Otitis Externa

Condition

• Otitis Externa

Definition

• Inflammation of the ear canal
• Can be caused by bacterial (e.g. streptococcus or pseudomonas) or fungal (aspegillos niger or candida species) 

History

• pain 
• discharge
• no recent upper respiratory tract infection
• predisposing factors: swimming, trauma, known narrow ear canal and past history of exostoses
• itchiness and skin scaling from ear canals this could suggest underlying skin diseases e.g. eczema

Examination

• otoscope 

DDx

• Malignant otitis externa 
• potentially life threatening infection of the external ear and skull base
• most commonly presents in elderly patients, diabetic patients and the immunocompromised 
• usually presents with unrelenting otalgia over several weeks 
• examination will show ear discharge, granulation tissue visible in the floor of the external ear canal. 
• There may be facial nerve or other lower cranial nerve involvement
• needs urgent referral 

Treatment

• Ear canal debridment
• Keep ear dry 
• Ear drops
• Oral analgesia
• Treatment of underlying skin disorder

References

1. Hawke library

Epistaxis

Condition

• Epistaxis 

Causes (Adapted from General Practice by John Murtagh)

• Local causes
• idiopathic
• intracranial tumours
• Rhinitis
• Trauma including nose picking
• URTI
• Common cold
• influenza
• Sinusitis
• Systemic causes
• Blood disorders
• Cardiovascular disorders
• arteriosclerosis
• hypertension
• Drugs: anticoagulants, aspirin, others
• Hereditary haemorrhagic telangiectasia
• Systemic febrile infections
• Toxic agents

History

• Establish volume of blood loss e.g. duration
• Try to identify cause e.g. medications, trauma, common cold, rhinitis, drug and alcohol and any other sources of bleeding
• Try to differentiate between anterior and posterior bleed

Examination

• Good light, suction and speculum with local decongestant and anaesthetic spray ready

Other diagnoses to consider 

• Hereditary haemorrhagic telangiectasia 2-4/100 000. Inherited disorder through an autosomally dominant gene. 
• A young male patient with recurrent significant nosebleeds should be investigated for juvenile angiofibroma

Treatment

• Minor bleed: kenacomb ointment 
• Severe bleed --> ED

References:

- General practice by John Murtagh

- RACGP Check program ENT 2011 Case 5

Haematuria: overview

I had an OSCE station on microscopic haematuria. I didn't really know how to approach, hence, this post on some key facts and checkpoints. Most of this is from John Murtagh's text book and some Australian guidelines.

Key points:

1. Macroscopic haematuria is always abnormal except in menstruating women.

2. Joggers and athletes engaged in very vigorous exercise can develop transient microscopic haematuria.

3. Microscopic (asymptomatic haematuria) can be classified as either:

•  glomerular (from kidney parenchyma): common causes are IgA nephropathy and thin membrane disease
• non-glomerular (urological): the common causes are bladder cancer, benign prostate hyperplasia and urinary calculi

4. 20 % of people with visible haematuria have cancer

5. It is important to exclude kidney damage, so patients should have blood pressure, urinary protein and plasma creatinine levels measured as a baseline and urine red cell cast

6. The possibility of sexually acquired urethritis should be kept in mind

7. Painful haematuria is suggestive of infection, calculi or kidney infarction.

8. Painless haematuria is commonly associated with infection, trauma, tumours or polycystic kidneys

9. A drug history is relevant, especially with anticoagulants and cyclophosphamide. A diet history should also be considered

10. There is no consensus guideline on what imaging test you should request, WA health has developed imaging pathway online and it is free for everyone to access: painless haematuria

11. Key questions (adopted from General Practice by John Murtagh)

• Have you had injury?
• Have you noticed whether the redness is at the start or end of your stream or throughout the stream?
• Bleeding elsewhere?
• Abdominal or loin pain?
• Burning or frequency of your urine?
• Problems with the flow of your urine?
• Have you having large amounts of beetroot, red lollies or berries in your diet?
• Could your problem have been sexually acquired?
• Recent strenuous exercise
• Any kidney problems in the past?

12. Presence of haematuria should not be contributed to anticoagulants or anti platelets, further evaluation is required. (3)

References:

1.  General Practice by John Murtagh
2. WA imaging pathway
3. General practice notebook 

Sun burn

Key points:

1. Sun is normally caused by UV-B. Severe sunburn may develop on relatively dull days because thin clouds filter UV-B poorly.

2. Burns can be quantified using a burns chart

3. Steroids, both topical and systemic, have proposed for sunburn, but have proved disappointing as they have little or no effect on the injury if used after the burn occurs and a role in exacerbating infection has been suggested.

4. Simple analgesics (ibuprofen and aspirin) are effective.

5. Bear in mind other differentials: drug induced general photosensitivity (e.g. thiazide, tetracyclines, sulphonamides, phenothiazines, griseofulvin, nasals, isotretinoin), acute systemic lupus erythematous and photocontact dermatitis.

6. Prevention:

• avoid direct exposure to summer sunlight during peak UV periods (10 am to 3 pm)
• Use natural shade
• Use sunscreen with a minimum of SPF 30 
• Wear hats and protective clothing

References:

- John Murtagh

- RACGP Check program: May 2016

Irritable bowel syndrome

Condition

• Irritable bowel syndrome

History

• chronic abdominal pain 
• altered bowel motions in the absence of an organic cause
• more common in women
• can present with wide array of symptoms including gastrointestinal and extra-intestinal complaints such as tiredness, sleeping difficulties and poor concentration

Examination

• apart from mild abdominal tenderness over the sigmoid colon, which is common, abdominal examination should be normal 

Diagnostic criteria

• ROME III Criteria for the diagnosis of IBS
• 
  

Investigations

• mainly to exclude other diseases
• FBE, Iron studies, UEC, CRP, TFTs, coeliac disease 
• the presence of the following symptoms usually suggest other disease 

• 
  

Management:

• Non pharmacological treatment
• Fibre restriction 
• dietary restrictions of lactose and/or fructose or FODMAPs 
• Probiotics: bifidobacteria and combination strains containing this bacteria, have shown some benefit in reducing IBS symptoms 
• Pharmacological treatment
• Antispasmodics - peppermint oil, hyoscine and mebeverine
• Antidiarrhoeals - loperamide 
• Antibiotics - rifaximin
• Antidepressants - TCAs and SSRIs
• Psychological therapies
• CBT and psychotherapy

Lower urinary tract symptoms

Key facts:
- Important to determine who much the symptoms are bothering the patient as treatment will be determined by that.

• Examination:
• abdominal examination: looking for a distended bladder
• DRE: looking for an abnormal prostate e.g. hard, nodular, asymmetry
• examination of the penis, checking for a tight phimosis or narrow meatus
• neurological examination of the perineum and lower limbs: looking for neurological condition that could cause a neurogenic bladder
• Investigations
• Urinalysis and urine MCS
• Fasting glucose to exclude diabetes
• UEC 
• PSA after discussing with patient 
• Urinary tract ultrasound 
• other investigations: bladder diary, urinary flow rate and urodynamic study 
• Differential diagnoses of LUTS
• Lower urinary tract obstruction 
• overactive bladder
• bladder irritation 
• polyuria
• neurological causes 
• Treatment option s
• conservative management for patients with mild symptoms 
• Medical therapy 
• alpha blockers: tamsulosin and prazosin. Tamsulosin is better as it has less side effects, doesn't cause erected dysfunction and acts quickly in few days
• 5 aplha reductase inhibitors: finesteride or dustasteride. slow onset (months) and may cause sexual dysfunction
• combination therapy: tamsulosin/dutasteride
• anticholinergics: best avoid 
• Surgical therapy
• TURP 
• Laser ablation, transurethral needle ablation (TUNA), thermotherapy or open operation

Reference:

- Check program 2012 October

Antenatal screening

Key points on first trimester antenatal screening:

• non fasting blood test at woman's 10 week of pregnancy and an obstetric ultrasound at the woman's 12 week
• Women need to understand that the test is only a risk assessment. It places their pregnancy in an increased or decreased risk category. 
• First trimester antenatal screening mainly looks for 3 conditions: down syndrome, edward syndrome and open neural tube defects. 
• The woman needs to understand that screening only tests for certain chromosomal abnormalities and does not guarantee them a normal child.
• A diagnostic test either an amniocentesis or chorionic villus sampling need to confirm the diagnosis 
• For first trimester screening, the blood is analysed for 2 biochemical markers (fbhCG and PAPP-A) for down syndrome. The 12 weeks U/S allows measurement of the nuchal translucency and osscification of the nasal bone.
•  Key information for the 10 week blood specimen
• patient's date of birth 
• weight 
• her ethnicity 
• diabetic or not
• the date of her last normal menstrual period
• her estimated date of delivery
• any previous pregnancies have been affected by down syndrome
• twin pregnancy?
• pregnancy achieved via IVF and if an egg donor was used, if yes, the age of the donor (if known) 
• First trimester screening has a detection rate of 95% and a screen positive rate of 2.5. This means that of 10 000 women tested, about 250 will have an increased risk for down syndrome, 19 have an affected pregnancy and one affected pregnancy will be missed. 
• It is not a free test. There will be an out of pocket expense of $ 100 for patients unless they are referred from a hospital 

References: 

- http://www.racgp.org.au/download/documents/AFP/2011/October/201110bonacquisto.pdf

- http://www.vcgs.org.au/pathology/downloads/mss/MSS-O-235_LMS_Alpha_DS_risk_calc.pdf

- http://www.vcgs.org.au/pathology/downloads/mss/BG-W-218_Charging_Policy.pdf