauma.

Regular medications:

Paracetamol and codeine for pain

Alendronic acid and calcium and vitamin D for osteoporosis

O/E she is tender on palpation of her pelvis and walk with an antalgic gait (painful walk).

I refer her for an X-ray


What does the X ray show?

Blood tests are vitamin D 76 (>50 normal), Ca 2.8 (2.2-2.6) and PTH 13.4 (1.6-7.2)

What is her diagnosis?

Is this primary or secondary?

What is the commonest cause and how do you treat it?

What are the complications of this treatment?

If this treatment isn’t available how can you manage the patient?




Home made spacer for asthma

As requested by

Here is a photo of a spacer made from a bottle-500ml ideally. Please make one and keep it handy for when patients come with asthma attacks. 10 puffs through a spacer is equivalent to a nebuliser and is more effective if the patient is not too short of breath to manage it.

In the UK, all patients are encouraged to use a spacer with every dose of inhaler as it improves the drug delivery to the lungs (from 10% with no spacer to more than 30% with spacer)

  1. Assemble spacer (if necessary)
  2. Remove inhaler cap
  3. Hold inhaler upright and shake well
  4. Insert inhaler upright into spacer
  5. Put mouthpiece between teeth (without biting) and close lips to form good seal
  6. Breathe out gently, into the spacer
  7. Keep spacer horizontal and press down firmly on inhaler canister once
  8. Breathe in and out normally for 3 or 4 breaths
  9. Remove spacer from mouth
  10. Breathe out gently
  11. Remove inhaler from spacer
  12. If more than one dose is needed, repeat all steps starting from step 4
  13. Replace inhaler cap

Atrial fibrillation extras

As discussed in the podcast, here is the stroke risk calculator and an ECG example

CHADS2 Scoring Scheme

Condition Points
C Congestive heart failure 1
H Hypertension 1
A Age > 75 years 1
D Diabetes Mellitus 1
S2 Prior Strokeor TIA 2

Annual Stroke Risk with Respect to CHADS 2 Score (1)

CHADS2 Score Stroke Risk % 95% confidence interval
0 1.9 1.2-3.0
1 2.8 2.0-3.8
2 4.0 3.1-5.1
3 5.9 4.6-7.3
4 8.5 6.3-11.1
5 12.5 8.2-17.5
6 18.2 10.5-27.4

AF rapid ventricular response



Complete heart block


Complete Heart Block

Complete heart block (or third-degree AV heart block)

A colleague showed me an unusual looking ECG on a patient with no cardiac symptoms. We asked a cardiologist for advice and he diagnosed Complete Heart Block (CHB). As the patient was well he was referred to cardiology clinic the following day for a pacemaker.

Complete heart block is the most serious type of AV heart block.  This is an abnormal heart rhythm (arrhythmia) that happens when there is a complete absence of electrical impulses (AV conduction) between the atria and ventricles.

Normally a back-up system keeps ventricles beating (junctional or ventricular escape rhythm), but the ventricles beat much slower than normal. This can affect the flow of blood to the body and brain and will cause symptoms of confusion, collapse, dizziness, breathlessness and tiredness.

Alternatively, the patient may suffer ventricular standstill leading to syncope (if self-terminating) or sudden cardiac death (if prolonged).

What causes complete heart block?

Most people with complete heart block have an underlying heart condition like coronary heart disease, cardiomyopathy or congenital heart disease.

It can also be caused by ageing of the electrical pathways in your heart (meaning you’re more likely to get it if you’re older), electrolyte imbalances, and some medicines (e.g. calcium-channel blockers, beta-blockers, digoxin)


The patient will have severe bradycardia (slow heartbeat) with independent atrial and ventricular rates, i.e. AV dissociation on ECG-see below.

Example of complete heart block

The atrial rate is approximately 100 bpm.

The ventricular rate is approximately 40 bpm.

The two rates are independent; there is no evidence that any of the atrial impulses are conducted to the ventricles.


Patients require urgent admission for cardiac monitoring, backup temporary pacing and usually insertion of a permanent pacemaker.