45 yo female presents with itchy arms and some sores all over them. No regular medications. Has already seen a GP one week prior who gave her some hydrocortisone cream, but this hasn’t helped. She see is seeing you for a second opinion. Questions below:
What further history would you like?
Dr. Mel Clothier of GreenGP has listed some good points to cover on history, including some I should have asked. Here is more of the history that I gleaned on first visit:
- Rash had been there for 3-4 days before seeing first GP, hasn’t changed since hydrocortisone. So now ~10 days in total
- Has only tried paw paw ointment and some barrier creams
- Never been allergic to anything in the past, no history of eczema/asthma
- Somewhat icthy, but not driving her mad. Still sleeping well
- Lives alone, but no other contacts with rash
- Occupation (big point to cover): works at an animal shelter, looking after stray domestic pets and some natives.
- No change to soaps, washing detergents etc
- I didn’t ask about nutritional status, mental health issues, family history of skin problems or delve into past medical history.
How would you describe the lesions/skin?
These pictures are from the second visit. Initially there were more reddish vesicles with some pus and a few crusted lesions.
What would your initial management be?
My first thought was that it looked a touch like impetigo. I wondered about scabies or even possibly pruritis from some internal med issue. The story of the exposure to animals was interesting, but DermnetNZ had said that animal mites do not infect humans. I swabbed a purulent wound for bacterial MCS, started a course of oral Flucloxacillin and prescribed some Celestone (betamethasone) cream. Because of the mild itch, I didn’t say anything about anti-histamine use. At this early stage, I thought I would leave bloods and biopsy until after the antibiotics had done their thing (or not).
Twitter already has a few ideas bouncing around:
— Minh Le Cong (@rfdsdoc) May 7, 2013
— Ewen McPhee (@Fly_texan) May 7, 2013
— Francois Pretorius (@docdownunder) May 7, 2013
One week later, my patient has booked back in to see me. She says the redness is a bit better and the lesions have scabbed over mostly, but they have spread to her legs and are starting to itch some more. The swab results are also back:
She also tells me a bit more about her work. It turns out that the animal shelter uses old mattresses and blankets directly from donations (i.e. not via Op Shops). She thinks that the spots had come up after a recent batch had come through to be used, but was adamant that the sheets etc had been cold washed prior.
What are the preferred diagnoses now?
What would the next step in management be?
Is there anything to follow up or advise the patient about?
In September last year, I was relatively new to Twitter. I had probably been using it for about 6-8 months posting on little observations, but nothing much productive or useful. Then while waiting for a tram in Melbourne, I happened across the AHPRA draft social media policy. The tone was rather disappointing and it seemed as though the regulation body was looking to tightly regulate health professionals’ use of social media so that it would be rendered too risky to take part. The regulatory version of sticking fingers in your ears and shouting “na na na.” However online communities like #hcsmanz (health care social media Australia & NZ) and blogs like Croakey started making some noise.
At the time, I was attending the GPET conference in Melbourne. Co-incidentally, I had been attending social media workshops and seeing Twitter being used brilliantly by people like Dr George Forgan-Smith. It jolted me enough to start getting involved with #hcsmanz, using Twitter more often and blogging about the issue with this piece. It was a call to arms, ironically fueled by the group seemingly wanting to limit doctors’ online presence. I have since made many strong online bonds with those who were on the front line during those days. Via GPRA, my response called for collaboration of various stakeholders including ours which represented many Gen Y future GPs with a large online presence. (N.B. To this day, @AHPRA on Twitter is still devoid of posts)
Cut to May 2013. Just last week AHPRA formally released this consultation paper that includes amongst other sections, a new draft social media policy, revised Code of Conduct and guidelines for advertising. Dr Edwin Kruys has dissected more about the effect of incorporating social media aspects into the Code and advertising guidelines as it pertains to his practice in Geraldton on his blog.
It looks like AHPRA have listened to what the stakeholders have said in response to the draft last year. But what questions do the new social media guidelines raise for GP registrars and fellows?
Do online as you do in person?
In essence, the social media policy appears to repeatedly refer back to the Code of Conduct which regulates health professional behaviour in the real world. While this may be good for continuity, it still my stifle progress and new online initiatives that come forward in the future. Understandably, real life and the online world are very different entities. So should there be a separate Code of Conduct for social media?
Do we need another policy or guideline(s)?
Rightly so, AHPRA has defined their place for their own social media policy. Unlike the policy produced by the AMA to protect professionals online, AHPRA’s mandate is to protect the public. I hope that the new policy is framed not only to best protect the public, but also to encourage novel use of social media which may enhance patient care.
Will my online work breach confidentiality?
The same rules will apply for online use of unauthorised use of photographs or patient information as those in the real world. However, given the vast use of clinical data for teaching may mean that those posting online will need to be very careful and use proper documentation and consent.
Do they know what we’re doing?
Yes, fortunately AHPRA recognises the ever expanding use of social media ‘user generated content’ on blogs, websites and more widely known social media sites. They stop short of endorsing its use in this way, but again remind health professionals of their obligations to maintain standards especially with the permanent and public nature of online material.
What does AHPRA want to know from you?
As part of the call for feedback, there is also a list of questions that the regulatory body has posed:
- Do you support the approach of including general guidance in the draft policy, the Guidelines for advertising and the Code of conduct, with appropriate cross-referencing?
- Does the guidance in these documents reflect the National Boards’ regulatory role?
- Do you agree with the approach of referring practitioners to other sources for guidance on social media that goes beyond the National Boards’ regulatory role?
- Is the content of the draft Social media policy helpful?
- Is there any content that needs to be changed, added or deleted in the draft policy?
- Do you have any other comments on the draft policy?
Lastly, I’m not sure if this sentence (which is dreadfully too long) even responds to the concerns raised in September:
“The National Boards have responded to this feedback and are proposing an approach which addresses the regulatory issues related to social media, consistent with the Boards’ role, but which does not unnecessarily restrict the use of social media that is unrelated to a practitioner’s professional life.”
The responses last year were so impassioned because of the very opposite of this. Many practitioners are using social media AS PART of their professional life. All for the benefit of education, and interaction which in turn are for the betterment of patient care. Any attempt to restrict its use for this purpose may only create further tension. Reassuringly, AHPRA has stated that it will review the guidelines each year and they do appear to be much less stringent than what was seen last year. A wise move given the dynamism needed to keep up with changes in social media.
AHPRA is requesting feedback via firstname.lastname@example.org by close of business on 30 May 2013 to the social media policy
So this 9 year old boy came through the clinic the other day. He sat in the chair closest to the desk. Good start. I started with “G’day, what can we do for you today fella?” Response *look straight at Mum* Ah well, can’t win em all!
Anyway, he had been having trouble with a non healing scab/wound on his proximal thumb. It had started about a week or two ago when he thought that something might have bitten him. After that it swelled up and went a bit red. Mum said that it only lasted for 2-3 days and had got better so she didn’t get it checked out. After a week some yellow blisters appeared and then popped with some clear/yellowish fluid drained. Since then it hasn’t really got much better. His immunisations were up to date and there wasn’t anyone sick at home or at school. Feel free to comment below and weigh in…
Description of the lesion?
Im going to go with Penny’s description of an inflamed lesion on the proximal right thumb that has some crusted yellow sores. I wondered whether the middle reddish part of the lesion was an initial injury or bite that kicked off the infection.
Preferred diagnosis with differentials?
From the history and from the looks of the lesion, impetigo was my first thought. Not sure what the cause here might have been, usually a scratch or insect bite. Dr Penny Wilson makes the good point that it could be due to an area of prolonged irritation such as with a thumb sucker. DermnetNZ also mentions that scratched eczema could also present like this. Scabies and head lice should always be considered also.
Investigations and treatment options?
For this chappy, I took a bacterial swab and started him on oral Flucloxacilin. I suppose that given the localised nature of the infection, I probably could have got away with a topical antibacterial such as mupirocin (Bactroban). Dr Mel Clothier added that a viral swab to rule out underlying HSV may be helpful. Apart from oral antibiotics there are a few simple measures that both the Therapeutic Guidelines and DermnetNZ suggest including:
- Soak moist and crusted areas with cloth containing vinegar/tepid water mixture (1 cup in a litre)
- Antiseptic or antibiotic ointment if simple case
- Treat carriers: full body bath with small amount of bleach and/or mupirocin per nostrils
- Avoid close contact, cover sores, separate linen/towels
- Non infectious once crusts dried out
In the end, Mum found that the lesion had reduced in size, was healing well and didn’t need further treatment. She sent me this photo which highlighted the benefit of teaching our patients and parents to take good images! The microbiology results showed Staphylococcus aureus and was sensitive to penicillins.
More images of impetigo from DermnetNZ.
In this short podcast interview (below), Prof Murtagh talks about his own pathway to medicine and general practice in the country. Starting as a science teacher interested in maths and physics, he came to medicine after being inspired by his own GP in the country town he grew up in. Part of Monash University’s first medical cohort, John said that he “liked everything” and that the “country is the place to be.” Seems like rural general practice was an easy choice for Prof Murtagh, but not without its challenges as he explains.
He found some isolation in the country, however help was only a phone call away. We wonder whether the advent of social media and blogs may help reduce this tyranny of distance even more. Also in the interview are some memories from the Prof, including risque interactions with octogenerians, exam preparation tips and pearls of wisdom for medical students just starting their own journey. I hope that you enjoy this chat and learn just as much as I did from a great mentor and spokesman for general practice.
I remember my first removal/re-insertion of a suprapubic catheter (SPC) very well. In fact, it will be something that will remain in my memory for a long time to come. During medical school there had been plenty of standard urinary indwelling catheter (IDC) insertion and removal rehearsals with those hard rubber models. I’m sure we all know the ones with the unrealistic non-malleable appendages and ‘bits.’ Then I had even managed to practise many real life IDCs on the hospital wards as a senior medical student (and actually longed for those practice manikins that actually held their shape!) But I had never been able to attempt or even witness a removal of a catheter that went straight into the lower abdomen. We had learnt all about suprapubic techniques in paediatric rotations, but my first foray into this area was during a country general practice intern placement (PGPPP).
My patient for the day was a 50-year-old lady who had been using suprapubics for the past year. However, she had found the whole process so painful and unbearable that each change was conducted at the hospital under analgesic cover. Unfortunately her level of pain tolerance, or lack thereof meant that these episodes were usually quite a scene. Three changes before my shot, the patient had throttled the closest nurse out of sheer desperation. Luckily the GP in this town was open to alternative techniques and enrolled the help of a hypnotist from the next major town. On previous changes the patient had been instructed to imagine everyone naked and giggled her way through the whole procedure. Then it came my turn. Fortunately the naked trick was not being used this day. As I entered the room I could hear singing. My patient had been hypnotised and was already in a trance like state singing the tune “Somewhere over the Rainbow”.
So it came to be that my first suprapubic catheter removal was performed with the patient calm and singing sweetly in my ear. Unfortunately, the Wizard of Oz has since lost some of its magic for me and consequently will never think of the Yellow Brick Road in quite the same way again! I guess Im just happy it wasn’t a double rainbow “all the way across the sky…”