Re: Healing by second intent

70 year old man with history of multiple non-melanoma skin cancers presented for a routine skin check. A skin examination revealed a  nodule on the left temporal region adjacent to the lateral canthus. The nodule was around 5 mm in size and non tender on palpation. (Figure 1) A shave skin biopsy was performed and confirmed the diagnosis of a nodular basal cell carcinoma (BCC).

Question 1
What are the treatment options ? What are the disadvantages and advantages of the treatment options?

Question 2
What are the wound closure options at this site ?

Question 3
What are the advantages and disadvantages of healing by second intent ?

Question 4
What factors can we use to predict the cosmetic outcome when we use healing by second intent?

Question 5
What dressing is appropriate and what instructions do you give the patient for post-op wound care?

Answer 1

The preferred treatment for most BCCs are complete excision because it has the highest 5 year cure rate. (BCC guideline). Other treatment options include topical treatment such as imiquimod or efudix, cryotherapy, curettage and cautery and phototherapy. Table 1 listed the advantages and disadvantages of each treatment options.

The BCC is located at the high risk zone (figure 2) on the face. The recurrence rate is higher in the high risk zone. Therefore, excision was chosen as the treatment option to provide the highest cure rate.

 The Telederm plastic surgeon was consulted for advice because the lesion was located at a cosmetically sensitive area.


Answer 2

The surgical options include:

1. Ellipse excision with primary closure. The lesion is closed to the lateral cants of the left eye. Ellipse excision with primary closure may distort the shape of the left eye and most people would consider this cosmetically unacceptable.

2. Excision with full thickness graft. This will provide reasonable cosmetic outcome. However, the procedure requires a doctor with more surgical experience, it takes longer time and more costly.

3. Excision with healing by second intent. This will provide reasonable cosmetic outcome in concaved area on the face. However, it takes longer to heal and the patient will need to be  motivated to clean and dress the wound daily.

After considering the local resources, costs and patient preferences, we treated the lesion with excision with healing by second intent.

Answer 3

The advantages of healing by second intent:

• It can provide reasonable cosmetic outcomes, and under certain circumstances SIH can offer cosmetic outcomes that are equal or superior to those achieved by primary closure, grafts, and flaps. (4-6)
• Low complication rate and the avoidance of complex procedures in patients who are at risk of long operation time. (7)

The disadvantages:

• prolonged healing time
• the need for daily wound care, and occasionally unpredictable cosmetic results. 
• The cosmetic outcome can only be assessed after complete wound healing

Answer 4

The factors which can affect cosmetic outcome:

• Location is probably the most important factor. Concave area tends to do better than convex area. 
• The size of the lesion. (Wound smaller than 2.5 cm tends to do better)
• Aged skin, from our experience, tends to do better. This was also suggested by few other authors 
• The willingness and motivation of the patient to look after the wound. Some patients may not have the dexterity to change dressing daily or does not have the motivation to do it. 

Answer 5

Currently there is no evidence showing using a particular type of dressing facilitates wound healing.
Cochrane review showed that using gauze is associated with more pain and discomfort. The dressing we used jelonet and prima pore on this patient. We told the patient to change the dressing after shower daily and clean the wound with soap and water. The patient was reviewed weekly and after 4 weeks. (Figure 4)

We found that healing by second intent is a technique that is being under utilised in general practice. It has been described for the last 50 years. Healing by second intent provides the best cosmetic outcome on concaved area on the face.


Key points:

• Healing by second intent often produce good cosmetic outcome especially in concaved area on the face. 
• Healing by second intent is under utilised in general practice 
• In selected cases, the cosmetic outcome can be better by skin graft/skin flap. 

References:

4. Zitelli JA. Secondary intention healing: an alternatvie to surgical repair. Clin dERMATOL 1984:2:92-106
5. Moscona R, Pnini A, Hirshowitz B. In favour of healing by secondary intention after excision of medial cantonal basal cell carcinoma. Last Reconstr Surg 1983:71:189-95.
6. Bernstein G. Healing by secondary intention. Dermatol Clin 1989:7:645-60.
7/ Goldwyn RM, Rueckert F. The value of healing by secondary intention for sizeazble defects of the face. Arch Sug 1977:112: 285-92.

Re: Cast study 9 Breaking bad news

Today, I saw a patient who may have a potential diagnosis of lung cancer. As a junior GP, I do not break bad news often. Breaking bad news is similar to other skills, it takes preparation and practice with a set of framework. There are many guidelines and acronyms out there, the acronym I used is called "SPIKE".

SPIKE stands for:

S: Setting up the interview
P: Assessing the patient's perception
I: Obtaining the patient's invitation
K: Giving knowledge and information to the patient
E: Addressing patient's emotions with empathetic response

In my own experience, preparation is the key. Clean up your room, tell the receptionist to hold the calls, check the investigations and look up anything that you are uncertain. Finally, prepare yourself emotionally. Breaking bad news require energy so I tend to take a small break from the last patient so that I can concentrate on the next consultation.

I usually break the bad news in two separate consultations. The first consultation I tell them about the diagnosis and organise a referral for them to see a specialist. Then, I will ask them to return in 1 week. Returning after 1 week serves two purposes. One is to answer any questions that they may have. Two is to make sure that they have an appointment with the specialist. You will be surprised by the number of times that the patients returned after a week and still have not made an appointment.

Finally, look after yourself. Breaking bad news is exhausting. Take breaks before and after breaking bad news. Debrief with other colleagues or your supervisors if you need to.

Re: Case study 8 Patch of numbness

60 yr old man presented with 1 year history of left lateral thigh numbness.

He saw a different GP 1 year ago and was diagnosed with sciatica. The numbness resolved after a few weeks. This episode started again around 2-3 weeks ago.

His main complaint was numbness on the lateral part of his thigh. It tended to get worse with prolonged walking and standing. There was no associated weakness on his lower limb. There was no back pain

On examination, you mapped out the area of sensory change on his left lateral thigh. The lower leg neurological examination was normal. The straight leg raise was negative.

Question 1
What is your diagnosis ?

Question 2
What can you do about it ?

Answer 1

This is lateral cutaneous nerve of thigh entrapment. The nerve gets trapped when it passes through the inguinal ligament. It is a pure sensory nerve so motor function is not affected.

It is more common in obese people and also associated with diabetes.

Answer 2

Nothing. There is really not much you can do. You tell them to lose weight and you warn them about wearing tight pants or belt which may compress on the nerve. Most of the time, the symptom resolves by itself. In some occasions, it persists and anti epileptic may help.

Case 6: Headache

21 year old female presented with 6 months history of intermittent headache associated with transient visual loss.

She presented to the clinic multiple times and saw a different general practitioner with headache for the last 6 months. She is generally well with no past medical problems.

She is currently on the pill and has been on it for the last few years.

She described the headache as throbbing and bilateral. There was no particular trigger. There was no associated vomiting or weakness. The headache usually does not wake her up at night.

She has had extensive investigations in the past , including CT and MRI Brain. MRI reported empty sella. Patient was prescribed a low dose of amitriptyline and had a good response.

She re-presented today because she found that the amitriptyline no longer worked. She has been experience headache almost daily. She also described transient visual field defect in a few occasions for 1-2 minutes. The vision returned to normal after that.

Question 1
What are your differential diagnoses?

Question 2
Is the MRI finding significant?

Question 3
What are the clinical presentations of IIH?

Question 4
What is the diagnostic criteria?

Question 5
What is the treatment?

Answer 1

This is a tricky case as she has had headache for some time and it is getting worse. Imaging results seem to be relatively normal. She now has new neurological symptom.

Using the murtagh model:
Red flags: malignancy, benigh intracranial hypertension, venous thrombosis, malignant hpertension
Common presentations: tension headache, migraine

Answer 2
Empy sella is a relatively common incidental finding, however, it has a well-established association with benign intracranial hypertension.

Given the headache, transient visual loss, patient's age (she is not overweight), gender, and the empty sella sign. She is likely to have benign intracranial hypertension.

Answer 3

Typical presentation of IIH is young, obese woman with headache with papilloedema on examination.

The most common symptoms of idiopathic intracranial hypertension were (1):

• Headache 84-92 percent
• Transcient visual obscuration (68-72%)
• Intracranial noises (52-69 %)
• Photopsia 48-54%
• Back pain 53 %
• Retrobulbar pain 44%
• Diplopia 18-38%
• Sustained visual loss 26-32%

On examination, the most common signs in IIH are:

• Papilledema
• Visual field loss 
• Sixth nerve palsy 

Answer 4 

The modified Dandy criteria:

• Symptoms and signs of increased intracranial pressure
• No other neurological abnormalities or impaired level of consciousness
• Elevated intracranial pressure with normal cerebrospinal fluid composition 
• A neuroimaging to exclude secondary cause
• No other cause of intracranial hypertension apparent

Answer 5 

• Carbonic anhydrase inhibitors: acetazolamide, topiramate
• Loop diuretics: Frusemide 
• Corticosteroids (not recommended on UpToDate)
• Indomethacin 
• intermittent lumbar puncture to relieve pressure

Case 5: Below Knee DVT

35 year old Female presented with ultrasound confirmed diagnosis of right below knee DVT.

She ruptured her ACL 2 weeks ago while playing netball. After the injury, she had a MRI and saw an orthopaedic surgeon. She wanted to have the knee reconstruction ASAP.

Few days ago, she started to feel throbbing pain in her right leg. Incidentally, she had an appointment with another GP at a different clinic for skin cancer check. During the consultation, she mentioned her lower limb swelling and an ultrasound was ordered which confirmed the below knee thrombus.

She was started on clexane and sent back to you.

Question 1
Other than clexane, what are other options?

Question 2
How long will you put her on anti-coagulation for?

Question 3
She is extremely concerned about her ruptured ACL. She wants to have it fixed ASAP. What do you tell her ?

Answer 1

I still remember prescribing clexane and warfarin for people with below knee DVT when I was an intern 5 years ago. With the new oral anticoagulants, there are many more options.

The available treatments (1):

• Subcutaneous low molecular weight heparin such as clexane in this case
• The oral factor Xa inhibitors rivaroxaban or apixaban
• Bridging clexane then warfarin 
• Dabigatran or edoxaban. (requiring 5 to 10 days course of heparin prior to commencement of treatment)

The standard practice now at most hospitals is rivaroxaban (starting with 15 mg for 3 weeks, then increase to 20 mg). Interestingly, therapeutic guideline in Australia is till recommending clexane and warfarin as first line treatment. 

Of course, there is no hard and fast rule in selecting anticoagulants. If in doubt, use clexane for the first few days so that you and the patient can have time to think about the options.

Answer 2

According to therapeutic guideline, a person with provoked DVT, the minimum length of treatment is 3 months. Usually we will re-assess with ultrasound to ensure the resolution of the thrombus prior to ceasing the anti-coagulation.

Answer 3

Many patients have a fixed perception that ruptured ACLs have to be fixed ASAP. They probably get the idea from the media. It often reports Australian footy player receives surgery right away after an ACL rupture, and 2 months later, they are playing on the field again! (They forgot to mention the players are getting paid few hundred thousand dollars per game.)

So far, there is no evidence that early ACL repairs improve outcome. The rehabilitation time after an ACL repair is long, usually 6 - 12 months. It takes motivation and effort to return to pre-injury level activities. I have seen many people with poor outcome from ACL re-constructions.

Many people can continue playing sports without ACLs. In short, there is absolutely no indication for an urgent ACL repair. (Of course, unless you are getting paid 100,000 per game)

I told her that no orthopaedic surgeon will risk her life (the chance of developing a PE from having the surgery) with an ACL reconstruction.

References:

Lip G, Hull R. Overview of the treatment of lower extremity deep vein thrombosis (DVT). In: UpToDate, Post TW(Ed), UpToDate, Waltham, MA. (Accessed on April 26,2017)

Friedberg R. Anterior cruciate ligament injury. In: UpToDate, Post TW(Ed), UpToDate, Waltham, MA. (Accessed on April 26, 2017)

Case 4: A suspicious haematoma

A 75 years old man presented with an enlarging left thigh lump after he fell down from a roof 6 months ago.

He saw a general practitioner few weeks after the injury. Two ultrasounds were performed and the diagnosis of a large intramuscular haematoma was made. He was advised to manage the swelling with warm compress and simple analgesic.

He re-presented today because he noticed that the lump was enlarging and it started to affect his walking, however, there was minimal pain. In addition, he reported weight loss of around 10 kg and feeling fatigue over the last few months.

Physical examination revealed a large firm immobile mass in the medial-posterior aspect of the left thigh. There was significant oedema on his left leg. There was no evidence of neuromuscular compromise of the extremity.

An urgent MRI was performed. (Figure 1)

 
Figure 1



1. What does the MRI show?

Case continues: Patient was referred to an orthopaedic surgeon with a special interest in sarcoma. A biopsy confirmed the diagnosis of a myxofibroidsarcoma.

2. Could this lesion be associated with his injury?

3. Can the use of imaging differentiate a soft tissue sarcoma from a benign haematoma ?

4. Is the delay in diagnosis of soft tissue tumour common?

5. How would you manage this patient?


1. The MRI showed a large intra muscular mass with heterogeneous enhancement measuring in the posteromedial thigh. It rose the possible diagnosis of a sarcoma.


2. An association between trauma and soft tissue sarcoma has been suggested for over 200 years.(5) Currently, there is no evidence to say that the relationship is causal. The usual history is of a traumatic incident occurring shortly prior to the awareness of the mass. Because of the relatively short time frame, we think that the trauma merely brings the patient's attention to the mass. (5)(7).

3. Even with the advances in modern technology, we cannot use imaging to safely differentiate a soft tissue sarcoma from a haematoma.  (2,5,7,8). Gomez et al reported three cases similar to our case study. All three patients had history of trauma prior to consulting their family physicians with lumps. They had MRIs and CTs, and were all initially reported as haematomas. This highlights the difficulty in differentiating malignant tumour from a benign haematoma using imaging alone. The imaging results need to be interpreted in the context of clinical history and examination. When there is enough clinical suspicion of a soft tissue sarcoma, patient should be referred to a specialist unit for biopsy. (8)

4. The delay in diagnosis of soft tissue sarcoma is a common problem. Many studies were conducted in an attempt to identify the sources of delay.  (2,3,4) The identified sources of delay include patient delay in presentation, mis-diagnosis, and waiting for investigations such as imaging and biopsy. The average time frame between the onset of symptoms to patient presentation is around 12 months, and the average time frame between patient presentation to referral to a specialist unit is 13.5 months.

Sarcoma is a rare tumour. There are around 800 new cases diagnosed in Australia per year. Most general surgeons or general practitioners will only encounter a soft tissue sarcoma once or twice in their careers. Therefore, it is important to be vigilant and treat any lump greater than 5 cm or deep to the fascia as sarcoma until proven otherwise.

5. Studies have shown that early referral to a specialist unit improves survival rate and treatment outcome.  Imaging and biopsies at non-specialist units are often inadequate and further delay the diagnosis. Poor biopsy techniques can potentially complicate future surgical excisions. Hence, an early referral for biopsy or management is recommended.

Case continue

Further imaging at the specialist unit showed pulmonary metastases. He underwent radiotherapy and definite surgical excision. The surgical excision was of palliative intent due to his pulmonary metastases. At the time of writing, he had returned home and recovered well from his surgery. He will require regular review and ongoing surveillance .

Key points:
- Any lumps greater than 5cm in diameter or deep in fascia should be treated as sarcoma until proven otherwise.
- Imaging results need to interpreted in the context of clinical history and examination. A biopsy is required to exclude soft tissue sarcoma.
- An early referral to a specialist unit provides the best survival rate and treatment outcome.


References:

Cancer Council Australia Sarcoma Guidelines Working Party. Clinical practice guidelines for the management of adult onset sarcoma.

Sydney: Cancer Council Australia. [Version URL: http://wiki.cancer.org.au/australiawiki/index.php?oldid=138276, cited 2017 Apr 11].

Available from: http://wiki.cancer.org.au/australia/Guidelines:Sarcoma

2. Ashwood N, Witt JD, Hallam PJ, Cobb JP. Analysis of the referral pattern to a supraregional bone and soft tissue tumour service. Ann R Coll Surg Engl 2003 Jul;85(4):272-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12855033.
4. Stiller CA, Passmore SJ, Kroll ME, Brownbill PA, Wallis JC, Craft AW. Patterns of care and survival for patients aged under 40 years with bone sarcoma in Britain, 1980-1994. Br J Cancer 2006 Jan 16;94(1):22-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16317433
5. Soft tissue sarcomas of the extremities. Blake A. Morrison. Available at
6. Uptodate pathogenetic factors in soft tissue and bone sarcomas
7. http://www.bcmj.org/article/soft-tissue-sarcomas-extremities-how-stay-out-trouble
8. High grade sarcomas mimicking traumatic intramuscular hematoms: a report of three cases. Pablo Gomez and jose Morcuende Available at:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1888428/pdf/1555-1377v024p106.pdf
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Case 3: Lung function test

68 yr old male came for regular check up.

He had a lung function test last year.

He used to be a heavy smoker, quit last year. His exercise tolerance is limited to around 50m.

What is your diagnosis ?

With a long smoking history and shortness of breath, this lung function indicates Chronic Obstructive Pulmonary Disease (COPD) . COPD is confirmed by the presence of persistent airflow limitation. FEV1/FVC < 0.7.

The problem we are having now is that we over diagnose people with COPD. Around 20-30% of patients who have a diagnosis of COPD has never had spirometry. Remember, COPD is a spirometry diagnosis.

What are your differential diagnoses?

COPD has many causes including asthma, smoking, occupation exposures, and anti tripsin 1 deficiency.

Is this severe disease ?

The current classification from lung foundation Australia classify this patient with severe disease.

How would you manage this patient?

This patient requires multi-disciplinary approach. 

1. GP management plan and TCA
2. Prevention of exacerbation: flu vaccination and pneumococcal vaccination
3. Stop smoking 
4. Optimise medications: use COPD stepwise treatment flowchart (link)
5. COPD action plan 
6. Refer to lung rehabilitation or physiotherapist or exercise physiologist to improve lung function 
7. Regular review and assess inhaler techniques 

According to the latest COPD guideline, severe COPD with more than 2 exacerbations per year should be managed by LABA + Inhale corticosteroid. 

Reference:

1. COPD-X concise guideline

Jaundice

68 yr old woman presented with jaundice. (Really jaundice, sort of like simpson kind of yellow)

It started 2 weeks ago. There is intermittent abdominal discomfort but mostly pain free. She noted that her stool is getting pale and hard to flush. The urine is getting darker and darker.

She is otherwise well. Not any medication. Denies ETOH abuse or any new medications.

This is the first time you see her.

Examination is essentially normal other than jaundice. She is haemodynamically stable, afebrile. Abdomen is soft, non tender, no ascites and no hepatomegaly.

What are your differentials at this stage ? How would you manage this patient ?

A structured approach will break down jaundice into pre, intra and post hepatic cause.

 In my mind, I thought this is going to be carcinoma of head of the pancreas. (Painless jaundice).

I was putting all my money on post hepatic jaundice.

The differentials listed in Murtagh

• Intrahepatic 
• Alcoholic hepatitis/cirrhosis 
• Drugs
• Primary biliary cirrhosis 
• Viral hepatitis 
• Extrahepatic 
• Cancer of bile ducts
• Cancer of pancreas
• Other cancer: primary or secondary spread
• Cholangitis
• Pimary sclerosing cholangitis 
• Common bile duct gallstones
• Pancreatitis
• Post-surgical biliary stricture or oedema 

I spoke to my supervisor because I thought about sending this patient to the hospital. 

The final decision was that we started the initial work up first. 

What investigations would you order? Any bedside test?

I contemplated whether to send this woman to hospital to work up in the community. Because she was well so I decided to order some blood tests and review her in a few days time. 

The blood tests I ordered at that time: FBE, LFT, Ca-125, ESR, CRP, UEC, Hepatitis B, Hepatitis A and hepatitis C serology, urinalysis

Hepatitis screen is normal.

The following is the LFT.   What does it tell you and What would you do now ?

This LFT picture is worrying. The bilirubin is 20 times over the normal limit. Combining this with the derrange ALP and GGT. This lady requires an urgent decompression. I ordered an urgent CT chest, abdo and pelvis. The following is the report. 

 It shows gross intrahepatic biliary dilatation likely secondary to cholangiocarcinoma. I contacted one of the local surgeons and he said this patient needs urgent decompression. 

She was transferred to a tertiary hospital for urgent decompression. An ERCP was performed and a stent was inserted. The surgery was complicated by post-op haematoma and re-obstruction. The obstruction subsequently resolve by itself and patient was discharged with out patient upper GI follow up for curable surgery. 

Lessons learned from this case:

- Get advice from other people when you are not sure

- Needs a structured approach to jaundice 

- Clinical appearance can be deceiving
- Urinalysis can be helpful in determining the cause of jaundice. The presence of bilirubin in urine  and the absence of urobilinogen indicates post hepatic obstruction.