Related to the "Primary Care ManageRelated to the "Primary Care Management" and "Problem Solving Skills" ment" and "Problem Solving Skills" Domains of the new curriculumDomains of the new curriculum

What the F*** do I do with What the F*** do I do with that?that?

How to deal with some How to deal with some common problems presenting common problems presenting

to GP Registrarsto GP Registrars

IntroductionIntroduction

• Minor Ailments and other less glamorous Minor Ailments and other less glamorous medical problems are often neglected medical problems are often neglected during medical educationduring medical education

• They are rarely seen in hospital, so it is They are rarely seen in hospital, so it is difficult for VTS trainees to gain difficult for VTS trainees to gain experience in their managementexperience in their management

• Only around 10% of patients with minor Only around 10% of patients with minor ailments visit a GP with their problems – so ailments visit a GP with their problems – so generally when they do, they want generally when they do, they want something doing about them!something doing about them!

(There might be a prize for the winne(There might be a prize for the winner)r)

Let’s play a Let’s play a game!game!

(we may have fibbed about the prize!(we may have fibbed about the prize!! . . .sorry)! . . .sorry)

How did you all How did you all do?do?

Question 1Question 1

• Mrs Dawn Smith, 35, comes to your Mrs Dawn Smith, 35, comes to your surgery c/o pain when opening her surgery c/o pain when opening her bowels. She also tells you that bowels. She also tells you that occasionally when wiping she also occasionally when wiping she also sees bright red blood on the paper. sees bright red blood on the paper. How do you manage this?How do you manage this?

HaemorrhoidsHaemorrhoids

Aetiology:Aetiology:

• ConstipationConstipation

• Increased anal sphincter toneIncreased anal sphincter tone

• Obstruction of venous flow Obstruction of venous flow eg:pregnancyeg:pregnancy

Grading:Grading:

• 1- Don’t prolapse out of anal canal1- Don’t prolapse out of anal canal

• 2- prolapse on defecation but reduce 2- prolapse on defecation but reduce spontaneouslyspontaneously

• 3- Require manual reduction3- Require manual reduction

• 4- Can’t be reduced4- Can’t be reduced

Clinical features:Clinical features:

• Bleeding after defecationBleeding after defecation

• Faecal soilingFaecal soiling

• Mucous dischargeMucous discharge

• Pruritis aniPruritis ani

• PainPain

• Grades 2-4 may be felt as rectal Grades 2-4 may be felt as rectal mass.mass.

Differential diagnosis:Differential diagnosis:

• Rectal prolapseRectal prolapse

• Anal polypAnal polyp

• Inflammatory Bowel diseaseInflammatory Bowel disease

• Rectal carcinomaRectal carcinoma

Investigations:Investigations:

• General examinationGeneral examination

• PRPR

• Proctoscopy (1st or 2nd degree piles)Proctoscopy (1st or 2nd degree piles)

• Sigmoidoscopy (if history of bleeding Sigmoidoscopy (if history of bleeding or symptoms of possible malignancy)or symptoms of possible malignancy)

Strangulation:Strangulation:

• Severe pain and discomfort at site.Severe pain and discomfort at site.

• Haemorrhoid appears black/blue +/- Haemorrhoid appears black/blue +/- surrounding oedemasurrounding oedema

• Treat with bed rest, analgesia and Treat with bed rest, analgesia and stool softeners.stool softeners.

• If severe can have debridement.If severe can have debridement.

Management:Management:

• Conservative:Conservative: – HygieneHygiene– Digital replacement if prolapseDigital replacement if prolapse– Local anaesthetic creamsLocal anaesthetic creams– Treatment to reduce spasm of internal Treatment to reduce spasm of internal

anal sphincter eg:GTN, botulinum toxin anal sphincter eg:GTN, botulinum toxin injectioninjection

Management:Management:

• Surgical:Surgical: – SclerotherapySclerotherapy– Rubber band ligationRubber band ligation– PhotocoagulationPhotocoagulation– CryotherapyCryotherapy– Anal dilatationAnal dilatation– HaemorrhoidectomyHaemorrhoidectomy

Question 2Question 2

• Name these conditions:Name these conditions:– (3 pictures of rashes)(3 pictures of rashes)

• List any associated signs/symptomsList any associated signs/symptoms

• How would you diagnose the How would you diagnose the condition?condition?

• What is the treatment?What is the treatment?

MMRMMR

MeaslesMeasles

• Age:Age: Usually children, especially aged 5 years + Usually children, especially aged 5 years +• Incubation:Incubation: 1-2 weeks. Prodromal symps include 1-2 weeks. Prodromal symps include

fever, malaise, upper respiratory symps, fever, malaise, upper respiratory symps, conjunctivitis and photophobia.conjunctivitis and photophobia.

• Infectious:Infectious: 4 days before rash, until 5 days after. 4 days before rash, until 5 days after.• Signs/symps:Signs/symps:

– FeverFever– ColdCold– CoughingCoughing– Light sensitivityLight sensitivity– Koplik’s spots (often before rash)Koplik’s spots (often before rash)– Macular rash on face, trunk and limbs.Macular rash on face, trunk and limbs.

MeaslesMeasles

• Development and resolution:Development and resolution: Rash Rash becomes papular with coalescence. May becomes papular with coalescence. May have haemorrhagic lesions and bullae have haemorrhagic lesions and bullae which fade to leave brown patches.which fade to leave brown patches.

• Diagnosis: Diagnosis: Specific antibodies may be Specific antibodies may be detected. They are at their max 2-4 detected. They are at their max 2-4 weeks.weeks.

• Treatment:Treatment: Supportive only. Supportive only. • Complications:Complications: Encephalitis, OM and Encephalitis, OM and

bronchopneumonia.bronchopneumonia.

MumpsMumps

• Age:Age: Most commonly 2 years + Most commonly 2 years +• Incubation:Incubation: Up to 3 weeks Up to 3 weeks• Signs/symps:Signs/symps:

– Discomfort in jawDiscomfort in jaw– FeverFever– Facial swellingFacial swelling

• Treatment:Treatment: Supportive Supportive• Complications:Complications: Orchitis, oophoritis, Orchitis, oophoritis,

meningitis and pancreatitis.meningitis and pancreatitis.

RubellaRubella

• Age: Age: Children and young adults Children and young adults

• Incubation:Incubation: 14-21 days 14-21 days

• Prodromal symps:Prodromal symps: – None in young children.None in young children.– Fever, malaise and upper respiratory symps if older.Fever, malaise and upper respiratory symps if older.

• Initial rash:Initial rash: Some patients develop erythema Some patients develop erythema of the soft palate and lymphadenopathy.of the soft palate and lymphadenopathy.

• Later pink macules appear on the face, Later pink macules appear on the face, spreading to trunk and limbs over 1 or 2 days.spreading to trunk and limbs over 1 or 2 days.

RubellaRubella

• Development:Development: Rash clears over next 2/7, Rash clears over next 2/7, and sometimes no rash develops.and sometimes no rash develops.

• Complications:Complications: Congenital defects – Congenital defects – biggest risk in 1st month pregnancy.biggest risk in 1st month pregnancy.

• Diagnosis:Diagnosis: Clinical signs. Serum taken for Clinical signs. Serum taken for antibodies and test repeated at 7-10 days.antibodies and test repeated at 7-10 days.

• Prophylaxis:Prophylaxis: Active immunisation. Active immunisation.

• Treatment:Treatment: Supportive Supportive

Question 3Question 3

• Mrs M is a 49yr old lady who attends surgery Mrs M is a 49yr old lady who attends surgery because she is experiencing hot flushes which are because she is experiencing hot flushes which are particularly troublesome at night, she is waking at particularly troublesome at night, she is waking at least once a night soaked in sweat. She feels tired least once a night soaked in sweat. She feels tired all the time and lacking in energy. She had all the time and lacking in energy. She had surgery for breast cancer 4 yrs ago, followed by surgery for breast cancer 4 yrs ago, followed by chemotherapy and is currently taking tamoxifenchemotherapy and is currently taking tamoxifen– How would you approach this as a GP?How would you approach this as a GP?– What investigations would be useful?What investigations would be useful?– What are the menopause and climacteric?What are the menopause and climacteric?– How would you treat this lady’s hot flushes?How would you treat this lady’s hot flushes?

HOT FLUSHESHOT FLUSHES

AetiologyAetiology

• MenopauseMenopause

• HyperthyroidHyperthyroid

• MalignancyMalignancy

• InfectionInfection

• DrugsDrugs

HistoryHistory

• Nature of flushesNature of flushes

• Assoc symptomsAssoc symptoms

• Menstrual historyMenstrual history

• General Health – Weight/AppetiteGeneral Health – Weight/Appetite

• MedicationMedication

InvestigationsInvestigations

• FBC,ESR,CRP,TFTFBC,ESR,CRP,TFT

• FSH/LHFSH/LH

DefinitionsDefinitions

• Menos Menos [month] [month] PaususPausus [end] [end]

• Climacteric = Transition from fertility Climacteric = Transition from fertility to infertiliy [45-55yrs]to infertiliy [45-55yrs]

Alternatives to HRTAlternatives to HRT

• Lifestyle measuresLifestyle measures– Aerobic exercise,regular and sustainedAerobic exercise,regular and sustained– Decrease alcoholDecrease alcohol– Decrease caffeineDecrease caffeine

Alternatives to HRTAlternatives to HRT

• PharmacologicalPharmacological

– Clonidine Transdermal betterClonidine Transdermal better– SSRI/SNRI – Venlafaxine 37.5mg bdSSRI/SNRI – Venlafaxine 37.5mg bd– Gabapentin 900mg/day [specialist only]Gabapentin 900mg/day [specialist only]

Complimentary therapyComplimentary therapy

• Phytoestrogens [Soy/Red clover]Phytoestrogens [Soy/Red clover]– Breast cancer = CIBreast cancer = CI

• HerbalHerbal– Black Cohosh – some evidenceBlack Cohosh – some evidence– Evening primroseEvening primrose– Dong quaiDong quai– Gingko bilobaGingko biloba– GinsengGinseng– Liquorice Liquorice

• Acupuncture – some evidenceAcupuncture – some evidence

• Reflexology -no different to foot Reflexology -no different to foot massagemassage

• HomeopathyHomeopathy –More data needed –More data needed

• Vit E 800 iu/dayVit E 800 iu/day

SummarySummary

• Aerobic sustained regular exerciseAerobic sustained regular exercise

• SNRISNRI

• Clonidine transdermal patchClonidine transdermal patch

• AcupunctureAcupuncture

Question 4Question 4

• Jade, a 21 yr old student, comes for a repeat Jade, a 21 yr old student, comes for a repeat prescription of the COCP. On her way out of the prescription of the COCP. On her way out of the door she says “There is one other thing, would door she says “There is one other thing, would you mind checking this mole for me?”you mind checking this mole for me?”

• She shows you this: (picture 1 on sheet)She shows you this: (picture 1 on sheet)– How would you manage this situation?How would you manage this situation?– What is your differential diagnosis?What is your differential diagnosis?– Are you worried?Are you worried?– What advice would you give jade about moles in the What advice would you give jade about moles in the

future?future?– Would your answers be different if she showed you: Would your answers be different if she showed you:

(picture 2 on sheet)(picture 2 on sheet)

MolesMoles

MolesMoles

• Posh name – acquired melanocytic naeviPosh name – acquired melanocytic naevi

• Very Common – average white-skinned Very Common – average white-skinned young adult will have between 10-40young adult will have between 10-40

• Different groups which represent different Different groups which represent different stages of the same maturation process:stages of the same maturation process:– Junctional naevi (most common in kids)Junctional naevi (most common in kids)– Compound naevi (most common in early to mid Compound naevi (most common in early to mid

adult life)adult life)– Intradermal naevi (most common in elderly)Intradermal naevi (most common in elderly)

Junctional Naevus

Compound Naevus Intradermal Naevus

Dysplastic NaeviDysplastic Naevi

• Difficult to differentiate from early Difficult to differentiate from early melanomamelanoma

• Often larger (>1cm diameter)Often larger (>1cm diameter)• Irregular borderIrregular border• Trunk is most common siteTrunk is most common site• May be single or multipleMay be single or multiple• Increased risk of developing into Increased risk of developing into

melanoma, but majority are stablemelanoma, but majority are stable

Dysplastic Naevi

PMH of PMH of melanomamelanoma

FH of FH of multiple multiple naevinaevi

FH of FH of melanomamelanoma

Increased risk Increased risk of melanomaof melanoma

AA NONO NONO NONO x4x4

BB NONO YESYES NONO x8x8

CC YESYES NONO NONO x100sx100s

DD YESYES YESYES YESYES x100sx100s

MelanomaMelanoma

• 6400 cutaneous malignant melanomas 6400 cutaneous malignant melanomas diagnosed in UK in 2001diagnosed in UK in 2001

• Responsible for 1500 deathsResponsible for 1500 deaths• Potentially curable if caught earlyPotentially curable if caught early• 4 main types4 main types• Superficial spreading type most commonSuperficial spreading type most common• Prognosis depends on Breslow thickness at Prognosis depends on Breslow thickness at

time of treatment time of treatment • Excision only form of treatmentExcision only form of treatment

Superficial spreading malignant melanomas

Commonest site in males = back and females = leg

Breslow ThicknessBreslow Thickness

Breslow Breslow ThicknessThickness

(mm)(mm)

SurvivalSurvival

5-year (%)5-year (%)

IntradermalIntradermal

< 0.75< 0.75

0.75 – 1.50.75 – 1.5

1.50 – 4.01.50 – 4.0

> 4.00> 4.00

100100

9898

8585

7070

4545

Examination ChecklistsExamination Checklists

• ABCDEABCDE

• Mackie’s seven point checklistMackie’s seven point checklist

ABCDEABCDE

• A = AsymmetryA = Asymmetry

• B = Border IrregularityB = Border Irregularity

• C = Colour VariationC = Colour Variation

• D = Diameter >7mmD = Diameter >7mm

• E = Enlargement of a moleE = Enlargement of a mole

Mackie’s 7 point checklistMackie’s 7 point checklist

• Major featuresMajor features

• Change in sizeChange in size

• Change in colourChange in colour

• Change in shapeChange in shape

• Minor featuresMinor features

• Diameter equal or Diameter equal or more than 7mmmore than 7mm

• Sensory changes Sensory changes such as itchingsuch as itching

• Oozing/crusting/Oozing/crusting/bleedingbleeding

• InflammationInflammation

Risk FactorsRisk Factors

• White skinWhite skin

• Fair/Red HairFair/Red Hair

• H/o bad sunburnH/o bad sunburn

• Presence of FrecklesPresence of Freckles

• Presence of Moles +/- Dysplastic naeviPresence of Moles +/- Dysplastic naevi

• FH/PMH of dysplastic naevi/melanomaFH/PMH of dysplastic naevi/melanoma

Of Interest to Jade. . .Of Interest to Jade. . .

16-24 year olds, when compared with 16-24 year olds, when compared with older age groups:older age groups:

• had the highest sun exposure and desire for had the highest sun exposure and desire for suntansuntan

• took the most frequent sunny holidaystook the most frequent sunny holidays• were the least knowledgeable about skin were the least knowledgeable about skin

cancercancer• contained the lowest percentage of mole contained the lowest percentage of mole

checkerscheckers• contained the lowest percentage who knew contained the lowest percentage who knew

the major clinical signs of early melanomathe major clinical signs of early melanoma

Question 5Question 5

• Mr R is a 22yr old man who is very Mr R is a 22yr old man who is very concerned that his hair is thinning, concerned that his hair is thinning, particularly as his father went bald particularly as his father went bald aged 25yrsaged 25yrs– What are the possible causes of Mr R’s What are the possible causes of Mr R’s

problem?problem?– What is the long term prognosis of the What is the long term prognosis of the

most common cause of his problem?most common cause of his problem?– What can be done about it?What can be done about it?

Diffuse Hair LossDiffuse Hair Loss

Diffuse Hair LossDiffuse Hair LossNormal hair cycleNormal hair cycle-Each follicle -Each follicle produces a number of hairs during a produces a number of hairs during a lifetime. There are 3 phases:lifetime. There are 3 phases:

1.1. Anagen (growth phase)-Anagen (growth phase)-longest phase lasting longest phase lasting 3-5years, with up to 90% of follicles in it at 3-5years, with up to 90% of follicles in it at any one time.any one time.

2.2. Catagen phase ( intermediate phase between Catagen phase ( intermediate phase between active and cessation of growth)-active and cessation of growth)-Lasts approx. Lasts approx. 2 weeks.2 weeks.

3.3. Telogen Phase (resting stage)-Telogen Phase (resting stage)-Hair remains in Hair remains in the follicles but does not grow. Lasts about 3 the follicles but does not grow. Lasts about 3 months.months.

Causes of diffuse hair Causes of diffuse hair loss.loss.• Chronic illness (malignancies, leukaemia).Chronic illness (malignancies, leukaemia).

• Deficiencies (iron, folic acid).Deficiencies (iron, folic acid).

• Medication (e.g cytotoxic drugs).Medication (e.g cytotoxic drugs).

• Hormonal Changes (pregnancy, diabetes, Hormonal Changes (pregnancy, diabetes, hypo/hyperthyroidism)-hypo/hyperthyroidism)-can cause anagen can cause anagen phase to end prematurely.phase to end prematurely.

• Improper Hair Care (cosmetics, strong Improper Hair Care (cosmetics, strong sunlight)-sunlight)-hair breaks at weakest point on hair breaks at weakest point on the shaft.the shaft.

Male-Pattern (androgenic) Male-Pattern (androgenic) AlopeciaAlopecia• It shows a strong familial trait and tends to affect It shows a strong familial trait and tends to affect

men from their late teens onwards, becoming men from their late teens onwards, becoming progressively more common with advancing age. progressively more common with advancing age. Increased sensitivity of hair follicles to androgenous Increased sensitivity of hair follicles to androgenous steroids. steroids.

• The 2 patterns are bitemporal recession and a The 2 patterns are bitemporal recession and a central recession to produce a characteristic horse-central recession to produce a characteristic horse-shoe shape of remaining hair.shoe shape of remaining hair.

• Growth phase of hair is shortened, while the hair Growth phase of hair is shortened, while the hair growth cycle is accelerated-thus hair follicles ‘used growth cycle is accelerated-thus hair follicles ‘used up’ prematurely.up’ prematurely.

• In women, follicles extra sensitive to testosterone.In women, follicles extra sensitive to testosterone.

Patient HistoryPatient History

• Is the problem increasing baldness? Is the problem increasing baldness? (indicates a natural process such as male (indicates a natural process such as male pattern baldness). pattern baldness).

• Is the problem increasing hair loss? (indicates Is the problem increasing hair loss? (indicates a more acute and unnatural process).a more acute and unnatural process).

• Is there a family history?Is there a family history?• Has the patient any chronic illnesses?Has the patient any chronic illnesses?• Is the patient on any medication?Is the patient on any medication?• Are there any symptoms indicating endocrine Are there any symptoms indicating endocrine

disorders (hypo/hyperthyroidism, DM).disorders (hypo/hyperthyroidism, DM).

ExaminationExamination• Structure and form of hair with hair loss Structure and form of hair with hair loss

pattern. Is the hair falling out at root or pattern. Is the hair falling out at root or broken off at shaft.broken off at shaft.

• Scalp inspected for flaking, infection, Scalp inspected for flaking, infection, scarring and presence/absence of follicles.scarring and presence/absence of follicles.

• Look for signs of thyroid disease, DM, Look for signs of thyroid disease, DM, anaemia, malignancies, malnutrition and anaemia, malignancies, malnutrition and presence of hirsutism and acne in women.presence of hirsutism and acne in women.

• Many systemic illnesses affect the nails as Many systemic illnesses affect the nails as well as the hair, so close inspection of the well as the hair, so close inspection of the nails is necessary.nails is necessary.

• Lab investigations, such as TFTs, only Lab investigations, such as TFTs, only arranged if patient’s history or examination arranged if patient’s history or examination suggests underlying disorder.suggests underlying disorder.

Treatment of Male pattern hair Treatment of Male pattern hair lossloss

• No completely satisfactory therapy No completely satisfactory therapy available.available.

• MinoxidilMinoxidil

• Finasteride Finasteride

• Wigs, hair transplants (not available on Wigs, hair transplants (not available on the NHS)the NHS)

• Address psychosocial aspects of hair Address psychosocial aspects of hair loss.loss.

MinoxidilMinoxidil

• Minoxidil comes in 2% and 5% solution Minoxidil comes in 2% and 5% solution that is applied to the scalp twice daily. The that is applied to the scalp twice daily. The 5% solution is for men only. 5% solution is for men only.

• It may well be 6 months before any It may well be 6 months before any improvement is seen and it should be improvement is seen and it should be discontinued if there is none after a year. discontinued if there is none after a year.

• Any improvement will wane after stopping.Any improvement will wane after stopping.• Minoxidil is successful in about 15%Minoxidil is successful in about 15%• The cost is around £25 a month for The cost is around £25 a month for

minoxidil 2%, £30 a month for 5%.minoxidil 2%, £30 a month for 5%.

FinasterideFinasteride

• Finasteride 1mg tablets are for men only. Finasteride 1mg tablets are for men only. The dose is 1mg daily, compared with The dose is 1mg daily, compared with 5mg for benign prostatic hyperplasia. 5mg for benign prostatic hyperplasia.

• It may be up to 6 months before benefit is It may be up to 6 months before benefit is seen and it reverts on cessation. seen and it reverts on cessation.

• Finasteride is successful in about 60%. Finasteride is successful in about 60%.

• The cost is around £55 a month for The cost is around £55 a month for Finasteride.Finasteride.

Internet searchInternet search

• Search for: Treatment of hair lossSearch for: Treatment of hair loss onon yahoo yahoo revealed 2090000 sites.revealed 2090000 sites.

This shows how very important it is to This shows how very important it is to make the patients realise all the make the patients realise all the treatment options and the true treatment options and the true prognosis. It may help to prevent the prognosis. It may help to prevent the patients seeking miracle cures which patients seeking miracle cures which are often very expensive.are often very expensive.

Question 6Question 6

• Mr N is a 30yr old man presenting Mr N is a 30yr old man presenting with pain, swelling and redness of with pain, swelling and redness of the lateral part of his big toethe lateral part of his big toe– What would you specifically ask in the What would you specifically ask in the

history?history?– What treatment options are available?What treatment options are available?– What future preventative measures What future preventative measures

could you advise?could you advise?

Ingrowing (Toe)nailsIngrowing (Toe)nails

Ingrowing nailIngrowing nail• The nail becomes 'ingrowing' when the side The nail becomes 'ingrowing' when the side of the of the nail cuts into the skin next to the nail.nail cuts into the skin next to the nail.

• The distal lateral edges of the nail grow The distal lateral edges of the nail grow inwards inwards and so damage the skin.and so damage the skin.

• May be accompanied by secondary May be accompanied by secondary infections and infections and granulation tissue.granulation tissue.

• Nails of big toe most commonly affected.Nails of big toe most commonly affected.

• Common in teenagers and young adults.Common in teenagers and young adults.

CausesCauses• Usually there is no apparent reason why it occurs. Usually there is no apparent reason why it occurs. • Tight fitting shoes may be a cause in some cases. Tight fitting shoes may be a cause in some cases. • More common in people who cut their toenails More common in people who cut their toenails

very short and 'round'. very short and 'round'. • The correct way of cutting nails is 'straight The correct way of cutting nails is 'straight

across'. This helps the nail to grow normally and across'. This helps the nail to grow normally and may prevent ingrowing toenails from developing.may prevent ingrowing toenails from developing.

• Those with excessively sweating feet, making the Those with excessively sweating feet, making the nail grooves macerated and soft, are more prone.nail grooves macerated and soft, are more prone.

PresentationPresentation

• Pain, swelling and redness of the lateral part of Pain, swelling and redness of the lateral part of toe.toe.

• Infection and granulation tissue can result in pus Infection and granulation tissue can result in pus discharge.discharge.

• Pain on walking and wearing shoes.Pain on walking and wearing shoes.

• More commonly seen in patients of lower socio-More commonly seen in patients of lower socio-economic classes.economic classes.

Patient HistoryPatient History

• When the symptoms began.When the symptoms began.

• Whether the patient wears tight Whether the patient wears tight shoes.shoes.

• About the nail cutting methodAbout the nail cutting method

TreatmentTreatment

• If caught early: If caught early: positioning cotton wool under positioning cotton wool under the lateral nail edge, designed to force the nail the lateral nail edge, designed to force the nail to grow over the skin. Then cutting straight to grow over the skin. Then cutting straight across rather than rounded off at the end. across rather than rounded off at the end. Assistance of a chiropodist may be helpful.Assistance of a chiropodist may be helpful.

• If active inflammation is present: If active inflammation is present: Lateral Lateral nail excision with the application of phenol.nail excision with the application of phenol.

• If the condition is left untreatedIf the condition is left untreated:  The :  The worst scenario would be that the infection gets worst scenario would be that the infection gets worse, then spreads resulting in cellulitis and worse, then spreads resulting in cellulitis and septicaemia. septicaemia.

PreventionPrevention

• Correct method of cutting toe nails. You Correct method of cutting toe nails. You should cut the nails to the shape of the should cut the nails to the shape of the end of the toe, and file any sharp edges. end of the toe, and file any sharp edges.

• Comfortable fitting shoesComfortable fitting shoes

• Good feet hygiene-Keeping your feet clean Good feet hygiene-Keeping your feet clean with regular bathing. Drying them with regular bathing. Drying them thoroughly, and applying foot powder.thoroughly, and applying foot powder.

Thank You for listeningThank You for listening

• We hope you’ll now be better equipped to We hope you’ll now be better equipped to deal with some of the common problems deal with some of the common problems you might see in your GPR year which you you might see in your GPR year which you rarely see in hospitalrarely see in hospital

• Obviously there are many more!Obviously there are many more!

• For further reading a great book isFor further reading a great book is– ““Minor Ailments in Primary Care – An Evidence Minor Ailments in Primary Care – An Evidence

Based Approach” by Just A. H. Eekhof et alBased Approach” by Just A. H. Eekhof et al