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...

References

In MIMS Disease Index (2nd edn). Sydney IMS Publishing, 1996, 139-141. 2. Davies B. An introduction to clinical psychiatry. University of Melbourne, 1977, 76-77. 3. Serry DK, Serry M. Masked depression and the use of antidepressants in general practice. Med J Aust, 15 February 1969, 35-37. 4. Depression Masked or missed Patient Care, Oct 1972, 1(3) 6-14. 5. Robinson MJ. Practical paediatrics (2nd edn), Melbourne Churchill Livingstone, 1990, 552-553. 6. Moulds...

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

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

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...

Seven masquerades checklist

Of these conditions, depression and urinary tract infection have to be seriously considered. For the young woman with upper lumbar pain, especially if she is pregnant, the possibility of a urinary tract infection must be considered. These patients may not have urinary symptoms such as dysuria and frequency. Depressive illness has to be considered in any patient with a chronic pain complaint. This common psychiatric disorder can continue to aggravate or maintain the pain even though the...

Pitfalls

A very common pitfall is misdiagnosing acute appendicitis, especially in the elderly, in children, in pregnancy and in those on steroids, where the presentation may be atypical. Early appendicitis presents typically with central abdominal pain that shifts to the right iliac fossa RIF some 4 to 6 hours later. This causes confusion early on. It can cause diarrhoea with abdominal pain, especially if a pelvic appendix, and can be misdiagnosed as acute gastroenteritis. Disaccharidase deficiencies...

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...

Constipation

If opioids need to be maintained, the laxatives need to be peristaltic stimulants, not bulkforming agents. Aim for firm faeces with bowels open about every third day. e.g. senna Senokot 2 daily or bd bisacodyl Durolax 5-10 mg bd Rectal suppositories, microenemas or enemas may be required, e.g. Microlax. Shaw's cocktail is useful for severe constipation. With a small quantity of water melt one tablespoon of Senokot granules in a microwave oven. Add 20 mL Agarol and constitute to 100 mL with cold...