Transcript What the F*** do I do with that?

What the F*** do I do with
that?
How to deal with some common
problems presenting to GP
Registrars
Related to the "Primary Care
Management" and "Problem
Solving Skills" Domains of the
new curriculum
Introduction
• Minor Ailments and other less glamorous
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medical problems are often neglected during
medical education
They are rarely seen in hospital, so it is difficult
for VTS trainees to gain experience in their
management
Only around 10% of patients with minor
ailments visit a GP with their problems – so
generally when they do, they want something
doing about them!
Let’s play a game!
(There might be a prize for the
winner)
How did you all do?
(we may have fibbed about the
prize!! . . .sorry)
Question 1
• Mrs Dawn Smith, 35, comes to your
surgery c/o pain when opening her
bowels. She also tells you that
occasionally when wiping she also sees
bright red blood on the paper. How do you
manage this?
Haemorrhoids
Aetiology:
• Constipation
• Increased anal sphincter tone
• Obstruction of venous flow eg:pregnancy
Grading:
• 1- Don’t prolapse out of anal canal
• 2- prolapse on defecation but reduce
spontaneously
• 3- Require manual reduction
• 4- Can’t be reduced
Clinical features:
• Bleeding after defecation
• Faecal soiling
• Mucous discharge
• Pruritis ani
• Pain
• Grades 2-4 may be felt as rectal mass.
Differential diagnosis:
• Rectal prolapse
• Anal polyp
• Inflammatory Bowel disease
• Rectal carcinoma
Investigations:
• General examination
• PR
• Proctoscopy (1st or 2nd degree piles)
• Sigmoidoscopy (if history of bleeding or
symptoms of possible malignancy)
Strangulation:
• Severe pain and discomfort at site.
• Haemorrhoid appears black/blue +/-
surrounding oedema
• Treat with bed rest, analgesia and stool
softeners.
• If severe can have debridement.
Management:
• Conservative:
– Hygiene
– Digital replacement if prolapse
– Local anaesthetic creams
– Treatment to reduce spasm of internal anal
sphincter eg:GTN, botulinum toxin injection
Management:
• Surgical:
– Sclerotherapy
– Rubber band ligation
– Photocoagulation
– Cryotherapy
– Anal dilatation
– Haemorrhoidectomy
Question 2
• Name these conditions:
– (3 pictures of rashes)
• List any associated signs/symptoms
• How would you diagnose the condition?
• What is the treatment?
MMR
Measles
• Age: Usually children, especially aged 5 years +
• Incubation: 1-2 weeks. Prodromal symps include
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fever, malaise, upper respiratory symps, conjunctivitis
and photophobia.
Infectious:
4 days before rash, until 5 days after.
Signs/symps:
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Fever
Cold
Coughing
Light sensitivity
Koplik’s spots (often before rash)
Macular rash on face, trunk and limbs.
Measles
• Development and resolution: Rash
becomes papular with coalescence. May
have haemorrhagic lesions and bullae
which fade to leave brown patches.
• Diagnosis: Specific antibodies may be
detected. They are at their max 2-4
weeks.
• Treatment: Supportive only.
• Complications: Encephalitis, OM and
bronchopneumonia.
Mumps
• Age: Most commonly 2 years +
• Incubation: Up to 3 weeks
• Signs/symps:
– Discomfort in jaw
– Fever
– Facial swelling
• Treatment: Supportive
• Complications: Orchitis, oophoritis,
meningitis and pancreatitis.
Rubella
• Age: Children and young adults
• Incubation: 14-21 days
• Prodromal symps:
– None in young children.
– Fever, malaise and upper respiratory symps if older.
• Initial rash: Some patients develop erythema
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of the soft palate and lymphadenopathy.
Later pink macules appear on the face,
spreading to trunk and limbs over 1 or 2 days.
Rubella
• Development: Rash clears over next 2/7,
and sometimes no rash develops.
• Complications: Congenital defects –
biggest risk in 1st month pregnancy.
• Diagnosis: Clinical signs. Serum taken for
antibodies and test repeated at 7-10 days.
• Prophylaxis: Active immunisation.
• Treatment: Supportive
Question 3
• Mrs M is a 49yr old lady who attends surgery because
she is experiencing hot flushes which are particularly
troublesome at night, she is waking at least once a night
soaked in sweat. She feels tired all the time and lacking
in energy. She had surgery for breast cancer 4 yrs ago,
followed by chemotherapy and is currently taking
tamoxifen
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How would you approach this as a GP?
What investigations would be useful?
What are the menopause and climacteric?
How would you treat this lady’s hot flushes?
HOT FLUSHES
Aetiology
• Menopause
• Hyperthyroid
• Malignancy
• Infection
• Drugs
History
• Nature of flushes
• Assoc symptoms
• Menstrual history
• General Health – Weight/Appetite
• Medication
Investigations
• FBC,ESR,CRP,TFT
• FSH/LH
Definitions
• Menos [month] Pausus [end]
• Climacteric = Transition from fertility to
infertiliy [45-55yrs]
Alternatives to HRT
• Lifestyle measures
– Aerobic exercise,regular and sustained
– Decrease alcohol
– Decrease caffeine
Alternatives to HRT
• Pharmacological
– Clonidine Transdermal better
– SSRI/SNRI – Venlafaxine 37.5mg bd
– Gabapentin 900mg/day [specialist only]
Complimentary therapy
• Phytoestrogens [Soy/Red clover]
– Breast cancer = CI
• Herbal
– Black Cohosh – some evidence
– Evening primrose
– Dong quai
– Gingko biloba
– Ginseng
– Liquorice
• Acupuncture – some evidence
• Reflexology -no different to foot massage
• Homeopathy –More data needed
• Vit E 800 iu/day
Summary
• Aerobic sustained regular exercise
• SNRI
• Clonidine transdermal patch
• Acupuncture
Question 4
• Jade, a 21 yr old student, comes for a repeat
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prescription of the COCP. On her way out of the door she
says “There is one other thing, would you mind checking
this mole for me?”
She shows you this: (picture 1 on sheet)
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How would you manage this situation?
What is your differential diagnosis?
Are you worried?
What advice would you give jade about moles in the future?
Would your answers be different if she showed you: (picture 2
on sheet)
Moles
Moles
• Posh name – acquired melanocytic naevi
• Very Common – average white-skinned young
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adult will have between 10-40
Different groups which represent different
stages of the same maturation process:
– Junctional naevi (most common in kids)
– Compound naevi (most common in early to mid adult
life)
– Intradermal naevi (most common in elderly)
Junctional Naevus
Compound Naevus
Intradermal Naevus
Dysplastic Naevi
• Difficult to differentiate from early
melanoma
• Often larger (>1cm diameter)
• Irregular border
• Trunk is most common site
• May be single or multiple
• Increased risk of developing into
melanoma, but majority are stable
Dysplastic Naevi
PMH of
melanoma
FH of multiple
naevi
FH of
melanoma
Increased risk of
melanoma
A NO
NO
NO
x4
B NO
YES
NO
x8
C YES
NO
NO
x100s
D YES
YES
YES
x100s
Melanoma
• 6400 cutaneous malignant melanomas
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diagnosed in UK in 2001
Responsible for 1500 deaths
Potentially curable if caught early
4 main types
Superficial spreading type most common
Prognosis depends on Breslow thickness at time
of treatment
Excision only form of treatment
Superficial
spreading malignant
melanomas
Commonest site in males = back
and females = leg
Breslow Thickness
Breslow Thickness
(mm)
Survival
5-year (%)
Intradermal
< 0.75
0.75 – 1.5
1.50 – 4.0
> 4.00
100
98
85
70
45
Examination Checklists
• ABCDE
• Mackie’s seven point checklist
ABCDE
• A = Asymmetry
• B = Border Irregularity
• C = Colour Variation
• D = Diameter >7mm
• E = Enlargement of a mole
Mackie’s 7 point checklist
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Major features
Change in size
Change in colour
Change in shape
• Minor features
• Diameter equal or
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more than 7mm
Sensory changes such
as itching
Oozing/crusting/bleed
ing
Inflammation
Risk Factors
• White skin
• Fair/Red Hair
• H/o bad sunburn
• Presence of Freckles
• Presence of Moles +/- Dysplastic naevi
• FH/PMH of dysplastic naevi/melanoma
Of Interest to Jade. . .
16-24 year olds, when compared with older
age groups:
• had the highest sun exposure and desire for
suntan
• took the most frequent sunny holidays
• were the least knowledgeable about skin cancer
• contained the lowest percentage of mole
checkers
• contained the lowest percentage who knew the
major clinical signs of early melanoma
Question 5
• Mr R is a 22yr old man who is very
concerned that his hair is thinning,
particularly as his father went bald aged
25yrs
– What are the possible causes of Mr R’s
problem?
– What is the long term prognosis of the most
common cause of his problem?
– What can be done about it?
Diffuse Hair Loss
Diffuse Hair Loss
Normal hair cycle-Each follicle produces
a number of hairs during a lifetime. There
are 3 phases:
1. Anagen (growth phase)-longest phase lasting 3-
5years, with up to 90% of follicles in it at any one
time.
2. Catagen phase ( intermediate phase between active
and cessation of growth)-Lasts approx. 2 weeks.
3. Telogen Phase (resting stage)-Hair remains in the
follicles but does not grow. Lasts about 3 months.
Causes of diffuse hair loss.
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Chronic illness (malignancies, leukaemia).
Deficiencies (iron, folic acid).
Medication (e.g cytotoxic drugs).
Hormonal Changes (pregnancy, diabetes,
hypo/hyperthyroidism)-can cause anagen phase
to end prematurely.
• Improper Hair Care (cosmetics, strong sunlight)hair breaks at weakest point on the shaft.
Male-Pattern (androgenic) Alopecia
• It shows a strong familial trait and tends to affect men
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from their late teens onwards, becoming progressively
more common with advancing age. Increased sensitivity
of hair follicles to androgenous steroids.
The 2 patterns are bitemporal recession and a central
recession to produce a characteristic horse-shoe shape
of remaining hair.
Growth phase of hair is shortened, while the hair growth
cycle is accelerated-thus hair follicles ‘used up’
prematurely.
In women, follicles extra sensitive to testosterone.
Patient History
• Is the problem increasing baldness? (indicates a
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natural process such as male pattern baldness).
Is the problem increasing hair loss? (indicates a
more acute and unnatural process).
Is there a family history?
Has the patient any chronic illnesses?
Is the patient on any medication?
Are there any symptoms indicating endocrine
disorders (hypo/hyperthyroidism, DM).
Examination
• Structure and form of hair with hair loss pattern.
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Is the hair falling out at root or broken off at
shaft.
Scalp inspected for flaking, infection, scarring
and presence/absence of follicles.
Look for signs of thyroid disease, DM, anaemia,
malignancies, malnutrition and presence of
hirsutism and acne in women.
Many systemic illnesses affect the nails as well as
the hair, so close inspection of the nails is
necessary.
Lab investigations, such as TFTs, only arranged if
patient’s history or examination suggests
underlying disorder.
Treatment of Male pattern hair loss
• No completely satisfactory therapy available.
• Minoxidil
• Finasteride
• Wigs, hair transplants (not available on the
NHS)
• Address psychosocial aspects of hair loss.
Minoxidil
• Minoxidil comes in 2% and 5% solution that is
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applied to the scalp twice daily. The 5% solution
is for men only.
It may well be 6 months before any
improvement is seen and it should be
discontinued if there is none after a year.
Any improvement will wane after stopping.
Minoxidil is successful in about 15%
The cost is around £25 a month for minoxidil
2%, £30 a month for 5%.
Finasteride
• Finasteride 1mg tablets are for men only.
The dose is 1mg daily, compared with 5mg
for benign prostatic hyperplasia.
• It may be up to 6 months before benefit is
seen and it reverts on cessation.
• Finasteride is successful in about 60%.
• The cost is around £55 a month for
Finasteride.
Internet search
• Search for: Treatment of hair loss
on yahoo revealed 2090000 sites.
This shows how very important it is to
make the patients realise all the treatment
options and the true prognosis. It may
help to prevent the patients seeking
miracle cures which are often very
expensive.
Question 6
• Mr N is a 30yr old man presenting with
pain, swelling and redness of the lateral
part of his big toe
– What would you specifically ask in the
history?
– What treatment options are available?
– What future preventative measures could you
advise?
Ingrowing (Toe)nails
Ingrowing nail
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The nail becomes 'ingrowing' when the side of the
nail cuts into the skin next to the nail.
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The distal lateral edges of the nail grow inwards
and so damage the skin.
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May be accompanied by secondary infections and
granulation tissue.
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Nails of big toe most commonly affected.
Common in teenagers and young adults.
Causes
• Usually there is no apparent reason why it
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occurs.
Tight fitting shoes may be a cause in some
cases.
More common in people who cut their toenails
very short and 'round'.
The correct way of cutting nails is 'straight
across'. This helps the nail to grow normally and
may prevent ingrowing toenails from developing.
Those with excessively sweating feet, making
the nail grooves macerated and soft, are more
prone.
Presentation
• Pain, swelling and redness of the lateral part of
toe.
• Infection and granulation tissue can result in pus
discharge.
• Pain on walking and wearing shoes.
• More commonly seen in patients of lower socioeconomic classes.
Patient History
• When the symptoms began.
• Whether the patient wears tight shoes.
• About the nail cutting method
Treatment
• If caught early: positioning cotton wool under
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the lateral nail edge, designed to force the nail
to grow over the skin. Then cutting straight
across rather than rounded off at the end.
Assistance of a chiropodist may be helpful.
If active inflammation is present: Lateral
nail excision with the application of phenol.
If the condition is left untreated: The worst
scenario would be that the infection gets worse,
then spreads resulting in cellulitis and
septicaemia.
Prevention
• Correct method of cutting toe nails. You should
cut the nails to the shape of the end of the toe,
and file any sharp edges.
• Comfortable fitting shoes
• Good feet hygiene-Keeping your feet clean with
regular bathing. Drying them thoroughly, and
applying foot powder.
Thank You for listening
• We hope you’ll now be better equipped to deal
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with some of the common problems you might
see in your GPR year which you rarely see in
hospital
Obviously there are many more!
For further reading a great book is
– “Minor Ailments in Primary Care – An Evidence Based
Approach” by Just A. H. Eekhof et al