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What the F*** do I do with that?. How to deal with some common problems presenting to GP Registrars. Introduction. Minor Ailments and other less glamorous medical problems are often neglected during medical education

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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
Introduction
  • Minor Ailments and other less glamorous 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!
slide3
Let’s play a game!

(There might be a prize for the winner)

slide4
How did you all do?

(we may have fibbed about the prize!! . . .sorry)

question 1
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?
aetiology
Aetiology:
  • Constipation
  • Increased anal sphincter tone
  • Obstruction of venous flow eg:pregnancy
grading
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
Clinical features:
  • Bleeding after defecation
  • Faecal soiling
  • Mucous discharge
  • Pruritis ani
  • Pain
  • Grades 2-4 may be felt as rectal mass.
differential diagnosis
Differential diagnosis:
  • Rectal prolapse
  • Anal polyp
  • Inflammatory Bowel disease
  • Rectal carcinoma
investigations
Investigations:
  • General examination
  • PR
  • Proctoscopy (1st or 2nd degree piles)
  • Sigmoidoscopy (if history of bleeding or symptoms of possible malignancy)
strangulation
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
Management:
  • Conservative:
    • Hygiene
    • Digital replacement if prolapse
    • Local anaesthetic creams
    • Treatment to reduce spasm of internal anal sphincter eg:GTN, botulinum toxin injection
management1
Management:
  • Surgical:
    • Sclerotherapy
    • Rubber band ligation
    • Photocoagulation
    • Cryotherapy
    • Anal dilatation
    • Haemorrhoidectomy
question 2
Question 2
  • Name these conditions:
    • (3 pictures of rashes)
  • List any associated signs/symptoms
  • How would you diagnose the condition?
  • What is the treatment?
measles
Measles
  • Age: Usually children, especially aged 5 years +
  • Incubation: 1-2 weeks. Prodromal symps include fever, malaise, upper respiratory symps, conjunctivitis and photophobia.
  • Infectious: 4 days before rash, until 5 days after.
  • Signs/symps:
    • Fever
    • Cold
    • Coughing
    • Light sensitivity
    • Koplik’s spots (often before rash)
    • Macular rash on face, trunk and limbs.
measles1
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
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
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 of the soft palate and lymphadenopathy.
  • Later pink macules appear on the face, spreading to trunk and limbs over 1 or 2 days.
rubella1
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
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
    • 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?
aetiology1
Aetiology
  • Menopause
  • Hyperthyroid
  • Malignancy
  • Infection
  • Drugs
history
History
  • Nature of flushes
  • Assoc symptoms
  • Menstrual history
  • General Health – Weight/Appetite
  • Medication
investigations1
Investigations
  • FBC,ESR,CRP,TFT
  • FSH/LH
definitions
Definitions
  • Menos [month] Pausus [end]
  • Climacteric = Transition from fertility to infertiliy [45-55yrs]
alternatives to hrt
Alternatives to HRT
  • Lifestyle measures
    • Aerobic exercise,regular and sustained
    • Decrease alcohol
    • Decrease caffeine
alternatives to hrt1
Alternatives to HRT
  • Pharmacological
    • Clonidine Transdermal better
    • SSRI/SNRI – Venlafaxine 37.5mg bd
    • Gabapentin 900mg/day [specialist only]
complimentary therapy
Complimentary therapy
  • Phytoestrogens [Soy/Red clover]
    • Breast cancer = CI
  • Herbal
    • Black Cohosh – some evidence
    • Evening primrose
    • Dong quai
    • Gingko biloba
    • Ginseng
    • Liquorice
slide34
Acupuncture – some evidence
  • Reflexology -no different to foot massage
  • Homeopathy –More data needed
  • Vit E 800 iu/day
summary
Summary
  • Aerobic sustained regular exercise
  • SNRI
  • Clonidine transdermal patch
  • Acupuncture
question 4
Question 4
  • Jade, a 21 yr old student, comes for a repeat 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)
    • 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)
moles1
Moles
  • Posh name – acquired melanocytic naevi
  • Very Common – average white-skinned young 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)
slide39

Junctional Naevus

Compound Naevus

Intradermal Naevus

dysplastic naevi
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
melanoma
Melanoma
  • 6400 cutaneous malignant melanomas 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
slide43

Superficial spreading malignant melanomas

Commonest site in males = back and females = leg

examination checklists
Examination Checklists
  • ABCDE
  • Mackie’s seven point checklist
abcde
ABCDE
  • A = Asymmetry
  • B = Border Irregularity
  • C = Colour Variation
  • D = Diameter >7mm
  • E = Enlargement of a mole
mackie s 7 point checklist
Major features

Change in size

Change in colour

Change in shape

Minor features

Diameter equal or more than 7mm

Sensory changes such as itching

Oozing/crusting/bleeding

Inflammation

Mackie’s 7 point checklist
risk factors
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
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
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 loss1

Diffuse Hair Loss

Normal hair cycle-Each follicle produces a number of hairs during a lifetime. There are 3 phases:

Anagen (growth phase)-longest phase lasting 3-5years, with up to 90% of follicles in it at any one time.

Catagen phase ( intermediate phase between active and cessation of growth)-Lasts approx. 2 weeks.

Telogen Phase (resting stage)-Hair remains in the follicles but does not grow. Lasts about 3 months.

causes of diffuse hair loss
Causes of diffuse hair loss.
  • 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
Male-Pattern (androgenic) Alopecia
  • It shows a strong familial trait and tends to affect men 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
Patient History
  • Is the problem increasing baldness? (indicates a 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
Examination
  • Structure and form of hair with hair loss pattern. 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
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
  • Minoxidil comes in 2% and 5% solution that is 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
  • 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
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
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 nail

Ingrowing nail

The nail becomes 'ingrowing' when the side of the nail cuts into the skin next to the nail.

The distal lateral edges of the nail grow inwards and so damage the skin.

May be accompanied by secondary infections and granulation tissue.

Nails of big toe most commonly affected.

Common in teenagers and young adults.

causes
Causes
  • Usually there is no apparent reason why it 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
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 socio-economic classes.
patient history1
Patient History
  • When the symptoms began.
  • Whether the patient wears tight shoes.
  • About the nail cutting method
treatment
Treatment
  • If caught early: positioning cotton wool under 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
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
Thank You for listening
  • We hope you’ll now be better equipped to deal 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