The effect of illness

Serious illness often precipitates crises in individual members of the family, crises which have not previously surfaced in the apparently balanced family system. It is recognised, for example, that bereavement over the unexpected loss of a child may lead to marital breakdown, separation or divorce. In the long term, other family members may be affected more than the patient. This may apply particularly to children and manifest as school underachievement and behaviour disturbances. During the...

Acute low back painno spasm

The common problem of low back pain caused by facet joint dysfunction and or limited disc disruption usually responds well to the following treatment. The typical patient is aged 20-55 years, is well and has no radiation of pain below the knee. 14 encouragement of normal daily activities according to degree of comfort regular non-opioid analgesics, e.g. paracetamol exercise program (when exercises do not aggravate), swimming (if feasible) physical therapy stretching of affected segment, muscle...

Chronic renal failure

I have never yet examined the body of a patient dying with dropsy attended by albuminous urine, in whom some obvious derangement was not discovered in the kidneys. Chronic renal failure (CRF) is defined as a severe reduction in nephron mass over an extended period of time resulting in uraemia. 1 It is not common but can present surreptitiously and be a real master of disguise in clinical practice. Asymptomatic CRF may be discovered on routine health screening, as a chance finding in...

Movements of the lumbar spine

There are three main movements of the lumbar spine. As there is minimal rotation, which mainly occurs at the thoracic spine, rotation is not so important. The movements that should be tested, and their normal ranges are as follows extension (20 -30 ) (Fig 33.5 a) lateral flexion, left and right (30 ) (Fig 33.5 b) flexion (75 -90 average 80 ) (Fig 33.5 a) Measurement of the angle of movement can be made by using a line drawn between the sacrum and large prominence of the C7 spinous process. Fig....

Pain patterns

The pain patterns are presented in Figure 30.3 . Colicky pain is a rhythmic pain with regular spasms of recurring pain building to a climax and fading. It is virtually pathognomonic of intestinal obstruction. Ureteric colic is a true colicky abdominal pain, but so-called biliary colic and renal colic are not true colics at all. Fig. 30.3 Characteristic pain patterns for various causes of 'colicky' acute abdominal pain

Internal haemorrhoids

Haemorrhoids or piles are common and tend to develop between the ages of 20 and 50. About one out of two Westerners suffers from them by the time 50 is reached. 3 Internal haemorrhoids are a complex of dilated arteries, branches of the superior haemorrhoidal artery and veins of the internal haemorrhoidal venous plexus Fig 32.2 . The commonest cause is chronic constipation related to a lack of dietary fibre. perianal haeimatnima Fig. 32.2 Classification of haemorrhoids jrfi-degree proiapsed...

Asthma and other respiratory diseases

The death rate and morbidity rate for asthma and other respiratory diseases is unacceptable and much of it can be prevented. 15 A recent report claims that at an estimated cost of 585 to 720 million per year the cost of asthma to the Australian community compares with the total cost of coronary artery disease ( 623 million). 15 The report also claimed that there is evidence that a significant proportion of diagnosed asthmatics are currently receiving treatment that does not provide the best...

Connective tissue disorders and the vasculitides

In its more aggravated forms diffuse scleroderma is one of the most terrible of all human ills. Like Tithonus to 'wither slowly' and like him to be 'beaten down and marred and wasted', until one is literally a mummy, encased in an ever shrinking, slow contracting skin of steel, is a fate not pictured in any tragedy. The connective tissue disorders and the vasculitides are groups of diseases that are difficult to classify because their causation is generally unknown. They all cause joint and...

Management of dementia

There is no cure for dementia the best that can be offered to the patient is tender loving care. Education, support and advice should be given to both patient and family. Multidisciplinar evaluation and assistance are needed. Regular home visits by caring sympathetic people are important. Such people include relatives, friends, general practitioners, district nurses, home help, members of a dementia self-help group, religious ministers and meals on wheels. The sufferers tend to manage much...

Tremors can be classified as follows Resting tremorParkinsonian

The tremor of Parkinson's disease is present at rest. The hand tremor is most marked with the arms supported on the lap and during walking. The characteristic movement is 'pill-rolling' where movement of the fingers at the metacarpophalangeal joints is combined with movements of the thumb. The resting tremor decreases on finger-nose testing but a faster action tremor may supervene. The best way to evoke the tremor is to distract the patient, such as focusing attention on the left hand with a...

Unclassified spondylarthritis

Patients in this category seem to be the most frequently encountered in family practice. They clearly have a spondyloarthropathy but fail to meet the criteria for any one of the individual entities within the group. A typical patient is a young male in his third decade with a painful knee or other joint, unilateral (or bilateral) back pain with one of the entheseal problems, e.g. plantar fasciitis. Investigations Radiological sacroiliitis is central to the diagnosis. Changes include narrowing...

Secondary prevention

Secondary prevention includes actions taken to stop or delay the progression of disease. The term is usually applied to measures for the detection of disease at its earliest stage, i.e. in the presymptomatic phase, so that treatment can be started before irreversible pathology is present. The early recognition of hypertension through routine testing (screening) of patients allows treatment during the presymptomatic phase of the illness process. Screening for cervical cancer allows the treatment...

Neurological dilemmas

The disease is of long duration to connect, therefore, the symptoms which occur in its later stages with those which mark its commencement, requires a continuance of observation of the same case, or at least a correct history of its symptoms, even for several years. James Parkinson (1755-1824) An essay on the shaking palsy In general practice there are many neurological problems that present a diagnostic dilemma with some being true masquerades for the non-neurologist. This applies particularly...

Hepatitis A B E

Hepatitis A is a common problem in rural areas of developing countries. There is a declining level of antibodies to hepatitis A in developed countries and adults are at special risk so 1 or 2 doses of hepatitis A vaccine should be given. If there is insufficient time a single injection of human immunoglobulin (IG) can give protection for 3 to 6 months. It is safe for all age groups but children under 8 years should not need it. A blood test for hepatitis A antibodies should be carried out to...

Abdominal aortic aneurysm

An abdominal aortic aneurysm (AAA) may be asymptomatic until it ruptures or may present with abdominal discomfort and a pulsatile mass noted by the patient. There tends to be a family history and thus screening is appropriate in such families. Ultrasound screening is advisable in first-degree relatives over 50 years. The risk of rupture is related to the diameter of the AAA and the rate of increase in diameter. The normal diameter of the abdominal aorta, which is palpated just above the...

Alcohol

Excessive drinking of alcohol can cause several clinical manifestations. Identification of the alcohol-affected person is complicated by the tendency of some to hide, underestimate or understate the extent of their intake. In order to diagnose and classify alcohol-dependent people, the family doctor has to rely on a combination of parameters that include clinical symptoms and signs, available data on quantity consumed, clinical intuition, personal knowledge of the social habits of patients, and...

Mortality and morbidity considerations

An understanding of the mortality and morbidity patterns in the modern human being is essential to the planning of preventive programs. The great infectious diseases of the past, such as tuberculosis, syphilis, smallpox, influenza, diphtheria and streptococcal infections, have been largely contained but other diseases have become prominent as life expectancy increases. The great modern diseases are atherosclerosis (hardening of the arteries), malignant disease (cancer), HIV infection and...

Ovarian cancer

Ovarian cancer has the highest mortality rate of all the gynaecological cancers because the majority of patients present in the late stage of the disease. It is usually asymptomatic prior to the development of metastases. Epithelial tumours are the most common of malignant ovarian tumours. They are uncommon under 40 years of age and the average age of diagnosis is 50 years. 3 The most common presentation is abdominal swelling (mass and or ascites). Non-specific symptoms, which may be present...

The role of immunity in cancer

The development of a number of cancers appears to be related to a depression of the individual's immune system, particularly in relation to cellular immunity, in a similar way (albeit on a different scale) to the effect of HIV infection. Studies have shown that the immune system is adversely influenced by stress, especially bereavement On the other hand, a protective effect on the immune system is provided by food antioxidants (Table 9.4) tranquillity Food antioxidants (Table 9.4) appear to...

The holistic approach to management

In a healing profession obsessed with interventionism, invasive technology and drug management, the general practitioner has an obligation to his or her patients to use natural healing methods wherever possible and be very discerning and conservative with investigatory medicine. Patients appreciate natural remedies and taking responsibility for their own management wherever possible and appropriate. Examples include relative rest, exercise, swimming, stress management, meditation, spiritual...

Clinical stages and pathology

First-degree internal haemorrhoids three bulges form above the dentate line. Bright bleeding is common. Second-degree internal haemorrhoids the bulges increase in size and slide downwards so that the patient is aware of lumps when straining at stool, but they disappear upon relaxing. Bleeding is a feature. Third-degree internal haemorrhoids the pile continues to enlarge and slide downwards, requiring manual replacement to alleviate discomfort. Bleeding is also a feature. Fourth-degree internal...

Prevention of HIV infection

Counselling the person at risk re 'safer practices' No effective vaccine has been developed. Modification of behaviour is the only valid strategy for prevention of HIV infection. Education programs to encourage sexual practices that reduce the exchange of genital secretions (safe sex) may achieve risk reduction for sexually active individuals. Condoms provide a barrier if used properly and consistently but may be too easily damaged to offer reliable protection during anal intercourse. A...

Pharmacological treatment

Nicotine replacement therapy, which should be used in conjunction with an educational support program, has been proved to be effective and is available as chewing gum or transdermal patches (the preferred method). Ideally the nicotine should not be used longer than 3 months. Low dependence (less than 10 cigarettes per day) use non-pharmacological methods rather than replacement Moderate dependence (10-14 cigarettes per day) 2 mg High dependence (> 15 per day) 4 mg initially, changing to 2 mg...

Mesenteric adenitis

This presents a difficult problem in differential diagnosis with acute appendicitis because the history can be very similar. At times the distinction may be almost impossible. In general, with mesenteric adenitis localisation of pain and tenderness is not as definite, rigidity is less of a feature, the temperature is higher, and anorexia, nausea and vomiting are also lesser features. The illness lasts about five days followed by a rapid recovery. Comparisons between the two are presented in...

Table 331 Major causes of low back leg pain presenting in the authors general practice

Musculoligamentous strains tears 1.2 Relevant causes are illustrated in Figure 33.1 S biliary disorders U penetrating duodenal ulcer ft pancreatitis ft renal disorders aoftic aneurysm (ruptureil dlssectinfll female pelvic disorders e.g. endometriosis clauc cj ion of arter jI occlus ve disease - S biliary disorders U penetrating duodenal ulcer ft pancreatitis ft renal disorders aoftic aneurysm (ruptureil dlssectinfll female pelvic disorders e.g. endometriosis clauc cj ion of arter jI occlus ve...

References

Practice a handbook of primary health care. London Kluwer-Harrap Handbooks, 1980 3(68) 1-10. 2. Sloane P, Slatt M, Baker R. Essentials of family medicine. Baltimore Williams and Wilkins, 1988, 228-235. 3. Maigne R. Manipulation of the spine. In Basmajian JV ed, Manipulation, traction and massage. Paris RML, 1986, 71-96. 4. Bogduk N. The sources of low back pain. In Jaysom M ed. The lumbar spine and back pain (4th edn). Edinburgh Churchill Livingstone, 1992...

Lung cancer

Apart from non-melanoma skin cancer, lung cancer is the most common cancer in Australia both in terms of incidence and death, accounting for at least 20 of cancer deaths. 1 In the United States it accounts for 35 of cancer deaths in men and 21 of deaths in women. Only 10-25 are asymptomatic at the time of diagnosis but lung cancer can cause an extraordinary variety of clinical symptoms and signs with a reputation for several paraneoplastic syndromes. The paraneoplastic syndromes include...

Pitfalls

Pitfalls include ischaemic heart disease presenting with interscapular pain, herpes zoster at the preemption stage and the various gastrointestinal disorders. Two commonly misdiagnosed problems are a penetrating duodenal ulcer presenting with lower thoracic pain and oesophageal spasm which can cause thoracic back pain. Inflammatory rheumatological problems are not common in the thoracic spine but occasionally a spondyloarthropathy such as ankylosing spondylitis manifests here, although it...

Management of essential tremor

Most patients do not need treatment and all that is required is an appropriate explanation. 1 If necessary, use propranolol (first choice) or primidone 4 . A typical starting dose of propranolol is 40 mg bd many require 120-240 mg day. 4 If the tremor is only intrusive at times of increased emotional stress, intermittent use of benzodiazepines, e.g. lorazepam, 30 minutes before exposure to the stress may be all that is required. Modest alcohol intake, e.g. a glass of scotch, is very effective.

A diagnostic approach

A summary of the safety diagnostic model is presented in Table 34.1 Table 34.1 Thoracic back pain diagnostic strategy model A. Musculoligamentous strains (mainly postural) vertebral dysfunction Q. Serious disorders not to be missed pulmonary infarction Neoplasia A lung (with infiltration) A. metastatic disease Severe infections osteomyelitis Pneumothorax Osteoporosis pancreatic A. Herpes zoster Spondyloarthropathies Fibromyalgia syndrome Polymyalgia rheumatica Chronic infection Q. Is this...

Psychological

AIDS Health understanding Hysteria Hypochondriasis Personality disorders Sensitive issues, e.g. sexuality, bereavement, malignancy Deaf, blind, speech impairment Speech disorders, visual impairment Acutely ill injured Aggrieved, e.g. fees, mistakes Perception of doctor's authority Social class Ethnic group Education Dress However, doctors have a professional responsibility to transcend interpersonal conflict and facilitate productive communication by establishing a...

Depression in the elderly

Severe depression affects 1-2 of the elderly population while 10 have significant depression affecting their life. Milder depression can affect a further 20 . Depression can have bizarre features in the elderly and may be misdiagnosed as dementia or psychosis. Agitated depression is the most frequent type of depression in the aged. 1 Features may include histrionic behaviour, delusions and disordered thinking. Depression is often missed in the elderly because it is atypical and less expressive,...

Specific characteristics

The causes of these signs are listed below. Butterfly 'rash' Erythema, scaling with a discrete red advancing edge on the cheeks and bridge of the nose. The sharp border, lack of pustules and adherent scale make it differ from rosacea. Papules, pustules and telangiectasia on an erythematous background on cheeks, forehead and chin. Painful, erythematous, indurated skin infection with a well-defined raised edge. Red and scaly rash involving eyebrows, eyelids,...

Inspection

Inspection begins from the moment the patient is sighted in the waiting room. A patient who is noted to be standing is likely to have a significant disc lesion. Considerable information can be obtained from the manner in which the patient arises from a chair, moves to the consulting room, removes the shoes and clothes, gets onto the examination couch and moves when unaware of being watched. The spine must be adequately exposed and inspected in good light. Patients should undress to their...

Specific infectious diseases and immunisation

Protection from many types of infection is available through immunisation. All travellers should be immunised against tetanus, polio and diphtheria and measles. Protection against tetanus requires an initial course of three injections followed by a booster every 10 years. Vaccinations are required for special circumstances. Yellow fever vaccination is a legal requirement for any travellers returning from a yellow fever endemic area. Cholera is not usually required. Some travellers may be...

Serious disorders not to be missed

Most of the causes of the acute abdomen are serious and early diagnosis is mandatory to reduce mortality and morbidity. It is vital not to misdiagnose a ruptured ectopic pregnancy, which causes lower abdominal or suprapubic pain of sudden onset, or the life-threatening vascular causes such as a ruptured or dissecting aortic aneurysm, mesenteric artery occlusion and myocardial infarction (which can present as epigastric pain). Perforated ulcers and strangulated bowel, such as volvulus of the...

Thyroidstimulating hormone free thyroxine triiodothyronine

Note Results similar to hyperthyroidism can occur with acute psychiatric illness. * Main tests Raised autoantibodies (antimicrosomal or antithyroid peroxidase) are suggestive of Hashimoto's disease (autoimmune thyroiditis). This is the single most cost-effective investigation in the diagnosis of thyroid nodules. It is the best way to assess a nodule for malignancy. Care needs to be taken in the interpretation of the cytology results in conjunction with an experienced cytologist pathologist. The...

Medication

Explain tactfully that since there is no clinical evidence of inflammation, his NSAIDs can be ceased. Because he is depressed with an anxiety component and insomnia, an antidepressant can be prescribed to be taken at night ( click here for an explanation for the patient). He can be assured that not only will this help his psychological state but it should help 'shut the pain pathway gate' and reverse the overactivity of the nervous system. Patient education including patient education handouts...

Chronic renal failure in children

The incidence of CRF in children is about 2 per million of the total population per year. The commonest causes include chronic glomerulonephritis, obstructive nephropathy and reflux nephropathy. Identification of structural renal abnormalities by obstetric ultrasound and early investigation of urinary tract infections may decrease the incidence of CRF. Dialysis and transplantation are normally considered for children over 2 years of age with end-stage CRF. For children under 2 years there are...

Inspection as a clinical skill

More mistakes, many more, are made by not looking than by not knowing Sir William Jenner (1815-98) General practitioners have an ideal opportunity to practise the art of careful observation and to notice all the signs and features characteristic of a patient from the time seen in the waiting room until the physical examination. We should be 'like Sherlock Holmes' in our analysis of the patient and accept the challenge of being astute diagnosticians and proud members of a noble profession. It is...

Folic acid deficiency

The main cause is poor intake associated with old age, poverty and malnutrition, usually associated with alcoholism. It may be seen in malabsorption and regular medication with antiepileptic drugs such as phenytoin. 3 It is rarely, but very importantly, associated with pregnancy, when the demands of the developing foetus together with the needs of the mother outstrip the dietary intake the so-called 'pernicious anaemia of pregnancy' which, if not recognised and treated immediately, can still be...

Neurological examination

A neurological examination is performed only when the patient's symptoms, such as pain, paraesthesia, anaesthesia and weakness, extend into the leg. The importance of the neurological examination is to ensure that there is no compression of the spinal nerves from a prolapsed disc or from a tumour. This is normally tested by examining those functions that the respective spinal nerves serve, namely skin sensation, muscle power and reflex activity. The examination is not daunting but can be...

Seven masquerades checklist

Depression, diabetes, drugs, spinal dysfunction and urinary tract infection can all cause abdominal pain although the pain may be more subacute or chronic. Abdominal pain and even tenderness can accompany diabetic ketoacidosis. Drugs that can cause abdominal pain are listed in Table 30.4 . Spinal dysfunction of the lower thoracic spine and thoracolumbar junction can cause referred pain to the abdomen (Fig 30.1). The pain is invariably unilateral, radicular in distribution, and related to...

Recurrent or chronic urinary tract infections

Recurrent infections occur as a relapse of a previously treated infection or because of reinfection, often with differing organisms. Persistent (chronic) UTIs indicate that the organism is resistant to the antimicrobial agents employed or that there is an underlying abnormality such as a renal stone or a chronically infected prostate in the male patient. Such infections may be treated with prolonged courses of an appropriate antibiotic or removal of the focus of infection. In men and children...

Masked depression

This is a difficult yet common type of depression in practice and tends to be misdiagnosed. Patients do not complain of the classic symptoms and tend to deny depression, which is perceived as a social stigma and a sign of weakness. They usually have multiple minor complaints of the 'ticket of entry' type. Mood changes may be elicited only after careful questioning. The classic affective features of depression are masked by a complex of somatic complaints. Such symptoms include fatigue anorexia...

Anatomical and clinical features

The functional unit of the thoracic spine is illustrated in Figure 34.1 . It appears that pain from the thoracic spine originates mainly from the apophyseal joints and rib articulations. Any one thoracic vertebra has ten separate articulations, so the potential for dysfunction and the difficulty in clinically pinpointing the precise joint at a particular level are apparent. The costovertebral joints are synovial joints unique to the thoracic spine and have two articulations costotransverse and...

Antidepressant medication

The initial choice of an antidepressant depends on the age and sex of the patient, prior response to medication, safety in overdosage and the sideeffect profile. All antidepressants are equally efficacious. The tricyclics and tetracyclics have been the first-line drugs but the newer drugs, the selective serotonin reuptake inhibitors and moclobemide (a reversible monoamine oxidase inhibitor (MAOI) antidepressant) are equally effective, are better tolerated, have a wider safety margin 6 and are...

A global strategy for good health

The World Health Organisation defines good health as 'a state of dynamic harmony between the body, mind and spirit of a person and the social and cultural influences which make up his or her environment'. Table 9.1 Common causes of deaths in Australia Cerebrovascular disease 10 35 Malignant disease Respiratory disease Accidents, poisoning and violence Digestive disease Source Australian Institute of Health & Welfare, 1996. A considerable amount of epidemiological information has emerged to...

Dementia Pseudodementia

Onset Insidious Clear cut, often acute Course over 24 hours Insight Orientation Memory loss Responses to mistakes Worse in evening or night Worse in morning Present Reasonable Recent remote Gives up easily 'Don't know' Slow and reluctant but understands words (if cooperative) Response to cognitive testing Near miss It is vital to detect depression in the elderly as they are prone to suicide. 'Nothing to look back on with pride and nothing to look forward to.' The middle-aged and elderly may not...

Urinary infections in pregnancy

UTI in pregnant women requires careful surveillance. Asymptomatic bacteriuria should always be excluded during early pregnancy because it tends to develop into a full-blown infection. Acute cystitis is treated for 10 to 14 days with any of the following antimicrobials cephalexin, amoxycillin potassium clavulanate or nitrofurantoin (if a beta-lactam antibiotic is contraindicated). The dosages are the same as for other groups. Asymptomatic bacteriuria should be treated with a week-long course.

Adverse drug reactions

An adverse drug effect is defined as 'any unwanted effect of treatment from the medical use of drugs that occurs at a usual therapeutic dose'. Almost every drug can cause an adverse reaction, which must be elicited in the history. Any substance that produces beneficial therapeutic effects may also produce unwanted, adverse or toxic effects. The severity of the reaction may range from a mild skin rash or nausea to sudden death from anaphylaxis. A study has shown that the incidence of adverse...

Back pain in children

The common mechanical disorders of the intervertebral joints can cause back pain in children, which must always be taken seriously. Like abdominal pain and leg pain, it can be related to psychogenic factors, so this possibility should be considered by diplomatically evaluating problems at home, at school or with sport. Especially in children under the age of 10, it is very important to exclude organic disease. Infections such as osteomyelitis and tuberculosis are rare possibilities, and...

Thoracic back pain

Since learning about the various causes of chest wall pain I am continually amazed about the number of pain syndromes that I am diagnosing as originating from the thoracic spine. I wonder what I was thinking beforehand. RACGP Back Pain Course participant, Brisbane 1986 Thoracic (dorsal) back pain is common in people of all ages including children and adolescents. Dysfunction of the joints of the thoracic spine, with its unique costovertebral joints (which are an important source of back pain),...

Chronic pain

Patients suffering from long-term pain are a special problem, especially those with back pain who seem to be on a merry-go-round of failed multiple treatments and complex psychosocial problems. These patients are frequently treated in pain clinics. As family doctors we often observe an apparently normal, pleasant person transformed into a person who seems neurotic, pain-driven and doctor-dependent. The problem is very frustrating to the practitioner, often provoking feelings of suspicion,...

Connective tissue disorders

The connective tissue disorders or diseases comprise three distinct conditions, namely systemic lupus erythematosus, systemic sclerosis and polymyositis dermatomyositis (Fig 28.1). 1 Mixed connective tissue disorder is that disease which includes features of all three disorders and is sometimes referred to as 'overlap' syndrome. Common features include immunological abnormalities

Dengue fever

Also known as 'breakbone fever', dengue is an arthropod-borne viral disease found mainly in Asia and Africa (click here for further reference). The features are the acute onset of fever, headache, retrobulbar pain, severe backache and aching of muscles and joints. Lymphadenopathy, petechiae on the soft palate and skin rashes may occur. The diagnosis of dengue is based on clinical suspicion and also viral isolation by tissue culture in sera obtained early in the disease. Severe fatigue and...

Explanatory supportive notes for patients and relatives

Most people feel unhappy or depressed every now and again, but there is a difference between this feeling and the illness of depression. Depression is a very real illness that affects the entire mind and body. People cannot seem to lift themselves out of their misery or 'fight it themselves'. Superficial advice like 'snap out of it' is unhelpful, because the person has no control over it. The cause is somewhat mysterious, but it has been found that an important chemical is present in smaller...

Examination screening specific to children

Childhood health record books provide an excellent opportunity for communication between different health care givers parents should be provided with the record books and encouraged to bring them to every visit. Various recommendations for screening are made under the following headings. Height weight head circumference. Record height from age 3 and weight at regular intervals to age 5 years. Record head circumference at birth and then up to 6 months. The adequacy of a child's growth cannot be...

Halitosis

Summary of diagnostic strategy model 1. Dietary habits Orodental disease Dry mouth, e.g. on waking Smoking alcohol 2. Q. Serious disorders not to be missed lung, oropharynx, larynx, stomach, nose, leukaemia Pulmonary tuberculosis Quinsy Lung abscess 1. Nasal and sinus infection Systemic infection Appendicitis Bronchiectasis Hiatus hernia Rarities Pharyngeal and oesophageal diverticula 4. Q. Seven masquerades checklist 5. Q. Is the patient trying to tell me something 1. Possible manifestation of...

Illustrative case history

John R, aged 47, bus driver. Disease-centred problem. Low back pain for 5 months, after sudden onset of left sciatica (now settled) Fig. 11.1 Mr JR site of low back pain and illustration of painful limitation of movement on direction of movement diagram Yes lifting a large suitcase out of the bus. Low lumbar central and unilateral (left), left buttock. Dull ache (severe at times). Has changed from a throbbing burning pain to a deep ache. Present after sitting for long periods and...

Infective discitis and vertebral osteomyelitis

Severe back pain in an unwell patient with fluctuating temperature (fever) should be considered as infective until proved otherwise. Investigations should include blood cultures, serial X-rays and nuclear bone scanning. Biphasic bone scans using technetium with either indium or gallium scanning for white cell collections usually clinch this diagnosis. Strict bed rest with high-dose antibiotic therapy is usually curative. If left untreated, vertebral end plate and disc space collapse is common...

Management guidelines for lumbosacral disorders summary

The management of 'mechanical' back pain depends on the cause. Since most of the problems are mechanical and there is a tendency to natural resolution, conservative management is quite appropriate. The rule is 'if patients with uncomplicated back pain receive no treatment, one-third will get better within 1 week and by 3 weeks almost all the rest of the other two-thirds are better'. 13 Practitioners should have a clear-cut management plan with a firm, precise, reassuring and conservative...

Patient education

Evidence has shown that intervention by general practitioners can have a significant effect on patients' attitudes to a change to a healthier lifestyle. If we are to make an impact on improving the health of the community, we must encourage our patients to take responsibility for their own health and thus change to a healthier lifestyle. They must be supported, however, by a caring doctor who follows the same guidelines and maintains a continuing interest. Examples include modifying diet,...

Physical therapy

Active exercises are the best form of physical therapy (Fig 33.14 a, b). Spinal mobilisation is a gentle, repetitive, rhythmic movement within the range of movement of the joint. It is safe and quite effective (Fig 33.16). Fig. 33.16 Lumbar spinal mobilisation illustration of the effective forces involved REPRODUCED FROM C. KENNA AND J. MURTAGH, BACK PAIN AND SPINAL MANIPULATION, BUTTERWORTHS, SYDNEY, 1989, WITH PERMISSION Spinal manipulation is a high velocity thrust at the end range of the...

Probability diagnosis

The commonest cause of low back pain is vertebral dysfunction, which then has to be further analysed. Muscle or ligamentous tears or similar soft tissue injuries are uncommon causes of back pain alone they are generally associated with severe spinal disruption and severe trauma such as that following a motor vehicle accident. In the lumbar spine most problems originate from either the apophyseal joints or the intervertebral discogenic joint, or from both simultaneously. The disc can cause pain,...

Psychogenic considerations

The patient may be unduly stressed, not coping with life or malingering. It may be necessary to probe beneath the surface of the presenting problem. A patient with low back pain following lifting at work poses a problem that causes considerable anguish to doctors, especially when the pain becomes chronic and complex. Chronic pain may be the last straw for patients who have been struggling to cope with personal problems their fragile equilibrium is upset by the back pain. Many patients who have...

Psychosocial health promotion

The preceding health goals and targets focus mainly on physical illness and do not emphasise mental health. However, this area represents an enormous opportunity for anticipatory guidance. It includes the important problems of stress and anxiety, chronic pain, depression, crisis and bereavement, sexual problems, adolescent problems, child behavioural problems, psychotic disorders and several other psychosocial problems. Time spent in counselling, giving advice, stressing ways of coping with...

Thoracic back pain in children

The most common cause of thoracic back pain in children is 'postural backache', also known as 'TV backache', which is usually found in adolescent schoolgirls and is a diagnosis of exclusion. Important, although rare, problems in children include infections (tuberculosis, discitis and osteomyelitis) and tumours such as osteoid osteoma and malignant osteogenic sarcoma. Dysfunction of the joints of the thoracic spine in children and particularly in adolescents is very common and often related to...

Thoracic back pain in the elderly

Thoracic back pain due to mechanical causes is not such a feature in the elderly although vertebral dysfunction still occurs quite regularly. However, when the elderly person presents with thoracic pain, a very careful search for organic disease is necessary. Special problems to consider are malignant disease, e.g. multiple myeloma, lung, prostate vertebral pathological fractures Paget's disease (may be asymptomatic) o ischaemic heart disease o penetrating peptic ulcer o oesophageal disorders o...

Thoracic disc protrusion

Fortunately, a disc protrusion in the thoracic spine is uncommon. This reduced incidence is related to the firm splintage action of the rib cage. Most disc protrusions occur below T9, with the commonest site, as expected, being T11-T12. The common presentation is back pain and radicular pain that follows the appropriate dermatome. However, disc lesions in the thoracic spine are prone to produce spinal cord compression, manifesting as sensory loss, bladder incontinence and signs of upper motor...

What conditions are often missed

This question refers to the common 'pitfalls' so often encountered in general practice. This area is definitely related to the experience factor and includes rather simple non-life-threatening problems that can be so easily overlooked unless doctors are prepared to include them in their diagnostic framework. Classic examples include smoking or dental caries as a cause of abdominal pain allergies to a whole variety of unsuspected everyday contacts foreign bodies occupational or environmental...

Insulin regimens for type I diabetes

The most commonly used insulin injection preparations are the 'artificial' human insulins. Insulins are classified according to their time course of action rapid-acting and short duration lispro insulin short-acting neutral (regular, soluble) (NPH) or lente mixed short intermediate biphasic (neutral + isophane) It is important to use the simplest regimen for the patient and to provide optimal education about its administration and monitoring. Full replacement of insulin is achieved by using 2,...

Depression

I am ignorant and impotent and yet, somehow or other, here I am, unhappy, no doubt, profoundly dissatisfied In spite of everything I survive. Depressive illness, which is probably the greatest masquerade of general practice, is one of the commonest illnesses in medicine and is often confused with other illnesses. It is a very real illness that affects the entire mind and body. Unfortunately, there is a social stigma associated with depression and many patients tend to deny that they are...

Complications of diabetes

Complications may occur in both type I and type II diabetes even with early diagnosis and treatment (Fig 17.3). Insulin dependent diabetics still have a significantly reduced life expectancy. The main causes of death are diabetic nephropathy and vascular disease (myocardial infarction and stroke). Diabetes causes both macrovascular and microvascular complications but microvascular disease is specific to diabetes. Complications are illustrated in Figure 17.3 . Special attention should be paid to...

Epstein Barr mononucleosis

Epstein-Barr mononucleosis (infectious mononucleosis, glandular fever) (EBM) is a febrile illness caused by the herpes (Epstein-Barr) virus. It can mimic diseases such as HIV primary infection, streptococcal tonsillitis, viral hepatitis and acute lymphatic leukaemia. There are three forms the febrile, the anginose (with sore throat) and the glandular (with lymphadenopathy). It may occur at any age but usually between 10 and 35 years, commonest in 15-25 year old age group. The typical clinical...

Common presenting symptoms

Common presenting symptoms in Australian practices are presented in Table 1.1 , 5 where they are compared with the United States of America. 6 The similarity is noticed but the different classification system does not permit an accurate comparison. In the third national survey of morbidity in general practice in Australia 5 the most common symptoms described by patients were cough (7.5 per 100 encounters), throat complaints (4.7 per 100), back complaints (3.8 per 100) and skin symptoms (3.6 per...

Key facts and checkpoints

HIV is a retrovirus with two known strains that cause a similar spectrum of syndromes HIV1 and HIV2. Always consider HIV in those at risk enquire about history of STDs, injection of illicit drugs, past blood transfusions, sexual activities and partners. About 50 of patients develop an acute infective illness similar to glandular fever within weeks of acquiring the virus (the HIV seroconversion illness). 2 The main features are fever, lymphadenopathy, lethargy and possibly sore throat, and a...

Costovertebral joint dysfunction

The unique feature of the thoracic spine is the costovertebral joint. Dysfunction of this joint commonly causes localised pain approximately 3-4 cm from the midline where the rib articulates with the transverse process and the vertebral body. In addition it is frequently responsible for referred pain ranging from the midline, posterior to the lateral chest wall, and even anterior chest pain. When the symptoms radiate laterally, the diagnosis is confirmed only when movement of the rib provokes...

Bereavement

Bereavement or grief may be defined as deep or intense sorrow or distress following loss. 9 Raphael uses the term to connote 'the emotional response to loss the complex amalgam of painful affects including sadness, anger, helplessness, guilt, despair'. 10 The general practitioner will see grief in all its forms over a wide variety of losses. Although the nature of loss and patient reaction to it varies enormously the principles of management are similar. 1. Shock or disbelief. Feelings include...

Cytomegalovirus infection

Cytomegalovirus (CMV) has a worldwide distribution and causes infections that are generally asymptomatic. The virus (human herpes virus 5) may be cultured from various sites of healthy individuals. It has its most severe effects in the immunocompromised, especially those with AIDS, and also in recipients of solid organ transplants and bone marrow grafts 90 of AIDS patients are infected with CMV and 95 have disseminated CMV at autopsy. CMV infection can be an important development following...

Slump test

The slump test is an excellent provocation test for lumbosacral pain and is more sensitive than the straight leg raising test. It is a screening test for a disc lesion and dural tethering. It should be performed on patients who have low back pain with pain extending into the leg, and especially for posterior thigh pain. A positive result is reproduction of the patient's pain, and may appear at an early stage of the test (when it is ceased). 1. The patient sits on the couch in a relaxed manner....

Rupture of aneurysm

This is a real surgical emergency in an elderly person who presents with acute abdominal and perhaps back pain with associated circulatory collapse (Fig 30.8). The patient often collapses at toilet because they feel the need to defecate and the resultant Valsalva manoeuvre causes circulatory embarrassment. The patient should be transferred immediately to a vascular surgical unit, which should be notified in advance. Two important emergency measures for the 'shocked' patient are intravenous...

Perforated peptic ulcer

Perforation of a peptic ulcer can cause acute abdominal pain both with and without a prior history of peptic ulcer. It is an acute surgical emergency requiring immediate diagnosis. Consider a history of drugs, especially NSAIDs and H2 antagonists. Perforated ulcers may follow a heavy meal. There is The maximal incidence is 45-55 years, most common in males, and a perforated duodenal ulcer is more common than a gastric ulcer. Consider the clinical syndrome in 3 stages 2. reaction (after 2-6...

Urinary infections in the elderly

The typical settings in which UTIs occur in the elderly are in the frail, those who are immobilised, and those with faecal incontinence and inadequate bladder emptying. The presenting symptoms may be atypical, especially with upper UTI where fever of undetermined origin and behaviour disturbances may be a feature. In men obstructive uropathy from prostatism should be excluded by ultrasound. Uncomplicated infections should be treated the same way as for other age groups but no antimicrobial...

Marital disharmony

Family doctors often have to provide marital counselling for one or both partners. The problems may be resolved quite simply or be so complex that marital breakdown is inevitable despite optimal opportunities for counselling. Opportunities for prevention, including anticipatory guidance about marital problems, do exist and the wise practitioner will offer appropriate advice and counselling. Examples include an accident to a child attributable to neglect by a parent, or similar situation in...

Nephropathy

Prevention of diabetic nephropathy is an essential goal of treatment. Early detection of the yardstick, which is microalbuminurea, is important as the process can be reversed with optimal control. The dipstick method is unreliable. Screening is done simply by an overnight collection (10-12 hours) of all urine including the first morning sample. It is sent to the laboratory to determine the albumin excretion rate. Microalbuminurea is 20-200 *g minute (2 out of 3 positive collections). ACE...

Drugs in sport

It is important for general practitioners to have a basic understanding of drugs that are banned and those that are permissible for elite sporting use. The guidelines formulated by the International Olympic Committee (IOC) Medical Commission are generally adopted by most major sporting organisations. 7 Tables 18.4 and 18.5 provide useful guidelines. The IOC's list of prohibited drugs is regularly revised. Banned classes of drugs include stimulants, narcotics, anabolic agents, diuretics and...

Not to be missed

A special problem with the thoracic spine is its relationship with the many thoracic and upper abdominal structures that can refer pain to the back. These structures are listed in Table 34.2 but, in particular, myocardial infarction and dissecting aneurysm must be considered. Table 34.2 Non-musculoskeletal causes of thoracic back pain duodenum (including ulcers) The acute onset of pain can have sinister implications in the thoracic spine where various life-threatening cardiopulmonary and...

Low back pain

Last Wednesday night while carrying a bucket of water from the well, Hannah Williams slipped upon the icy path and fell heavily upon her back. We fear her spine was injured for though she suffers acute pain in her legs she cannot move them. The poor wild beautiful girl is stopped in her wildness at last. Low back pain accounts for at least 5 of general practice presentations. The most common cause is minor soft tissue injury, but patients with this do not usually seek medical help because the...

Acute seroconversion illness

At least 50 of patients have an acute illness associated with seroconversion. The illness usually occurs within 6 weeks of infection and is characterised by fever, night sweats, malaise, severe lethargy, anorexia, nausea, myalgia, arthralgia, headache, photophobia, sore throat, diarrhoea, lymphadenopathy, generalised maculoerythematous rash and thrombocytopenia. Neurological manifestations including meningoencephalitis and peripheral neuritis are commonly observed. Acute HIV infection should be...

A heartsink survival kit

A pilot workshop of managing 'heartsink' patients described by Mathers and Gask 4 led to the formulation of a 'heartsink survival' model for the management of patients with somatic symptoms of The first part of the three-part model, which is called 'feeling understood', includes a full history of symptoms, exploration of psychosocial cues and health beliefs, and a brief focused physical examination. In the second stage, termed 'broadening the agenda', the basic aim is to involve discussion of...

Gout monosodium urate crystal disease

Dip Joint Touching

Gout is an abnormality of uric acid metabolism resulting in hyperuricaemia and urate crystal deposition. Urate crystals deposit in joints acute gouty arthritis soft tissue tophi and tenosynovitis urinary tract urate stones Four typical stages of gout are recognised Stage 1 intercritical gout (intervals between attacks) chronic tophaceous gout and chronic gouty arthritis Asymptomatic hyperuricaemia 10 times more common than gout 7 elevated serum uric acid (> 0.42 mmol L in men, > 0.36 mmol L...

Anatomical and pathophysiological concepts

Recent studies have focused on the importance of disruption of the intervertebral disc in the cause of back pain. A very plausible theory has been advanced by Maigne 3 who proposes the existence, in the involved mobile segment, of a minor intervertebral derangement (MID). He defines it as 'isolated pain in one intervertebral segment, of a mild character, and due to minor mechanical cause'. It is independent of radiological and anatomical disturbances of the segment. The most common clinical...

The masquerades

It is important to utilise a type of fail-safe mechanism to avoid missing the diagnosis of these disorders. Some practitioners refer to consultations that make their 'head spin' in confusion and bewilderment, with patients presenting with a 'shopping list' of problems. It is in these patients that a checklist is useful. Consider the apparently neurotic patient who presents with headache, lethargy, tiredness, constipation, anorexia, indigestion, shortness of breath on exertion, pruritus,...

The face as a mirror of disease

A fascinating aspect of the art of clinical medicine is the clinical interpretation of the patient's facies. Not only are specific skin lesions common on the face but the face may also mirror endocrine disorders and organ failure such as respiratory, cardiac, renal and liver failure. Jaundice may be masked by the natural colour of the cheeks but the yellow conjunctivae will be distinctive. A marked plethoric complexion may be seen in chronic alcoholics (alcohol may produce a pseudo-Cushing's...

Interpreting body language 11

Barrier Signals Body Language

The interpretation of body language, which differs between cultures, is a special study in its own right but there are certain cues and gestures that can be readily interpreted. Examples illustrated include the depressed patient (Fig. 4.7), barrier-type signals often used as a defensive mechanism to provide comfort or indicate a negative attitude (Figs 4.8 a,b,c) and a readiness gesture indicating a desire to terminate the communication (Fig. 4.9). Fig. 4.7 Posture of a depressed person head...

Intussusception

Intussusception Sausage Shaped Mass

Intussusception is the diagnosis that should be foremost in one's mind with a child aged between 3 months and 2 years presenting with sudden onset of severe colicky abdominal pain, coming at intervals of about 15 minutes and lasting 2-3 minutes. Early diagnosis, within 24 hours of the onset, is essential, for after this time there is a significant rise in morbidity and mortality. It is due to telescoping of the segment of bowel into the adjoining distal segment, e.g. ileocaecal segment,...

Tests for nonorganic back pain

Several tests are useful in differentiating between organic and non-organic back pain (e.g. that caused by depression or complained of by a known malingerer). Magnuson's method (the 'migratory pointing' test) 1. Request the patient to point to the painful sites. 2. Palpate these areas of tenderness on two occasions separated by an interval of several minutes, and compare the sites. Between the two tests divert the patient's attention from his or her back by another examination. Paradoxical...

Abdominal pain

A great fit of the stone in my left kidney all day I could do but three or four drops of water, but I drunk a draught of white wine and salet oyle, and after that, crabs' eyes in powder with the bone in the carp's head and then drunk two great draughts of ale with buttered cake and I voyded with an hour much water and a stone as big as an Alexander seed. God by thanked Abdominal pain represents one of the top 15 presenting symptoms in primary care 1 and varies from a self-limiting problem to a...

Hyperthyroidism

Lethargy, tiredness Dry skin Husky voice Myofibrositis Musculoskeletal Myalgia Ischaemia Cardiomegaly Pericardial effusion Bradycardia Hyperlipidaemia Menstrual irregularity Menorrhagia mainly Oligomenorrhea Myxoedema coma Postanaesthetic hypoventilation Reduced libido Weight gain Cold intolerance Warm, thin, soft, moist skin Vitiligo Tachycardia Atrial fibrillation Heart failure Systolic hypertension Reduced libido Eye signs Fever uncommon Premature grey hair Weight loss Hashimoto's disease...