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Post by blinda on Oct 24, 2009 15:30:14 GMT
Hi All,
Having a conversation with a couple of colleagues about the necessity for histology of what we would clinically diagnose as benign tumours, i.e periungual fibromas, eccrine poromas, naevi, even VP`s, etc and would like to hear others opinions.
After taking a detailed med hx, I generally apply the ABCDE approach to any lump or bump; check Asymmetry, Border, Colour, Diameter & Evolution (change) and only refer for biopsy if there is unorganised proliferation or suspiscion of malignancy, but is this enough?
For example; Would you routinely request surgical excision and a histology examination on say a periungual fibroma that was not interfering with nail formation or causing discomfort?
I`d be interested to hear your views.
Cheers, Bel
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seekerofwisdom
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Post by seekerofwisdom on Oct 24, 2009 18:53:51 GMT
Hi Bel
With experience comes an instinct for things that are not quite right. Once all the observations have been made, and possibly the condition monitored for changes, then can the decision be made whether to refer on for histology or further tests. A good history is a large part of the diagnosis. as you say.
The danger with referring everything on regardless, is that it starts to appear that you lack the confidence in your disgnosis, and GPs are not happy to incur extra expenses that they do not believe to be necessary. Since I only refer on in worrying cases, the GPs now take my word for it and refer as necessary.
In my experience, most of these benign type tumours remain the same and cause no problems. I would of course refer if sudden changes took place or complications arose.
sunseeker
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Post by seekerofwisdom on Oct 25, 2009 5:24:40 GMT
Hi sunseeker and Bel.
Sunseeker 'Instinct'? mmm perhaps not the right word but I think I know what you mean.
Bel I was under the impression you were in PP, if so I tend to go along with SS about 'requesting tests' from GPs.
Perhaps it's just me but a request for assistance from a GP is the same as loosing a patient, they NEVER reply to my letters and always pass the patient on to the NHS Podiatry service where they enter the long cycle of assessment, often inappropriate treatment then discharge, sometimes return to me thoroughly confused and disillusioned.
So I tend to make sure I understand what I am looking at and if in any doubt advise the patient to consult the GP, I do not request any action from the GP, after all it's their job, and it's them or the dermatologists who are going to have to deal with it. Having successfully diagnosed more than one life threatening conditions I have never had any feed back from a GP. If very concerned I advise a private consultation with a dermatologist, £100 well spent.
Bob
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Post by blinda on Oct 25, 2009 16:26:44 GMT
Thanks for your replies Bob & Sunseeker, we appear to be singing from the same hymn sheet. Of course experience does help a practitioner, I`ve only been in practice for 7 years so am relatively `young` in the profession, with only one year of that working for the NHS. Yes, I am only working in PP now but also work closely with a few GP practices here as I undertake their diabetic annual reviews in the surgeries, so do have a very good referral system in place with them. However, I also agree with what you are saying SS, it is our job to make the clinical diagnosis and I very rarely refer on unless I have good reason. This does indeed gain the GP`s respect. I hear what you are saying Bob, and I used to (and still do with some GPs) find it frustrating when letters and requests for appropriate (not NHS podiatry) referrals are largely ignored by GPs. It has helped that many GPs have got to know me now, but I also make sure that when I do make a referral to the NHS dermatology dept via their GP, the patient is given a copy of the referral letter so they can take the matter further, should they wish. I have on occasion advised patients to seek a private consultation with a dermatologist too, but £100!! That is very cheap in comparison to Winchester prices! Perhaps I should send them West? Cheers guys, Bel
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Post by seekerofwisdom on Oct 25, 2009 17:31:58 GMT
There we go Bel
In practice for 7 years, but post degree 2? no criticism intended.
I think what you are demonstrating is the classic 'medical model', they refer only to those they have shared a relationship. Also the King report still applies the best service is received by middle class articulate patients. No problem but it is a hard market to break into.
Look at the SCP 10 point plan for 'joint working' if you can find it?
In the meantime well done for breaking the ceiling.
£100? Well Cornwall is the lowest waged county in the UK, but think of the transport costs.
Respect
Bob
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Post by seekerofwisdom on Oct 28, 2009 16:38:53 GMT
I agree with sunseeker & bob. If it ain't broke don't fix it. You get a "nose" for these things if you have been in practice for a while and no GP will appreciate you calling 'wolf' on a regular basis. That's why I have a problem with the grandparented who haven't done enough clinical hours to tell a melignant melanoma if it got up and waved to them.
Contraversial seeker.
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Post by blinda on Oct 28, 2009 22:09:35 GMT
Controversial Seeker;
As you can clearly see from my posts, I agree with Sunseeker and Bob that to routinely send pts with benign tumours for histology is not necessary, and would reflect badly on us as practitioners if we did so.
Can we try sticking with the thread instead of turning it into a bashing of grand-parented pods episode? Thanks.
Bob,
Where do we go? Not sure I understand your point here. I have acknowledged the obvious i.e. that experience is evidently beneficial to a practitioner and I have made no secret of my clinical practice prior and post degree. What does that have to do with referring clinically diagnosed benign tumours?
Maybe I am a subscriber to the medical model; this is taught at uni and that is how I would interpret the recommended building and maintaining of referral pathways. The `shared relationship` benefits all practitioners involved as well as the patient. Surely that is a desirable position to be in? Agree with regard to the King report; we have many who fit the criteria in Winchester, it does help.
Nice to know I have earned your respect.
Cheers, Bel
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Post by davidsmith on Jan 5, 2010 18:58:48 GMT
Bel Surprised this thread died so easily and quickly. It's an important area to scrutinise and we should have a reliable method of evaluating lesions. First off, we all know what common things look like coz we see them all the time but we should be careful not to be complacent or dismissive. Second, use a primary system of assessment that will lead to a useful evaluation i.e. like the ABCDE and history Third, once there are suspicions then have a more in depth system to eliminate false positives or always refer suspicious lesions. Suspicious is, however a subjective term closely linked to risk. How risky is it not to refer and what's the risk of loosing face if you refer to many benign / harmless / non proliferating lesions. I like to use Dockery's Cutaneous Disorders of the Lower Extremity. The flow charts and descriptive terminology with photos of lesions and diagnostic studies make this an invaluable book to the podiatrist who does not specialise in Dermatology or even if they do. I think you have this book don't you Bel? I find the more you use it even for less suspicious lesions the more familiar I become with lumps n bumps in general. (I don't know about you but I often get someone sidling up to me outside of my clinic setting and asking about some spot or lump that they are concerned about.) It is also very useful to use the book to enhance my referral content to the GP with impressive terminology and valid reasons why I have referred. If you diagnose it as non malignant then do you need a biopsy? Wouldn't the better question be 'what would we diagnose as a malignant or pre-malignant lesion or tumour'? Once referred, do we need to know the histological details, interesting as they might be, or just the result? i.e. yes or no and perhaps type for future reference. Like others I rarely get a result back directly from the medic/specialist, rather it comes via the patient. Fortunately despite many referrals only very few (of the results known about) in 10 years have actually been malignant. The ones that we should probaly be acutely aware of are those lumps and bumps that look like innocuous or every day common or garden variates of lesion but are in fact sinister. E.G. Basal cell and squamous cell carcinomas and malignant melonomas, which can often resemble v.p. or a blood blister or a gnat bite or a dermatitis/eczema lesion. Many of the malignant lesions presented in this book were first diagnosed by a medic as something less sinister. I am interested in how you present your findings to the patient. You decide to refer and so inform the patient - "oh why's that then?" "Well just being cautious" "so it's probably nothing" "well these things usually are" So I'll go next month when I have an appointment about my arthritis yeah?" Well No perhaps it would be a good idea to go sooner, like this week" Oh! so it is serious then?" (Concerened look on patients face - now it's getting scary ) "Well no but erm aaah! best be on the safe side you know" Patient phones his mum to tell her he might not have long to live and can she look after the kids and don't let Dad have the Man U kit collection, that's for Eric he's been to all the away matches. Oh No he guesses he'll never see Rooney cry ever again. "Do you know what Mr Pratt it's just a verrucae after all" "EH!" Just the other day a guy from the Gym next door who's always chatty, asked me about his thick yellow /white nails, "got psoriasis?" "Yep" - "that's probably it then" "Oh ok" "By the way I've got this brown line come up in my thumb nail that nothing, is it?" Referred him to his GP, query lentiginous melonoma / longitudinal melonychia, and now he's being uncharacteristically quiet?? I don't like to ask why, perhaps I will. All the best Dave
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Post by seekerofwisdom on Jan 19, 2010 6:49:42 GMT
CS has a point.
This is not "grandparented bashing", it's raising a very real concern.
We already have an example elswhere on this site of a grandparented pod having problems with a high-risk patient. That practitioner had the good sense to ask for advice but I wonder how many don't? We will never know.
This post may be off-topic and will probably be moved from this thread but is still very valid.
SOW 1
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