(Great Britain—The Practitioner, September 1998, p. 627.) Although only a small proportion of men with testicular lumps have testicular neoplasm, accurate diagnosis based on history, physical examination and selected investigations can significantly reduce patient anxiety. Key features of the history include duration of the mass, rate of enlargement, presence of associated urinary symptoms or pain, and history of trauma, surgery or tuberculosis. A thorough physical examination is required to detect signs of malignant disease, tuberculosis or sexually transmitted disease. Testicular examination should determine the exact location of the testicular mass, its most likely source (testicle, epididymis or other structure) and presence of transillumination. Benign causes of testicular masses include epididymal cysts, spermatoceles, hydroceles, hematoceles, varicoceles, inguinal hernia and epididymoorchitis. The most common malignant masses are teratomas and seminomas occurring in men 20 to 40 years of age, and these masses often present with significant pain.
Central Serous Chorioretinopathy
(Canada—Canadian Family Physician, September 1998, p. 1833.) Central serous chorioretinopathy presents as a sudden distortion of vision with distinctive findings of sub-retinal pooling of fluid on ophthalmoscopy. The condition is believed to be an acute idiopathic transudate from choroidal vessels, possibly occurring as a result of increased catecholamine production. The condition has also been associated with the use of corticosteroids and conditions that elevate levels of endogenous corticosteroids. Central serous chorioretinopathy is usually self-limited, but laser therapy has been used in some cases.
Hypertension in Diabetic Patients
(Great Britain—The Practitioner, August 1998, p. 587.) Up to one half of all patients with diabetes also have hypertension, making the prevalence of hypertension in diabetic patients double that of the nondiabetic population. Both large- and small-vessel disease contribute to this increased prevalence of hypertension through a variety of mechanisms, including the secondary effects of nephropathy. The benefits of controlling hypertension have been clearly demonstrated for both type 1 and type 2 diabetes (formerly known as insulin-dependent and non-insulin-dependent diabetes mellitus, respectively). The strongest evidence of benefit is for treatment using angiotensin converting enzyme (ACE) inhibitors in patients with microalbuminuria. Treatment should be directed toward achievement of systolic pressures of 125 to 140 mm Hg and diastolic pressures of 75 to 88 mm Hg. Calcium channel blockers reduce blood pressure and may be particularly effective in patients of African descent, but these drugs have not been shown to reduce microalbuminuria. Alpha-blocking drugs are also effective in lowering blood pressure but have no known renal benefit and may cause postural hypotension. Most of the evidence supporting treatment of hypertension in patients with diabetes is based on studies of patients less than 65 years of age. Research to guide therapy in older diabetic patients with hypertension is limited.
Basal Cell Carcinoma
(Great Britain—The Practitioner, October 1998, p. 718.) Basal cell carcinoma, or “rodent ulcer,” is the most common malignant skin lesion. Sun exposure is the predominant etiologic factor, but previous irradiation, local trauma and the ingestion of arsenic have also been implicated. Basal cell carcinoma usually begins as a translucent pearly papule with telangiectatic vessels on the surface. The most common site is the face, but basal cell carcinoma may occur on any part of the body and may be missed if situated behind the ear. The lesion grows very slowly and usually develops central ulceration. Metastasis rarely occurs. Treatment of basal cell carcinoma usually consists of local excision, but radiotherapy also works well.
(Australia—Australian Family Physician, August 1998, p. 735.) Impetigo is usually caused by infection with Staphylococcus aureus or Streptococcus pyogenes. If the infecting strain produces an epidermolytic toxin the result is bullous impetigo, which is characterized by thin-walled blisters that rupture to produce moist, crusted erosions. The differential diagnosis includes herpes simplex, tinea and nummular dermatitis. Oral antibiotics given for 10 days is the recommended therapy, although topical antibiotic treatment may be used. Stringent hygiene measures should be enforced to prevent spread to contacts and to minimize the chance of recurrence. If S. pyogenes causes impetigo, there is a risk of glomerulonephritis developing two to four weeks after the acute skin infection.