Melanoma

Condition

• Melanoma

Definition

History

• Risk factors for melanoma
• Older age
• Men > Women
• History of sun burn (Melanoma is more associated with episodic intense sunburns than more continuous sun exposure).
• past history of melanoma increases risks by 10 fold
• non melanoma skin cancer may increase the risk fourfold 
• Family history: first-degree relative doubles the risk of a person developing melanoma

Examination

• examine the whole skin surface under good lighting 
• if melanoma is suspected, the patient should be examined for enlarged lymph nodes in the appropriate draining area (e.g. axial or groins)

Investigation 

• excisional biopsy if possible: 
• stage 0 < 0.1mm
• stage 1 < 2 mm without ulceration or up to 1mm with ulceration 
• stage 2 > 2mm 
• Stage 3: spread to lymph nodes
• stage 4: distant spread

Management

• excisional biopsy 
• often requires referral

Key points:

• In Australia, it has been shown that up to 75% of patients detect their own recurrences.
• No evidence that earlier detection by routine scans or examinations improves the outcome.
• Instruct patient to gain awareness of lesions on their skin and report any persisting symptoms promptly.
• Sun protection when the ultraviolet (UV) index is 3 or above to prevent further skin damage and subsequent skin cancers

References:

Check program 2015 September Cancer

Differentials of scrotal pain or swelling

• Torsion of the testis
• Torsion of a testicular appendage
• Epididymo-orchitis
• Mumps orchitis
• Acute hydrocele
• Idiopathic scrotal oedema
• Haematoma/haematocele
• Testicular neoplasm
• Henoch-Schonlein purpura
• Strangulated inguinoscrotal hernia 
• Scrotal skin conditions 
• Varicocele
• Referred pain (e.g. spine, ureteric colic, abdominal aorta)

Approach to urinary disorders

Approach to Dysuria

Probability diagnosis 

• UTI esp. cystitis 
• Urethritis 
• Urethral syndrome 
• Vaginitis

Serious disorders not to be missed

• Neoplasia
• Bladder
• Prostate
• Urethra
• Severe infection 
• gonorrhoea
• NSU
• Genital herpes
• Reactive arthritis
• Calculi (e.g. bladder)

Pitfalls 

• Menopause syndrome
• Prostatitis
• Foreign bodies in LUT
• Acidic urine 
• Acute fever
• Interstitial cystitis
• Urethral caruncle/diverticuli
• Vaginal prolapse
• Obstruction 
• benign prostatic hyperplasia
• urethral stricture
• phimosis 
• meatal stenosis 

Grave's disease

Condition

• Grave's disease

Definition

• Grave's disease named after Rober J Graves, is an autoimmune disease characterized by hyperthyroidism due to circulating autoantibodies.

History

• Female: Male ratio 5-10: 1
• Peak onset 40-60 years
• Diffuse, usually symmetrical goitre
• Graves ophthalmopahty
• Associated with other autoimmune diseases 
• The most frequent symptoms of thyrotoxicosis are nervousness, heat intolerance, palpitations, fatigue and weight loss (weight gain occurs in 10% people)

Examination

• Agitation 
• Sinus tachycardia 
• Fine tremor 
• Hyper-reflexia
• Graves ophthalmopathy 
• Pretibial myxodema 1-2 %
• thyroid acropachy (digital clubbing < 1%)

Investigation

• Blood test: Thyroid function test, TSH receptor Ab positive, TPO Ab often positive
• Radionuclide thyroid scan: normal or elevated diffuse uptake pattern

Management

• Oral medications
• Carbimazole 
• Propylthiouracil 
• Agranulocytosis is a rare but life threatening complication of both antithyroid drugs with an incidence of 0.2-0.5%. Most commonly happen in the first 3 months, but can happen at any time
• Severe hepatocellular inury occurs with propylthiouracil in 0.1% of patients treated with the drug, and approximately 10% of these patients develop liver failure resulting in either a liver transplant or death
• 4 weeks following initiation of therapy, clinical review with repeat thyroid function tests should be undertaken to avoid hypothyroidism
• Beta blockers may be used for symptom control. A nondihydropyridine calcium channel blocker (e.g. verapamil) can be used to control heart rate when beta blockers are not tolerated

References:

• http://www.racgp.org.au/afp/2012/august/evaluating-and-managing-patients-with-thyrotoxicosis/

Testicular Torsion

Condition

• Testicular Torsion

History

• sudden onset, severe scrotal pain
• Swollen and painful scrotum
• Vomiting and abdominal pain 
• Can occur at any age but more common in neonates and children between the age of 12 - 14

Examination 

• Red, tender, swollen scrotum
• Loss of cremasteric reflex
• High lying testes secondary to twisting of the spermatic cord
• Horizontal lie of the contralateral testes 

Investigation

• Do not order ultrasound to confirm diagnosis in paediatric cases 

Management 

• Urgent referral to hospital for operation 
• Torsion must be corrected within 4-6 hours to prevent gangrene of the testis

References

- DCH:  common surgical problems South