Colorectal cancer is the third most common cancer in the U.K., with an annual incidence of 36,100 in England and Wales. It is also the second leading cause of death from cancer in the U.K. However, there has been a significant increase in five-year survival over the past decade, from 22% to 50% despite more than 55% of patients presenting with lymph node or distant metastases. Around 80% of colorectal cancer is sporadic, i.e., caused by the interaction of genetic and environmental factors via the adenoma-carcinoma sequence and cancer may take up to ten years to develop in this way. Adenomas are more common with age and one in four of the population aged over 50 will develop one or more polyps, with 10% of these polyps progressing to cancer over time. Risk factors for colorectal cancer include: age over 60; K-ras and p53 mutations; a diet high in saturated animal fat and low in fibre and vegetables; lack of exercise, obesity and excessive alcohol intake. Inflammatory bowel disease is a risk factor for development of colorectal cancer through the association of chronic inflammation and development of malignancy. Around 20% of colorectal cancer cases are familial and in a primary care setting taking a family history may determine those with a higher than average risk who may need onward referral. A large proportion of patients with rectal or sigmoid cancers present with a combination of rectal bleeding and a change in bowel habit (usually an increased frequency of defecation and/or looser stools). Rectal bleeding in the absence of anal symptoms occurs in over 60% of those with cancer, and a palpable rectal mass with or without tenesmus is present in 40-80% of those with rectal cancer.

Acute coronary syndrome (ACS), encompassing unstable angina (UA), non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI), is often the result of an acute thrombotic occlusion of the coronary vessels, associated with atheromatous plaque rupture or erosion. ACS is associated with a severely impaired prognosis and requires prompt and efficient specialist treatment. The clinical presentation may be identical across all three components of ACS. Establishing an accurate diagnosis without delay is of paramount importance to start treatment promptly. Patients with suspected ACS need to be referred immediately to A&E. Prehospital treatment, which includes aspirin, nitrates, morphine and oxygen (if hypoxic), should be initiated rapidly. Important features pointing towards a diagnosis of ACS include: typical characteristics of chest pain, presence of risk factors, and ECG changes suggestive of myocardial ischaemia. Chest discomfort in patients with ACS typically occurs at rest, is anginal in character and can range from mild tightness to central crushing chest pain. It may be associated with nausea, dyspnoea or diaphoresis. The chest pain may radiate to the arms, back or jaw and is often >20 minutes in duration. An accurate clinical history and a detailed examination are vital. Initial investigations are the same for all ACS events, with the need for urgent serial ECGs and the measurement of cardiac troponin levels, to assess myocardial damage. In NSTEMI, ECG changes suggestive of ischaemia are often present and associated with elevated cardiac troponin. In UA, there is a considerable reduction in myocardial perfusion leading to symptoms; but there is no rise in cardiac troponin. Risk stratification is imperative in assessment of ACS to allow efficient delivery of specialist care. Treatment includes: antiplatelets; antithrombotic agents; angina drugs; analgesia, and PCI.

HIV is now a treatable medical condition and the majority of those diagnosed with the virus remain fit and well on treatment. Patients living with HIV may well now have a near-normal life expectancy with antiretroviral treatment. In all, 77,000 people are known to be infected with HIV in the UK. However, 28% are unaware of their infection and are therefore unable to access treatment. Late diagnosis is the most important factor associated with HIV-related morbidity and mortality in the UK. The RCP guidelines recommend that GPs should offer an HIV test to patients: from communities or geographical locations where HIV is common; who present with a medical condition in which HIV might be implicated; with a medical condition compatible with AIDS or with any HIV indicator disease. GPs should also consider offering an HIV test to new patients who register with the practice in areas where diagnosed HIV prevalence in the local population (PCT/LA) exceeds 2 in 1,000. The pre-test discussion should cover: an explanation of why the test is recommended; the benefits of testing to the individual; details of how the result will be given; confidentiality and informed consent. The need for a repeat HIV test, if the patient is still within the window after a specific exposure, should be discussed.