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

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What the F do I do with that?

• How to deal with some common problems presenting
  to GP Registrars

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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!

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• Lets play a game!

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• How did you all do?

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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?

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Haemorrhoids
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Aetiology

• Constipation
• Increased anal sphincter tone
• Obstruction of venous flow egpregnancy

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Grading

• 1- Dont prolapse out of anal canal
• 2- prolapse on defecation but reduce
  spontaneously
• 3- Require manual reduction
• 4- Cant be reduced

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Clinical features

• Bleeding after defecation
• Faecal soiling
• Mucous discharge
• Pruritis ani
• Pain
• Grades 2-4 may be felt as rectal mass.

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Differential diagnosis

• Rectal prolapse
• Anal polyp
• Inflammatory Bowel disease
• Rectal carcinoma

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Investigations

• General examination
• PR
• Proctoscopy (1st or 2nd degree piles)
• Sigmoidoscopy (if history of bleeding or symptoms
  of possible malignancy)

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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.

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Management

• Conservative
• Hygiene
• Digital replacement if prolapse
• Local anaesthetic creams
• Treatment to reduce spasm of internal anal
  sphincter egGTN, botulinum toxin injection

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Management

• Surgical
• Sclerotherapy
• Rubber band ligation
• Photocoagulation
• Cryotherapy
• Anal dilatation
• Haemorrhoidectomy

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Question 2

• Name these conditions
• (3 pictures of rashes)
• List any associated signs/symptoms
• How would you diagnose the condition?
• What is the treatment?

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MMR
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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
• Kopliks spots (often before rash)
• Macular rash on face, trunk and limbs.

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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.

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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.

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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.

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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

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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 ladys hot flushes?

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HOT FLUSHES
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Aetiology

• Menopause
• Hyperthyroid
• Malignancy
• Infection
• Drugs

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History

• Nature of flushes
• Assoc symptoms
• Menstrual history
• General Health Weight/Appetite
• Medication

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Investigations

• FBC,ESR,CRP,TFT
• FSH/LH

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Definitions

• Menos month Pausus end
• Climacteric Transition from fertility to
  infertiliy 45-55yrs

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Alternatives to HRT

• Lifestyle measures
• Aerobic exercise,regular and sustained
• Decrease alcohol
• Decrease caffeine

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Alternatives to HRT

• Pharmacological
• Clonidine Transdermal better
• SSRI/SNRI Venlafaxine 37.5mg bd
• Gabapentin 900mg/day specialist only

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Complimentary therapy

• Phytoestrogens Soy/Red clover
• Breast cancer CI
• Herbal
• Black Cohosh some evidence
• Evening primrose
• Dong quai
• Gingko biloba
• Ginseng
• Liquorice

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• Acupuncture some evidence
• Reflexology -no different to foot massage
• Homeopathy More data needed
• Vit E 800 iu/day

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Summary

• Aerobic sustained regular exercise
• SNRI
• Clonidine transdermal patch
• Acupuncture

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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)

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Moles
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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)

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Junctional Naevus
Compound Naevus
Intradermal Naevus
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Dysplastic Naevi

• Difficult to differentiate from early melanoma
• Often larger (gt1cm diameter)
• Irregular border
• Trunk is most common site
• May be single or multiple
• Increased risk of developing into melanoma, but
  majority are stable

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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
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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

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Superficial spreading malignant melanomas
Commonest site in males back and females leg
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Breslow Thickness
Breslow Thickness (mm) Survival 5-year ()
Intradermal lt 0.75 0.75 1.5 1.50 4.0 gt 4.00 100 98 85 70 45
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Examination Checklists

• ABCDE
• Mackies seven point checklist

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ABCDE

• A Asymmetry
• B Border Irregularity
• C Colour Variation
• D Diameter gt7mm
• E Enlargement of a mole

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Mackies 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

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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

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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

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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 Rs problem?
• What is the long term prognosis of the most
  common cause of his problem?
• What can be done about it?

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Diffuse Hair Loss
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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.

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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.

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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.

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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).

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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 patients history or examination suggests
  underlying disorder.

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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.

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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.

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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.

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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.

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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?

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Ingrowing (Toe)nails
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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.

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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.

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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.

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Patient History

• When the symptoms began.
• Whether the patient wears tight shoes.
• About the nail cutting method

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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.

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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.

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Thank You for listening

• We hope youll 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