3About this presentation: The scenarios in this slide presention are based wholly or partly on real patients who have presented to GP surgeries. They have been anonymised for use as a teaching tool for GPs in Training. For realism the patients have been given fictional names, ages and professions.
4It’s my left knee, I can hardly walk! Mr Barlow, 49It’s my left knee, I can hardly walk!
6Mo, 28“I’ve noticed a lump on one of my testicles…
7Painless lump, dull ache, heaviness Testicular CancerPainless lump, dull ache, heavinessAges1% of all male cancersFH and undescended testesSeminomas 40%, Teratomas 60%Respond well to Chemotherapy95% cured if identified early
10ACNE GRADINGGrade 1 (mild) – acne is mostly confined to whiteheads and blackheads with just a few papules and pustules.Grade 2 (moderate) – there are multiple papules and pustules which are mostly confined to the face.Grade 3 (moderately severe) – there is a large number of papules and pustules as well as the occasional inflamed nodule. The back and the chest are also affected by acne.Grade 4 (severe) – there is a large number of large painful pustules and nodules.
11I’ve had blood in my semen! Peter, 25I’ve had blood in my semen!
12Haematospermia UTI Prostate Cancer if > 40 (NICE CKS) Testicular CancerBPHProstatitisTrauma or instrumentationSTIBleeding disorder3 or more episodes if no identifiable cause needs investigation. If age < 40 sinister cause very unlikely if less than 3 episodes
14Roger, 32“I keep needing to go to the loo every 15 minutes and in the night as well!”
15Mr Parker, 62“I keep needing to go to the loo every 15 minutes and in the night as well!”
16PSA is a type of enzyme secreted by the prostate gland It liquefies semen and allows the sperm to swim freelyIt becomes elevated in prostate cancer
17PSA PSA test counselling PSA has a high rate of false positive results with only 30 percent of patients who have high PSA level are prostate cancer positive after biopsy.Other causes of raised PSA?PSA is mildly raised in 30-50% of men with BPH. Higher levels increase likelihood of CaPSA is normal in 20% of cases of prostatic cancer.
19Mr Parker, 62“I keep needing to go to the loo every 15 minutes and in the night as well!”PSA (age 60 to 69 normal <4)
20Brian, 31“Sometimes I can’t get an erection and it’s starting to bother my wife”
21Possible causes of erectile dysfunction Vasculogenic — such as cardiovascular disease, hypertension, hyperlipidaemia, diabetes mellitus, smoking.Neurogenic — such as multiple sclerosis, Parkinson’s disease, tumours, stroke.Anatomical — such as Peyronie’s disease, hypospadias.Hormonal — such as hypogonadism, hyperthyroidism, hypothyroidism, Cushing’s disease.Drugs — such as diuretics, antihypertensives, antidepressants, cytotoxics, alcohol.Psychosocial — relationship problems, mental health problems.
22Sildenafil Citrate (Viagra) Acts by inhibiting cGMP-specific phosphodiesterase type 5 (PDE5)PDE5: an enzyme promoting degradation of cGMP, which regulates blood flow in the penisTadalafil (Cialis)Levitra (Vardenafil)
23Sildenafil Citrate (Viagra) Sildenafil is now available as an NHS prescription
24SLS (Selected List Scheme) DM, MS, PD, Polio, Prostate Ca. severe pelvis injury, genetic neurological disease, spina bifida, spinal cord injuryOn dialysis for renal failureRadical pelvic surgery or prostatectomy, renal transplantWere getting them free or similar before 1998Severe distress – only by a specialist
25Daniel Hoffman 49I’ve come for my results. My mouth was sore – she took a sample
27Swab result – Candida isolated What is the significance of the result?What is the differential diagnosis?Any other questions to ask?Further tests?
28Sohail, 25“I can get an erection, but sex is over in about 2 minutes!”
29Premature Ejaculation (PE) Many men are unsure about how long ‘normal’ sex should last before ejaculation.A study looking at 500 couples from five different countries found the average time between penetration and ejaculation was around five-and-a-half minutes.
30Premature Ejaculation (PE) However, it is up to the individual and his partner to decide whether or not they are happy with the time it takes for him to ejaculate.Regularly ejaculating before or within one minute of penetration would usually be regarded as a medical problem that requires treatment.
31PE self help Masturbating an hour or two before having sex Using a thick condom to help decrease sensationTaking a deep breath to briefly shut down the ejaculatory reflex (an automatic reflex of the body during which ejaculation occurs)Having sex with your partner on top (to allow them to pull away when you are close to ejaculating)Taking breaks during sex and thinking about something boring
32Medication: SSRIs – paroxetine, fluoxetine, sertraline PE – therapy optionsCouples therapySqueeze techniqueMedication: SSRIs – paroxetine, fluoxetine, sertralineDapoxetine (PRILIGY) – new. Short acting SSRI. 1h before sex
33Attends with mum: ‘He’s got a lump under his nipple’ Danny 14Attends with mum: ‘He’s got a lump under his nipple’
34Pubertal gynaecomastia Danny 14Pubertal gynaecomastiaPatient Information Leaflet:https://www.bsped.org.uk/patients/docs/GYNAECOMASTIA_TR_VERSION.pdf
35‘I think I’ve got blood in my urine!’ Patrick, 31‘I think I’ve got blood in my urine!’
36Renal/ureteric stones Urethritis BPH, prostate Ca HAEMATURIACommon:UTIBladder tumourRenal/ureteric stonesUrethritisBPH, prostate Ca
39HAEMATURIA MANAGEMENT Painless microscopic (male or female) - refer urgentlyMacroscopic and no infection - refer urgentlyAll adults > 40 years old with persistent UTI and haematuria – refer urgently<50 and with proteinuria & raised creatinine – renal referral
40‘I think I’ve got blood in my urine!’ Patrick, 31‘I think I’ve got blood in my urine!’
41Mr Odeyo, 46Clip No. 1‘A Request for Slimming Pills’
42CSAMarked in 3 areas:Data Gathering, Technical and Clinical Assessment skillsClinical Management skillsInterpersonal skills
43Tom 19, University Student I’ve got some spots on my penis can you have a look?
44Tom 19, University Student Does it look OK to you…Size wise?Average 14-16cm ( inches) when erectAverage girth for an erect penis is 12-13cm ( inches)A penis would only be considered unusually small if it was less than 3 inches (7.6cm) long when erect
45Penis AnxietyDistorted views about normality and importance of penis size, affecting self-confidence and causing fear about sexual relationshipsCounselling/psychological therapies
46Jake, 15Attended with Mum – Can you do anything about his feet – the smell is disgusting – its not normal