About this blog: information for everyone else

Hi there! I’m a GP and this blog consists of the notes I take on journal articles, as part of my continuing professional development. It is intended purely for my own use in recording and remembering the things I learn so that I can refer back to them in the medical setting. While anyone is welcome to read it, please do not take it as any kind of substitute for seeing your own doctor for any medical-related queries or problems.

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About this blog: information for appraisers

I use this blog to record my learning points/reflections arising from my CPD. It’s a very handy way of doing it, as it lets me refer back to it easily and use the search function and category menu to find the notes I’ve made on a topic when needed.

My CPD typically consists of a mixture of online modules, articles which I come across in the course of routine journal reading and find useful, answers to DENs that I’ve looked up, and the usual regular courses in CPR and (on a three-yearly basis) child safeguarding. Of the online modules, some are compulsory; the rest I pick based on DENs I identify, either specific (“I wonder what the answer is to this question that arose with this patient?”) or general (“I really need to brush up on my knowledge of skin cancers”).

To read my overall notes for this year, just click on the picture at the top to get to the home page; you can then read the posts in reverse date order (newest first). If you want to check the list of posts on CPD that isn’t from learning modules (as CPD credits for those are recorded separately), those are under the category ‘Credits ____’ with the current year. You can find this by scrolling down the category menu on the right (under the archive menu). I will normally also put in a direct link to this category in my appraisal record.

Hope that’s clear, but happy to discuss any questions at appraisal.

Posted in About this blog, Credits 2016, Credits 2018 | 2 Comments

Nail disorders

Acute paronychia: antibiotics usually enough (occasionally needs drainage). Most often due to S. aureus.

Chronic paronychia: most important thing is to stop doing whatever’s exacerbating it, such as frequent washing up. Can also be treated with antifungals (either topical or oral) or topical steroids. Tends to be due to a mixture of micro-organisms, often Candida + gram-negatives. However, be aware that it can sometimes be due to malignancy.

Glomus tumour: shows up as a small bluish spot visible through the nail plate, and causes severe pulsing pain which can be spontaneous but can also be triggered by minor trauma or by temperature change. Use MRI scan to check size/limits.

Posted in Dermatology, Nails | Leave a comment

Melanoma

7-point weighted checklist (7PCL)

Major features:

  • Change in size
  • Irregular shape
  • Irregular colour

Minor features:

  • >7mm
  • Oozing
  • Inflammation
  • Change in sensation

2 points for a major feature, 1 for a minor feature; 3 or more -> 2ww referral (unless obviously benign such as a clear-cut seborrhoeic keratosis).

ABCDE checklist

  • Asymmetrical lesion
  • Irregular/ragged border
  • >2 colours
  • Diameter increasing
  • Evolution (change) in any of the above parameters over time

Other warning signs:

  • New lesion persisting for >8 weeks, especially if growing or pigmented
  • Pigmented line in a nail (especially if extending into the nailfold; Hutchinson’s sign) or lesion under a nail

A person’s moles will typically be similar to one another; beware of a mole that looks noticeably different from the other moles.

Remember that melanomas are not always pigmented. They can be any of a variety of colours, including skin-coloured, so be suspicious of any new or spreading lesion.

Vitamin D is apparently an issue; low or high levels can be a problem, it’s not known what the optimum level is to aim for, and people who’ve had melanoma will often run low due to sun avoidance. Recommendations now are for it to be measured when melanoma is diagnosed. Not clear where to go from there but the module recommended checking yearly.

(BMJ module: Clinical pointers: melanoma)

Posted in Dermatology, Don't miss, Skin lesions | Leave a comment

Undescended testis

Examination technique

  • Child supine and frog-legged, stripped from umbilicus to knees (can be on parent’s lap)
  • Warm hands
  • Kneel to right of child
  • Place left hand lateral to deep inguinal ring and move it, pressing down, along the inguinal canal, to ‘milk’ the testis down. (This is to overcome the cremasteric reflex.)
  • When left hand reaches the pubic tubercle, use right hand to feel for testis and pull it down to the scrotal base.
  • Repeat on other side.
  • Check for penile abnormalities (see below)

Criteria for urgent referral

  • Associated penile abnormality (might be disorder of sex development)
  • Bilateral impalpable testes (one of the possible causes is CAH, and the electrolyte disturbance can be life-threatening)
  • Ambiguous genitalia (ditto)
  • Painful testis (can indicate acute torsion)

Criterion for routine referral

If testes still undescended by three months.

 

Other notes:

  • If the testis can be successfully manipulated down to the scrotal base without tension, it’s retractile rather than undescended.
  • Don’t request imaging prior to referral; it’s unhelpful and sometimes misleading.
Posted in Credits 2019, Paediatrics, Testicular problems, Urology | Leave a comment

Iliotibial band syndrome

History

  • Occurs in people practicing various forms of athletics (most commonly running, but can be cycling, rowing, swimming, hiking, team games)
  • Most commonly lateral knee pain, but can sometimes affect the hip or thigh.
  • Can show up if training intensity or pattern has changed recently
  • Typically has recurrent, predictable point in activity at which it shows up.
  • Worse on cambered circuits or on downhill running.
  • Doesn’t cause locking, giving way, or swelling; those are more typical of intra-articular pathology (OA, meniscal pathology, cruciate injury).
  • Anatomical factors such as foot overpronation or leg length discrepancy can cause it; if this is the case, orthotics might help.

Examination

  • Classically, there is tenderness 2 or 3 cm above the lateral joint line.
  • Also, classically there is crepitus over the lateral femoral epicondyle at 20 – 30 degrees of knee flexion.
  • There might be subtle loss of power of abduction when patient lying laterally, due to gluteal weakness.
  • Provocation tests (Ober’s/Noble’s test) aim to reproduce pain on compression of the ITB over the lateral femoral epicondyle.
  • Remember that swelling, effusion, or joint line tenderness are not typical.

Management

Usually conservative: reduce or stop exercise sessions, particularly activities such as downhill running that exacerbate the pain, and do stretches. For details, check out information guide for patients, downloadable from the BMJ website. Replacing damaged, ill-fitting or old training shoes might also help; these can increase ITB friction.

It’s often possible to do high speed interval training without exacerbating the condition, as the knee flexion angles are different during fast running, so replacing longer, slower runs with interval sprint training might help.

Second-line treatment is physiotherapy or, sometimes, corticosteroid injection if eight weeks of stretches plus activity modification hasn’t helped. Rarely, if symptoms persist for longer than 6 – 12 months, surgery might be needed.

Prognosis

Good. 44% of sufferers can expect to be back to sport by eight weeks and 92% by six months.

(From BMJ article at above link.)

 

Posted in Credits 2019, Musculoskeletal, Orthopaedics, Sports medicine | Leave a comment

Raised intracranial pressure

(This was from an article in an old BMJ; I read it while doing some catching up.)

Symptoms

  • Headache: usually worsens over weeks, but sometimes over hours or days. Note that two-thirds of sufferers will not have the classic ‘worse on waking’ pattern. Can mimic chronic migraine or chronic TTH. Bottom line: be very suspicious of any new headaches or significant changes in previous headache pattern.
  • Visual loss: as well as diplopia, it’s possible to get blurred vision and transient loss of vision/greying-out of vision (often associated with postural change and lasting less than a minute). Typically the fields, rather than the acuity, are affected; acuity is typically normal.
  • Pulsatile tinnitus: a rhythmic whooshing sound heard in one or both ears, synchronous with the heartbeat (probably 2ry to intensified vascular pulsation from the high RCP).
  • Vomiting
  • Neck or back pain
  • Lethargy/weakness
  • Behavioural changes
  • Problems with moving or talking
  • Decreased consciousness
  • Seizures

Examination

  • Check BP: malignant hypertension is a rare cause of RICP that is treatable.
  • Full neuro examination.
  • Optic discs: look not just for blurred disc margin, but also for obscuration of the vessels over the disc (you should be able to see them extending onto the disc, and if you can’t then that’s a danger sign) and disc hyperaemia (reddening of the central area).

Note that if papilloedema is seen, the person needs same day neuroimaging.

Posted in Credits 2019, Don't miss, Headache, Neurology | Leave a comment

Dyspareunia

Note that this may present indirectly; repeated failure to attend cervical screening, persistent dissatisfaction with contraception, describing disgust with her genitals, dissociating during examination.

History

  • Open questions, kept to a minimum; encourage description.
  • ‘When do you get the pain?’
  • ‘Show me where you feel the pain?’
  • ‘When do you think this started? Was there anything else happening around this time?’
  • ‘How would you describe your relationship?’
  • ‘Does your partner have any difficulties with sex?’
  • ‘Are there any other symptoms?’ (burning, itching, abnormal discharge)
  • History of STI or of painful periods

Reflect back emotions: “You seem very tense when you talk about…”

Sudden onset of symptoms can suggest a psychosexual cause triggered by a particular event. Gradual increase is more likely to be physical or anatomical.

Examination

Check for abdominal mass (unusual, but needs to be excluded). Vulvovaginal examination only if the patient feels at ease with the clinician and only to the extent that the patient finds it comfortable. Look for:

  • Tears or fissures (check posterior fourchette; microfissuring might be caused by dermatitis)
  • Herpes lesions
  • Erythema
  • Candidiasis – white plaques
  • Lichen sclerosis or other dermatosis
  • Poor repair/scarring if past vaginal deliveries/episiotomies.
  • Discharge (take swabs if necessary)
  • Signs of vulvovaginal atrophy; hypopigmentation, non-elastic smooth tissue, shiny epithelium. (Remember that this can occur postnatally, especially if breastfeeding; it can also occur in spite of systemic HRT, and local oestrogen may be needed.)
  • Vaginal examination – tender nodules in rectovaginal septum/pouch of Douglas may indicate endometriosis, as may an immobile uterus. Also check for anatomical variants such as vaginal septum

A rapid response to the article added the possibility of urogenital prolapse as a cause, and suggested doing VE in standing position as well as lying down. (The letter also advised specialist women’s health physio as first-line treatment for prolapse.)

Don’t perform a speculum examination on a patient who has vulvodynia or vulvar dermatosis, or if there is a clear psychosexual cause with nothing to indicate a physical cause. If performing speculum examination, beware of offering a small speculum; it can inadvertently reinforce a patient’s concerns about small vaginal size. If a patient asks for a small speculum, ask why she feels she needs one. Do use plenty of lubricant.

In patients with vulval dermatitis or pruritus, consider a ferritin level; 5% of such patients may be iron deficient.

Management

Obviously, work on whatever the problem is (physical, emotional, or both); however, here are some general tips:

  • Perineal massage can be useful for treatment of vulvodynia and of vaginismus, as well as for generally helping women who have been avoiding touching or looking at their genitals get acquainted or reacquainted with them. Recommend doing this twice daily with coconut oil or other inert oil (I have no idea what makes an oil inert rather than otherwise, so I wish they’d given more examples); using the thumb is easier.
  • Avoid allergens. Use an inert oil such as olive oil (aha! Thanks!) for washing instead of soap or shower gel. Avoid biological or perfumed laundry products. Use unbleached, undyed cotton items for sanitary protection. I assume all of this point is meant to be aimed at problems such as dermatitis and maybe vulvodynia? It really isn’t very clear. This just doesn’t sound like good all-purpose general advice for a set of problems which, in the nature of things, is going to involve quite a few people having complex hangups about the problem.
  • Desensitising lubricants such as menthol or water-based lidocaine preparations might be helpful in reducing pain from penetrative sex.

(BMJ practice pointer article from 2018)

Posted in Credits 2019, Gynaecology, Sexual health | Leave a comment

Mirtazapine + SSRIs

I’ve occasionally seen Mirtazapine used as an add-on to SSRIs in resistant depression. An RCT recently showed that adding Mirtazapine to an SSRI or SNRI in resistant depression works no better than adding placebo. That said, the definition of ‘resistant’ here appeared to be ‘first drug not working after at least six weeks’; it still seems possible that there might be a small subgroup of people who just don’t respond to whatever single meds are tried for however long but do respond to a combo. At the very least, however, this shows we need to be extremely cautious about Mirtazapine/SSRI or SNRI combos, since the chances that they actually work better than single drugs are at best low.

Interesting point; typically, if someone isn’t responding to an SSRI, I’ll consider Mirtazapine as second-line monotherapy, not add-on therapy. But if it’s not working as an add-on, would it work on its own? Should we just avoid it?

Posted in Credits 2019, Medication, Psychiatry | Leave a comment