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.

Posted in About this blog | Leave a comment

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

Sudden sensorineural deafness, and vibration without a tuning fork

From this month’s BJGP: Sudden sensorineural hearing loss (SSNHL) is an otological emergency. The guidance is that sudden hearing loss that developed within the past 30 days needs to be referred for assessment within 24 hrs. If over 30 days ago, it should still be referred within 2 weeks. The most urgent part of this is steroid treatment, and, while this can be done via intratympanic injection, it can also be done orally. The article gives an example regime of 1 mg/kg (maximum 60 mg) od for 7 days. This should ideally be started within 48 hrs, but can still be started if within 2 weeks of onset of symptoms.

(In a rather awkward bit of timing, the authors stated that the attitude should be ‘Why should I NOT prescribe steroids?’ Excellent advice at almost any other time, but here we are, less than a month later, with a very good reason to be wary of prescribing steroids when we don’t have to. But, of course, they couldn’t really have anticipated this.)

And a useful practical piece of information: I’ve dithered over whether to get a tuning fork, and not, as yet, done so as they were quite expensive when (admittedly some time ago) I last checked on Medisave. Well, seems I don’t have to. The authors of this article experimented with doing Weber’s test with a mobile phone app called Real Razor, on silent vibration mode with a bottom corner of the phone placed on the centre of the patient’s forehead. Although the app vibrates at 163 Hz rather than 256, their results still showed >97% agreement with the results from tuning forks. (Note, however, that the tested group consisted of 74 adults post middle-ear surgery, and, as it’s described as a ‘bedside test’, this implies that it might have been done during the recovery period from surgery. I don’t know how this would affect the results as compared to a population of patients in general practice, so I’m wary. Still, I’ve downloaded the app; better than nothing.)

Posted in Credits 2020, ENT, Hearing loss | Leave a comment

A couple of tips on skin cancers

From last week’s BMJ, this article on non-melanotic skin cancers. Again, mostly visual, but here are a couple of things I want to remember:

Deciding whether a lesion is an AK or SCC? Look for:

  • Induration
  • Ulceration
  • Tenderness
  • Rapid enlargement

If it has none of those four features, it should be OK.

Morphoeic BCCs: Difficult to pick up, but look like gradually enlarging white scars. Tricky bastards.

Posted in Credits 2020, Dermatology | Leave a comment

5-Fluorouracil

This week’s BMJ has an article about Bowen’s disease and its differential diagnosis. As you might expect, revision from this one was mostly visual, reminding my occipital cortex of what the different images look like; it doesn’t translate well into notes. (Though remember the 5 Ps of lichen planus: pruritic polygonal purple papules and plaques. And remember the thin translucent rolled border around superficial BCCs, which can be used to distinguish them from Bowen’s disease.)

However, there was one very useful bit of advice about using 5-fluorouracil on lesions that are at high risk of ulceration (lower legs in elderly person); start with more infrequent use and increase gradually. So, start with twice-weekly application. After a fortnight, move to alternate nights. Then, daily. Finally, up to bd. If the area becomes bright red and sore, reduce the frequency.

Having never forgotten the time when my well-meaning insistence on treating a frail elderly lady’s lower leg lesion with 5-fluorouracil resulted in her developing a leg ulcer that had still not healed up when she died a few months later from one of her other co-morbidities… well, for one thing, I’m a lot more cautious about that sort of thing than I used to be, and I have definitely learned to abide by the Jurassic Park advice that just because you could do something doesn’t mean you should. But sometimes these lesions do need treating, so I definitely appreciated this snippet.

Posted in Credits 2020, Dermatology | Leave a comment

Bell’s palsy

Management

  • Eye care (lubricants + night-time taping)
  • If seen in 1st 72 hrs, 50 mg Prednisolone daily for 10 days
  • If Ramsay-Hunt syndrome (look for painful vesicles around ear, mouth, or scalp) also antivirals.

Note that rates of complete resolution without steroids are 72%, but with steroids (within 72 hrs) are 83%, so NNT about 10.

Indications for referral

In early phase: concerns about either 1. eye or 2. accuracy of diagnosis.

Eye: ophthalmology review if corneal irritation or ulceration or if persistent dry eye.

Accuracy of diagnosis: Refer to ENT or to neurology, whichever seems more appropriate, if any of the following features of concern are present:

  • Other neurological findings besides the facial palsy
  • Bilateral facial palsy
  • Onset over >3 days
  • Palpable pre-auricular mass
  • Systemic constitutional symptoms

Later: Refer if no improvement by 3 weeks or incomplete resolution after 3 months. However, the pathway is different: in both cases referral should be in order to exclude an alternative aetiology, but in the second case there’s another reason, which is to look at whether early surgical or non-surgical interventions might improve the short-term or long-term outcome. Therefore, if no improvement by 3/52 then the referral should be to a facial palsy service run by ENT, but if incomplete resolution by 3/12 it should be to facial palsy services run by plastic surgery.

 

Posted in Credits 2020, Neurology | Leave a comment

Localised hypopigmentation

Causes

  • Vitiligo
  • Pityriasis alba
  • Pityriasis versicolor
  • Depigmented seborrhoeic keratosis
  • Idiopathic guttate hypomelanosis
  • Sarcoidosis (rare but important)
  • Mycosis fungoides (rare but important)

 

Vitiligo

  • Most often, but not invariably, on peripheral sites
  • Repigmentation occurs in a perifollicular pattern
  • Local areas can be treated with topical immunosuppression either with steroid cream or calcineurin inhibitors (tacrolimus, etc.). More widespread vitiligo can be treated with narrow-band UV phototherapy.

Pityriasis alba

  • Mainly in children/adolescents, especially with darker skin
  • Round or oval non-scaly hypopigmented patches on face/neck/trunk, ill-defined border
  • Typically better in autumn/winter
  • Doesn’t need treatment; if treated, can use low-potency topical steroids, or topical calcineurin inhibitors
  • Generally resolves with puberty.

Pityriasis versicolor

  • Caused by Malassezia yeasts
  • Scaly macules are originally hyperpigmented and then hypopigmented (as Malassezia produces azelaic acid and this impairs melanocyte function)

Depigmented seborrhoeic keratoses

  • Have same stuck-on appearance as the more usual SKs, but hypopigmented
  • Don’t need treatment

Idiopathic guttate hypomelanosis

  • Very common in the over-40s, gets more so with age
  • Multiple discrete, circumscribed, porcelain-white macules
  • Tends to favour sun-exposed sites, though not exclusively so
  • Treatment not needed

Sarcoidosis or mycoides fungosis

  • Main thing to look for, in both cases, is diffuse/progessive depigmentation not responding to vitiligo treatment.
  • Hypopigmentation in the case of sarcoidosis occurs over granulomas in the dermis or SC tissue
  • MF is a cutaneous T-cell lymphoma. Patches of hypopigmentation are typically observed on the trunk and proximal extremities, especially the buttocks and pelvic girdle; they’re round and might or might not be scaly.
  • Refer for skin biopsy if either condition is expected.

 

(Another one from the archives: BMJ Sept 2018)

Posted in Credits 2020, Dermatology | Leave a comment

Hypertension: updated NICE guidelines

BMJ article from November summarised the updates to the previous guidelines, which I wrote about here. The actual guidance is here. Points to be aware of:

Measuring BP

  1. Initially, check both arms; if the difference between arms is ≥15 mmHg, then from then on use the one with the higher BP.
  2. If the value obtained is ≥140/90, repeat the measurement; if it’s ‘substantially different’, repeat a third time and use the lower of the second and third as the final answer. (I assume that asking the audience or phoning a friend are not options.)

When it’s urgent

If BP is ≥180/120 mmHg, check for:

  • New-onset confusion
  • Chest pain
  • Signs of CCF
  • Retinal haemorrhages or papilloedema
  • AKI

Any of these, with this level of blood pressure, require same-day specialist referral. If none of these signs or symptoms are present, recheck in 7 days.

When it’s not urgent

If BP is 140 to 179 systolic and 90 to 119 diastolic, then:

  • Offer ABPM to confirm. If this is unsuitable or not tolerated, offer home BPM instead.
  • Assess CV disease risk
  • Look for target organ damage; if any signs of it, consider starting treatment straight away rather than waiting for monitoring results.

Stage 1 hypertension = 135/85 to 149/94 mmHg (which sounds contradictory to the above guideline that further investigation is only considered from 140/90, so I suppose those are the results after monitoring, and an initial BP <140/90 is enough to consider hypertension unlikely and not monitor further)

Stage 2 hypertension: 150/95 or over.

Management

Lifestyle advice all round, as always.

Allowing for common sense in the case of frailty and multimorbidity, offer medication treatment to everyone with Stage 2 hypertension.

In Stage 1 hypertension in <80-year-olds, discuss medication treatment as an option if any of the following is the case:

  • Diabetes
  • CV risk ≥10%
  • Target organ damage: LVH, hypertensive retinopathy, cerebrovascular damage, raised ACR, CKD
  • Renal or cardiovascular disease (which I would have thought counts as target organ damage, but it’s listed separately)

Consider medication in >80s with BPs >150/90mmHg.

Medication choices

In Type 2 DM and in <55s if not Afro-Caribbean:

  1. ACEi/ARB*
  2. CCB or thiazide
  3. Whichever wasn’t used in Step 2
  4. Check ABPM or HBPM, discuss adherence, check person not getting postural hypotension. If WCH or poor adherence not the issue, consider spironolactone as long as K+ ≤4.5mmol/l; if K+ >4.5, consider alpha or beta-blocker.

In patients not in those categories (i.e. non-diabetic, plus 55 or more and/or Afro-Caribbean):

  1. CCB
  2. ACEi, ARB*, or thiazide
  3. and 4. As for the DM/<55 category.

Note that in people of Afro-Caribbean origin, ARB likely to be better than ACEi.

Targets

Clinic targets: <140/90 in <80s, <150/90 in 80s and up.

Targets for ABPM/HBPM: knock 5 mmHg off all above figures.

 

 

Posted in Cardiovascular, Credits 2020, Hypertension | Leave a comment

Vulval itch

Another one from the same old BMJ.

Questions to ask:

  • The usual; duration, affect on life (ask about sex life), exacerbating/relieving factors
  • Vaginal discharge (?thrush)
  • Anything used in that area for toiletries, treatment, fragrances, also condoms/spermicides/lubricants
  • STI risk
  • Other skin complaints (see below)
  • Current medications
  • Previous treatments for this
  • Menopause?
  • Urinary leakage; can cause irritation
  • Dysphagia (oesophageal lichen planus)

General skin conditions that can involve the genitals include eczema, seborrhoeic dermatitis, psoriasis and lichen planus (not to be confused with lichen sclerosus).  Lichen planus can cause scarring, red, erosive or atrophic areas on the vestibule, labia minora and clitoris, sometimes with architectural alterations from interlabial or clitoral adhesions.

Treatment

Treat thrush, if necessary. Genital hygiene, avoid irritants, use emollients as soap substitutes, use cotton undergarments. Bland emollients such as emulsifying ointment or paraffin-based emollients can help.

Seborrhoeic dermatitis, lichen planus, genital psoriasis, persistent eczema, and of course lichen sclerosus, can all be treated by potent/very potent topical corticosteroid ointment, half a fingertip unit, daily for 4 – 8 weeks. (If pubic hair is getting in the way, then it might work better to try medicatded solution, foams, or gels.) Maintenance twice-weekly treatment might be needed long term.

Posted in Credits 2020, Dermatology, Gynaecology | Leave a comment