Breast lump

Key points:

• History needs to include her mentrual and reproductive history, and any known risk factors for breast cancer 
• Approach is clinical examination, U/S and FNA. If all came back negative, then you can re-assure patient. If equivocal, refer to breast surgeon
• Risk factors for breast cancer
• Family history of breast and ovarian cancer
• increasing age
• late childbearing (after the age of 30 years)
• Nulliparity (no children)
• Early menarche (<12 age="" li="" of="" years="">
• Late menopause
• Use of hormone replacement therapy
• Ashkenazi jewish ethnicity
• Obesity (post-menopausal women)
• Lifestyle factors (e.g. high alcohol consumption, high-fat diet)
• Tamoxifen
• it is prescribed to treat early stage oestrogen receptor - positive breast cancer in premenopausal and postmenopausal women
• Tamoxifen is usually taken for up to five years 
• As tamoxifen is an anti oestrogen drug, the common side effects are hot flushes, night sweats and vaginal dryness. Less commonly, tamoxifen increases the risk of blood clots, stroke, cataracts, endometrial cancer, mood swings, depression and loss of libido
• Only about 5% of women have breast cancer due to a genetic predisposition or inherited gene mutation, such as BRCA1 and BRCA2.

Anal pruritus

Key points:

1. Anal pruritus is estimated to affect up to 5% of the population, with a male to female ratio of 4:1

2. In up to 25% of cases the anal pruritus is idiopathic

3. Even mild degrees of faecal soiling, which the patient may not be aware of, may be enough to cause an itch-scratch cycle

4. Dietary associations with pruritus anti include caffeine, alcohol, chocolate, tomatoes, spices and citrus fruit

5. Important to educate the patient about the recurring, benign nature of this irritating condition and to ensure adherence to the following simple, yet essential, measures to eliminate irritants and resolve symptoms

6. Management strategies

• Normalisation of bowel motions
• Cleaning after defaecation: rubbing or scrubbing the area should be actively discouraged
• Clothing
• Soaps and cleansers: do not use soaps
• Do not scratch: easy to say than done. May need help with topical steroid. Suggested regimen: start with methylprednisolone fatty ointment --> reducing to a moderate potency preparation such as betamethasone validate and then 1% hydrocortisone cream. Not curative. May need to return to high potency steroid from time to time 
• topical capsaicin in a 0.006% preparation (only available in a compound pharmacy. needs to be mixed with white paraffin )

References:

http://www.racgp.org.au/download/documents/AFP/2010/June/201006maclean.pdf

Male baldness

Key points:

1. 5AR converts testosteron to dihydrotestosterone, inhibition of 5AR improves hair growth and slows hair loss.

2. Finasteride (a type 2 5AR inhibitor) and dutasteride (type 1 and 2 isoenymes) are used to treat Androgenic alopecia

3. Main side effects of 5AIRs are effects on sexual function, breast enlargement and a possible increase in the risk of prostate cancer

4. Early onset of AGA is a strong predictor of early onset of severer coronary heart disease and metabolic syndrome

5. Hair thinning usually on ly becomes noticeable after losing 50 % or more of scalp hair

6. The typical history for a man with AGA is gradual onset of thinning after puberty. There is a gradual thinking of hair on the crown and vertex of the scalp, and frontal recession

7. When discussing treatment, emphasis

• no treatment will completely reverse the process
• the response to treatment is quite variable 
• some people will not respond to particular treatments

8. Treatment options 

• no treatment 
• hair piece
• medical treatment 
• topical minoxidil 2-5%
• oral finasterid 1 mg daily 
• oral dutasteride 0.5 mg daily (not approved for hair loss use yet in Australia)
• surgery 

Reference

http://gplearning.racgp.org.au/content/AFP/16Apr/Clarke.pdf

Paresthesia and peripheral neuropathy

1. The author suggested that clarifying clearly the patients' symptoms is the first step.

2. To my surprise, the  medications commonly caused include amiodarone, STATINS (didn't know that), antiretrovirals, tacrolimus or levodopa.

3. Nutritional/Dietary history is important as well such B6, B12 and Thiamine.

4. Carpal tunnel and ulnar neuropathy can be usually managed at gp practice without referral to neurologist

5. The median nerve supplies only four muscles in then hand, represented by the mneumoni LOAF:

• lateral two lumbricals
• opponens pollicis
• abductor pollicis brevis 
• flexor pollicis brevis 

6. The ulnar nerve supplies the following muscles 

• abductor digiti minimi
• medial humeral epicondyle 

7. Treatment is very general and as it is a short article so the author essential can't list out all the possible treatments.  But for carpal tunnel, use night splints. Ulnar nerve compression use medial elbow padding. 

Reference:

1. http://www.racgp.org.au/afp/2015/march/paraesthesia-and-peripheral-neuropathy/

Dermatology

Topics related to Dermatology:


Ingrown toenail

Pruritus ani

Male baldness

actinic keratosis

punch biopsy

shave biopsy

BCC

Cutaneous B cell lymphoma 

Benign lymphocytic infiltrates

Dermatofibrosarcoma protuberans

Approach to problem behaviour in children

Key points:

- Use the following table to take a focused history on things which can affect a child's behaviour

 

• Use the mnemonic ABC to clarify events surrounding the behaviour
• Antecedent - what were the events preceding the behaviour?
• Behaviour - what is the behaviour exactly?
• Consequence - what did the parents do to resolve the situation?
• Examination 
• physical examination 
• brief developmental assessment 
• General management (Box 1 lists out principles of behaviour management)
• Encourage positive behaviour 
• Ensure a consistent approach 
• Set clear boundaries and expectations
• Set clear consequences for actions and makes parents can follow through
• Tantrums and oppositional behaviour in toddlers (1-3 years old)
• Remain calm and do not raise your voice
• ask the child to stop and re-direct them to another activity
• if they do stop, praise them
• it they do not stop, go to quiet time (same room)
• if they keep coming out of quiet time, or are aggressive again, go to time out (in another room)
• keep conversation minimal at this time as the child might be too agitate to understand explanations 
• the child stays in time out until they are quiet and calm 
• Anger and aggression in preschoolers (3-5 years)
• Management involves prioritising behaviours in terms of severity level
• low priority behaviours can be dealt with by 
• ignoring the behaviour
• distracting the child
• logical consequences for the child's action 
• High priority behaviour, such as behaviour with associated safety concerns should be dealt with through time out as described 
• Hyperactivity or inattention in school aged children (5-11 years)
• At school, teachers will be doing the work 
• At school, removing/withdrawal of privileges 
• When to refer 
• all else fails 
• not coping at school 

References

- http://www.racgp.org.au/download/documents/AFP/2011/September/201109luangrath.pdf
- http://www.racgp.org.au/afp/2015/december/finetuning-behaviour-management-in-young-children/

Approach to dysmenorrhoea

History

• Pain
• It is important to determine if the pain is actually related to the menstrual cycle or has another underlying cause
• where is the site of the pain ?
• How would you describe the pain ? e.g. continuous or colicky
• How long has it been present 
• Is the pain associated with gastrointestinal function; do you have nausea, vomiting or diarrhoea/loose bowels
• does opening your bowels ease or make the pain worse?
• Do you have pain on urination?
• Menstrual history
• How old were you when you first had your period?
• How often do you have periods and how long does each one last?
• is the period heavy ? if so, on which day of the period?
• What size tampon or pad do you use? do you ever use both?
• how often do you change them?
• do you ever flood through tampon/pad or at night in bed?
• Have your periods caused you to miss school/work/social actives before this period?
• What associated symptoms, including pain and discomfort, do you have?
• What pain relief have taken and does it help?
• Medical and family history 
• do you have any family members with 
• diagnosed endometriosis?
• pelvic pain or pain during menstruation?
• problems getting pregnant or involuntary childlessness?
• Sexual history 
• when the first intercourse occurred
• male or female partners
• route of intercourse
• use of contraception 
• discussion of STIs
• vaccination history including hPV 
• pain or bleeding during sex 
• Examination 
• abdominal examination 
• vaginal examination is often not required esp. in adolescent girls who have never had sexual intercourse before
• Investigation 
• Blood test + STD screen 
• Vaginal or transabdominal ultrasound 
• DDx
• can be broadly classified in primary or secondary dysmenorrhoea 
• for further details about primary dysmenorrhoea, please go to the following link 
•  

• Management
• Analgesia: NSAID
• Suppression of ovarian function: COCP, GnRH agonist, IUD, etonorgestrel implant and oral dienogest
• surgical ablation 
• management of infertility 30-35% of women with endometriosis have infertility
• Prognosis
• Chronic condition 
• recurrence rate of 10-50% one year after surgery

Rosacea

Rosacea

• Epidemiology
• 2-3% of general population 
• Rosacea tends to occur in adults over the age of 30 years.
• In groups aged younger than 35 years or older than 50 years, men and women are affected equally, however, there is a predominance in women in the 36-50 year age group.
• Most common in fair skinned, anglo-celts
• Cause
• multifactorial and exact mechanisms are not well understood
• Genetics may play a role
• Neurovascular dysregulation and augmented immune detection and response
• infection:  the face mite demuxed folliculorum, an obligatory parasite of human pilosebaceous follicles, has been identified in elevated numbers in patients with rosacea
• Clinical features
• commonly affects the central convex areas of the face(cheers, nose, chin and forehead)
• Diagnosis can be made using the following features
• flushing 
• erythema
• inflammatory lesions 
• telangiectasia 
• Differential diagnoses of rosacea
• Acne vulgaris
• Seborrhoeic dermatitis
• Perioral dermatitis
• steroid induced acneiform eruption 
• lupus erythematousus-discoid, systemic or subacute cutaneous 
• Cutaneous sarcoidosis of the nose 
• Tinea faciei
• Essential telangiectasia
• Carcinoid syndrome 
• Drug reaction 
• polymorphous light eruption 
• atypical infections 
• contact dermatitis 
• Lupus vulgaris (cutaneous tuberculosis)
• Acne agminata
• Dermatomyositis
• Polycythaemia rubra vera
• Superior vena cava obstruction 
• Treatment: 
• Education 
• Avoid precipitants
• sun screen and hats
• 
  
• Oral agents
• tetracycline 500 mg bd 
• doxycycline 50 mg - 100 mg / day (intermittent use is preferable)
• erythromycin 500 mg bd 
• erythromycin ethyl succinate 800 mg bd
• Topical agents
• metronidazole 
• erythromycin 
• brimonidine 0.33% gel 
• azelaic acid (available as a 20% lotion or 15% gel) 
• other agents
• diclofenac
• isotretinoin for refractory cases
• clonidine, spironolactone, beta blockers,  naloxone and ondansetron
• ivermectin 
• Recurrence is routine 
• Complications 
• depression 
• ocular rosacea (symptoms include tearing, conjunctival hyperaemia, foreign body sensation, burning, stinging, dryness, itching, light sensitivity and blurred vision)
• lymphoedema
• salivary gland involvement --> reduce in salivary secretions and dry mouth 

References:

http://medicinetoday.com.au/system/files/pdf/medicine_today/article/MT2015-01-034-CHEE.pdf

What vitamins should I take for my macula ?

• General dietary and lifestyle advice to reduce the risk of a person developing macular degeneration and to minimise loss of vision if AMD is present is outlined below. 
• Lutein and zeaxanthin are particularly important nutrients for good macular health, and are derived through the diet, mainly from green vegetables. 
• Other nutrients important for macula health and general eye health are zinc, vitamin C, vitamin E and the omega 3 fatty acids
• Supplements based on the Age-related Eye disease study (AREDS) formula may considered by people who have been diagnosed with AMD
• 
• In 2001, the Age related eye disease study (AREDS), large (n4757), multi centre prospective trial over 6 years, used 80 mg of elemental zinc. Lower since was used in subsequent study to improve safety and efficacy but the conclusion remained that 80 mg zinc is safe and more effective in preventive AMD. 
• In patients who are not consuming enough lutein and zeaxanthin ( 3 quarters of a cup of cooked spinach), supplement helps to reduce 45% reduction in the progression of AMD. 
• AREDS used tablet formula only as copper containing formulae is considered unsafe in capsule form. The combination of linoleic acid-rich oil and copper may produce toxic products. 
• supplements that include copper and fish oil and/or LZ in the one tablet or capsule are not recommended because of potential for toxicity.
• The author of the article takes Macuvision, Lutein-vision advanced tablet, coenzyme Q10 and B12 supplement as his B12 supplement is low, so he takes B12 as well. 

Reference:

http://medicinetoday.com.au/system/files/pdf/medicine_today/article/MT2014-05-048-BEAUMONT.pdf

Early pregnancy bleeding

• 20 - 40 % of pregnant women will experience bleeding during the first trimester of pregnancy
• Major causes are miscarriage (10-20%) and ectopic pregnancy (1-2%)
• Establishing the site of the pregnancy is vital, as failure to correctly diagnose an ectopic can have potentially life threatening consequences
• Initial assessment is haemodynamic stability. Unstable patients need to be transferred to the emergency department
• History
• gestational age of the pregnancy
• the amount of blood loss
• any associated pain symptoms 
• the presence of syncope, chest pain and shortness of breath may point to anaemia from significant blood loss, and shoulder tip pain may be associated with intra-abdominal bleeding 
• Examination 
• Assess for haemodynamic instability 
• abdominal examination 
• speculum examination to assess the amount and origin of ongoing bleeding
• bimanual examination allows assessment of uterine size, dilatation of the cervical os, pelvic tenderness and cervical motion tenderness
• Investigation 
• Beta HCG (Serum HCG levels rise exponentially up to six to seven weeks of gestation, increasing by at least 66 % every 48 hours)
• Ultrasound assessment
• Testing for maternal blood group and antibody status will determine the need for RhD immunoglobulin administration 
• On TVS, a gestational sac will usually be visible from 4 weeks and 3 days after the last menstrual period
• Management 
• Rh D immunoglobulin is indicated for the prevention of Rh D sensitisation in Rh D negative women. This should be given within 72 hours of the sensitising event.

References:

http://www.racgp.org.au/afp/2016/may/early-pregnancy-bleeding/