Puns and Dens
1)Temporal arteritis what should I do? Who to refer to, what about a biopsy, what about PMR reducing regimes?
2)Anal warts ?how to treat?
3)Investigation of secondary hypertension, 25 yr man with raised bp on a gym membership application. BP 170/92
What hx, exam, invst or referal to do ?what treatment
4) Dipstick haematuria, what to do and how quickly!
5)Bursitis, should I aspirate and inject or does this risk infection precipitation
6) How long can I give a patient dianette for?
7) Clopidogrel started after stenting post MI how long is this for?
8) Should I aim to suppress the TSH completely (endo seemed to like this) now biochemistry seem to like it to be in the normal range not below,
9) Anal pain, fissures etc??
10) GOUT in old pts who are constipated and asthmatic and stomach upsets with colchicine
11) Raised B12 in glandular fever pt. raised lymphocytes ?need to rpt
12) how long does a NAAT Chlamydia result stay positive for?
14) I have a patient is convinced that she may have lyme disease but she didn’t see a tick, looks like a mosquito bite.
15) Unilateral tremor in 62 yr man, noticed over last year, no drugs, no pmhx no rigidity no slowness nor cerebellar signs, not really ‘pill rolling’ improved on finger nose task, ?essential/intention tremor late onset ?tests/referral to neuro as late onset
16)pt has koebner phenomenom, differential
17)The dermatologists ordered an HIV test on my patient, I haven’t had the letter yet, she has no risk factors, I have a positive result in my inbox.
Should I code this on her notes as an active problem, should I put an alert on for clinical staff blds etc, who can see this, does it matter, she has told her 15 yr old daughter that she has cancer to avoid the stigma from friends, her daughter is registerd with us, should I somehow alert staff that she doesn’t know the diagnosis or presume that they will maintain confidentiality anyway??
18)Solar keratosis
Should I use 5fu or not?
19)can girls under 25 request a smear for ‘peace of mind’ maternal hx of CIN at age 21 yrs, non smoker no pcb/imb How much does Gardasil cost privately?
20) should all Hyperthyroidism be referred or just start carbimazole?
21) Girl age 8. PV bleeding isolated episode, 24hrs heavy bleed then stopped, no other secondary sexual characteristics, no fhx, maternal menarche 15yrs, older sister is 10, no menarche. No abuse indicators. ?INVST ?refer
22) Celadrin, is this better than glucosamine for oa
23) 3 female pts of 48-50yr with borderline low ferritin, still menstruate infrequently but say not really heavy. No hx pr blood or malaena, now I cant do FOBs do they all need colonoscopy and ogd?
24) 38 yr man with Pr blood bright red no maleana no change in bowel habit otehrwise, I cant see any piles but he says itchy, is inhouse sigmoidoscopy enough?
25) I have a district nurse who has self diagnosed with celiac disease she says that many of her non specific symptoms improve on a wheat free diet which she has been on for several yrs now. She wants me to prescribe gluten free products on the nhs I realise a TTG or biopsy is no use unless she well return to gluten containing diet is there a way to dx her without returning to gluten?
26) Do people monitor LFTs on terbinafine for toe nail infections?
27) Coxa profunda on xray report 35yr woman hip pain,
28) Is it possible to do an exercise test if a pt has LBBB?
29) Mirena, does this have to be fitted at day 1-7 of bleed, pt has erratic cycle.
30) 6 yr old with genital warts, mum has hand warts, also violent partner who has had no contact with for 6 months.
My Findings from Research and Responses, (not answers)
1)all need urgent crp and viscoscity, your practice may do ESR there and then, high risk symptoms= 1.5-2mg/kg oral pred and ppi. Refer to eye dept. medium/low risk, crp >24 and pv>1.9 ESR>50 initiate pred 1-2mg/kg/day
an elevated pv/esr with a normal crp virtually excludes GCA
starting steroid doesn’t affect likelihood of a positive biopsy if visual symptoms refer to opth, if no visual symptoms refer to rheum for advice on dx/man and vascular/general surgeons for the biopsy
tapering of steroids should be guided by PV and CRP rvw 2-3 wkly until less than 40mg daily every 4-6 wks until maintenance established.
Also for bisphosphonates,
2)Warticonbd for 3 days then 4 days without and then repeat,
3)
History
FHx, meds, exercise, fatigue, flushing sweating, palpitations?
Examination
Radio-radio delay radio femoral delay? Bruits, BP pulse,
Investigation of secondary hypertension,
U/Es – exclude cons, TFT
Fasting cortisol – exclude cushings,
24 hr BP monitoring,
ECG
ECHO
Renal USS ?R artery stenosis
Urinalysis for catecholamines
4)Repeat the sample
Ck for infection,
CK U/E ?raised creatinine/reduced eGFR?
?PSA recently ?LUTs
BP?age consider, renal/uro referral
5)Tell pt to avoid friction
From the history (no systemic illness,site and temp) should be able to exclude a joint infectrion
Infected bursitis is possible and some people aspirate only send if cloudy and inject depomedrone with a different syringe, not much role for oral abx unless you think it is cellulitic
6)Point out the heavy type box in the bnf and record in notes have done so and explained more risk of dvt than other pills, benefits to pt may outweigh risks,
7)1 year, if allergic to aspirin then forever.
8) This is conflicting, pt symptoms could be the main marker
9) Topical GTN paste, diltiazem2% 2cm of cream for 8 wk trial,
10) Laxatives +codeine, Ice or prednisolone.
11)B12 (stored in the liver) and ferritin are inflammatory markers and will be raised in and inflamm condition (b12 if it affects the liver.
Only need to rpt lymphocytosis if marked/pt doesn’t get better.
12) Stay positive for up to 5 wks and shouldn’t retest for 6
13) Paeds reg advised me not to use ibuprofen for pyrexia in child with chicken pox. As some cases of necrotising fasciitis assoc.
14) Tick bites, only treat if erythema migrans (several wk rash (doxy/amox) If multiple tick bites just treat. Persistent/anxious patients treat.
15) parkinsons can be unilateral in the 1st stages. Decreased arm swing is worth looking for. Essential tremor improves with alcohol and b blockers, maybe refer!
16) Differential of koebner, psoriasis, lichen planus, atopic dermatitis, molluscum, ?eczema.
17) I rang the derm consultant to ck she knew about the test, she did fortunately but presumed would be neg. it took 30 mins to break the news. Saw her in evening as phoning to suggest she brought a friend along the next day would have alarmed and been long wait.
Rather mixed responses when I asked, so I did put as active problem and major alert ‘high risk’ for bld samples, I haven’t done anything re the daughter, I am hoping that the GUM clinic will address the issue re testing in more depth and I asked her to tell them that its weighing on her mind
18)Partners in my practice don’t but are thinking about a protocol, they just use diclofenac (solaraze)
19)Not on the NHS, can be done if clinical indication but lab may not process it, unless you highlight and beg! Needs to be a real indication, they may say refer to gynae in these cases, can get private smear £80 bath clinic, gardasil about £300 for the course.
20)many partners seem to treat themselves unless child. I have been referring mine to endo as sometimes they seem to go for radioactive iodine and others for carbimazole
21)I spoke to paeds they wouldn’t normally invst a one off unless mum v anxious then they said! just check for bruising/nose bleeds etc + blds for clotting and hormones to ascertain pubertal stage. LHFSHoestradiol and FBC + clotting. Self take infections swabs, for mum. Also ck she hasn’t found anyones oral contraceptive pill. Refer if abnormal.
22) response overwhelming, no it is a load of fatty acids, stick to glucosamine + chondrotin
23) Maybe! Repeat ferritin and see if rises with ferrous sulphate, this reassures some people.
Another response was ‘chasing ferritins in women of childbearing age is a mugs game. Nice recommend bowel screening for 55 + when significant anaemia (10.5) or low ferritin. By repeating blds you are chasing shadows and reinforcing illness, smile and say your bloods look ok to me!!
24) small amounts of fresh red blood is ok for sigmoidoscopy rigid, any red flags/change in bowel habit straight for colonoscopy
25)Gastro response ‘ gluten intolerance’ is a common descriptive term, a v small no of pts have celiac disease. If no objective evidence of celiac disease I wouldn’t prescribe on nhs, pts choice is go without the script or eat gluten measure TTG and then see if falls when stops, then small bowel biopsy if it does to confirm.
26) if you use ‘sporanox’ on cyclical scripts then you don’t need to.
27) Coxa profunda on xray report 35yr woman hip pain, could represent impingement (femoroacetabular) classically occurs on one movement, often internal rotation
28) Pretty uninterpretable.
29) Mirena, least best time is just before period (higher expulsion risk (anytime as long as not pregnant)
30) I refered to child prot consultant, child not in immediate danger, put into urgent clinic, no other infections, possible sexual abuse they are still considering.