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

1. 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

2. 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!

3. Let’s play a game! (There might be a prize for the winner)

4. How did you all do? (we may have fibbed about the prize!! . . .sorry)

5. 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?

6. Haemorrhoids

7. Aetiology: • Constipation • Increased anal sphincter tone • Obstruction of venous flow eg:pregnancy

8. 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

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

10. Differential diagnosis: • Rectal prolapse • Anal polyp • Inflammatory Bowel disease • Rectal carcinoma

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

12. 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.

13. Management: • Conservative: • Hygiene • Digital replacement if prolapse • Local anaesthetic creams • Treatment to reduce spasm of internal anal sphincter eg:GTN, botulinum toxin injection

14. Management: • Surgical: • Sclerotherapy • Rubber band ligation • Photocoagulation • Cryotherapy • Anal dilatation • Haemorrhoidectomy

15. Question 2 • Name these conditions: • (3 pictures of rashes) • List any associated signs/symptoms • How would you diagnose the condition? • What is the treatment?

16. MMR

17. 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.

19. 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.

20. 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.

22. 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.

24. 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

25. 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?

26. HOT FLUSHES

27. Aetiology • Menopause • Hyperthyroid • Malignancy • Infection • Drugs

28. History • Nature of flushes • Assoc symptoms • Menstrual history • General Health – Weight/Appetite • Medication

29. Investigations • FBC,ESR,CRP,TFT • FSH/LH

30. Definitions • Menos [month] Pausus [end] • Climacteric = Transition from fertility to infertiliy [45-55yrs]

31. Alternatives to HRT • Lifestyle measures • Aerobic exercise,regular and sustained • Decrease alcohol • Decrease caffeine

32. Alternatives to HRT • Pharmacological • Clonidine Transdermal better • SSRI/SNRI – Venlafaxine 37.5mg bd • Gabapentin 900mg/day [specialist only]

33. Complimentary therapy • Phytoestrogens [Soy/Red clover] • Breast cancer = CI • Herbal • Black Cohosh – some evidence • Evening primrose • Dong quai • Gingko biloba • Ginseng • Liquorice

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

35. Summary • Aerobic sustained regular exercise • SNRI • Clonidine transdermal patch • Acupuncture

36. 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)

37. Moles

38. 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)

39. Junctional Naevus Compound Naevus Intradermal Naevus

40. 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

41. Dysplastic Naevi

42. 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

43. Superficial spreading malignant melanomas Commonest site in males = back and females = leg

44. Breslow Thickness

45. Examination Checklists • ABCDE • Mackie’s seven point checklist

46. ABCDE • A = Asymmetry • B = Border Irregularity • C = Colour Variation • D = Diameter >7mm • E = Enlargement of a mole

47. 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

48. 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

49. 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

50. 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?