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MESSAGES/PREFACE

Singapore International Foundation 2004


Published by
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First Published June 2004


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ISBN 981-04-9688-5

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is not intended for commercial sale.

CONTENTS
Foreword by Minister for Health, Indonesia
Message from President, Indonesian Medical Association
Message from Chairperson, Indonesian Association of Family Physicians
Message from Chairman, Board of Governors, Singapore International Foundation
Message from Chief Executive Officer, World Organisation of Family Doctors (Wonca)

PREFACE
SVO Specialist Team (Family Medicine) Project Leader and Wonca Regional
President, Asia Pacific Wonca
Country Representative, Indonesia

10

SECTION 1 HEALTHCARE DELIVERY SYSTEM IN INDONESIA

13

SECTION 2 FAMILY MEDICINE ORIENTED PRIMARY CARE


1. Vision of Family Medicine Oriented Primary Care
2. Introducing Family Medicine to Health Care Systems
3. A Training Programme for Indonesia

23

SECTION 3 PACKET A CONCEPTS OF FAMILY MEDICINE


1. The Central Values of Family Medicine
2. Personal Care, Continuing Care and Comprehensive Care
3. Family as a Unit of Care
4. Emergency Care, Housecalls and Home Care
5. Palliative Care

41

SECTION 4 PACKET B MANAGING THE FAMILY MEDICINE PRACTICE


1. Managing People & Resources
2. Managing Facilities & Utilities
3. Managing Information
4. Managing Finances, including Managed Care

77

SECTION 5 PACKET C MEDICAL TECHNICAL SKILLS & CARE IN


SPECIFIC SITUATIONS (A) PRACTICE SKILLS
1. The Consultation Process
2. Communication Skills
3. Counselling Skills
4. Changing Behavior
5. Disease Management Skills
6. Emergency Care Skills

111

MESSAGES/PREFACE

SECTION 6 PACKET C MEDICAL TECHNICAL SKILLS & CARE IN


SPECIFIC SITUATIONS (B) COMMON SYSTEMS
1. Fatigue
11. Vomiting
2. Weight Loss
12. Abdominal Pain
3. Fever
13. Skin Rash
4. Dyspepsia
14. Backache
5. Breathlessness
15. Joint Pain
6. Cough
16. Giddiness
7. Sorethroat
17. Headache
8. Chest Pain
18. Insomnia
9. Diarrhoea
19. Persistently Crying Baby
10. Constipation
20. Red Eye

167

SECTION 7 PACKET C MEDICAL TECHNICAL SKILLS & CARE IN


SPECIFIC SITUATIONS (C) SPECIFIC DISORDERS
1. Cardiovascular and Respiratory Disorders
2. Gastrointestinal Disorders
3. Renal and Hematological Disorders
4. Psychological Disorders
5. Skin Disorders
6. Bone and Joint Disorders
7. Nervous System, Eye and Ear Disorders
8. Nutritional, Metabolic and Endocrine Disorders

257

SECTION 8 PACKET D APPLIED MEDICINE IN THE VARIOUS


AGE GROUPS
1. Child and Adolescent Health
2. Womens Health
3. Mens Health
4. Health of the Working Adult
5. Elders Health
6. Public Health

361

SECTION 9 TEACHING FAMILY MEDICINE


1. Tasks of Teaching
2. Curricular Planning
3. Organising the Workshop
4. Giving a Lecture
5. Small Group Teaching
6. One-to-one Teaching
7. Formative and Summative Assessments

477

SECTION 10 ROADMAP OF FAMILY MEDICINE RESEARCH

501

FOREWRD
FAMILY MEDICINE ORIENTED PRIMARY CARE IN INDONESIA
I am pleased to write this foreword. Indonesia is a huge country sometimes referred to as
the country of a thousand islands. Making health care accessible and affordable is the
responsibilility and great challenge of any Government.
The solution lies in the development of a common vision amongst the various stakeholders
in Government, Professional, Voluntary and Private Sectors. The integration of health
promotion and disease prevention, cure and care services, as well as health care system and
health financing reforms are the operational aspects to the solution.
The present health care delivery system in this country has been built around the twin pillars
of public health and hospital specialist care. WHOs Health for All movement introduced
through the Alma Ata Declaration in 1978 created a paradigm shift of making primary care
the central focus of healthcare delivery for each country. This is the bridge between the two
pillars, which in my opinion would integrate the whole spectrum of health care. This bridge
is now strengthened by the development of Family Medicine oriented prmary care.
The developement of a general practice/family medicine practice to meet the needs of
people has been taking place around the world in the last thirty years. This gathered
momentum with the formation of Wonca as the world forum for family doctors. General
practice/family medicine and its concepts are not new, but nevertheless require a
renaissance to bridge the twin pillars of modern public health and hospital specialist care.
Indonesia sees the need to develop its general practice/family medicine practice too. In this
context, I am pleased that the various stakeholders in healthcare delivery have got together
and with the fillip provided by the Singapore International Foundation and Wonca Family
Medicine leaders in this part of the world have begun to make an impact.
The gift of this Primer on family Medicine Practice from the Singapore International
Foundation will help to speed up the capacity building of our frontline doctors to provide
Family Medicine oriented primary care. I am told that it will be the forerunner of a Primer
written in Bahasa Indonesia by Indonesian Family Medicine leaders.
Finally. I must thank the Singapore International Foundation and through them, the Lee
Foundation who funded the printing of this project, the Family Medicine leaders in
Singapore and in this country, the various healthcare stakeholders for pursuing the vision of
Family Medicine oriented health care in Indonesia. May I wish you great success in this
journey into the future.
Dr Achmad Sujudi
Minister for Health
Republic of Indonesia
Jakarta
5

MESSAGES/PREFACE

MESSAGE FROM PRESIDENT,


INDONESIAN MEDICAL ASSOCIATION
The move to expand Family Medicine in Indonesia began in the early 1980s following a
decision made in the 1982 national meeting of the Indonesian Medical Association (IMA).
But over the last two decades, the development of Family Medicine in Indonesia has not
made significant achievements. The fragmentation in the development of Family Medicine
and the lack of resources in health care delivery system development are two main reasons
identified. The development of Family Medicine in Indonesia should be managed together
with the involvement of all stakeholders with the IMA playing an important role. Family
Medicine is now listed as a top priority programme of the IMA.
There are many things to do. This Primer on Family Medicine Practice as a product that
resulted from the technical cooperation between the Singapore International Foundation
(SIF) and the Ministry of Health Republic of Indonesia together with the Indonesian
Association of Family Physicians (IAFP), is one of the fundamental and strategic steps of
achievement.
On behalf of IMA, I express my appreciation and sincere gratitude to the SIF and the SVO
Specialist (Family Medicine) Team for their assistance in providing this Primer on Family
Medicine Practice as a part of an important phase in the development of Family Medicine in
Indonesia.
My heartfelt thanks go to the writers for their work that makes this book a very valuable
thing for expanding Family Medicine in Indonesia.
Professor Dr. Farid Anfasa Moeloek, Obgyn
President
Indonesian Medical Association
Jakarta

MESSAGE FROM CHAIRPERSON,


INDONESIAN ASSOCIATION OF FAMILY PHYSICIANS
It was two decades ago when the Indonesian Medical Association (IMA) affirmed the need
for developing Family Medicine in Indonesia in the framework of restructuring the
healthcare system in Indonesia. But the situation at that time was different. Policies and
programmes were not suitable enough for the advancement of the Family Medicine. Many
fragmented efforts were made, but did not achieve good results.
The situation is changing today. Since 1998, following a Letter of Understanding between
the Ministry of Health Republic of Indonesia (MOH-RI) and the Singapore International
Foundation (SIF) Republic of Singapore, Indonesia has developed many programmes
designed to facilitate the development of Family Medicine in Indonesia. The SVO Specialist
(Family Medicine) Team, the MOH-RI together with the Indonesian College of Family
Physicians (now renamed by the Indonesian Association of Family Physicians) have
conducted training programmes for practitioners and trainers in Family Medicine, and
based on the above experiences, they have also developed this Primer on Family Medicine
Practice.
Within the context of overall development, and in line with the new national health system,
the development of Family Medicine is increasingly recognised as a major priority. With the
focus to develop Family Medicine, this Primer on Family Medicine Practice undoubtedly
reflects high interest that this vital programme takes off successfully.
On behalf of the Indonesian Association of Family Physicians, I wish to express my sincere
thanks to the SIF and the MOH-RI for their efforts to provide this book. It also conveys a
feeling of great hope and optimism that this book will bring improvement in the
development of Family Medicine in Indonesia.
Professor Dr. Azrul Azwar, MPH
Chairperson
Indonesian Association of Family Physicians
Jakarta

MESSAGES/PREFACE

MESSAGE FROM CHAIRMAN, BOARD OF GOVERNORS,


SINGAPORE INTERNATIONAL FOUNDATION
The Singapore International Foundation is pleased, through the SVO Specialist Team (Family
Medicine) Project, to be able to contribute to the development of Family Medicine oriented
primary care in Indonesia.
Started in 1998, the collaboration between Family Medicine leaders from Indonesia and
Singapore seeks to introduce and reinforce the core precepts in the practice of Family
Medicine oriented primary care to stakeholders in the Indonesian health sector. Using the
approach of Training of Trainers to build capacity, our Singaporean volunteer team and its
Indonesian partners have worked untiringly at upgrading the skills and knowledge of
practising family physicians and trainers in the Universities.
Their steadfast efforts have paid off. There is now a perceptible acceptance and
implementation of Family Medicine oriented primary care by both Indonesian medical
educators and practising family doctors. Through the process of forming, storming,
norming, and performing, the Indonesian Association of Family Physicians together with
the Ministry of Health, have developed a four-packet Family Medicine oriented primary care
training programme. Packet A with its focus on imparting the concepts of family medicine
and Packet B that focuses on the management of services have been introduced. Packet C
that focuses on medical technical skills and Packet D that focuses on applied medicine in
the various age groups of the population are next to be rolled out.
To commemorate the successful completion of this significant partnership project, the
Singapore International Foundation is pleased to publish this book as a resource guide for
the development of the four packets of Family Medicine oriented primary care programme
in Indonesia. Together with our corporate partner, the Lee Foundation Community Abroad
Assistance Fund, we are honoured to present it as a gift to Family Medicine doctors of
Indonesia and their patients.
I also have the pleasure to record our thanks to Associate Professor Goh Lee Gan, his team
members and their Indonesian partners for not only putting this book together, but also for
demonstrating the rewards of bringing people from different communities and cultures
together to learn from one another in a spirit of mutual respect and growth.
Mr Barry Desker
Chairman, Board of Governors
Singapore International Foundation
Singapore

MESSAGE FROM CHIEF EXECUTIVE OFFICER,


WORLD ORGANISATION OF FAMILY DOCTORS (WONCA)
I am pleased to contribute a message to this Primer on Family Medicine Practice as the CEO
of the World Organisation of Family Doctors (Wonca). This Primer represents an important
step forward in the development of Family Medicine in Indonesia as well as a milestone in
the collaboration between the primary care medical professions of Indonesia and
Singapore.
Family Medicine is an important bridge between hospital care and public health. Countries
around the world have paid much attention to develop both hospital care and public
health. The missing link to a seamless system of care is the healthcare provider (the
vocationally trained Family Doctor) who is focused on the patient as an individual and as a
member of the family unit that he or she belongs to. It is therefore timely that Indonesia
sets its vision to develop this bridge.
Well-trained family doctors can help to save costs for the nation in three ways. Firstly, by
being judicious gatekeepers, they help to relieve the overloaded hospitals and reduce
ballooning hospital care costs. Secondly, the preventive focus of family medicine will help to
reduce the disease burden from chronic diseases like hypertension, diabetes mellitus and
the resultant complications of ischaemic heart disease, strokes, renal failure and blindness.
And finally, family medicine has the best chance among the stakeholders of healthcare
delivery to persuade all other stakeholders, namely, the policy maker, the healthcare
professional, the academician, the health care manager, and the community to work
together towards the unity for health (TUFH). The savings of healthcare costs are likely to be
substantial if each of the stakeholders pulls his or her weight in the same direction, instead
of different directions. This is the vision of TUFH as a collaborative project of Wonca and
WHO - working towards unity for health.
The Family Medicine programme in Indonesia is now gathering good momentum. It has
designed its curriculum of training consisting of four packets of modular Family Medicine
training programme. There are now some 89 trainers exposed to family medicine teaching,
thanks to the efforts of the Singapore International Foundation. And the universities in
Indonesia are now looking into introducing Family Medicine into its undergraduate
programme.
This Primer would have served its purpose if each copy is read and used extensively. It will
be a catalyst for more development in Family Medicine oriented primary care in Indonesia.
My best wishes in your future endeavours in the development of Family Medicine.
Dr Alfred WT Loh
Chief Executive Officer
World Organisation of Family Doctors (Wonca)
Singapore

MESSAGES/PREFACE

PREFACE FROM SVO SPECIALIST TEAM (FAMILY MEDICINE)


PROJECT LEADER & WONCA REGIONAL PRESIDENT, ASIA PACIFIC
This Primer on Family Medicine Practice is a milestone in the development of Family Medicine
oriented primary care in Indonesia. The knowledge base of Family Medicine is broad.
A Primer is a first book. It is a road map that has sufficient details, but without being
bogged down by minutiae.It is a starting point from which the reader will be directed to
further readings and the school of life to acquire the experiential skills of caring for patients
in the Family Medicine oriented way. The contents of this Primer has been organized with
the Indonesian Family Medicine Teaching Programme in mind namely, the four-packet
modular system.
It has been written in English because it is the fastest way to get the body of knowledge
together in the time available. Hopefully, it can be translated and expanded to meet the
needs of the family doctors as time goes on. As has been pointed out by my colleague Dr
Sugito whom I have worked closely in this SIF project, the content is likely to change over
time as knoweldge and care situations change. It would then be time to write a new Primer,
this time in Bahasa Indonesia.
Thanks are due to my many colleagues and friends in Indonesia who have been the
fountain of strength and source of encouragement that made the effort of producing this
Primer meaningful. In particular I would like to thank Professor Azrul, Dr Widyastuti, Dr
Sugito, Dr Lucky, Dr Nitra, Dr Dhanasari, Professor Asiniati, Dr Donald Padede, Dr Erna
Mulati, Dr Trisa Wahjuni Putri, Dr Zulnilda, Dr Yulherina and Dr Ferlindah for their unstinting
support, encouragement and hospitality. I hope I have not missed out anybody.
Thanks are due to my many friends, my colleagues in the Family Medicine world and the
Wonca world both in Singapore, Philippines, Australia and beyond as well as my colleagues
in the hospital specialities in Singapore for their written resources. To each of them, too
many to mention by name, I gratefully acknowledge the resources used.
I would also need to thank the Chairman and Director of the Singapore Volunteers
Overseas (SVO) Programme in the Singapore International Foundation for the opportunity
to lead this Family Medicine Project with the Ministry of Health in Indonesia. In particular, I
would like to thank the many SIF staff, both present and past, all of whom I have great
satisfaction in working with. They are Ms Lee Mui Ngah, Ms Coleen Beck, Ms Rosemary
Chng and Ms Lydia Ang. Grateful thanks are due to Mr Tan Beng Seng and his staff from
Onion Design Pte Ltd who have worked hard to get this Primer out of the press within the
really narrow margins of time that I have given them. I must not forget to thank Lee
Foundation Community Abroad Assistance Fund who have generously sponsored the
printing of this Primer.
Associate Professor Goh Lee Gan
SVO Specialist (Family Medicine) Team Leader
Wonca Regional President, Asia Pacific
Singapore
10

PREFACE FROM COUNTRY REPRESENTATIVE WONCA, INDONESIA


The principles of Family Medicine, albeit in parts, have long been implemented in
Indonesia and could be in any other countries as well, Most general practitioners, since the
early years of medical education, namely, during their undergraduate schooling and
training, have been introduced to the practice of medicine in the family doctors way. In my
opinion, Family Medicine is the generic of medicine and family doctor is the generic of
medical doctor. Since specialties are in fact the branches of medicine, they are also the
branches of Family Medicine. This rationale implies that the practice of medicine, in any
specialty and general practice is included, there should be the learning of the principles of
Family Medicine. This is the only way to establish an effective and efficient health care
delivery system that leads to quality health care. Family Medicine oriented health care
service in not only primary care but also secondary, and tertiary care is considered
fundamental. This becomes the unifying aspect of health care - a service delivery that pays
attention not only to cure but also prevention; a service that is more than caring for diseases
in disordered organs.
Community oriented medical services instead of individual, family, and community
oriented medical services has been introduced for long time in many countries including
Indonesia in accordance with WHO policy. Indonesian undergraduate medical teaching
has been set to produce doctors who will deliver community oriented medical services;
most of the graduates will then work in a community or public health centres (PHC)
provided by government. As a consequence individual and family oriented medical
services, and the other Family Medicine services especially the coordinative and
collaborative cares is not given enough emphasis. District oriented PHC have been
established throughout the country and they effectively provide community oriented
health care services; they do fortunately make available individual medical care as well. In
the meanwhile, most general practices are held by solo practice general practitioners
who are formerly, during their undergraduate education, conditioned to deliver
community oriented health services. However some general practitioners naturally apply
family practice principles in serving their patients although not in the complete setting of
Family Medicine oriented practice. Thus, in my opinion, instead of entirely new medical
entity, Family Medicine is an attempt to go back to the origin of medicine. It is a
renaissance of medicine and is welcomed.
The other problems in Indonesia are the large number of private and new state faculty of
medicine with varying quality of training, which in turn produce a large number of new
medical doctors each year with varying quality of professional skills. The standardization of
competence and services is therefore mandatory. In addition, by the emergence of Family
Medicine as a new paradigm in providing quality medical services, addditional and
conditional training to be a family physician or family doctor, must be considered
obligatory. This book will be very useful in providing the beginning of such standardization
and additional training.

11

MESSAGES/PREFACE

In early 1980s, the Study Group on Family Medicine (Indonesian Study Group on Family
Medicine = ISGFM) was established. It gave additional training on Family Medicine
especially in the principles of family practice. At the same time in a smaller proportion,
clinical issues were also discussed in a seminar-like training given by the relevant specialists.
It was quite successful to generate awareness among general practitioners in the
importance of Family Medicine principles and their implementation. At that early time, to
accelerate the dissemination, the ISGFM joined the WONCA world. In 1990, the ISGFM
organised WONCA Regional Asia-Pacific Conference and the study group decided to
change the name of the group to the Indonesian College of Family Physicians (ICFP). This
is a milestone in the development of family practice in Indonesia. It took a long time to
write a standard training curriculum to provide an accountable systematic training that
can be audited appropriately. Medical doctors who have been passed the entire program
will then be certified as family physician.
In accordance wth the consensus in WONCA Regional ASPAC program and the help of the
College of Family Physicians, Singapoe (CFPS), and in collaboration with Singapore
International Foundation (SIF), several Training of Trainers have been conducted which
results in the certification of 98 peoples to be trainers. Some of the certified trainers are
now actively teaching or training other colleagues. This book will help trainers in such
training to plan the training more effectively.
Finally in 2002, the standard curriculum is finished and printed with the compliments of
Indonesian Department of Health. It consists of four packages, those are:

Packet
Packet
Packet
Packet

A
B
C
D

Dealing
Dealing
Dealing
Dealing

with
with
with
with

the Principles of Family Medicine


Managing the Family Medicine Practice
Medical Technical Skills and Care in Specific Situations
Applied Medicine in the Various Age Groups

To maximise the usefulness of this Primer, the topics have been arranged in line with the
curriculum. Thus, you will find all the packets in similar sequential arrangement. This book
is set in a practical layout that make it easy to follow the stream of learning. Both
practitioners and trainers can use this book productively; practitioners can use it as quick
reference in their daily practice and trainers can use it to plan the training programme for
their trainers to reach the standard of competence. But, it has to be wisely used since this is
only a handbook with limited contents. For further information you can read the current
literature available at the end of each topic or chapter. No one is an island; your self help
and efforts are needed to complete the content of this book.
Acknowledgement is addressed to SIF who have encouraged us to finish and publish this
book; and provide the financial supports as well. A lot of thanks are also addressed to the
College of Family Physicians, Singapore especially to Associate Professor Goh Lee Gan who
has helped wholeheartedly to finish this book.
Dr Sugito Wonodirekso
Wonca Country Representative, Indonesia
Jakarta
12

A PRIMER ON

F A M I LY
MEDICINE
PRACTICE

Edited by
Goh Lee Gan
Azrul Azwar
Sugito Wonodirekso

13

SECTION 01

THE PRESENT STATUS OF


HEALTHCARE SERVICES IN INDONESIA

13

SECTION 01
SECTION 01 THE PRESENT STATUS OF THE HEALTHCARE SERVICES IN INDONESIA

CHAPTER 1

THE PRESENT STATUS OF


HEALTHCARE SERVICES
IN INDONESIA

By Prof. Dr. Azrul Azwar MPH


Chairperson, the Indonesian Association of Family Physicians
Outline
National health development program
Brief description of the country
National health status
Public health services
Medical care services
Financing of health services

NATIONAL HEALTH DEVELOPMENT PROGRAM


The general objective of the National Health Development Program in Indonesia as
stipulated in the National Health System is to provide a healthy life for all Indonesians.
The specific objectives of the National Health Development Program in Indonesia are:

To
To
To
To
To

enable people to maintain their own health and live a healthy and productive life
promote an environment conducive to the health of the people
promote good nutrition among the people
decrease morbidity and mortality
promote a healthy and prosperous family life

To achieve these objectives, various healthcare efforts have been implemented, including
among others, the strengthening of the healthcare delivery system as part of an overall
health development program. This is being carried out both by government and the
private sector. This paper aims to assess the present status of the healthcare services
in Indonesia.

BRIEF DESCRIPTION OF THE COUNTRY


Indonesia is the worlds largest archipelago, extending between two continents, Asia to
the North and Australia to the South. It lies between two oceans, the Indian to the West
and the Pacific to the East. The distance from the west to the east point of Indonesia is
3,200 miles, and the distance from the North to the South is 1,100 miles. The total area
of Indonesia is 5,193,260 square miles, covering both land and sea territories. The total
land area is an approximately 1,904,650 square miles, comprising 13,677 islands of
which only 7.25% (992 islands) are inhabited. Almost 85% of the total land area is
included in the five main islands, Kalimantan (the biggest), Sumatera, Papua, Sulawesi
and Java.
Because Indonesia lies along the equator, the climate is tropical, with high humidity, slight
changes in temperature and heavy rainfall. Except at higher elevations, the temperature

14

generally ranges from 20 to 30 Centigrade. Humidity ranges from 60% to 90%. Table 1
summarizes the physical features of Indonesia.
Table 1. Physical Conditions of Indonesia
PHYSICAL CONDITION

FIGURES

Total area (sq ml)


Land area (sq ml)
Number of islands
Number of islands inhabited
Temperature (celsius)
Humidity (%)

5,193,260
1,904,650
13,677
992
20-30
60-90

Indonesia gained its independence on August 17, 1945, after more than three and a half
centuries of occupation by the Dutch and a further three and a half years by the
Japanese. Indonesia is a republic, with a President as head of state, chosen by the
Peoples Consultative Assembly every five years. The capital city is Jakarta, situated on the
island of Java.
Administratively, Indonesia is divided into 32 provinces, each with a legislative council
and headed by a Governor. The provinces are divided into Districts and Municipalities,
each with a legislature and headed by a Bupati for the regencies and a Walikota for the
municipalities. At present, there are 243 districts in Indonesia, while the total number of
municipalities is 61.
East district and municipality is divided into sub-districts, headed by a Camat, and is
further divided by villages. Each village is headed by a Lurah and divided into hamlets
which, in turn, are further divided by neighborhoods. The villages (except in the big
cities), hamlet and neighborhood groupings are headed by elected persons who serve in
a voluntary capacity. At present, the total number of sub-districts in Indonesia is 3,839
and the total number of villages amount to 65,554. Provinces, districts and municipalities
are autonomous regions with administrative responsibilities. They have to finance public
services, including the health sector, in their respective area of responsibility. The
information about the administrative divisions of Indonesia, mentioned above, is
summarized in Table 2.
Table 2. Administrative Divisions of Indonesia
ADMINISTRATIVE DIVISIONS

NUMBERS

Number
Number
Number
Number
Number

32
243
61
3,839
65,554

of
of
of
of
of

Provinces
Districts
Municipalities
Sub-districts
Villages

The total population of Indonesia in 2000 was 203,456,005, making it the fourth most
populous country in the world. The rate of population increase is 1.34%. The population
distribution is uneven, with about 59.3% of the population live on Java Island, although
Java occupies only 7% of the total land area. About 69.1% of the people live in rural
areas, where health facilities and most other public infrastructure are unsatisfactory.
15

SECTION 01 THE PRESENT STATUS OF THE HEALTHCARE SERVICES IN INDONESIA

Indonesians are basically of Malay heritage and are divided into approximately 300 ethnic
groups, about 360 languages and dialects. Islam is predominant religion and the national
language is Bahasa Indonesia. Indonesia has passed law providing compulsory education
for children. Primary school enrollment rate is 97%. It is estimated that around 15.9% of
the population is illiterate.
The main occupation of majority of the people is in agriculture. The primary sources of
governments income are from export revenues of oil, LNG (liquefied natural gas) and
lumber. The annual growth rate is running at an average rate of 4%, and the GNP per
capita in 2000 is US$680. Information about the social and economic condition of
Indonesia can be seen in Table 3.
Table 3. Socio-Economic Condition, the Year 2000 Figures
SOCIAL & ECONOMIC CONDITION

FIGURES IN 2000

Total population (millions)


Rate of population increase (%)
No. of people living in rural areas (%)
Ethnic groups
Moslem(%)
Literacy rate(%)
Primary school enrolment rate(%)
Annual economic increase rate (%)
GNP per capita (US$)

203.5
1.35
57.7
300
90
84.1
97
4
680

NATIONAL HEALTH STATUS


Due perhaps to the fact that Indonesia is still a developing country, the present condition
of Indonesian healthcare remains unsatisfactory although there have been major
improvements compared to two decades ago. Various health indicators for Indonesia can
be seen in Table 4.
Table 4: Health Status Indicators for Indonesia
INDICATOR/VARIABLE

YEAR

FIGURES

Infant mortality rate per 1000 live births


Under five mortality rate per 1000
Maternal mortality rate per 100.000 live births
Crude death rate per 1000
Life expectancy male
female
Low birth weight (%)
Protein Calorie Deficiency per 100 Underfives
Clean water supply per 100 population
Latrines per 100 population
Percentage EPI coverage

1993
1993
1993
1994
1993
1993
1993
1993
1986
1986
1993

58.0
81.0
425
6.0
60.8
64.6
15.0
40.0
30.0
37.9
93.6

The primary cause of death in Indonesia since 1995 is cardiovascular diseases that now
overtake predominant infectious diseases, reflecting the double burden faced today.
16

The pattern of death in Indonesia is still strongly related to general poverty, low income
per capita, high rates of illiteracy and various socio-cultural factors. According to
Household Health Surveys, the 10 leading diseases in the country are: acute respiratory
tract infection, diseases of skin, diseases of teeth, mouth and gastro-intestinal tract, other
infectious diseases, bronchitis-asthma and other disease of respiratory tract, malaria,
nerve disorders, cardiovascular disorders, diarrhoea and tuberculosis.

PUBLIC HEALTH SERVICES


The responsiblility for dealing with public health problem in Indonesia lies with the
government. Following the basic principle of sound public health, public health services
provision in Indonesia strongly encourages community participation through primary
health care services.
The main health body entrusted with carrying out public health services in Indonesia is
the Community Health Center (Puskesmas), situated at sub-district level serving a
population of about 30,000-40,000. There are over 7,000 such centers in the country by
the year 2000. The Puskesmas render 6 basic services (health promotion, MCH/FP, CDC,
Nutrition, Environmental sanitation, Curative care) and various developmental services
according to local areas need. In most instances, a doctor, with a staffing between 8-32,
consisting of nurses, midwives and other auxiliary personnel, heads each Puskesmas.
In densely populated areas, there are Sub-Community Health Centers (Puskesmas
Pembantu) at the village level, generally headed by a senior nurse or midwife, and
operated under the supervision of, and linked to, the Community Health Center.
At present, the total number of Puskesmas Pembantu in Indonesia is 19,977
To serve people who live in very remote areas, there are Mobile Community Health
Center (Puskesmas Keliling), operated by and based at the local Puskesmas. The staff of
Puskesmas Keliling consist of one doctor, assisted by two or three personnel, including
nurses/midwives and a driver. At present, there are about 6,024 Puskesmas Keliling
serving villages within the sub-district.
To support the activities of the Puskesmas, the community health effort is organized in
the form of the Integrated Services Post (Posyandu), located at the hamlet level.
The responsible community institution to Posyandu is the village community resilience
committee. The activities of each Posyandu, assisted and supervised by local Puskesmas
staff, consist of five basic types of health services. These are: (i) MCH Services, (ii) Nutrition
Services, (iii) Family Planning Services, (iv) Diarrhoeal Disease Control and (v) Immunization
Services. At present, there are about 251,459 Posyandu registered in Indonesia.
The position of the healthcare delivery system responsible for combating public health
problems in Indonesia is summarized in Table 5.
Table 5. Public Health Delivery System in Indonesia
PUBLIC HEALTH DELIVERY SERVICES POINT

FIGURES

Community Health Center


Sub-Community Health Center
Mobile Community Health Center
Integrated Services Post

7,100
19,997
6,024
251,459
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SECTION 01 THE PRESENT STATUS OF THE HEALTHCARE SERVICES IN INDONESIA

To guarantee successful operation of the Puskesmas, a referral system has been


introduced. Any public health problem that cannot be overcome by the Puskesmas will
be referred to higher health institutions/offices at the district, provincial or even the
national level.
In accordance with the principle of devolved autonomy, there are District Health Offices
at the district level and the Provincial Health Office at the provincial level. The Ministry of
Interior and the Ministry of Health at the national level coordinate the health offices that
are directly under the coordination of the local government.
The general rule is that the main function of the Ministry of Health is to provide
conceptual guidance, technical guidance and material, as well as financial contribution
and assistance to the local government district and provincial health offices. In brief, the
organizational structure of the health offices in Indonesia is shown in below Table 6.
Table 6. Organizational Structure of the Health Offices in Indonesia.
Central

Ministry of
Health

Ministry of
Interior

Province

Provincial
Health Office

Provincial
Government

District

District Health
Office

District
Government

Sub District

Community
Health Centre

Camat

Sub Community
Health Centre

Lurah

Hamlet

Integrated
Services Post

Head of
Hamlet

Neighborhood

Community

Village

Mobile
Community
Health Centre

Head of
Neighbourhood

MEDICAL CARE SERVICES


The healthcare delivery system that is responsible for medical problems in Indonesia, in
general can be divided into three categories: (i) primary medical care facilities, (ii)
secondary medical care, and (iii) tertiary medical care facilities. In contrast to public health
concerns which are under the government, the responsibility of the government is to
encourage medical care services in Indonesia to have a considerable private sector
involvement. Management of medical care services in Indonesia is therefore a shared
responsibility between the public and private sectors.
The primary level personal/medical care facility managed by the government is the
Puskesmas assisted by the Puskesmas Pembantu and Puskesmas Keliling. Besides the
18

provision of medical personal care, the Puskesmas also makes provision for public
healthcare services in the community medical care facilities.
The primary medical care facilities managed by the private sector vary. There are private
midwives practitioners and private medical practitioners found in almost every part of the
country. The number of private midwives practitioners in Indonesia is estimated to be
approximately 34,000. Around 20% of the private medical practitioners are specialists,
while the rest are general practitioners.
Since most of the midwives and doctors are government employees, their private practice
is usually conducted in the afternoon after the closing of government offices.
In some places, although it is illegal, paramedics also have their own private practices. Most
private medical practitioners in Indonesia operate their practices as a sole practice, although
in the big cities there is now an increasing trend for group practices that become more
popular. Other types of primary medical care facilities managed by the private sector in
Indonesia are the MCH clinic and the polyclinic. These types of medical facilities are usually
managed by midwives or nurses, although the responsible person for these facilities is still
the doctor. Unfortunately, the actual number of private MCH clinics and private polyclinics
in Indonesia is not available.
Table 7. Situation of Private Medical Care Facilities in Indonesia (1993)
TYPE OF FACILITIES
Private
Private
Private
Private

NUMBERS

midwife practitioners (estimated)


medical practitioners (estimated)
MCH clinics
polyclinics

45,000
34,000
NA
NA

The secondary and tertiary medical care facilities in Indonesia are located at hospitals. There
are around 1,200 hospitals registered in the country, of which 404 hospitals are
government or local government hospitals. The total number of beds available in all
hospital is 111,460, which means that for every 100,000 people there are around 59.8
hospital beds available. In brief, the number of hospitals in Indonesia is shown in Table 8.
Table 8. Number of Hospitals in Indonesia by the Year 2000
TYPE OF HOSPITALS
Government
Army
State-Owned
Private
Total

NUMBER OF HOSPITALS

NUMBER OF BEDS

404
111
83
589

58,912
11,427
7,874
34,247

1,187

113,460

Government hospitals are divided into five categories, namely the A, B, C, D and E type.
Type D (with 25-100 beds) and type C (with 100-400 beds) government hospitals are
considered to be secondary level medical care facilities in Indonesia. These hospitals are
situated in the district capitals, of which there are 305 in the country. Type D hospitals are
in transitional period and ought to be promoted to a type C hospital. Type C hospital are
expected to be able to provide at least six major specialty services, namely internal
medicine, pediatrics, obstetric and gynecology, surgery, radiology and clinical pathology.
19

SECTION 01 THE PRESENT STATUS OF THE HEALTHCARE SERVICES IN INDONESIA

Type B (with 200-500 beds) and the type A (with 100-400 beds) government hospitals
are considered as secondary level medical facilities in Indonesia. Type B hospitals are
located in the provincial capitals and are expected to be capable of providing a broad
spectrum of specialist services, while type A hospitals are expected to provide a broad
spectrum of sub-specialist services. At present, the total number of type B government
hospitals is 23 and the total number type A government hospitals is 4.
Type E hospitals are specialized hospitals, numbering 72 throughout the country. The
specialized hospitals operated by government are predominantly for specific diseases
commonly found in the community, such as leprosy, TBC and mental illness. The number
of government hospitals in Indonesia is shown in the following table:
Table 9. Number of Government Hospitals in Indonesia (1992)
TYPE OF HOSPITALS
Type
Type
Type
Type
Type
Total

A
B
C
D
E

NUMBER OF HOSPITALS

NUMBER OF BEDS

4
23
121
184
72

3,510
12,050
20,058
11,654
11, 651

404

58,912

Most of the private hospitals in Indonesia, belong to missionaries and charity foundations
and are usually general and specialized hospitals, managed on voluntary basis. In the
recent years, the government has introduced a new policy that allows private hospitals to
be managed on a profit-making basis, the majority of which are found in the big cities.

FINANCING OF HEALTHCARE SERVICES


Health Services in Indonesia are operated under a fee for service system. The number of
people covered by health insurance schemes is still limited mainly to civil servants and some
private employees. In brief, the number of people covered by health insurance schemes in
Indonesia can been seen in the following table.
Table 10. Number of People Covered by Health Insurance Schemes
TYPE OF HEALTH INSURANCE SCHEMES

NUMBER OF PEOPLE COVERED

Government civil servant


Private employee social security scheme
Public health funded scheme
Private health insurance scheme

15 million
2.5 million
14 million
1 million

Total

31 million

Annual health expenditure in Indonesia is still very low. It is estimated to be around 2.5% of
GNP or about US$18 per capita, a level far under the WHO recommended expenditure level
of at least 5% GNP. A big portion of total health expenditure in Indonesia comes from the
people, whereas the contribution of government is only around 30%. The small
contribution of government are utilized for all-line subsidy that creates unfair health
financing for the poor. Most of private spending on health care is out-of-pocket, because
20

only around 20% are protected by various types of prepaid care.

CONCLUSION
Indonesia still faces various health problems. To overcome these challenges, Indonesia
has implemented, since 1969, a series of Five Year National Development Programs,
including the National Health Development program. Significant progress has been
achieved in health care sector, both in public health services as well as in medical services.
The management of the healthcare delivery system in Indonesia is carried out both by
government and the private sector, including some forms of public-private mix.
The low level of health spending, the misdirection of government subsidies, and the big
portion of population with out-of-pocket spending indicating low proportion of people
protected by prepaid care, are challenges in that needs to be reformed gradually towards
more fairness in health financing.

21

22

SECTION 01 THE PRESENT STATUS OF THE HEALTHCARE SERVICES IN INDONESIA

1 Vision Of Family Medicine


Oriented Primary Care
2 Introducing Family Medicine
To Health Care Systems
3 A Family Medicine
Training Programme For Indonesia

SECTION 02

FAMILY MEDICINE ORIENTED PRIMARY CARE

SECTION 02
SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE

CHAPTER 1

VISION OF FAMILY MEDICINE


ORIENTED PRIMARY CARE

Associate Professor Goh Lee Gan


Wonca Regional President, Asia Pacific
Outline
Challenges in health care systems
Meeting peoples needs
Is family medicine the solution?
Making things work Towards Unity For Health
Closing the financial gap a 6-Strategy roadmap
Where do we go from here

CHALLENGES IN HEALTH CARE SYSTEMS


The universal challenges to optimal health care delivery in health care systems are the
result of the dream and reality struggle. The dream is the desire of the different
stakeholders policy makers, health professions, academic institutions, health care
managers, and communities to meet their subsystem goals of quality and equity in each
stakeholders perspective. The reality is that such a system will not be sustainable. The
interim results are well-known: limited health budget, rapidly rising costs as more
unprevented disease burden takes its toll, inequitable distribution of resources between
need and want, and inefficiencies in delivery of care as different stakeholders work
towards a subsystem optimum. The reality is the need for relevance and costeffectiveness. The solution A balance is needed between quality and equity on the one
hand and relevance and cost-effectiveness on the other hand.
Various models have been introduced to find the balance 1978 Alma Ata Declaration:
Primary Health Care for All (WHO, 1978), Improving health systems: the role of family
medicine (WHO Europe, 1998), and the WHO-Wonca vision of family medicine
(WHO-Wonca Working Paper, 1994). To varying extent, some balance towards equity is
being achieved.
The lack of unity for health is now seen to be the cornerstone that the various
stakeholders in the health care delivery system need to address A new unity based on a
common vision is needed. This has led to the WHO and Wonca working jointly towards
unity for health in the WHO-Wonca TUFH (Towards Unity For Health) Project across the
world. In this project, the primary care doctor has a role of bridging the different
stakeholders to work toward a common vision for health care delivery.

MEETING PEOPLES NEEDS


What do people need from the health care delivery system has been addressed in a
WHO-Wonca Working Paper, Making Medical Practice and Education More Relevant to
Peoples Needs: The Contribution of the Family Doctor, the result of the 1994 Ontario,
24

Canada Conference and subsequently by WHO Europe in 1998 in its paper Framework
for Development of FP/GP.
Family Medicine, by the nature of its work and core values, can help health systems to
meet peoples needs which are to:

Address common health problems


Improve access to care and equity
Integrate prevention and care, physical and psychological, acute and chronic diseases
Collaborate and co-ordinate care with the health care team more efficiently
and cost-effectively
Integrate care of individuals, families and communities.

IS FAMILY MEDICINE THE SOLUTION?


Family medicine is the bridge and not the solution. The 1994 Ontario, Canada
Conference Paper alluded to earlier had this to say:
To meet peoples needs, fundamental changes must occur in the health care system, in
the medical profession and in medical schools and other educational institutions. The
family doctor should have a central role in the achievement of quality, cost effectiveness
and equity in health care systems.
The family doctor is a good bridge between hospital care & public health; he is able to
help save costs through being a five star doctor, a model conceptualized by Dr Charles
Boelen, a WHO staff who is now a healthcare consultant. The five star doctor is one
who is:

Care provider,
Decision maker,
Communicator,
Community leader, and
Manager of healthcare resources.

How does a family doctor (syn. primary care doctor, general practitioner) help to save
costs? Some examples illustrate the possibilities:
Treatment of acute problems timely and appropriately, getting things right the first
time particularly in children and the aged prevents death and disability.
Encouraging appropriate lifestyle to control chronic diseases will reduce disease
burden and truly save costs to the individual, family, community, and nation.
Diet, exercise and weight control (DEW) together they will prevent or reduce the
prevalence of hypertension, heart disease, diabetes mellitus, hyperlipidemia and the
downstream consequences from strokes, heart disease and the long term
complications of diabetes mellitus.
Smoking respiratory consequences of chronic obstructive lung disease, cancer of the
lung and ischaemic heart disease are prevented or reduced.
Sexual behaviour sexually transmitted infections including AIDs are prevented.
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SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE

MAKING THINGS WORK TOWARDS UNITY FOR HEALTH


How does working towards unity for health work? The common vision of reduction of
disease burden, and promotion of health will place the use of limited healthcare budgets
to achieve the greatest impact on health status. The activities among the stakeholders
will not be divergent. There will be self-care by patients motivated to keep themselves
healthy and to avoid unnecessary use of health resources; appropriate level of use of
services and not more healthcare and in particular, hospital care; primary care doctors not
just doing gatekeeping and the denial of care but to encourage the appropriate use of
resources where appropriate. The outcome of such healthcare reforms in the minds of
the stakeholders will be health systems that meet peoples needs.

CLOSING THE FINANCIAL GAP A 6-STRATEGY ROADMAP


Closing financial gap needs to be systems oriented. There are six strategies that need to
be considered and implemented in parallel.
Alignment of Vision Strategy 1
Work towards unity for health: work together for the benefit of all stakeholders.
Need for meetings and discussions on how unity for health can be achieved.
Work towards appropriate level of care self-care, primary care, and hospital care
(secondary care and tertiary care).
Deal with sub-maximisation of goals due to conflict of interests of carers between
levels of care. The primary care doctor can play a 5-star doctor role here in reminding
all stakeholders the ultimate goal of health care which is the reduction of disease
burden and promotion of health.
Set Quality Standards Strategy 2
Cost control without standards result in cutting of quality
Pay attention to outcome standards examples are control of blood pressure, diabetes
mellitus, obesity, lipid levels, and the levels of disability and mortality in the community.
Reduce Unnecessary Expenditure Strategy 3
The easiest first to reduce expenditure will be to reduce variation of care define best
practice based on available standards.
Work towards standardisation of services with clinical guidelines get a buy-in by
stakeholders, publicise them, promote them, update them to keep them current.
Need the support of all primary care doctor, specialists and patients.
Full payment or co-payment by users for non-essential expenditure is a useful cost
control measure need a political will to implement this.
Training Strategy 4
Train ALL stakeholders on their unity role in the health care system.
How can they best contribute to close the financial gap must be the common vision.
Pay Everybody Equitably Strategy 5
Poor payment results in cutting corners this is the biggest reason for a failed primary
26

care healthcare delivery system it becomes a system with the proverbial outcome of
penny wise and pound foolish.
Payment may not always be in dollars and cents.
Recognition and mutual support for the mission of reducing the financial gap in the
healthcare system are powerful incentives as equity in kind.
Adequate funding for the primary care and prevention have big benefits in savings
that has never been truly comprehended or never implemented because of lack of
political will.
Premium or consultation fee has to be adequate only then can unseen costs be
controlled e.g. unnecessary referrals, incomplete care, reluctance to use
essential drugs.
Premium or consultation fee has to be adequate only then will the optimal benefits
of the GP be realised.
Prevention must have an adequate budget for training and implementation of
patients and doctors it is not free to the health care system. And it is a worthwhile
investment for the healthcare system in the short, medium and long run.
Financing system for the primary care doctor
The important considerations for a managed care system are:
Adequate consultation fee for a visit.
Number of times per year which will depend on gender and age.
Medicine at cost plus 15%.
Some formulas for managed care:
Acute conditions = [(Consultation + medicines + injections) X visits per year]/12 per
month e.g. in Singapore NTUC pays [$20 + $5 + 2]X6/12 = $13.50 per head/year.
Chronic conditions = [(Consultation X average of 4 extra visits a year) + (medicines at
cost plus 15% X12 months)]/12 per month.
e.g. in Singapore NTUC pays ([$20 X 4] + [medicines at cost plus 15% X12 months])
/12 per month.
Payment system for the primary care doctor can be a variety of methods depending on
local factors and arrangements. Examples within the managed care system can be:
Once-off payments for more severe conditions requiring second line medicine
Example, Augmentin for a more severe cellulitis.
Minor procedures Standardised fees will help to reduce variation of costs.
Fee-for-service These require the support of the health care provider not to introduce
unnecessary visits or be willing not to charge for visits where the patients is followed
up for safety sake (there must be social capital in the community for this to work):
Acute condition = $X for consultation & medicine
Chronic condition = $Y for consultation & medicine
Encourage Best Practice Strategy 6
Discussions and presentations on best practice will spread the best solutions to close
the financial gap in health care.
The healthcare system may wish to consider the best stakeholders of the year award
on best practice policy maker, health professionals, academic institutions, health
managers & insurance providers, communities these will encourage best practice.
27

SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE

WHERE DO WE GO FROM HERE


Get the message across that closing financial gap can only succeed if stakeholders are
all working towards unity for health.
Organise discussion groups on how to close the gaps by the stakeholders.
Discuss on the funding for primary care and prevention.

TAKE HOME MESSAGES


Controlling health care costs is everybodys job, not just the policy makers job or the
GPs job.
Work towards a 6-point strategy.
Do something today about closing the financial gap of the health care system.

CHAPTER 2

INTRODUCING FAMILY MEDICINE


TO HEALTH CARE SYSTEMS:
SINGAPORE, INDONESIA, MYANMAR

Associate Professor Goh Lee Gan


Wonca Regional President, Asia Pacific
Outline
The Singapore Experience
The Indonesian Experience
The Myanmar Experience
Critical success factors in the introduction of family medicine
Syllabus for family medicine training
Five tasks in training

THE SINGAPORE EXPERIENCE


Critical Success Factor in Introducing Family Medicine into the Singapore
Health Care System: Link Up with Stakeholders
Ministry of Health wanted a vocational training programme; is supportive.
College of Family Physicians, Singapore saw the opportunity to promote Family
Medicine through Wonca.
The University had sympathetic supporters on adoption of Family Medicine
as a discipline.
An external change agent was available. In Singapores case, a Family Medicine
expert was invited to meet up with the various stakeholders to discuss the place of
family medicine, training requirements and organizational matters.
The Hospital specialists were convinced of the importance of well-trained primary
care doctors who were individually willing to contribute their efforts towards training
the doctors.
Sequence of developments
1988: pilot Family Medicine programme hospital rotation programmes and
polyclinic posting as pilot vocational training programme.
28

1991: started the definitive Masters Programme in Family Medicine hospital based
(Programme A) 3-year programme.
In 1993: first examination leading to MMed (Family Medicine) was conducted with 9
passes out of 17 who sat.
1995: started Private Practitioners Scheme (Programme B) doctors in primary care
practice 2-year programme entry to programme with experience of at least 4
years in active general practice.
2000: started the Diploma in Family Medicine 2 years course, leading to Grad Dip
Family Medicine entry to programme at experience of at least 1 year in
clinical practice.
MMED FAMILY MEDICINE (SINGAPORE)
The Master of Medicine in Family Medicine examination was established in the National
University of Singapore following the approval by the University Senate in 1991. Initially,
it was a programme for medical officers in the public sector healthcare system; this is
now known as Programme A. In 1995, it was felt to be important to have a training
programme leading to the same examination for doctors already in the private sector;
this is now known as programme B.

Programme A
Modular Course (made up of 3-monthly courses X 8 for the 2 years) the syllabus is
shown in Tables 1A & 1B. The Course is now run as a composite of distance learning
set of notes and face-to-face sessions of case-based workshops; application of the
course material takes place at the clinical and experiential level and tutorials are
conducted to take the learning and application further.
Weekly Tutorials & Monthly Workshops focused on case based issues and learning
areas in patients seen in the direct experience of doctors in training.
Skills courses BCLS.
Hospital rotating postings six monthly rotations, 4 choices out of a list of disciplines
namely, internal medicine (compulsory), paediatrics, O & G, orthopaedics, geriatrics,
psychiatry, A& E, dermatology, general surgery.
Examination.

Programme B
The course components are:
Modular Course (made up of 3-monthly courses X 8 for the 2 years) the same course
as for Programme A is attended by the Programme B participants (and also the Grad
Dip Family Medicine trainees).
Weekly Tutorials & Monthly Workshops 40 a year X 2 years focused on case-based
issues and learning areas in patients seen in the direct experience of doctors in
training: this is the key component of learning and teaching in this programme.
Skills courses BCLS, Clinical examinations skills course.
GP Practice (4 years experience at entry plus 2 years during the programme)
Examination.
MMed Examination

3 parts
Theory Essay paper (3hours and 4 questions), MCQ (3hours and 120 questions) &
Slide interpretation (1 hour and 30 questions).
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SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE

Practice Log 1 week profile, 6 case studies (30 minutes oral examination).
Clinical 2 long cases (each 45 minutes); 4 short cases (each 15 minutes).
Grad Dip In Family Medicine
This programme grew out of the recognition that the MMed (Family Medicine) 3 years
(Programme A) & 2 years (Programme B) may be too demanding for many family
doctors. Accordingly a Grad Dip Family Medicine was created and launched in 2000. To
date, the programme is in its third year and we have 70 doctors who have graduated.
Grad Dip Family Medicine components:
2 year-course
Same modular course for distance learning as the MMed (Family Medicine) course (2 years)
Quarterly tutorial (not weekly & monthly as for MMed (Family Medicine).
Own clinical practice or hospital work or Government outpatient clinic.
Simpler exam 100 MCQ & 10 KFP (3 hours), 10 OSCE based on GP clinical scenarios
(each 9 minutes).

THE INDONESIAN EXPERIENCE


The introduction of family medicine in Indonesia as family medicine oriented primary care
has three reasons to make it succeed:
There is a critical mass of primary care leaders, university teachers, and insurance
providers, as well as Ministry of Health primary care leaders who have been exposed
to the concepts and understanding of the role that family medicine can play in the
health care delivery system.
Indonesian needs family medicine oriented primary care doctors to be effective gate
keepers in the health care delivery system.
The project between Singapore International Foundation (SIF) & Indonesian
Ministry of Health allowed the transfer of skills and knowledge on the organization
and development of a family medicine programme.
What were done right
Time and efforts spent to foster a common vision of the various stakeholders in health
care delivery on the place of family medicine primary oriented care resulted in good
acceptance of the discipline.
TOT as the transfer of knowledge created a critical mass of committed primary care
leaders to spearhead the development of family medicine in the postgraduate and
also in the undergraduate level.
Attention to syllabus and content of family medicine will ensure that the family
medicine programme is built on a focused knowledge and skills base.

30

The Stakeholders who are positive for its introduction are:


Ministry of Health
Indonesian Association of Family Physicians
Indonesian Medical Association
Universities
Ministry of Education
Insurance providers

THE MYANMAR EXPERIENCE


Invitation of Singapore Medical Association and Myanmar Medical Association (MMA)
was the entry point for in-depth introduction of family medicine learning and teaching
strategies into Myanmar.
Reason for entry of family medicine into Myanmar Health Care Delivery System GP
as primary care provider is recognized to be important. Prior exposure of medical
leaders to the concepts and the role of the family doctor is again important.
Family Medicine Workshop & interaction with MOH & MMA as the means to transfer
of technology.
Knowledge Transfer Activities
The Myanmese medical leaders met their counterparts from Singapore and discussed
the tasks of organizing a family medicine programme, syllabus and teaching methods.
Myanmar has since developed its course and implemented it.
Demonstration of a GP Clinical Teaching Session (Small Group) was done in Yangon.
Clinical Short cases sessions were conducted jointly with the Myanmese hospital
specialists for the primary care doctors from Singapore and Myanmar.
Visit by Family Medicine programme director designate to Singapore to study training
implementation details in greater depth.

CRITICAL SUCCESS FACTORS IN THE INTRODUCTION OF FAMILY MEDICINE


Some Observations
There are common important milestones in introducing Family Medicine into health care
systems in Singapore, Indonesia and Myanmar. These are:
Adequate presentation to stakeholders on what Family Medicine can contribute
important not to over-promise.
Explanation, discussion and involvement of stakeholders in the planning and local
development is an important factor.
External help in developing the curriculum, teaching methods, TOT ideas, and
organization of the training programme expedites the implementation of the training
programme. In the case of Singapore, Australia and UK provided the external help.
Suitable Programme For Rapid Development
The experience from Singapore and Myanmar suggests a Diploma in Family Medicine as
31

SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE

the best level to work towards for rapid introduction. The following are suggested
features of such a programme:
Duration 2 years or 1 year.
Modular course for distance learning.
Workshops for face-to-face exchange of experience and skills.
Assessment MCQ, KFP, OSCE are valid and reliable instruments.

SYLLABUS FOR FAMILY MEDICINE TRAINING


The following syllabus was developed for the Singapore programme based on a study of
Australian, British and American family medicine programmes. It is generic for use in any
family medicine programme.
Aim of Training Programme
At the end of the programme, the participant should have achieved the following:
Primary care to have knowledge and skills to be right at the first time.
Personal care to have the ability to deal with ideas, concerns and expectations (ICE)
of patients, family members and significant others in the patients world.
Continuing care to have a core value to take care of the patient beyond
episodic care.
Comprehensive care to have the concept of curative, rehabilitative, preventive &
promotive components of care and be able to adopt these as core values in the
planning and implementation of care. This has been developed into a model by Stott
& Davis as acute care, behavioural modification, continuing care, and disease
prevention & health promotion.
Family as unit of care to have the core value of managing the individual and the
family unit as an integral system of relationships, care and concerns of the patient.
Emphasis on Care of Patients in the Lifecycle
The care of specific groups of patients is a key concept for the family doctor. The specific
groups of patients are:
Mother and child
Working adult
The elderly
Persons with chronic medical condition.
In recent years, mens health too has been included as a focus of learning and teaching
too. The excess morbidity and mortality is being addressed.
Mother and Child
The basic principles to be understood are:
Vulnerability to poor social conditions
- Mother: during pregnancy & childbirth
- Child: during infant & toddler years
Education of the mother is the key to better health.

32

More about the Mother


Other basic principles to be understood are:
Pregnancy: need to educate the patient to prepare for it nutrition of the female
child, birth spacing, self-care, family planning.
Childbirth: safe delivery, nutritional status of the mother is important.
Post-natal: adequate nutrition, education.
Gynaecological problems: menstrual disorders and anemia, cancer prevention
and detection.
More about the Child
Other basic principles to be understood are:
The infant: nutrition, immunisation, infection control, WHO IMCI project.
Toddler: infection, injury.
Older child: infection, behavioural problems, sexual issues.
Education of the mother is pivotal to reduce infant mortality.
Working Adult
Other basic principles to be understood are:
workstress.
occupational and work related disorders.
lifestyle and sexual issues.
chronic medical illness important with advancing age.
These issues require an individual and social approach
The Elderly
The family physician needs to pay attention to areas of care that will prevent or delay
onset of disease and frailty:
exercise, diet and lifestyle.
attention to acute illnesses & infection homeostenosis.
rehabilitation important, needs more time.
attention to the giants of geriatrics instability, iatrogenic diseases, incontinence,
intellectual failure.
Persons with Chronic Medical Conditions
The family physician needs to work on the following to reduce the disease burden from
chronic medical conditions hypertension, diabetes mellitus, hyperlipidemia, obesity,
ischaemic heart disease, stroke and bronchial asthma:
primary prevention risk factors.
control, compliance and complication intervention.
motivation, enablement and empowerment for self-care.
communication, counselling, care co-ordination skills on the family physicians part.
The model of care that has been developed to deal with such conditions is disease
management.

TIME TABLING STRATEGIES FOR SELF STUDY AND FACE-TO-FACE LEARNING


The big challenge in the implementation of any syllabus of family medicine is the large
33

SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE

number of topics that need to be considered. The strategies found useful are:
Modularisation Group related topics together e.g., those of importance to a special
group; or respiratory and cardiovascular systems being considered together because
the key organs are both in the chest cavity and have similar symptoms. The result is
modularization. The order of study of the modules is generally not crucial.
Distance learning Introduce distance learning which is to have notes and topics of
a module defined for the learner for his or her own self study.
Module sizing Determine the size of a module and the time to be devoted. This
depends on the interplay of which are the critically important topics that must be
covered and the time available. The grouping of topics into must know, good to
know, and nice to know is one way of helping to make decisions of what to include.
Portfolio learning Introduce the technique of portfolio learning which is for each
course participant to record on one page each case which offers something to learn in
the course of daily practice the following: (a) brief description of the case history,
clinical findings and other tests; (b) why is this case included difficulty in diagnosis,
pitfall avoided, mistake made, successful management, and other reasons; (c) learning
points. Over time, these cases become the learners portfolio for learning and
teaching. These are the cases that the course participant bring to the class discussion
in the tutorials.
Face-to-face learning Include face-to-face teaching sessions which can be small
group, or big group, and in some situations one-to-one. These can be (a) case-based
workshops where case-based scenarios that the learners have worked on as
assignments are discussed in class; (b) case based tutorials where cases from portfolios
are discussed; (c) clinical skills sessions e.g., physical examination techniques, problem
solving exercise, or learning a new technique like counseling, communication, stress
relaxation techniques. In other words, self-study is not enough. There is a need for
face-to-face sessions. The number of face-to-face sessions to the number of modules
of self-study will depend on the ability of the participants to meet. The frequency may
be weekly or fortnightly for small groups of 5-6 to meet for tutorials and monthly to
quarterly big group meetings for workshops.

FIVE TASKS IN TRAINING


There are five generic tasks in setting up a Family Medicine Programme. They are:

Syllabus development
Knowledge base reading texts
Training system
Training of trainers (TOT)
Standardised training programme

Task 1 - Syllabus Development


Three part syllabus see Table 1 made up topics in the columns of whole person
medicine, disease management by body systems, and practice management.
Principles of FM column 1 and row 1 of Table 1 consultation, communication,
counselling, problem solving; Care of people of different age groups and areas of care
patients with chronic medical problems, children, women, adult, elderly.

34

Systems medicine CVS & Resp; GI; blood & renal & oncology; Psychiatry; Skin;
Emergency, Bones & Joints; Nervous system, Eye, ENT; Nutrition, metabolic,
endocrine problems,
Practice management managing information & medical records, confidentiality,
computerization; managing people and resources; managing facilities and utilities;
managing finances including managed care; managing quality.
Task 2 - Knowledge Base Development
Compile as a teaching programme, knowledge and best practice related to relevant
problems in the setting covering:
Early disease, undifferentiated problems.
Established disease.
End stage disease.
Referral.
Health education and preventive focus.
Task 3 - System of Training
Some thought into the organization and administration of the training system is
necessary. Areas to be addressed are
1 Trainer to n trainees; a good number for n is 5.
Two year programme is adequate; one year may be a bit rushed.
Tutorials Weekly tutorial of about one to one-half hours will be adequate (40/ yr).
Each could be organized to have time for hot items could be an ECG, an aspect of
care to share, a drug update that the participant had learnt in the past one week
(30 min); case presentations (30 min X 2 cases); and discussions.
Workshops Monthly 1 1/2 hours (12/yr) these are devoted to more in-depth case
discussions where specialist resource persons may be invited.
Skills training back to hospital to learn examination of patients.
Task 4 - Training of Trainers
Attention to develop a corps of trainers is crucial. The areas to pay attention to are:
Tasks of a teacher role model, motivator, disseminator, assessor, researcher.
Methods of instruction (MOI) lecture, workshop, tutorial, clinical teaching,
case analysis.
TOT Workshop practice skills learning and transfer of technology designing a
course; teaching skills required of a workshop, a tutorial, a presentation, and a one-toone coaching and mentoring; paper assessment instruments i.e., Multichoice
Questions (MCQs) and Key Feature Problems (KFPs); practical assessment instruments
i.e.,Objective structured clinical examination (OSCE), short clinical cases, and
long cases.
Task 5 - Standardised Training Programme
Important concept to remember for sustainability in the long run.
The core programme must be standardised.
Care provided by practitioners need to be consistent irrespective of provider concept
of best practice and reasonable competence.
Reduce variation of care concept of practice guidelines.
35

SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE

References and further reading


CFPS website: http://www.cfps.org.sg
Fabb W, Goh LG. Family medicine development in the Asia Pacific Region. Sing Fam Physician Jul-Sep 2001:27(3):
31-36.
Goh LG, Lim J, Goh MC. Cultivating habits for life-long learning. Sing Fam Physician Jul-Sep 2001:27(3):50-53.

Table 1A. Family Medicine Syllabus Year 1 Singapore


Period

Whole person
medicine 4 units of study

Disease mgmt
by body systems
3 units of study

Practice mgmt
1 study in
brackets

Jul 2002
Sep 2002
of Family
Medicine

Practice skills
1A1 Principles
of Family Medicine
1A2 Consultation
skills
1A3 Counselling
1A4 Communication

Respiratory disorders
& Cardiovascular

1C: Medical records


& confidentiality

Oct 2002
Dec 2002

Child & adolescent


2A1 Acute
paediatrics
2A2 Developmental
paediatrics
2A3 Adolescent
medicine
2A4 Behavioural
paediatrics

Gastrointestinal
disorders
2B1 Upper GI
disorders
2B2 Lower GI
disorders
2B3 Liver & Biliary
disorders

2C: Notification,
certification,
and dispensing

Jan 2003
Mar 2003

Continuing care
3A1 Principles
3A2 Hyper- tension
3A3 Diabetes
mellitus

Urinary Tract, Blood


& Oncological disorders
3B1 Oncological disorders
3B2 Urinary tract
disorders

3C: Managing
the practice

3A4 Palliative
care

3B3 Anaemia,
bleeding,
haematological
cancers

Elderly health
4A1 Ageing,
fitness, &
assessment

Psychiatric disorders
4B1 Anxiety &
confusion
4B2 Community

4A2 Stroke &


rehabilitation
4A3 Frail elderly
4A4 Prescribing

psychiatry
4B3 Depression;
emergencies

One module
in 3 months
One module
has 8 study
units

Apr 2003
Jun 2003

36

1B1 Respiratory
infections
1B2 Non-infective
respiratory
disorders
1B3 Ischaemic heart
disease

4C: Computer use;


Medical
Information
system;
Research

Table 1B. Family Medicine Syllabus Year 2 Singapore


Period
One module
in 3 months
One module
has 8 study
units

Whole person
medicine
4 units of study

Disease mgmt
by body systems
3 units of study

Practice mgmt
1 study in
brackets

Jul 2003
Sep 2003

Community, Family
& Patient
5A1 Human
behaviour
& beliefs
5A2 Family in
health &
illness
5A3 Public health
disease
control &
immunisation
5A4 Preventive
medicine

Skin disorders,
STI & AIDS
5B1 Non infective
dermatoses
5B2 Infective
dermatoses
5B3 Acne, pigment,
nail & hair
disorders

5C: Standard of
care, managed
care, infamous
conduct

Oct 2002
Dec 2002

Adult Health
6A1 Occupational
health
6A2 Workplace
hazards &
occupational
diseases
6A3 Fitness to
work: return
to work
6A4 Travel
medicine

Rheumatic, Bone &


Joint Disorders
6B1 Emergency
care; housecall
6B2 Rheumatic,
bone & joint
disorders
6B3 Sports &
accidental
injuries

6C: Setting up
practice:
medical &
legal
perspectives

Jan 2003
Mar 2003

Womens Health (1)


7A1 Family
planning
& infertility
7A2 Common
gynaecological
disorders
7A3 Gynaecological
cancers
7A4 STD, HIV
& AIDS

Neurological, Eye &


ENT Disorders
7B1 Common
Neurological
Disorders
7B2 Eye disorders
7B3 Ear, nose, &
throat disorders

7C: Financial
management
accounting,
medical
perspective

Apr 2003
Jun 2003

Womens Health (2)


8A1 Anetnatal
care, &
drug use
in
pregnancy

Endocrine, metabolic &


Nutritional Disorders
8B1 Nutritional
counselling
8B2 Metabolic
disorders

8C: Quality assurance

8A2 Medical
disorders in
pregnancy
8A4 Postnatal care
pregnancy
8A3 At-risk

4B3 Endocrine
disorders

37

SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE

Further reading
Kerjasama Depkes IDI Fakultas Kedokteran. Pedoman Pelatihan Dokter Keluarga, 2003

CHAPTER 3

A TRAINING PROGRAME
FOR INDONESIA

Dr Sugito Wonodirekso, Wonca Country Representative & Associate Professor Goh Lee Gan, Wonca Regional
President, Asia Pacific

This chapter is reviewed from the Buku Pedoman Pelatihan Dokter Keluarga, written
as a consensus of prominent general practitioners and lecturers from several state
universities. The first edition of the Pelatihan was in 2000. A second edition was
produced in 2003. The writing and publication of the document was supported by the
Indonesian Ministry of Health.
The programme will make use of different teaching methods distance learning, faceto-face seminars and workshops, and experiential learning in the practice. The topics
chosen are focused on medical conditions which are common, important or have a great
impact on health status if left uncontrolled.
The Family Medicine syllabus is structured into four modular packets A, B, C, & D.
Packet A deals with the concepts of family medicine
Packet B deals with managing the practice
Packet C deals with medical technical skills and care in specific situations
Packet D deals with applied medicine in the various age groups.
The Family Medicine syllabus will be updated from time to time in line with the local
needs and tailored information from various sources to keep up the latest developments
in science and technology. The content of each package (especially package C, D) are
likely to have some alterations. Package A and B would have fewer changes, since they
deal with principles and concepts.
The topics in each of the packages will need to be modularized along some pragmatic
strategies. Some guidance has been given in the Kerjasama-IDI-Fakultas Kedok
-teran handbook.
Further refinement can be along the sections and chapters in this Primer which have
been summarized in Table 1. The final selection of topics, teaching methods will depend
on the balance of the need to standardize, local need and relevance, as well
as practicality.

38

Table 1. The Topics for Packet A, B, C & D Covered in this Primer


Packet A Concepts of family medicine Section 3
(Each topic below can be a self-study unit)
1.
2.
3.
4.
5.

The central values of family medicine


Personal care, Continuing care and comprehensive care
Family as a unit of care
Emergency care, housecalls and home care
Palliative care

Packet B Managing the practice Section 4


(Each topic below can be a self-study unit)
1.
2.
3.
4.
5.

Managing
Managing
Managing
Managing
Managing

people and resources


facilities and utilities
information medical records, confidentiality, computerisation
finances including managed care
quality

Packet C Medical Technical Skills & Care in Specific Situations C(A) Practice Skills
Section 5 (Each topic can be a self-study unit)
1.
2.
3.
4.
5.
6.

The consultation process


Communication skills
Counselling skills
Changing behaviour
Disease management
Emergency care skills

Packet C Medical Technical Skills & Care in Specific Situations C(B) Common symptoms
Section 6 (A group of 4 topic can be a self-study unit)
1.
5.
9.
13.
17.
20.

Fatigue
Breathlessness
Diarrhoea
Skin rash
Headache
Red eye

2.
6.
10.
14.
18.

Weight loss
Cough
Constipation
Backache
Insomnia

3.
7.
11.
15.
19.

Fever
Sorethroat
Vomiting
Joint pain
Persistently crying baby

4.
8.
12.
16.

Dyspepsia
Chest pain
Abdominal pain
Giddiness

Packet C Medical Technical Skills & Care in Specific Situations C(C) Specific disorders
Section 7 (Each topic can form 3-4 self-study units)
1.
2.
3.
4.
5.
6.
7.
8.

Cardiovascular and respiratory disorders


Gastrointestinal disorders
Renal, hematological and disorders
Psychological disorders
Skin disorders
Bone & Joint disorders
Nervous system, eye, and ENT disorders
Nutritional, Metabolic, and Endocrine disorders

Packet D Applied medicine in the various age groups


Section 8 (Each topic can form 3-4 self-study units)
1.
2.
3.
4.
5.
6.

Child and adolescent health


Womens health
Mens health
Health of the working adult
Elders health
Public health

39

SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE

CHAPTER 1

VISION OF FAMILY MEDICINE


ORIENTED PRIMARY CARE

40

1 Family Medicine In Health


Care Delivery
2 Personal Care, Continuing
Care & Comprehensive Care
3 Family As The Unit Of Care
4 Emergency House Calls &
Home Care
5 Palliative Care

SECTION 03

CONCEPTS OF FAMILY MEDICINE

41

SECTION 03
SECTION 03 CONCEPTS OF FAMILY MEDICINE

CHAPTER 1 FAMILY MEDICINE IN

HEALTH CARE DELIVERY

Outline
Family Medicine As A Discipline
Place Of Family Medicine In The Health Care
Working Towards Unity
Knowledge, Skills and Attitudes in Practice
Disease Patterns
Organisation Of Care

FAMILY MEDICINE AS A DISCIPLINE


Family Medicine
Family Medicine is a discipline concerned with the provision of personal, primary,
comprehensive and continuing health care of the individual in relation to his family,
community and his environment.
The discipline may also be known by various other names, namely, "General Practice" or
"Primary care medicine". For practical purposes they mean the same thing. The term
Family Medicine is preferred to emphasise the family as the sociological unit providing
support to the individual as well as to reiterate the importance of the family in the cause
and effect of health and disease in the individual.
The Family Doctor
The family doctor and his work may be defined as follows:
The family doctor is a qualified medical practitioner who provides personal, primary,
comprehensive and continuing health care to his patients in relation to their families,
the community and their environment. He may attend to his patients in his clinic, in
their homes or sometimes in the hospital.
In treating his patients the medical practitioner must take into consideration the whole
person, their psyche as well as their body systems and must not treat just the signs
and symptoms.
In providing comprehensive and continuing care he will need to interact with his
medical and para-medical colleagues. In promoting his patients' health he will not
only treat therapeutically but also educate and counsel his patients.
The Central Values Of Family Medicine
As a worldwide movement, family medicine had its prelude in the growing disenchantment of general practitioners and their patients with the fragmentation of care and
42

impersonal care brought about by subspecialisation and growth of high technology in


the 1960s.
There was clearly a need for a group of doctors to sound the warning of too much of
fragmentation as well as to address the consequences of this phenomenon. This was the
phase of counterculture (Stephens, 1998). The family physicians on both sides of the
Atlantic spearheaded the counterculture movement. Colleges of General Practice or
Family Medicine were formed. In 1972, the world body of family medicine, Wonca was
formed. The counterculture movement was become worldwide. Singapore and Canada
were the early members.
What are the central values of this counterculture to hospital specialist medicine?
There are six of them. We can remember them as 3 plus 3:

The first three are attitudes that we would want to infect all doctors with:
Patient centred care and attention to the doctor-patient relationship.
Holistic approach to the patient and his problems that recognizes contributions to illhealth and well-being come from not only physical disease but equally if not more
from social and psychological dimensions in the patient (the bio-psycho-social model
of ill-health) as well as from the family and his community; family doctors have found
that paying attention to these are often effective in solving the physical health
problems; the specialists should know this too. Indeed, the studies of Prof Michael
Marmot on the staff of Whitehall in London proved beyond doubt the importance of
removing poverty in removing ill health. So the solution to good health actually lies
outside medicine. Doctors only help to fix those wounded, many by social and
economic circumstances.
Emphasis on preventive medicine because this has greater long term impact on health
status than curative medicine.

The next three central values define the family doctors work:
The family doctor looks after health problems that may be initially unclear in terms of
seriousness the ability to deal with initially uncertain symptoms is important in the
makeup of the family physician.
The family doctor looks after people across the whole spectrum of age groups he is
a specialist in breadth, unlike the hospital specialist who is a specialist in depth.
The family doctor is willing to look after the patient not only in the consulting room
but also in the home and other settings as well.
The need for a holistic worldview of the patient and his medical problems is greater than
ever today with high technology medicine threatening to dehumanize medicine and to
fragment patient care. Clearly a balance has to be made all the time.

Bio-psycho-social model of illness


Engel (Engel, 1980) is credited with the link of the three dimensions of health and illhealth the now well-known bio-psycho-social model of illness. It is important to
recognise that every illness has varying admixtures of physical, social and psychological
consequences. It is not enough to pay attention to the physical aspects only. In the
43

SECTION 03 CONCEPTS OF FAMILY MEDICINE

hospital, the physical dimension assumes greater prominence; even then as the patient
recovers the social and psychological dimensions may assume greater prominence. In
general practice, a proportion of patients may have a social or psychological problems as
the underlying cause of ill health and these may be presented as physical complaints
(a phenomenon known as the hidden agenda).
The family as the unit of care
The family physician looks after more than one member of the family. The doctor gets to
know the health of the family as an unit. Also as the family goes through its family life
cycle, there are new tasks that the family has to complete. The family doctor is often
called to provide his advice and care.

THE PLACE OF FAMILY MEDICINE IN HEALTH CARE


Division of Labour
General Practice/Family Medicine is concerned with primary care (first contact care) whilst
the hospital is concerned with secondary and tertiary care. Such a division of labour is
cost effective on available health care resources.
A well developed General Practice/Family Medicine service will relieve the workload on
the hospital by looking after patients that could be managed outside the hospital:
minor illnesses.
post hospitalisation and rehabilitative care.
terminal care that the hospital can no longer help.
continuing care of chronic problems like hypertension, diabetes.
care of conditions that can be done jointly with the hospital e.g., cardiovascular
disease, bone and joint problems, chronic skin problems.
At the point of first contact, cases not requiring hospital care are filtered out and treated
so that only appropriate cases are sent to the hospital. This of course will work only
if patients do not use the hospital A & E Department as a point of entry for
non-emergency care.
The prevention of communicable diseases by immunisation and opportunistic patient
education is best done at the outpatient level, e.g., measures to limit the spread of
conjunctivitis, measles and other infections.
Similarly, the prevention of non-communicable diseases related to lifestyle through health
education on nutrition, smoking, alcohol intake and pursuance of healthy habits can be
the family physician's responsibility.
Working Towards Unity for Health
The development of Family Medicine into what we know of it today has gone through
three phases (Scherger, 1997). We have dealt with the first phase of counterculture. From
this phase of counterculture in the 1970s and the second phase of parity (seeking
recogntion to be on par with the specialties) in the 1980s, family medicine has moved
44

into a new phase of intgration in the 1990s and into the present. Here, the prevailing
mood is for integration of clinical activities. The judgment call is whether family
departments would want to integrate with hospital based disciplines like paediatrics,
general internal medicine and even geriatrics. The danger is for departments of family
medicine to be left behind if they choose to stand alone. And what about integration
between family medicine and public health?
Integration of health care activities and providers is now the focus of health care reform in
Singapore. The formation of the 2-cluster system of health care, the concepts of seamless
care, disease management, stepped down care, and shifting the center of gravity to the
family physicians are steps in this direction. We would need to look into sustaining health
care needs of not only the present but in the future as well. And we need to remember
that eradication of poverty eradicates ill health. So health must integrate with social and
economic development of the country.
Where do we go from here? The lack of integration was the starting point for the family
medicine counterculture. Family medicine has the role of integrating in the mind of every
doctor the balance between specialization and generalist approach in the care of
patients. The organ subspecialist needs to see how his expertise fits into the total wellbeing of the patient.
Specifically, we need to work on the following seven areas in our integrating efforts in
health care delivery. We can remember them as 4 plus 3:
The first 4 are processes of care
(1) Good preventive care Preventive care must take the forefront of our care the old
adage of prevention is better than cure will always remain true. We therefore need
to integrate preventive efforts in our curative work this applies to the specialist too.
(2) Good acute care Acute care is where we really need to integrate knowledge, skill
and experience and to share it with one another on how to do things right the first
time. It is not always easy and takes a lifetime to perfect. And good acute care is very,
very important in the elderly, particularly, in the very old because the window of
opportunity is small and we must act fast or they will never be the same again.
(3) Good chronic disease care management attention to these will surely reduce the
burden of disease on the sufferers. Good chronic disease care is a good example of the
need for integrative care. That is why across the world, chronic disease care is still very
poor. And good integrated chronic disease care will make a big difference in the
reduction of disease burdens.
(4) Good step-down care this is increasingly important with the rising cost of acute
hospital care and the increasing numbers of the elderly who take a longer time to
recover from their medical illnesses. Good step-down care again relies on integration.
It is a baton relay of care.
The next three concerns those where it is more care than cure
(5) Good elderly care the care of the elderly is perhaps the best example of the need for
integrated care both vertically and horizontally. Care of these people cannot be
good without adopting the paradigm of integrating the efforts of carers for a
common purpose.
45

SECTION 03 CONCEPTS OF FAMILY MEDICINE

(6) Good domiciliary care this is a very much underserved area of care in many parts of
the world. It will grow in importance as an area of need as more and more people live
to ripe old age.
(7) Good palliative care This will include not only terminal care but also the care that can
extend and enrich those with cancer who cannot be cured. Hope still springs eternal
when one day we may be able to slow down the destructiveness of cancers and give
the sufferers more life and longer life. The idea of controlling cancer just like
controlling diabetes mellitus may not be such a far-fetched idea. And good palliative
care goes beyond cancers. It is also needed to slow down the progression of end organ
disease states. Think of the end stage heart disease, kidney failure and stokes. The care
is all palliative.

KNOWLEDGE AND SKILLS REQUIRED IN PRACTICE


Knowledge
The family doctor working in any community requires three types of knowledge:
Basic clinical knowledge
This is the most essential area and has three broad elements:
The natural history of disease. Part of this is encountered in the hospital context;
the early part of the natural history of diseases often may be seen only in the family
physician clinic.
Human development. A sound knowledge is necessary to differentiate between
normal and abnormal development.
Human behaviour. Some knowledge of human behaviour is covered in medical
sociology and psychological medicine. In general practice, the doctor encounters
examples of human illness behaviour that are specific to general practice.
Knowledge of patient community & changing trends
Knowing the community is important. Each community has its cultural, ethnic, economic
characteristics that may be relevant to practice. Demographic changes are associated with
new health care needs and priorities. With better literacy and health, there is an
increasing demand for patient participation in medical decision making.
Knowledge of professional community & changing trends
Medical practice today requires the support of various services and the health care team.
The doctor in practice must know the services that are available for his patients. Such
services may change as medical technology changes.
Examples of such required knowledge are:
Knowledge of existing and new services provided by the laboratory, the hospital
such as that of, the day surgery centre, oncology centre, dialysis centre, to name
some examples.
Knowledge of emerging community facilities like day care centres, old folks homes,
and the hospice.
Knowledge of services available from physiotherapists, dietitians, and specialist colleagues.
46

Skills
The doctor requires four types of skills to be an effective family doctor.
General clinical skills, practical and procedural skills
General clinical skills include history taking, physical examination and simple laboratory
skills learnt in the hospital postings. Practical and procedural skills are skills that include
operative skills, orthopaedic manipulative skills etc. learnt during both undergraduate and
postgraduate training.
Special clinical skills of importance to general practice
There are a number of special skills important to general practice. These are:
Doctor-patient relationship This is the vehicle for caring to take place
Communication of facts, ideas, views and concerns This allows sharing to take place
on what action needs to be taken to deal with a particular problem.
Counselling and health education These skills empower and build capacity for the
patient to resolve conflicts and dysfunction; to provide self-care, lifestyle modification,
and care of family members.
Skills in managing special groups of patients Patients with a chronic problems,
the terminally ill, the bed-ridden patient, patients with problems of living, and
the members of at risk families, all require special skills for caring for these
people competently.
The solution of undifferentiated problems The family physician sees problems at its
earliest stages. It is through continuity of care, the appropriate use of time as a tool,
appropriate investigations and sometimes referral for observation that such problems
become resolved.
The identification of risks and early departures from normality This helps to identify
diseases in patients who are known to the family physician e.g., loss of weight, pallor,
changing complexion may be picked up by the observant family physician.
Skills in resource management
As a generalist and first-contact physician, the family physician has control of large
resources. He is able, within certain limits, to control admissions to hospital, use of
investigations, prescription of treatment, and referral to specialists. In most parts of the
world, resources are now limited. It is therefore, the family physician's responsibility to
manage these resources for the maximum benefit of his patients.
Practical management skills
These are necessary because most family physicians are managers to their clinics. Only the
very large practices employ professional managers.

DISEASE PATTERNS IN GENERAL PRACTICE


Knowledge of the disease pattern of cases in general practice is important in order to
make the correct diagnosis. As a generalization, the family physician sees medical
problems that are largely self-limiting and his task is to confirm this is so, provide the
necessary reassurance and treatment to resolve the symptoms. He needs to be vigilant
however, to spot the serious problems early enough for action to be effective.
47

SECTION 03 CONCEPTS OF FAMILY MEDICINE

Communicable diseases have receded in importance as the environment and water


supply is made safe from pollution by human discharges, and immunization for many of
the airborne childhood diseases. Nevertheless, the influx of people from other countries
for work or travel means that we have to continue to be vigilant.
One-Day Morbidity Study
One way of determining the disease patterns of the community is through a One-Day
Morbidity Study. The figures from such studies in Singapore as examples are given in
Tables 1 and 2.
Table 1. Leading Conditions seen at Private General Practitioner
Clinics and Primary Health Care Clinics 1998 in Singapore (One-Day
Morbidity Survey, 1998)
General Practitioner Clinics
Rank
Condition
1
2
3
4
5
6
7
8
9
10

Percentage of
all Attendances

Upper respiratory
tract infections
Arthritic conditions/
rheumatism
Dermatological
disorders
Diarrhoeal diseases

33.6

Hypertensive diseases
Asthma, Bronchitis,
and Emphysema
Gastritis

5.1
4.8
2.7

Diabetes mellitus
Conjunctivitis
Neurotic disorders
Ill-defined conditions
Others

2.1
1.4
1.1
9.1
24.1

Primary Health Care Clinics


Condition
Percentage of
all Attendances

6.1

Upper respiratory
tract infections
Hypertensive disease

27.9
12.4

5.7

Diabetes mellitus

8.0

5.2

Dermatological
disorders
Diarrhoeal diseases
Arthritic conditions/
rheumatism
Asthma, Bronchitis,
and Emphysema; Tuberculosis
Conjunctivitis
Gastritis
Ill-defined conditions

5.3

Others

24.3

3.6
3.5
3.1
1.8
1.2
6.5

Table 2. The Relative Frequency of Presenting Problems in Family


Practice (Singapore)
Paediatric
Cough
Fever
Sore throat
Lower ext. pain
Cold
Nasal discharge
Earache
Abdomen pain
Diarrhoea
Headache
Nasal stuffiness
Others 43%

48

Adult
14.4%
11.5%
7.3%
4.1%
4.1%
4.0%
3.6%
2.3%
1.9%
1.7%
1.5%

Cough
Nausea & vomiting
Sore throat
Fever
Headache
Chest pain
Fever
Back pain
Abdomen pain
Cold
Fatigue
Dizziness
Dyspnoea

Overall
7.1%
4.8%
4.7%
4.4%
3.6%
3.5%
3.3%
3.3%
3.3%
3.0%
2.0%
1.6%
1.4%

Cough
Sore throat
Nausea & vomiting
Vomiting
Cold
Lower ext. pain
Headache
Abdomen pain
Upper ext. pain
Chest pain
Back pain
Fatigue
Nasal discharge

9.1%
5.4%
4.8%
4.7%
3.3%
3.2%
3.1%
3.1%
2.8%
2.5%
2.5%
1.6%
1.6%

Table 2. The Relative Frequency of Presenting Problems in Family


Practice (Singapore) - Contd
Paediatric

Adult

Overall
Earache
Diarrhoea
Nasal stuffiness
Dizziness
Dyspnoea
Other

1.5%
1.4%
1.3%
1.2%
1.2%
46%

The disease patterns seen in individual clinics depends on several demographic factors in
the provider namely, age, sex, education, postgraduate training, personal and social
lifestyles, attitudes and interests, and experience, geographical location, consultation
hours and whether it is private or public institutions. The differences in incidence of
disease in the latter can be seen from a study of Table 1. The incidence of various medical
conditions also depend on age o the patient as is shown in Table 2.

ORGANISATION OF CARE
An integrated approach to the organization of care is important. Family Physicians are
in the best position to work towards the linking up of primary, secondary and tertiary
care services into a seamless network for the patient to move to and fro depending on
the stage of disease and management. This is a big challenge in any healthcare
delivery system.
Further reading
1. Stephens GG. Family Medicine as Counterculture. Family Medicine Teacher 1979; 11(5):14-8 (Reprinted in Fam
Med 1998;3(9):629-36)
2. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980;137:535044.
3. Scherger JE. Phase Three of Academic Family Medicine. Family Medicine 1997; 29(6):439-440.

CHAPTER 2 PERSONAL CARE, PRIMARY CARE,


CONTINUING CARE, &
COMPREHENSIVE CARE

Outline
Personal care
Primary care
Continuing care
Comprehensive care

PERSONAL CARE
This is care that is delivered with a close rapport between the patient and the doctor.
The patient may consult his family doctor not only when he is unwell but may seek his
counsel as a friend and mentor.

49

SECTION 03 CONCEPTS OF FAMILY MEDICINE

PRIMARY CARE
This is first contact care. In primary care, the patient may present with one or more of the
following reasons (reasons for encounter):
pain or other symptom.
accident and emergency.
preventive health care.
administrative requirements physical check-up and certification.
seeking assurance (worry about the meaning of symptoms).
problems of living.
legitimatisation of sick role.
Of these different reasons for encounter, acute care and preventive are the predominant
area of care. Some of the acute problems may be undifferentiated problems, meaning
that they could be self-limiting problems or they could be early presentations of serious
problems. For example, the abdominal pain is often due to a gastroenteritis but in some it
could be a symptom of appendicitis and in the woman, it could be an ectopic pregnancy.
For such situations, time is a useful tool to help the family physician come to a definitive
answer, provided the patient is well enough. This is where continuity of care (that is care
of an episode of illness by the same doctor) becomes important.
Two points need to be made: (a) The meaning of primary care here is clinically oriented
and is narrower than the wider scope WHO's elements of primary care; (b) what is seen by
the family physician is dependent on the decision of the patient the patient may choose
to see the specialist or the GP or self-medicate or do nothing about it.

CONTINUING CARE
Continuing care is care of a chronic medical problem which requires regular monitoring
and also care of complications that may arise. This care may be provided by the same
doctor entirely, or the doctor functions as a member of the team. The basic requirement
is the presence of a care plan for the problem. Examples of medical conditions requiring
continuing care are: hypertension, diabetes mellitus, and hyperlipidemia.
In chronic medical conditions, continuity of care may not be always feasible. Hence, it is
important that there is good medical record keeping, communication and discussion of
the care plan.
There is also the need to introduce the concept of team care here. The members of this
team consists of the family physician as the coordinator of care, the specialist who sees
the patient time and again to deal with complications or to conduct a periodic review of
the health status of the patient. Then there is the nurse practitioner who counsels and
assists the doctor is looking after the patient; the dietitian; the physiotherapist,
and others. For those who are bedridden, the domiciliary care staff will need to be
activated. There may also come a time where the patient can no longer be suitable to be
looked after at home for various reasons like the absence of a carer or nursing has to be
done frequently this is where the community hospital and nursing home comes into the
50

picture. Chronic medical conditions can be expensive and many may need financial
assistance. This is where the medical social worker may also need to be drawn into
the team.
How can Continuing Care be Encouraged?
Doctor - Patient relationship
In the care of patients with chronic problems, establishing a good doctor-patient
relationship is essential. This will ensure that patients comply with management strategies
and instruction on life-style changes, medication, etc. The provision of good personal care
by the doctor is important in maintaining a long-term relationship with the patient.
Consultation tasks
Pendletons list of consultation tasks provides a good framework for the holistic care of
patients with chronic problems. Some of these are: Achieving a shared understanding of
the problem with the patient; Choose, with the patients agreement, an appropriate
action for each problem; Involve the patient in the management and encourage him to
accept appropriate responsibility for his care.
Consultation time
In patients presenting with acute problems or requesting for non-illness related consultations, the physician should take the opportunity to review any continuing problems
present, and the current state of management of these problems. The lack of time is the
main constraint, and to make time for the patient requires interest and professional
discipline on the part of the physician.
Health education
Patients with chronic problems should be educated regarding the benefits of life-style
changes, compliance with management strategies, regular follow-up care.
Patients should also be taught what to do in the event of an acute illness which may or
may not be related to the chronic illness. In addition, they should be alerted as to the
symptoms which may signal the beginning of any complication, and when to seek
medical help.
Methods Which Facilitate Continuing Care
Medical records
Proper documentation is necessary for efficient continuing care, as well as for medicolegal purposes. Medical information should be systematically and legibly recorded, and
should reflect the patients main problems, findings, treatment and any future plans. They
should also include any special features of note, such as drug allergies, G6PD deficiency,
etc. Problem-orientated medical records. Computer recording systems are recommended
for efficiency of filing and retrieval.
Appointment and recall system
This is essential in the tracking of patients who come for regular follow-up visits.
51

SECTION 03 CONCEPTS OF FAMILY MEDICINE

Any patient who misses an appointment should be sent a reminder or contacted through
phone. The use of computer systems will make this simple and routine.
In group practices, the use of appointment systems will also ensure that patients get to
see their regular doctor as much as possible, as appointments can be rescheduled when
the doctor goes on leave.
Clinic hours and staff orientation
The extension of clinic-opening hours to evenings and weekends, to accommodate
patients with regular working hours and their family members, would greatly facilitate
regular follow-up. Advance notice of any change in clinic hours should be given.
Clinic staff should be orientated towards facilitating continuing care, in that patients with
appointments should be given priority over walk-in patients, when they are punctual for
their appointments. Trained staff can also reinforce any health advice given by the doctor.
Compliance in Continuing Care
Compliance is defined as the extent to which a persons behaviour (in terms of keeping
appointments, taking medications, and executing lifestyle changes) coincides with
medical advice. (Haynes et al)

Factors influencing compliance


The
(a)
(b)
(c)

patient
Socio-demographic characteristics e.g. age, gender, ethnic group.
Attitude towards illness, health care provider, medical treatment.
Knowledge about illness and its treatment.

The disease
(a) Increasing severity of disease is associated with better compliance.
(b) Chronicity of disease condition lowers compliance.
The treatment
(a) Treatment regimens that require behavioural changes are usually associated with
poor compliance, e.g. change in eating habits, exercising, stopping smoking.
(b) The greater the number of drugs prescribed, the poorer the compliance.
(c)
Complicated dosage regimens also result in poor compliance.
(d) Method of drug administration, e.g. by injection, affects compliance.
(e) Unpleasant drug side effects may cause a patient not to take certain medications
(f)
Cost of treatment is often a barrier for continuation of treatment.
The physician
(a) Physician prescribing habits.
(b) Physician attitude towards patient and his illness, i.e. type of care, doctor
patient relationship.

52

Detection of poor compliance


Clinical judgment
From studies conducted, this has been shown to be unreliable, regardless of the type of
relationship the doctor has with his patient.
Monitoring attendance
Patients who default follow-up appointments are usually non-compliant, though the
reverse need not be true.
Response to treatment
Failure to respond to treatment can be used as an indicator of compliance, though this is
again not infallible. Some patients who respond to treatment may be doing so because of
over prescribing rather than good compliance. Conversely, patients who do not respond
to treatment may be because the dosage prescribed is inadequate.
Asking the patient
Not always reliable. Even under optimal interview conditions, about half of non-compliant
patients will deny the fact.
Counting pills
Useful research tool, though not very practical for clinical purposes. Counting pills in the
clinic usually results in bias in the direction of overestimating compliance. In general, pill
counts give higher estimates of compliance than quantitative drug assays and lower
(but more accurate) estimates than patient self-reports.
Drug levels
Useful in drugs with long half-lives resulting in relatively steady serum levels,
e.g. phenytoin, digoxin, theophylline, but not so good for drugs with short half-lives.
Caution: individual variation in drug absorption, metabolism and excretion.

Prevention and treatment of poor compliance


Prevention
(a) Remove barriers to compliance e.g. Reduce waiting time, convenient appointment
schedule, simplify drug regimen.
(b) Involve patients in their care.
Treatment
(a) Trace defaulters.
(b) Increase attention and supervision.
(c)
Use positive reinforcement, give encouragement.
Spectrum of Continuing Care
The spectrum of continuing care in Family Medicine is wide, and ranges from patients
who are very young to those who are very old and those who are terminally ill.
53

SECTION 03 CONCEPTS OF FAMILY MEDICINE

Family physicians look after patients with a variety of chronic problems. These include
medical conditions such as hypertension, diabetes mellitus, bronchial asthma, stroke,
Parkinsons disease, epilepsy; psychological problems such as depression, anxiety; and
terminal conditions such as cancer.

COMPREHENSIVE CARE
Comprehensive care has three meanings: (a) comprehensive in that it cares for all age
groups; (b) comprehensive in that it spans promotive, preventive, curative, rehabilitative
and palliative care; and (c) comprehensive in that it deals not only with the physical but
also social and psychological problems (that is, whole person medicine).
This one of the core values of the family physician. He is willing to look after patients in
one or more of the dimensions of comprehensiveness.
Stott-Davis Consultation Framework
Doctors need a good aide memoire to remind them of the potential of the consultation to
provide comprehensive care. Out of the understanding of the patient and his or her
clinical problem, comes a series of potential operational tasks for the doctor to perform.
Which will be performed depends to a large measure on time available, then knowledge
and skills, then awareness. These operational tasks have been described and organized
into a framework by Stott and Davies which they published in a paper in the J RCGP in
1979 titled the potential in each primary care consultation an aide me moir (Stott and
Davies, 1979)
The four operational tasks are shown in Figure 1.
Figure 1. Stott-Davis Consultation Framework
A
Management of presenting problems

B
Modification of help-seeking behaviour

C
Management of continuing problems

D
Opportunistic Health promotion

Task A Management of presenting problems Every consultation needs to address this


area. Besides, dealing with the presenting problems, it is good practice to embark on the
other tasks as far as time permits.
Task B Modification of help-seeking behaviour It may be necessary on occasion to
change the help-seeking behaviour. For example, the patient may insist on antibiotics
which are not appropriate. The modification of such behaviour needs due attention to
ideas, concerns and expectations behind the help-seeking behaviour.
Task C Management of chronic problems There is a need to address the care of
chronic problems whenever the patient visits. Time spent in this task will result in better
compliance and reduce complications from chronic diseases.
54

Task D Opportunistic health promotion Much can be done to reduce the onset of
disease related to adverse life-style. However, this is a challenging task because the
adoption of healthy behaviours require the change of life-long habits.
Extending The Stott Davis Consultation Framework to Home Care
The Stott Davis Consultation Framework can be extended to home care for the frail
elderly by including two more areas, namely environmental assessment (E) and function
establishment. This is described below.
Task E: Environment assessment The frail elderly is an organism in homeostasis with his
environment. The environment can be seen in 2 parts:
1. Physical environment home setting.
2. Social environment presence of a caregiver as well as financial condition.
For example, failure to thrive may be due to elderly being unable to access nutritious food
either because of physical contraints or lack of finance.
Task F: Function establishment Establishing function is important in the frail elderly.
It allows for:
1. A baseline status.
2. Detecting of disease. E.g. any intellectual or functional decline may herald dementia /
depression or other illnesses requiring further investigations. Functional decline may be
the first indication of disease in the elderly.
3. Monitoring of response to intervention. E.g. functional improvement after treatment
of depression.
Function establishment looks at:
1. Cognition and mood A commonly used simple score used locally for cognition
screening is the modified Abbreviated Mental Test (Table 1).
Table 1: Modified Abbreviated Mental Test
Age (+2)
Year of Birth
Address
Place
Time (+1 hour)
Current year
Recognises 2 persons
Prime Minister
3 Objects recall
Serial 20 3
Total Score /10
_________________________________
0-4 Probable cause; 5-6 Borderline; >7 Normal

2. ADL activities of daily living This refers to self-care tasks that a person performs in
the course of living to maintain cleanliness, hygiene, appearance, nutrition and
55

SECTION 03 CONCEPTS OF FAMILY MEDICINE

mobility. ADL measures the ability to feed, toilet, transfer (getting in and out of bed),
bathe, dress, remain continent and walk.
3. IADL instrumental activities of daily living This refers to the more complex tasks
necessary to function in society and requires combination of physical and cognitive
activities easily remembered as SHAFT (Shopping; Household chores; Ability to
take medications on own; Finances banking and handling money; Transport
and telephone).
Assessing of function may be through simple reporting from patient or caregiver. Simple
office test includes seeing patient get up and go to see his mobility status. In a busy
outpatient consultation, the tasks will need to be spread out over several sessions. This
will make it less onerous and more manageable.
References for further reading
Stott and Davies. The potential in each primary care consultation an aide-memoire. J RCGP, Apr 1979: 201-205.
Ong JE. The frail elderly, homecare and the GP. Sing Fam Physician 2002; 28(4):54-8

CHAPTER 3

FAMILY AS AN UNIT OF CARE

Outline
Who forms a family?
Functions
Family Life Cycle
Developmental Tasks
Family Influence On The Individuals Health
Functional And Dysfunctional Families
Level of Physician Involvement
Family Dynamics

WHO FORMS A FAMILY?


The family is a small social system made up of individuals related to one another,
biologically or by reason of strong affections and loyalty, that comprises a permanent
household (or cluster of households) and persists over decades. Members enter through
birth, adoption, or marriage and leave by death; therefore, the roles of members change
over time and through the history of the groups.

FUNCTIONS OF THE FAMILY


Every family has five basic tasks. These are:
Support of one another. This support can be physical, financial, social or emotional or
combination of these. The support is provided through an organised network of
interdependent family roles. The support stems from the emotional ties among
members of the family.

56

Establishment of autonomy and independence for each member. The family


facilitates personal growth of individuals within the family. Each member has a defined
role within the family, as well as an individualised role that extends beyond the
boundaries of the family, into the society at large.
Creation of rules that govern the conduct of family members. The family rules are
largely unwritten. They are established by an informal decision-making process. The
rules deals with privacy, interaction patterns, authority and decision making.
Adaptation to change in the environment. The ability to adapt, change, and grow is
essential for the long-term progression through a family's life cycle. A change can be
first order or second order change. First order change is adaptation to change in the
environment not requiring much change in family structure e.g. the familys move to a
new place. Second order change This involves a fundamental change in the basic
family structure e.g. a family member leaving for study abroad.
Communication with one another. Communication is the key function without which
other functions are not possible. This can be verbal, non-verbal, implied messages.
Many of these messages are unintelligible to outsiders.

FAMILY LIFE CYCLE


In the course of its development, the family goes through a number of predictable
transitions. Families are more vulnerable during the transition from one developmental
stage to another.
The physician with an understanding of individual development, can form good
hypotheses about problems that his patients are experiencing, and are thus able to help
family members prepare for these problems, and to help to solve them. The family life
cycle is conceptualized as being made up of stages. Figure 1 shows a family life cycle
made up eight stages (From Duvall, 1977).
FIGURE 1. FAMILY LIFE CYCLE

10 to 15 +
Years

2
2.5
Yrs.
Yrs. 3.5
Yrs.
1 2

3
4

7 Years

5
7

15 + Years
8 Years

7 Years

1. Married couples (without children).


2. Childbearing families
(oldest child, birth - 30 months).
3. Families with preschool children
(oldest child 30 months - 6 years).
4. Families with schoolchildren
(oldest child 6 - 13 years).
5. Families with teenagers
(oldest child 13 - 20 years).
6. Families launching young adults
(first child gone to last child leaving home).
7. Middle-aged parents
(empty nest to retirement).
8. Aging family members
(retirement to death of both spouses).

57

SECTION 03 CONCEPTS OF FAMILY MEDICINE

DEVELOPMENTAL TASKS IN THE FAMILY


Developmental tasks in fhe family have been defined by Duvall (1977) as tasks that arise
at a given stage in the life of the individual or family. The success at the completion of
each stage leads to happiness and success with later tasks. Failure of these tasks leads of
unhappiness, disapproval by society, and difficulty with later tasks. Conflict of
developmental tasks between family members lead to tensions in family life. One
example is the adolescent's need to achieve independence vs his parents' tasks of guiding
him to a responsible maturity.

THE FAMILY'S INFLUENCE ON THE INDIVIDUAL'S HEALTH


The family has five main influences on an individual's health, namely :
Genetic influences
The family endows its genetic heritage to the individual and this includes genetically
transmitted diseases: single gene defects e.g. thalassaemia; chromosomal disorders
e.g. Down's syndrome; and multifactorial genetic influences e.g. diabetes mellitus.
A knowledge of the genetic influences is necessary for prenatal diagnosis,
genetic counselling; surveillance in anticipation of influences on the patient
e.g. familial cancers.
Influence on diseases
Transmissible diseases may be disseminated from one member to another
e.g. streptococcal sore throat, viral conjunctivitis, worm infestations. Increased risk of
neurotic illness in family members of neurotic patients.
Influence on child development
There is evidence of relationship between family pathology and childhood disorders,
both physical (e.g. accidents, enuresis) and behavioural (e.g. aggression,
social withdrawal).
Influence on morbidity and mortality in adults
There is well-documented increased mortality in widows and widowers during the first
year of bereavement. Bereavement is also associated with increased consultation rate
in family members. Clustering of visits may be an important cue to family problems.
Influence on recovery from illness
Family support is an important factor in determining the outcome of all kinds of
illnesses, especially chronic illness and disability. Religious and cultural beliefs of family
members are also important determinants of coping and recovery.

FUNCTIONAL & DYSFUNCTIONAL FAMILIES


Physicians who follow the same patients over long periods of time come to recognise that
at the two extremes, are the happy and unhappy families. Most families, in reality, exhibit
fluctuating mixtures of happy and unhappy features. For this reason, the majority of
families have been referred to by researchers and family therapists as "mid-range
58

families". Each mid-range family has its own strengths and vulnerabilities. Physicians can
be most effective by helping families capitalise on their strengths and deal with their
vulnerabilities in healthier ways.
Characteristics of Functional Families (Happy Families)
Functional families radiate a sense of integrity and caring. Adult members espouse and
live by clear human values, express feelings appropriately, communicate effectively, and
share power while negotiating decisions.
All family members children, adolescents, and adults are encouraged to develop their
own life goals and emotional independence while staying connected with the family as a
whole. Functional families cope relatively well with adversity, often coming out of a crisis
stronger for the experience. Individual functional families differ widely, however, in how
they organise and conduct family life, and their members tend toward a healthy diversity
in many ways.
Characteristics of Dysfunctional Families (Unhappy Families)
Dysfunctional families, instead of integrity, radiate a sense of chaos or rigidity. There is a
high level of chronic underlying tension in such a family. Family members may adopt
personal values from authority figures, such as parents or clergy, or from friends or other
peers without considering their logical and emotional consistency. Alternatively, family
members may form values by reacting in opposition to the espoused or actual values of
influential people, again without critical analysis of their merits or drawbacks.
Communication tends to be chaotic, rigid or sparse, paralysing decision-making processes
and creating coercive power differentials between spouses and among family members.
Dysfunctional families tend to view individual differences and independence as disloyalty
that threatens their precarious emotional survival.
Such families have great difficulty dealing with stressors, expected and unexpected. Such
families can be caring when life circumstances are calm. When dysfunctional families are
stressed, their members tend to shift quickly from the caring mode into counterproductive modes of clinging, assaulting or escaping. When the levels of individual and family
anxiety rise, emotional reactions tend to override rational responses. They may express
intense feelings, many of which are negative. This style creates a heated family
atmosphere. At the opposite extreme, family members may shut off, blunt, or hide their
feelings, creating a cold atmosphere.
Despite their numerous liabilities, many unhappy families have an admirable spirit dogged
persistence in the face of generations of trials and sorrow. Physicians who appreciate this
fortitude can be very helpful to such families and can derive great satisfaction from
serving as a needed advocate and ally.

59

SECTION 03 CONCEPTS OF FAMILY MEDICINE

Role of the Family Physician in Handling Family Dysfunction


An understanding of the family in terms of the its struggles to be functional will enable
the family physician to make more correct diagnoses and also intervene more appropriately. Helping individuals from dysfunctional families to recognise that there are more
healthy ways to respond to the situations of the day is often the start towards a more
functional individual and family.

LEVELS OF PHYSICIAN INVOLVEMENT IN THE FAMILY


There are five levels of physician involvement in the family (Doherty & Baird, 1986):
Level 1. Minimal emphasis on the family. The interaction is limited to the patient only
Level 2. Providing medical information and advice. This consists of teaching at least
one family member about the patient's illness either as a once-off or an ongoing series of
educational sessions.
Level 3. Providing feelings and support. Family support is enhanced by convening the
family members and encouraging them to discuss their concerns. The family physician
must be able to ask questions that elicit family members' expressions of concerns and
feeling related to the patient's condition and its effect on the family. He also needs to be
able to listen emphatically to their concerns and to normalise them where appropriate,
encouraging family members in their efforts to cope as a family and identifying
family dysfunction.
Level 4. Systematic assessment and planned intervention. At this level the family
physician engages the family members, including the reluctant ones in a planned family
conference or a series of conferences. He is also able to help the family generate
alternative, mutually acceptable ways to cope with their difficulty and he is able to help
the family balance their coping efforts by calibrating their various roles in a way that
allows support without sacrificing anyone's autonomy.
Level 5. Family therapy. At this level, the family physician has the ability to handle
intense emotions in families and self and to maintain neutrality in the face of strong
pressure from family members or other professionals.

FAMILY DYNAMICS
Family dynamics may be defined as the interactions and relationships among the
individual members of a family. Family dynamics reflect and influence the physical, mental
and spiritual health of the individuals in a family. An understanding of the dynamics helps
the attending family physician to diagnose the disease and dis-ease in the patient sitting
in his consultation room and to recognise the factors that may help or retard the recovery
of this patient.

60

Assessment of Family Dynamics


Family dynamics may be assessed through its:
Structure namely, the genogram.
Relationship of the members A child in agreeing to "draw your family" shows the
relationship of each member to one another by the distances separating each other.
Similarly, the nearness of the distances separating members in a family conference tells
us the relationship that each enjoys with the other members of that family.
Impact on members collect information of impact of family dynamics using the
acronym of BATHE (see previous chapter).
STRUCTURE The Genogram
The genogram is a biopsychosocial family tree. It records the family in its life cycle, family
illnesses and relationships.
A genogram can be drawn in skeletal form during one of the first few visits ideally the
first visit and then it can be elaborated during subsequent visits as more is known about
the family. See Figure 2 and the table of symbols on how it is done (Table 1).
Figure 2. Drawing the Genogram
Step 1 Drawing a skeletal genogram

Indicate the identified patient with a doubly outlined circle or square.


Represent each family member with a square for male and circle for female and link them up
as in the table of symbols. For the adult patient, the current and past marital partners,
children, parents and grandparents are included. Information about diseased members is
often useful (e.g. age at death and cause of death).
Place the "clinical nuclear family" roughly in the middle of the diagram, with
previous marriages off to the right and left.
Place siblings in chronological order, unless they are from multiple marriages.
Offset index patient, spouse(s), and ancestors a little below their siblings.
Indicate exact age (if known) inside the person's symbol, with date of birth
alongside, or indicate approximate ages relative to the patient as +4, -3 etc inside
or alongside the circle or square that symbolises the person.
Indicate death by crossing through the person's symbol: add date died beside,
and age at death inside or alongside the person's symbol.
Indicate separation with single slash, divorce with two slashes across the
marriage line.
Number marriages for sponses, with dates of marriage separation, and divorce.
Indicate remarriage to same person with multiple marriage lines.
Enclose current household members with an interrupted line (dashes).
Try to keep members of the same generation on the same horizontal level for
each branch of the family.
Link the relationship of two persons with lines of conflict or close relationship
as appropriate.

Step 2 Expanding the genogram


At a later date, enter serious physical and mental health problems for each family member, as they
become known. Specific inquiry is desirable for heart disease, high blood pressure, diabetes,
stroke, cancer, nerve problems, depression, alcoholism, and suicide.

61

SECTION 03 CONCEPTS OF FAMILY MEDICINE

Table 1 - Standardized Symbols used in Family Genograms


male

conflict

female

close relationship

sex not specified

members of
households

deceased
A

adopted female

date of birth

m date of marriage
d

married

m 3/8/76
m 3/18/76
d 6/10/79

divorced
unmarried
relationship

date of divorce

D date of death
abortion or miscarriage
m 11/9/84

m 9/11/79
d 1/3/82

m 5/6/72

b 10/21/78
oldest

b 4/13/80

m 3/18/76
d 5/10/79

marriage couple
with 3 children

married husband
with two previous
marriages

m 4/4/70

marriage
with
twin boys

b 8/1/82
youngest

b 9/17/76

Uses of the genogram. The genogram helps the doctor to:


Integrate quickly the data on the physical and mental aspects of health and illness in
the family (This information is diachotomized in written histories and notes).
Graphically displaying multigenerational patterns of illness and dysfunction, for the
clinician to inquire or intervene as time, interest and skills will permit.
Relationship of Members
Draw your family. In children, this may give some idea of the child's perceptive world.
The distant father may be drawn very small or left out altogether. The fierce uncle may be
given some embellishment to state the fact and so on.
Spatial relationship. The spatial distribution of members in a family conference can give
some information on the relationship amongst the family members. Those with better
relationships will sit closer to one another and those not so close will sit further apart.
References
Doherty WJ & Baird MA. Developmental levels in family-centered medical care. Family Medicine 1986;
18:3:153-156.
The Family in Health and Disease in: McWhinney. Chapter 10; A Textbook of Family Medicine, 2nd edition, 1997
pages 229 to 244.

62

CHAPTER 4

EMERGENCY CARE AND


HOUSE CALLS

Outline
Emergency care
House calls

EMERGENCY CARE
An emergency is an unforeseen occurrence or a combination of circumstances calling for
immediate action or remedy.
Scope of Emergency Care seen in General Practice:
Paediatric emergencies - E.g.: persistent crying, fever, vomiting, diarrhoea and abdominal
pain, childhood injuries, fits, foreign bodies, accidental poisoning, and epistaxis.
Cardiovascular emergencies - E.g. chest pain, acute left ventricular failure.
Respiratory emergencies - Mainly acute breathlessness secondary to asthma, pneumothorax, hyperventilation; acute laryngeal obstruction caused by foreign bodies or
angioedema. Haemoptysis occasionally.
Gastrointestinal emergencies - Abdominal pain and food poisoning, haemetemesis,
melena, rectal bleeding, etc.
Urogenital emergencies - Acute urinary retention, renal colic, acute testicular pain, etc.
Obstetric and gynaecological emergencies - Pregnancy-related conditions e.g. antepartum haemorrhage, ectopic pregnancy. Gynaecological conditions e.g. twisted
ovarian cyst, pelvic inflammatory disease with severe lower abdominal pain. Breast
engorgement and haemorrhage in the pueperium occasionally.
Neuromuscular emergencies - E.g. stroke, transient ischaemic attack, oculogyric crisis,
loss of consciousness, head injury, skeletal injuries.
ENT and eye emergencies - Foreign bodies; severe pain as in glaucoma, earache, a
particularly painful sore throat which may be perceived by the patient as an emergency;
vertigo; epistaxis; sudden loss of vision; physical and chemical injuries. Dental problems
such as bleeding after extraction occasionally.
Endocrine emergencies - Not common. E.g. diabetic ketoacidosis and hypoglycaemic coma.
Bites and stings, burns and scalds - Bee and wasp stings most common. Animal bites
such as by dogs, snakes and even fish, depending on the location of practice. Burns and
scalds common.
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Forensic emergencies - E.g. alleged assault or rape, death at home.


Psychological or psychiatric emergencies - E.g. patients who are acutely confused,
suicidal, extremely anxious, aggressive or violent, or those who are acutely psychotic.
Delivery of Emergency Care
Appropriate preparation : Equipment and clinic organisation
Basic equipment and essential drugs. Housecall bag.
Clinic staff trained to recognise emergency situations.
Priority treatment for such patients.
Request for emergency out-of-office calls should be screened first by the doctor, who
will decide on time of visit.
Skills development
Doctor - trained in management of emergencies. Continuing self-review to maintain
skills acquired.
Clinic staff - trained in emergency resuscitation and other management procedures.
Management Protocols
Work out in advance management protocols for the emergencies likely to be encountered. Clinic staff should be familiar with their roles in these protocols.
Dealing with Problems in Emergency Care Delivery
Acute paediatric problems - Many are trivial from a purely medical point of view, but
parental anxiety can be tremendous. The doctor should take the parents seriously, assess
each case according to severity and treat, reassure or refer as necessary.
The breathless child is a common night emergency. The patient may be a child with just a
bad cold or he may have a potentially serious condition such as epiglottitis. Careful
questioning on the telephone is essential before making a decision about whether or not
to make an immediate visit.
Loss of consciousness - May be potentially life threatening or trivial, depending on
the cause.
Immediate treatment required e.g. hypoglycaemic coma (intravenous glucose 50%).
Urgent hospital referral required e.g. head injuries, poisoning.
Non-life threatening causes e.g. vasovagal attack ('faint') and hysterical conversion
presenting as loss of consciousness. Management depends on the particular
circumstances. Referral may or may not be necessary.
Acute respiratory distress - Usually presents as difficulty in breathing. Quick history and
clinical assessment.
Urgent stabilisation before referral e.g. acute laryngeal oedema secondary to an
allergic reaction (subcutaneous adrenaline, intravenous hydrocortisone).
Urgent referral required without intervention e.g. acute epiglottitis in children.
Non-urgent conditions e.g. hyperventilation. Patient should be handled with tact,
especially so if accompanying relatives who are highly anxious.
64

Chest pain - Patient and relatives usually very anxious. Trivial causes e.g. musculoskeletal
causes or anxiety more common than serious causes. The task of the general practitioner
is to identify those that are medical emergencies (e.g. acute myocardial infarction), refer
these for further management, and treat the others as appropriate.
Severe abdominal pain - When a patient develops abdominal pain, it is often difficult
to decide whether to make a visit or to give advice over the telephone. But if the patient's
condition warrants a home visit, it is worthwhile spending time on a careful history and
examination and keeping a high index of suspicion for the unusual. E.g. renal, biliary or
abdominal colic, can be managed as outpatient initially followed by referral if indicated.
Gynaecological emergencies such as ectopic pregnancy and twisted ovarian cyst must be
referred immediately following initial stabilisation if necessary.
Bleeding in pregnancy - A pregnant woman who starts to bleed during the night
is likely to be extremely frightened, even though the bleeding usually settles fairly quickly.
Suspect retained products of conception or ectopic pregnancy if the patient is shocked
or in pain. If ectopic pregnancy is suspected, do not do a pelvic examination and arrange
for urgent hospital admission. Withhold antibiotics if bleeding follows therapeutic
abortion or previous evacuation until the uterus has been re-evacuated. Patients who
bleed in the second half of pregnancy require urgent hospital admission. Useful drugs to
bring along for housecall include ergometrine, oxytocin, diazepam, an opiate analegesic
and an antiemetic.
Injuries - Range from mild to severe. Causes include road traffic accidents, accidents at
home or at work, violent behaviour, etc. Patients and relatives usually very anxious and
agitated. The doctor's task is to quickly assess the severity, amount of bleeding if any,
decide whether to institute first aid measures and refer to the hospital straight away, or
whether the patient can be treated in the clinic. Relatives should be reassured, and the
treatment plan explained to them.
Allergic reactions - These range from mild skin rash to urticaria, angioedema. The task
of the general practitioner is to treat those conditions that are life threatening e.g.
subcutaneous adrenaline in generalised urticaria, arrange for hospital referral those that
are potentially severe e.g. early Steven-Johnson syndrome, treat those that are mild, and
allay anxiety in patient and relatives.
The disturbed patient/forensic problems - Assessing a psychiatric crisis is seldom easy.
The family physician often has to decide how to alleviate the crisis over the next 24 hours,
rather than trying to find a definitive solution to a long term problem. These are highly
emotionally-charged and take up a lot of time. Supporting staff such as medical social
workers would be a great help. Severely disturbed patients may need sedation with
paraldehyde or diazepam before referral for admission. Psychiatric referral may be
arranged at a later date if the situation is not so urgent. Cases of alleged rape need to be
referred to the gynaecologist for further evaluation. In the case of sudden death, a post
mortem is always prudent and the general practitioner should so advise the relatives.

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PATIENT EDUCATION
It is important that patients are educated as to which situation constitutes an emergency
and which doesn't. This is so that the emergency services of hospitals are not overloaded,
and that doctors are not called out-of-hours for trivial complaints.

HOUSECALLS
Scope of Housecalls as seen in General Practice
Assessment and/or management of acute illnesses - Assessment for home management vs hospitalisation : Home conditions and availability of family support important
factors to consider.
Assessment and management of patients discharged from hospital - e.g. postsurgery or recovering from illnesses such as myocardial infarction and stroke. Rehabilitation requires adaptation to the home and activities of daily living.
Management of patients with chronic illness - E.g. patients with stroke. Monitor
progress of the condition and impact of treatment instituted. Paramedical support such as
nursing staff from the Home Nursing Foundation are a great help.
Management of patients with terminal illness - Care of the terminally ill at home
requires adequate home support. The family physician provides support to the patient
and his family.
Assessment of home conditions and family function - Opportunity for the doctor to
meet family members, observe interactions among them, provide family counselling and
assessment of the patient's mental skills.
To allay patient or caller anxiety - To allay anxiety alone is sometimes a good enough
reason to make a home visit. Presence of physician gives reassurance and confidence to
the patient and his carers. Also an opportunity to build a closer rapport with family members.
Doing A Housecall
Preparation
Personal preparation : The doctor's readiness.
The doctor must be prepared personally to do housecalls.
Should be contactable. Arrangement for message-taking, e.g. via a pager.
Appropriate vocational training.
Ensure the doctor's safety as far as is possible.
Clinic organisation : Staff readiness.
Clinic staff trained to recognise an urgent call. All such calls to be screened by the
doctor who will decide on the time and mode of management.
66

Good to document details of all requests for housecalls, any advice given, and whether
or not a visit was made.
The housecall bag
The drugs carried by a family doctor are a matter of personal choice, but they also
depend upon the type of practice to which the doctor belongs. The medicine carried
in a family doctor's bag can play a life-saving role. By immediate administration they
will also relieve pain and suffering at the bedside. The doctor's bag needs to be
stocked and ready at all times and its contents should be checked and
updated regularly.
Finally, it must be remembered that the doctor's bag must be kept locked at all times,
as it contains controlled drugs.
Handling a request for housecall
Establish identity of the caller, contact telephone number, name of the patient,
and location.
Collect only enough information to decide whether a visit is necessary and if necessary,
ambulance at the same time.
In cases where advice is the only action needed, make it clear to the caller that if the
advice is not helpful or if symptoms change, another call will result in the patient
being seen.
In the case where a visit will be made, any first aid advice necessary should be given,
and the caller assured of the doctor's intention to visit in an estimated time frame.

Additional preparation
This can be decided after talking to the caller, and may indicate extra equipment, drugs or
clinic records.
Assessment of the urgency of the problem:
The use of emotionally charged terms e.g. collapse, a rapid delivery and a raised tone of
voice, is an indication of anxiety in the caller. The presence of internal inconsistency in the
message also indicates anxiety in the caller.
Categorisation of urgency of call:
High - urgent treatment necessary.
Medium - symptoms or circumstances of sufficient concern to justify a visit, where
prompt treatment would facilitate recovery.
Low - urgent visit not needed.

At the scene
Acute cases
Quick assessment. First aid, resuscitation and emergency treatment if necessary.
Organise admission to hospital if necessary.
If to treat at home, or if patient or his relatives oppose hospital admission, assess the
patient's problem, his family and home environment to decide if this is feasible. In such
a case, arrange for early follow-up visit.
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Important to attend to the patient and his family members' anxieties. In many
situations, it is the caller rather than the patient who needs reassurance
or explanation.
Vital to recognise that a definitive diagnosis not always possible in emergency
situations. Plan of action important in such cases. The doctor must be prepared to
revisit and reconsider his management plan.
Chronic cases
Not much urgency unless an acute exacerbation, an urgent new problem or a terminal
event. Management depends on the problem at hand.
Attend to patient and family's anxieties. Help organise the family's resources to cope
with problem, including considering the use of paramedical and community services.
Referral to hospital or specialist arranged when indicated.

Follow-up action
In any problem not requiring referral, after the initial treatment, the relatives should be
instructed to return to the clinic to collect further medications and to ensure that the
medical advice given are followed. Appointments should be given for the patient to
attend follow-up visits in the clinic, or, alternatively, subsequent home visits should be
arranged if indicated.

CHAPTER 5

PALLIATIVE CARE

Outline
Definition
Goals of Care
Scope of Palliative Care
The patient
Family support
Organisation of care

DEFINITION
The World Health Organisation defines palliative medicine as "the study and management of patients with active, progressive, far-advanced disease for whom the prognosis is
limited and the focus of care is the quality of life."
Such a definition encompasses not only patients with advanced cancer, but also patients
with end organ failures (e.g. intractable heart failure, respiratory cripple, end stage renal
failure) and other conditions like HIV, motor neuron disease and advanced dementia.

GOALS OF CARE
The main goals of palliative care are to provide patients:
1. relief from pain and other distressing symptoms.
68

2. psychological and spiritual care so that they may come to terms with their illness and
prepare for their own death as fully as they can.
3. a support system to help them live as actively and creatively as possible until death,
thereby promoting autonomy, personal integrity and self-esteem.
4. a support system to help their families cope with illness and bereavement.

SCOPE OF PALLIATIVE CARE


Care of the Patient and his Family
The aim of the treatment of terminal disease is not just the removal of pain and
symptoms, but to give to the patient and his family the motivation and the means to live
to the limits of their potential during that period of his life remaining.
The doctor and his team of carers must ensure that the patient receives the optimum
medical care, while providing strong psychological support to the patient as well as his
family during and after the period of dying.
The Family Doctor, Medical and Para-Medical Services
Unless a person dies unexpectedly far from home, the family physician is usually the first
to evaluate a potentially fatal illness and the last to preside over the actual exitus. It is the
family physicians prerogative and responsibility to provide coherent management by
offering treatment relief, guidance, support and safe conduct throughout the course of
the disease.
The family doctor is in the best position to provide this care because of his philosophy and
his training. He must give personal, comprehensive and continuing care to the patient as
well as his family, coordinating all the medical and para-medical personnel necessary for
terminal care. He is usually the one the patient and the family will turn to whenever
medical or social problems crop up, and he should respond with knowledge
and empathy.
Hospital Care, Domiciliary Care and Hospice Care
During the course of the illness, there will be need for the services of specialist and
hospital care, and they should be used judiciously. Hospice care has been established in
Singapore, and they provide an essential aspect of terminal care. In our Asian society,
most of the patients would have expressed a wish to die at home, and domiciliary care of
the terminally ill must be organised and provided for the patient.

THE PATIENT: HIS NEEDS AND CARE


Psychological Care
The family doctor must be able to cope with the dying patients' emotions and
his reactions.
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According to Dr Kubler Ross, the patient with terminal illness undergoes five stages
of dying:
(1) Denial (No, not me!)
(2) Anger (Why me?)
(3) Bargaining (Yes it is me, but .....)
(4) Depression ('It is me')
(5) Acceptance
This model provides a framework for understanding the feelings of a dying person. Not
all patients move systematically through these five stages, these emotional reactions are
not linear, but complex and varying. The different stages last for varying lengths of time,
replacing each other or, at times, existing side by side. The one thing that usually persists
throughout the process is HOPE - the hope that, despite everything, they will recover.
The age, sex, education, religion and culture of the patient affect and determine his
acceptance of his illness and death.
Most patients will suffer varying degrees of anxiety and depression, and the doctor must
provide psychotherapy and medication where necessary.
Objectives of psychotherapy:
1. Reduce stress from anxiety and confusion.
2. Provide opportunities for ventilation.
3. Offer insight.
4. Support defense mechanism.
5. Support of patient's family.
Patient has the right to know and the doctor should tell if the patient expresses a desire to
know. We must be honest with the patient, for he might need to make plans for the
family or make peace with himself and the loved ones.
Problems of when to tell, what to tell and how to tell: the doctor must equip himself with
the knowledge and the insight to manage these very real problems.
Physical Care

Pain control
The relief of pain in advanced, incurable illness is essential to alleviation of suffering
experienced by both the patients and their extended family. Cancer pain can be severe
and persistent and causes the patient to be demoralized and depressed. Pain from
terminal cancer is a chronic pain and unlike acute pain, gets worse rather than better and
grows to occupy the patients' entire attention, day and night. Such pain requires
constant relief.
Aims of pain control are:
Pain free during the day and at rest.
Pain free on movement.
Pain free during the night for a good night's rest.

70

Principles of Pain Management


1. Establish the cause of pain through a thorough history, physical examination
and selected investigation. Especially consider the possibility of neurophatic pain
which is due to compression or infiltration of nerves by tumour or to painful
peripheral neuropathy.
2. Always reduce sensory input by prescribing a peripherally active drug (paracetamol
500 mgm - 1000 mgm 4 hourly and/or NSAID).
3. If pain persists to any degree with peripherally active drugs prescribe ADDITIONALLY
either a week (codeine phosphate 30 mgm - 60 mgm 4 hourly) or a strong opiate
(morphine 4 hourly) depending on the intensity of pain.
4. Never depend on PRN prescribing alone. Always prescribe a regular combination
(eg paracetamol 500 mgm - 1 gm 4 hourly plus morphine 10 mgm 4 hourly).
Always use the oral route when possible.
5. Consider interventions that raise the "pain threshold" including discussion of the
disease, its treatment and prognosis, counselling, relaxation techniques and
anxiolytic therapy.
6. Always prescribe a laxative when starting narcotics.
7. Be prepared to prescribe antiemetics.
8. Analgesics given should be strong enough, in adequate amount and frequent enough
to keep patient pain free for 24 hours a day. The analgesics should be chosen
according to the severity of the pain. There should be no hesitation in using morphine
to its maximum benefit to relieve the patient's pain. Morphine should not be
withheld for fear of addiction or until pain is severe. Oral morphine is readily available
in Singapore.
9. Pain due to secondaries may need radiotherapy, chemotherapy or hormone therapy.
10.Corticosteroids may also reduce pain by modifying the disease process in brain and
nerve involvement, and reducing oedema around a tumour.
11.Psychotherapy and the use of tranquillisers and anti-depressants may be necessary in
some cases to relieve pain.
Causes of Pain in Cancer Patients
Tumour infiltration of bone, nerve, plexus or root, visceral organs and pleura
Pressure effects from ascites, lymphoedema and cerebral tumour
Infection
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Gastrointestinal obstruction from tumour and faeces


Immobility
Symptom Relief
As the disease progresses, many symptoms arise pertaining to various organ systems.
These must be seen to and alleviated as best as possible. The relief of these troublesome
symptoms do much to the well-being of the patient. Good symptom control requires
meticulous assessment and frequent review. Also symptoms change rapidly in the
dying patient. Fear and anxiety play a major role in aggravating symptoms. Good
symptom control requires a relationship of trust between the patient and the doctor.
Common Symptoms of Terminally Ill Patients besides Pain
Respiratory dyspnoea, cough and excessive bronchial secretions
Central nervous system headache, agitation and restlessness, anxiety and
depression and insomnia
Gastrointestinal anorexia, nausea and vomiting, hiccough, constipation and
diarrhoea, intestinal obstruction and mouth problems - candidiasis (thrush), mouth ulcers
Skin ulcers, fungating wounds, odours and pruritus
Incontinence
Prescription of medication is not the only way of treating symptoms. A more
comfortable bed, appropriate food, a kind word, gentle massage, the application of a
cold or warm pack: all these can be useful. This is holistic care.
Diet
It is convenient to say let the patient eat what he wants when he wants them. But to say
this callously is to indicate to the patient and the family the hopelessness of the illness.
The doctor should indicate to the family the need for adequate liquid and nutrition, the
necessity of careful preparation of the food in the form and substance which the patient
can take considering his weak state, his anorexia and his state of consciousness. The
doctor must be prepared to be asked about 'tonics' and herbs, and strengthening food.
Aids, Appliances and Equipment
When the patient is cared at home, it might be necessary to obtain special bed and
mattress, commode, wheelchair, etc. Some of these may be obtained on loan from the
Hospice Care group, or the Home Nursing Foundation.
Social Care

Religion and culture


The religion and culture of the patient can and do influence and determine the
expectation and the ability to cope with the terminal illness and death.
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By and large our Asian culture prepared us to be stoic and our religion help us to face
death more calmly, e.g., the Muslims are very philosophical when it comes to accepting
terminal illness and impending death, but sometimes unrealistically so.

Will and testimony


The patient may need to prepare these to provide for the family, and the advise and help
of the doctor may be sought. The doctor should give all the help necessary without
getting involved in any family differences.

Doctor/Patient communication
The family doctor is usually the one who referred the patient to the specialist or hospital,
or he may be the one to make the diagnosis. At some point in the terminal phase of the
disease, he would be the one to provide the care or co-ordinate the team of carers.
He should help the patient cope and come to terms with his illness and dying. He should
alleviate the pain and relieve all troublesome symptoms. Placebos are not palliation and
should not be used in terminal care. He should be a doctor, a friend and a counsellor to
the patient as well as his family.
The age, sex, education, religion and culture of the doctor also influence and determine
his reaction to and his ability to handle terminal disease and death. Doctors should
upgrade and update his knowledge of psychotherapy and therapeutics to be effective in
the management of his patients.

FAMILY SUPPORT
Doctor/Family Communication
Sometimes the relatives may not want the doctor to tell the patient. Agreeing to such a
conspiracy is to deny two essentials of any consultation - truthfulness and confidentiality.
Working with cancer patients in San Francisco, two social worker, Barney Glaser and
Anselm Strauss (1965) identified four types of awareness of dying:
1. Closed awareness. All but the patient knew the real situation. This collusion puts a
severe strain on family relationships and is impossible to sustain for long.
2. Suspicion awareness. Here, the patient constantly put out feelers in the hope of
receiving more information.
3. Mutual pretence awareness. Here, both the patient and the carers know the real
situation, but everyone acts as if it were otherwise.
4. Open awareness. Everyone knows, and are prepared to disclose what they know or
need to discover.

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It is necessary to identify the one in the family who is closest to the patient, or in authority
for effective communication with the family. This is usually the spouse, or the eldest son
though not necessarily always so.
Impact on Family
The family plays a significant role in the care of the terminally ill and their reactions will
contribute a lot to the patients' response to his illness. During a terminal illness the
patients' relatives experience a variety of emotions, these will vary according to the depth
of relationship between the patient and his family as well as by the duration of the illness
and mode of death.
The process of dying and death of a member creates a family crisis and imposes various
kinds of stress and strain on family situations. This may lead to breakdown of coherence
of the family unit with consequent re-allocation of roles within the family group, also the
dying patient's problems come to an end but the family's problems go on.
Family members undergo different stages of adjustments similar to the ones described for
dying patients. Like the patient the immediate family members need to work through
'denial, anger, bargaining and depression' if they are to achieve a positive acceptance of
the inevitable.
Family as Carers
Just as it is wrong to deny the patient the right to know, it is not prudent not to tell the
family, especially the closest ones. They should be given to understand the disease
process, the effect it has on the patient and the necessity for the different modalities of
treatment. The family members should be recruited and trained to help in the care of the
patient. In Singapore, our society is family-oriented, and very supportive in the care of the
dying. Our culture and religion help us to be so. Unfortunately, in recent times, this has
become less evident, and many families are too ready to put the patient in old age homes
or hospital "to die".
Care for the Family
The doctor should provide emotional support to the family members by counselling and
psychotherapy. He may need to prepare the family members face the impending death of
the patient. He may need to secure social welfare help and financial aid for the family. He
should facilitate the issuing of the death certificate, and instruct the family as to the
procedure of reporting the death, and even helping in contacting the casket company,
the religious organisation and personnel. Visiting the family just before and immediately
after the death of the patient may be a great confidence booster to the family.
Bereavement
The family doctor is the best person to provide skilled and compassionate bereavement
support. Grief starts when the diagnosis is made, and needs to be adequately managed.
74

Grief can be predicted, identified and preventive measures can be instituted early. It is
generally accepted that there are five stages in bereavement:
1. Period of relief
2. Period of relaxing
3. Period of resenting
4. Period of remembering
5. Period of repairing.

ORGANISATION OF CARE
Role of Family Physician/General Practitioner : Clinical and NonClinical Duties
The family doctor may be the first to know of the terminal illness and may be the final
one to take care of the patient. He should be prepared to give his empathic care and his
medical expertise to see that the patient dies with dignity and without agony. He must
not forget the family.
Regardless of consultants, specialists, technician and care-givers who come and go in the
interim, it is the family physician's prerogative and responsibility to provide coherent
management to the terminally ill by offering treatment relief, guidance, support and safe
conduct throughout the course of the disease. Management of the dying is a team
concern and the doctor is part of this team which includes the dying patient, his
immediate family, his children, his friends, his doctor, the lawyer, the nurses, the medical
social worker and other ancillary staff.
The role of the doctor in terminal care is multiple and can broadly be divided into clinical
duties and non clinical duties. Clinically, the physical health mental health, and well being
of the patient has to be maintained.
(a) Control of symptoms, e.g., dyspnoea, dysphagia, nausea
(b) Control of pain, chronic or acute from tumour infiltration of bone, nerves, viscera, etc.
(c) Emotional and psychological care of the patient
Talk about diagnosis : try to find out how much the patient wants to know and give
as much as he can handle.
Reveal just enough information to satisfy patient's needs and deal with further
questions as they come.
Maintain honesty and trust.
Reassure patient that you will do all possible to provide comfort.
Whenever appropriate, allow the patient to express a preference about his care.
Non-clinical duties include:
Providing emotional support to the family.
Make contact. Listen to family's concerns. Help them to work through their feelings.
Allay guilt, appreciate cultural and social influences.
Encourage family members to stay with patient.
Refer family to community resources that can provide social and emotional support
e.g., hospice.
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Reassure family that everything reasonable was done before death supervened.
Reassure family everything that you will do all possible to provide comfort.
Need to secure social welfare help and financial aid for the family.
Facilitate the issuing of the death certificate and instruct the family as to the procedure
of reporting the death and even helping in contacting the casket company, the
religions organisations and personnel.
Visiting the family just before and immediately after the death of the patient may be a
great confidence booster to the family.
Specialists/Hospitals
The need for specialists and hospital is usually early, to make and confirm the diagnosis,
to give all the management possible to cure or to alleviate the disease. It is of the utmost
importance to remember that an accurate diagnosis of the illness and of the prognosis
must be made before instituting what is termed terminal care. It is also necessary to
review the diagnosis and prognosis from time to time.
Admission to the hospital and hospice is sometimes necessary for the patient, and for the
distraught and tired family carers.
Domiciliary Terminal Care
The place and the family carers should be identified. The family members may need
to be trained by the doctor, the Hospice care organization or a voluntary organization
providing such a service. Regular visits by the doctor will be necessary to institute the
various modalities of treatment, especially pain relief. Psychological support at all times
is important.
Hospice Care
The Hospice movement was started in Britain in 1967 by Dame Cicely Saunders. Today
hospice care aims to provide total care for the terminally ill and support systems for the
relatives, in the conditions desired by the patient and family.
The broad care objectives of a hospice are:
to help provide hospice care to dying patients.
to help provide financial help for needy patients.
to educate the public and provide training in hospice care.
to maintain standards.
to encourage and support research in hospice care.
and to support and work closely with all services for the terminally ill.

76

1 Managing People and Resources


2 Managing Facilities and Utilities
3 Managing Information Medical Records,
Confidentiality, and Computerisation
4 Managing Finances, Including Managed Care
5 Managing Quality

SECTION 04

PACKAGE B MANAGING THE FAMILY


MEDICINE PRACTICE

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SECTION 04
SECTION 04 MANAGING THE FAMILY MEDICINE PRACTICE

CHAPTER 1

MANAGING PEOPLE
AND RESOURCES

Outline
Being a manager
Effective leadership
Managing people
Strategic management
Personal effectiveness

BEING A MANAGER
The doctor is often the manager of the practice. Managing is to get work done through
the efforts of others. Managing is also producing an output from input and processes.
Inputs have been called the three Ms manpower, money and materials. Processes are
operational work, developmental work, and organizational work. Outputs in the
clinic can be grouped into 2 interconnected components technical care, and
patient satisfaction.

BASIC FUNCTIONS OF A MANAGER


The four basic functions of a manager are planning, organising, leading and control.
Planning This is a process of setting objectives and formulating the steps which will be
necessary to attain these objectives. Planning can be long term which is also called
strategic planning or short term or operational planning.
Organising This a process of getting activities, people, materials structured to meet
organizational objectives. It includes the setting of job definitions, authority to act and
departmentalization.
Leading This is the process of influencing staff to meet predetermined objectives. The
skills to be an effective leader are communication and feedback skills, motivation of staff,
and the use of appropriate leadership styles to suit specific situations.
Control This is a process of ensuring that things happen according to plan and taking
corrective actions where necessary. Control is a three-step process: setting standards,
comparing performance against standards and correcting deviations.

ROLES OF A MANAGER
A manager has no less than ten roles according to a management guru, Mintzberg.
These ten roles can be grouped into 3 clusters. Each of us can make an inventory of the
roles that we are good in and those we are deficient in. The continuing improvement is
to strengthen those roles which we are weak in and ensure that the strong areas
are maintained.

78

The three clusters of roles are:


Leadership roles three roles are in this cluster: figurehead, leader and liaison person. In
these roles, the manager interacts with outside organizations.
Informational roles three roles are in this cluster: monitor, disseminator, and
spokesman. In these roles, the manager handles information.
Decisional roles four roles are in this cluster: entrepreneur, disturbance handler,
resource allocator and negotiator. In these roles, the manager makes decisions.

SKILL SETS OF THE MANAGER


The three skill sets are conceptual, human and technical.
Conceptual skills These are skills of perceiving how the parts of the organization link
together in structure and processes.
Human skills These are skills involved in working with people, often as a member of a
group. The ability to consider the interests of subordinates and co-workers, to motivate
them to contribute their best and to involve them in decision making are important for
the manager to get work done through the efforts of others.
Technical skills These are skills in managing things rather than people and are often
learned through on-the-job training programmes.

EFFECTIVE LEADERSHIP
Leadership is the process whereby one person influences the thoughts and behaviours of
others. Between the extremes of complete autocracy on the one hand and a totally
permissive approach on the other there exists a continuum of possible leadership styles.
Models of Leadership and Leadership Styles
Several models of leadership and leadership styles have been described in the
management literature. They provide an insight into the different facets of leadership
that are relevant at a particular situation.
The Task, Group, and Individual needs Leadership Model
According to John Adair, effective leaders simultaneously satisfy these three sets of
interdependent needs. What is effective leadership depends on the task, the group and
the individual.
Task needs These relate to the work that has to be completed. A leader must be seen to
strive to achieve group objectives, or he or she will lose the confidence of the group.
Failure to satisfy task needs result in disenchantment of the group, in criticism of the
leader and the eventual collapse of the group. Task needs may be satisfied through
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planning, allocating duties, giving targets to individuals, setting standards, and the
systematic appraisal of members performances.
Group needs These relate to team spirit and morale. The group must be held together
through effective communication, discipline and other measures for enhancing
teamwork. Discipline, that is, the means for ensuring that work is carried out and that
rules, norms of behaviour and instructions are obeyed, is improved if there are clear
instructions and each group member knows precisely what he or she is required to do.
Leaders enforce discipline in order to prevent harm being done to the efforts of the
group. Leaders should set a good example, not break rules themselves, and not exercise
favouritism or impose unreasonable obligations on others.
Individual needs These relate to the personal needs of group members. The leader
should seek to discover what each member wants from the group and how these needs
can be satisfied and harmonized with task and group requirements. Measures for
meeting individual needs are coaching, counseling, motivating and staff development.
The three needs interconnect because an action in one area affects others. Leadership
training, Adair argues, should be directed towards increasing a persons sensitivity to the
three sets of needs, particularly through training in how to define objectives, team
briefing, organization of work, practical motivation, planning and control. The leader
needs to alter the mix of efforts devoted to satisfying various needs according to the
overall situation.
Personal Leadership Styles
Each of us has a basic personal leadership style and may be motivating or demotivating
depending on the situation. An insight of the range of personal leadership styles helps us
to choose what is appropriate for the situation.
Autocratic or permissive. What choices of personal leadership style can we have?
Autocratic approaches might be suitable when subordinates work is repetitive and or
unpleasant. Permissive styles could be appropriate where subordinates are skilled, highly
motivated and or where complex work is involved.
Theory X or Theory Y. Should we be Theory X or Theory Y managers? Douglas
MacGregor thinks it is more effective to be Theory Y managers. Theory X managers have
negative assumption of people as workers. Such managers may not be motivating.
Fig 2. Theory X and Theory Y Managers

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THEORY X

THEORY Y

NEGATIVE ASSUMPTION

POSITIVE ASSUMPTION

Task-oriented
Control is needed
Coercion is required

People-oriented
Self-responsibility
Self-actualisation

Concern For Production And People: The Managerial Grid. In 1964 Robert Blake
and Jane Mouton devised a method for training managers in the diagnosis of their own
and other peoples leadership styles. The managerial grid is a taxonomy of management
styles classified according to the managers interest in subordinates as people in
comparison with his or her concern for production. Each concern is rated on a scale from
1 to 9 so that a 9,9 manager is a one who possesses both a very high concern for
people and a high concern for production. A 1,9 manager, with low concern for
production but great emphasis on human relations, pays careful attention to
subordinates human needs, but exerts little effort to ensure that work is actually done
properly. Such a manager is likeable, enjoys satisfactory relations with subordinates
and generates a friendly atmosphere in his or her department. The 9,1 manager on
the other hand arranges work as efficiently as possible, with little regard for
subordinate feelings.
With the grid defined by the two axes (one showing concern for people, the other
concern for production) five managerial types were distinguished. See Figure 3. Grid
training tries to help managers identify their inclinations within this framework. Ideally,
the 9,9 position should be the desired combination.
Fig 3. Managerial Grid Devised by Robert Blake and Jane Mouton
9,9
TEAM MANAGEMENT
WORK accomplishment is from
committed people;
interdependence though a
common stake in organization
purpose leads to relationships of
trust and respect.

1,9
COUNTRY CLUB MANAGEMENT
Thoughtful attention to needs of
people for satisfying relationships
leads to a comfortable friendly
organization atmosphere and
work tempo.

5,5
ORGANIZATION MAN
MANAGEMENT
Adequate organization
performance is possible
through balancing the necessity
to get out work with maintaining
morale of people at a satisfactory level.

1,1
Impoverished Management
Exertion of minimum effort to get
required work done is appropriate
to sustain organization
membership.

9,1
Authority-Obedience
Efficiency in operations results
from arranging conditions of
work in such a way that human
elements interfere to a minimum
degree.

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MANAGING PEOPLE
Scope of Managing People
From entry to exit of the staff, there are many aspects in managing people. The scope of
it all is summed up in Figure 4.
Fig 4. Scope of People Management
Entry-> Exit
* Recruitment
* Motivation
* Staff development
* Selection
* People handling
Delegation
* Induction training
* Structure
Appraisal
* Leadership
Courses
* Personal effectiveness
* Separation
* Change management
*Promotion

Motivation to Work
Motivating staff to contribute their best is a big challenge. Figure 5 shows the factors
that affect motivation. There is a need for an ongoing appraisal of the motivation level of
staff. Channels for upward communication must be open for staff dissatisfaction to be
identified and dealt with before it has caused widespread motivational problems.
Fig 5. Factors affecting Motivation in Organisations
INDIVIDUAL
CHARACTERISTICS

JOB
CHARACTERISTICS

Needs

Skill variety

Immediate work setting

Task identity

Peers
Manager

Task significance
Autonomy
Feedback
Interest

Organisational practices
Reward systems
Rules & regulations
Politics

Attitudes
Self
Job
Work Situation

ORGANISATIONAL
CHARACTERISTICS

Source: Porter & Miles. in: Motivation and Management. McGuire (ed), 1974:547 (adapted)

Dealing with Unpleasant Issues


People management requires the ability and willingness to deal with unpleasant issues.
Grievances
Grievances result form external circumstances (e.g. poor working conditions) or from the
staffs internal feelings of distress caused by bad personal relationship with other workers
or the perception of being treated less favourably than everyone else. Externally created
grievances may be remedied through altering environmental circumstances: improving
82

working conditions. Internally generated grievances may require the counseling of the
employee or transfer to a different department or job.
Often grievances are due to misunderstandings rather than to fundamental difficulties.
Examples are breakdowns in communications, petty jealousies, interpersonal rivalry and
departmental disputes.
Resolution may be informal in that the aggrieved parties try to work together and
resolving differences by increasing the flow of information through the organization, by
defining the authority and responsibilities of people and departments more carefully,
and by generally promoting co-operation between individuals and section groups.
Otherwise a formal grievance procedure is required. A 3-man-committee is formed to
mediate the differences.
Discrepancies
The discovery of discrepancies in the clinic requires immediate action. It is one of the
unpleasant tasks that the manager has to do. The discrepancy may be cash, medicines or
medical supplies. The steps are to prevent destruction of evidence, institute an
investigation to confirm the discrepancy, identify possible persons involved and decide
on options to take on the staff involved. The options to be decided are paying back what
has been wrongfully taken, and dismissal with or without making it a police case.
Absenteeism
Absenteeism can result from job dissatisfaction, individual inclinations not to attend
work, or from bad personal relationships within groups of workers. Job related factors
include poor physical conditions, boredom, inadequate supervision, stressful
environments and or inconvenient working hours. Other factors are: individuals general
state of health, distance from work and or traveling difficulties and extent of the
employees family responsibilities. Several of the factors are interconnected. For example,
it is a fact that women on average take more time off work than men, but it is also
known that females predominate in many tedious and low status occupations.
Absence control policies involve the following:

Job design and regular job rotation.


Employee participation in decision making.
Improved recruitment and selection procedures aimed at fitting individuals to jobs
Flexitime and job sharing.
Actions short of dismissal e.g., formal warnings, or denial of pay increase
Bonuses for regular attendance.
Employee counseling.
Careful record keeping to identify those with highest absenteeism rates.

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Ideas from the One-Minute Manager


The best seller, the One-Minute Manager by Spencer Johnson and Kenneth Blanchard
deals with three important people management skills one-minute telling, one-minute
praise and one-minute reprimand. The ideas are useful as part of people management
skills. Read the book if you can find the time.
One-minute telling Tell what is most important. Check to see it is understood
correctly.
One-minute praising Catch people doing right and praise them. Stop catching doing
wrong and scolding them.
One-minute reprimand This may be necessary: Tell the person you are disappointed
with the action. Divorce the action from the person. Remember that once it is over,
it is over.

STRATEGIC MANAGEMENT
Strategic planning has not been an activity in the management of small health care
enterprises such as the GP clinic. There is a need to introduce strategic planning as part of
the tools of modern management of the GP clinic.
Strategic management may be defined as planning in the future. The environment in
which organizations operate is changing so fast that without a future plan to help its
managers to identify future opportunities and problems, there will be no consistent plan
of action.
Two quotations highlight its place in management.
Henri Fayol: The plan of action facilitates the utilization of the firms resources and the
choice of the best methods to use for attaining the objective. It suppresses or reduces
hesitancy, false steps, unwarranted changes of course, and helps to improve personnel. It
is a precious managerial instrument.
Peter Drucker: While it is futile to eliminate risk, and questionable to try to minimize it,
it is essential that the risks taken be the right ones. The end result of successful strategic
planning must be capacity to take a greater risk, for this is the only way to improve
entrepreneurial performance To extend this capacity however, we must understand the
risks we take. We must be able to choose rationally amongst risk taking courses of action
rather than plunge into uncertainty on the basis of hunch, hearsay or experience.
Basics of Strategic Planning
Strategic planning has five steps:
Identification of current objectives and strategy.
Analysis of the external environment (environmental scan).
Analysis of the organizations strengths and weaknesses (Internal scrutiny).
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Strategic decision making to decide on services to introduce, services to scale down.


Strategic implementation at functional levels.
SWOT Analysis
The processes of the first three steps together form the SWOT Analysis which stands for
strengths, weaknesses, opportunities and threats. Opportunities and threats exist in the
external environment. Opportunities are prospects to fill existing or new service needs.
Threats come from competitors, policies and economic outlook, and changes in public
taste. Strengths and weaknesses are the state of the organization to sustain itself.
Gap Analysis
A comparison of the standards, resources (manpower, materials and money) and services
to achieve the future desired situation and the present situation provides the gap that
needs to be closed to be surviving in the future. Gap analysis is a prelude to step 4 of the
strategic planning.
Some Strategies Relevant to Health Care
The following strategies are not mutually exclusive. Also, stakeholders can collaborate
and work together in one or more of the strategies.
Non-price competition This include modern, elegant facilities; increased efforts to
achieve accessibility and acceptability of services; emphasis on developing goodwill and
positive institutional images in the consumers mind.
Vertical integration This is entering into the business that supply the resources needed
to run the main business operation. Examples are setting up a pharmaceutical facility or
a laboratory to service participating clinics.
Forward integration This is entering into services that move closer to the ultimate
consumer or end-user. Examples are one-stop services, health related clinics (exercise,
diet and smoking programmes).
Horizontal integration This is entering into arrangements to link service outlets to
achieve economies of scale, concentration of management talent, or more efficient
management of capital resources.
Management of Change
Part of strategic management is the management of change. Receptivity of the
organization to change is important to its long term survival. Doing the same service mix
more efficiently or opening the service facilities for longer hours may not be the best way
to be sustainable. Change of mindset, services, and image may be needed.
There are several models that describe the change process. There is often a need for an
external change agent to help in the change process. A simple management of change
model is a 3-step programme:
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Discussion of the need to change (Unfreeze);


making necessary changes (Change); and
consolidating the changes to be part of the organisations activities (Refreeze).

PERSONAL EFFECTIVENESS
Personal effectiveness is the ability to exert a positive influence on the tasks of
management. It is one of the activities of continuing improvement. Achieving personal
effectiveness as an ongoing process.
Make Yourself Look Good
There is a need for each of us to make a conscious effort to put our best foot forward:

Exhibit strong ability in your job


Be enthusiastic about your work
Accept organisations goals
Show imagination and ability to solve problems quickly
Demonstrate flexibility and co-operation
Have good interpersonal and communication skills
Get job done on time and budget

Managing Paper
The ability to handle papers is a valuable skill. The points to note are:
If possible, handle the paper once.
Sort incoming papers through the TRAF system; TRAF stands for throw, route, act and
file. This is a system to deal with every paper coming on to your table.
Retain only those papers for action; get rest routed, thrown or filed away in a
systematic way.
Work on 2-3 priority tasks each time.
Keep track of complex, deferred and referred actions with calendars or tickler files.
Do a quick desk check before you leave each day to make sure all papers are TRAFed.
Managing Meetings
The are a few tips to remember when it comes to meetings:
Meet only when there things to discuss.
Have an agenda and send this along to everyone early together with relevant
supporting papers.
Put important items either as second or third item; the items would not be hampered
by meeting participants coming late.
The chairman is to keep the discussion going until there is enough information to
make a good decide; he should then call for action.

86

Take succinct minutes.


Send the minutes out early so that participants can act on what they have agreed
to do.

CHAPTER 2

MANAGING FACILITIES
AND UTILITIES

Outline
Supplies and stores management principles
Maintenance and storage
Laboratory investigations and X-rays
Managing discrepancies

SUPPLIES AND STORES MANAGEMENT PRINCIPLES


The supplies and stores system deals with ordering; receipt; maintenance; and issue
when required. The supplies can range from drugs and pharmaceuticals to syringes and
needles as well as general use items like stationery. In the clinic, the types and quantity of
pharmaceuticals and medical supplies needed has to be worked out empirically or based
on historical usage. Stocks of pharmaceuticals and medical require close monitoring to
ensure they do not deteriorate or reach expiry dates, they are not pilfered and their
storage and usage comply with existing regulations.
The operating principles of supplies and stores management are:
Have an efficient system An effective supplies system is essential for the smooth
running of a health centre. The range of supplies and equipment needed need not be
large, but the confidence that the right goods will be in the right place at the right
time is crucial.
Determine stocking levels In determining how much stock to hold the following
factors should be taken into account: Monthly, quarterly or annual requirements for
each item; the price of items; the time taken between placing an order and receiving
the goods (lag time); and the purchasing cost for each order. Too little held in stock
can lead to frequent shortages; large stocks are costly and may deteriorate because
they are not used fast, run out of date and also provide greater opportunity for
pilferage. Where certain goods are used frequently, for example, dressings, needles
and so on, re-ordering is simplified by having a topping-up system whereby a top
limit of say, 50 or 100 items are held at any one time, and stocks are replenished to
this level each time deliveries are made. Control over the use of such items is obtained
by setting an upper limit to the number which can be used in any given period of time.
Have a storekeeper It is useful to have someone in charge of the supplies and
stores for

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Insist on bin cards These are important. They should be kept up to date and
checked regularly to keep control over losses, breakages, pilferage and so on.
Have a ordering system -- A good principle of delegation is that the person who
uses supplies should have the authority to order them subject to supervision by
the manager.
Have a store ledger -- Have a store ledger and keep it current. Within a the store,
records of goods held in stock should kept in a store ledger, and that should agree
with the number of items on the shelves of the store, which are also noted on a tally
card or bin card. As goods are received into the store, entries are made in the ledger
and on the tally cards, and as goods are issued against a requisition appropriate entries
are also made on a stores issue voucher and a in a stores issue book.
Have defined procedures Clear and well-understood supplies procedures are
needed to ensure that goods are ordered and obtained before stocks run down;
Conduct regular stock-takings A system of periodic stock-taking and auditing is
necessary to ensure that goods are not lost, stolen, misappropriated, or deteriorate
through poor storage.
Have a system to deal with problems Operational problems of running out of stock,
and overstocking, and pilferage are examples. Having operating instructions to
prevent and deal with these enables the practice to run smoothly.

MAINTENANCE AND STORAGE


Some rules are needed in the issue of drugs and pharmaceuticals:
proper accounting of items issued.
restriction of number of people having access to stores.
regular inventory taking and action taken to explain discrepancies.
Drugs. The operations management principles are:
Use principle of first in, first out (FIFO) is important to avoid running out of date.
Circulate information on maintaining shelf life through proper storage.
Do spot checks and regular inventory taking; they reduce wastage from date expiry,
poor storage and pilferage.
Vaccines. The operations management principles are:
Maintain the cold chain. Transport to outlying places must be carefully planned.
Refrigerators need proper maintenance and reliable fuel supplies.
Keep every one knowledgeable of the cold chain, down to the driver.
Review the cold chain regularly. To ensure that the cold chain works, regular review
of how the cold chain operates in the District should be made.
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LABORATORY INVESTIGATIONS & X-RAYS


The number of laboratory investigations that can be done in-house has increased with
advancing technology and these have speeded the clinical decision making process and
accuracy of diagnosis.
In-house or external tests? The choice depends on ease of performing the test and the
volume that justifies the purchase of automatic analysers. The availability of single sample
analyser kits make it possible to have some of the tests like cholesterol and triglycerides
done in-house.
Key points in quality control. Key points in quality control and results reporting in
laboratory services that must be recognised and periodically reviewed by operations
managers are:
Reliability of tests requisite training of staff; random checking of accuracy by
sending paired samples; period of posting of staff to hospital
Overloading workload of the lab should be monitored to see if there is overload;
more staff or fewer samples for examination may have to be considered.
Reporting prepared forms in duplicate or triplicate - one sent back to the doctor;
another filed; rubber stamps for routine results help to reduce time needed in
preparing reports; electronic transfer of information and faxing are emerging ways of
results reporting.

MANAGING DISCREPANCIES
Definition. Discrepancies may be defined as the differences between recorded and
actual quantity of money or inventory.
Reasons. There are many reasons that can explain the discrepancies:

Human error.
Machine counting error the number of pills in the tin may not be exactly correct.
Incomplete recording.
Pilferage.
Fraud.

Like in all things, prevention is better than having to deal with it when it has happened.
Preventive measures. Consider the following preventive measures:
Have an open system where every one is clear what is to be done, such as recording of
items that have been disimbursed
Declared disciplinary action for pilferage and fraud.
Random checks for discrepancies.
Personal accountability like signing for money collected, goods received and disimbursed.
Need for medicines for personal use to be authorised.
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Action to be taken for all discrepancies. There is a need to be well-versed on how to


take action. Take the following steps:

Take immediate action.


Parties involved to explain what they know of the matter.
Conduct the necessary investigation.
Take uniform decision reprimand, dismissal and others as has been laid down as
standard operating instructions.

CHAPTER 3

MANAGING INFORMATION

Outline
Medical records
Confidentiality
Computerisation

MEDICAL RECORDS
Medical records are more than an aide me moir or a documentation of clinical details.
Properly kept and used, they allow us to see the problem solving process form which we
can deliver better care. An effective record keeping system contributes to the standard of
care. Attention paid to how medical records are organized, filed and maintained is
integral to effective practice. The problem oriented medical record (POMR) is better than
the source oriented medical record (SOMR) and we should progress towards it.
Operations Management Principles for Paper Records
Operations management principles for paper records are:
have a workable filing system There are various ways of filing: by NRIC, by name, by
families and by address or combinations of these.
have a filing discipline Filing is a boring task which may not done properly and this
will result in missing records. There is a need to specify the time limit allowed for a
record to be left unfiled. Also movement of records need to be tracked.
have operational rules for missing records The creation of temporary records and
the merging of these when the main records are found need to be stated.
have a culling procedure As records grow in thickness, some culling will be
necessary. The duration of medical records that must be kept is generally seven years
but there exceptions for childrens records and records that may have medicolegal importance.

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From SOMR to POMR


Historically, medical records grew out of the need to keep notes on the consultation and
is relatively unstructured, particularly if the patient is seen over a span of time.
Information is recorded chronologically and sequentially as they are available irrespective
of the type of data or the clinical context. This is called the Source Oriented Medical
Record (SOMR). The SOMR is still the main format used in in-patient care where detailed
clinical records from many sources are accumulated as they become available.
A better format is the Problem Oriented Medical Record (POMR). This was first described
by Weed LL in 1969 as an attempt to address the deficiencies of the Source Oriented
Medical Record (SOMR) and to enhance care. The POMR record consists of 4 components,
namely, the master record, the progress notes, the flow charts and the source documents.

Component 1 of POMR The master record


The Master record has 4 groups of data:
Bio-data Various parameters that are used as indices for filing are written at the
folded edge easily visible when filed in the drawers. Other defined spaces are
allocated for data including language spoken, social and family data and drug
allergies all important in the holistic care of the patient and his family.
Problem List The table for the list has 3 columns viz. active date, the problem and
inactive date. A blank inactive field indicates that the problem is still active e.g. DM
while an entry in the inactive field indicates the problem is resolved e.g. acute
appendicitis post-op.
Report Summaries There are tables for immunization records and also events. Events
are summary information such as referrals, hospitalization etc which may not yet
constitute discrete problems. The records here can be referenced to source documents
if any filed within the folder or elsewhere.
Graphic Space This is meant for the family genogram or significant physical signs
which are best drawn.

Component 2 of POMR Progress notes and source documents


For the POMR, one can choose either a two-column or a four-column format:
Two-column format The first column contains the Subjective, Objective, and
Assessment data. The second column contains the Plans
Four-column format -- One column each contains one of the elements of Subjective,
Objective, Assessment, and Plans data, moving from left to right.

Component 3 of POMR Flow charts


Flow Charts are useful for continuing care for chronic problems or structured
consultation such as medical check-ups. The charts serve to improve care by providing
visual reminders and also an overview of the specific clinical parameters through time.
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Various charts have been developed for hypertension, diabetes mellitus and asthma.

Component 4 of POMR Source documents


Source documents can be laboratory, ECGs or radiological reports which are not easily
transcribed, referral letters and replies. These are stapled in the same card folder or in
another twin card folder if voluminous.
Organizing A New Record System
There are several steps in organizing a new record system:

Overcoming barriers to change


Storage of medical records
System of Filing Records and retrieval
Culling and Archiving records
Paperless medical records

Overcoming barriers to change There are two sets of barriers adopting the POMR
versus the SOMR system and changing the physical format of the records to
accommodate POMR. The POMR system needs greater discipline and discrimination
when entering data. If the family physician already has an existing SOMR system which
he finds workable, he may just want to adopt some elements such as POMR flow charts
for certain patients to enhance care.
Storage of medical records A common over-sight of many clinics is inadequate
provision for medical records when designing the layout. The storage system must also
allow for easy access.
System of filing records and retrieval Several ways of filing records physically may
be considered and one chooses which is most suitable for a practice.
Numeric An unique accession number is assigned to each patient. The number given
can be obtained by cross-checking against other information like name, address or
identity card if a register is kept. This register can be on computer to facilitate rapid
cross-checking.
Alphabetical This way of filing records run the risk of misfiling and retrieval due to
confusion with patients with similar names.
Address or company Some clinics may file their patient records according to
addresses if the majority of their patients are from few blocks of flats in the vicinity. In
the similar way, all the patients belonging to a company may be filed together. This
has the disadvantage of the patient moving to another address or change employer
and not informing the doctor. Nevertheless, this could be a sub-system if the number
of patients from a few block of flats or a company are frequent.
Colour coding Colour coding the cards by small adhesive tags according to the
index field decreases the risk of misfiling. Card-folders of different colour for the
92

master record can be used for different patients for example, blue for male patients
and pink for female patients. The rest of the records can use similar paper. Similarly,
filing records of discrete groups in different places e.g. contract versus private patients
helps retrieval.
Culling and Archiving records If the records are voluminous, culling (destroying)
and archiving into secondary storage not occupying premium space away from the busy
reception may have to be considered. When culling keep in mind medico-legal
requirements as records must be kept for 8 years from last encounter for most cases.
Archiving patients who are not seen in the past 3 to 4 years and therefore less likely to
consult again must be done periodically to keep the active records manageable. In the
event that such patients are seen again, the records can be retrieved and place with the
active records.
Paperless medical records Eventually, a totally electronic medical record may be
considered when such systems are stable, reliable, easily available and affordable to the
practice. In the meantime, some of the information can be on computer e.g., diagnosis,
treatment given, and investigations.

MEDICAL RECORDS AND PATIENT CONFIDENTIALITY


One needs to be careful that patient confidentiality of information in medical records is
not compromised. This is an especial risk in company patients, in patients with managed
care, and also when records are computerized. The persons allowed to view the medical
record must be limited to only four groups of people.
CARE Those providing direct care to the patient Information about a
patient should be available to healthcare providers that are providing direct care to the
patient. Doctors need to know relevant medical records, pharmacists and dispensers
need to know the medication prescribed, radiologists need to know relevant clinical
information when interpreting images. Even in this context, confidentiality should be
based on a need-to-know-basis and in the context of the care being provided.
CONSENT Those given the patients consent Information requested by those
in direct care of the patient needs to have the patients consent, preferably written
and signed.
COMPULSION Those empowered by legal statute Unlike legal
confidentiality, medical confidentiality is not absolute in the eyes of the law. A law
court cannot compel a lawyer to breach confidentiality of information learnt in the
lawyer-client relationship; but it can order a doctor to breach the confidentiality of his
patient. The doctor is then faced with the dilemma to risk censure for contempt of
court orders or to breach patient confidentiality if the patient do not consent to the
information being released. Where possible, informing the patient of such a legal
requirement should be done. It is also important that only those with legal authority,
confirmed if necessary by evidence of authority e.g., a writ or summons, are given
access to the information in the patients record.

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CONCERN In public interest The wider public interest in preventing harm to


others and preventing crime could exceptionally outweigh both the private interest in
confidentiality. However, there must be a real and serious risk of some other person or
persons suffering harm if the confidence is not broken. Breaking confidence to the
public must be shown to the only effective means of avoiding or minimizing
that harm.

COMPUTERISATION
Management Principles
The increasing use of computers and the availability of large capacity electronic storage
systems introduce new ways for storing and retrieving records. Operational management
principles for computer use are:
have a computer usage training programme for all staff The restriction to computer
use to certain staff only may lead to difficulties when such staff resign.
have well written operational manuals for staff to refer to Such manuals help to
smooth out difficulties, assist in proper use of equipment and proper coding of
stored information.
have a defined daily backup procedure for data A daily backup of data is necessary
in case of data loss.
have a system of password security This may be necessary to guard against
unauthorised access and tampering of data.
use a tried system In computer use, an unique system should be avoided where
possible. A hardware and software system that is widely used is a system that is less
likely to run into trouble.
computerise with future in mind Future upgrading of existing hardware that may
be required should be considered before purchase of a computer system. Disk
capacity tends to be under-estimated.
Work Processes to be Computerised
Depending on the functions to be computerized, the decision may be a standalone
initially at the front office and the doctors office and moving on to a local area network
(LAN) that links up the consultation rooms with the front and back offices and also
connected with the outside world for email and Internet. There is more than one
possibility so planning and strategic decisions have to be made. Table 1 lists the clinic
work processes that could be computerized.

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Table 1. List of Clinic Work Processes and Categorisation by Importance.


CLINIC RECEPTION

Patient register management (I)

Queuing patients (I)

Appointment scheduling (II or III may not need it if all cases are walk-ins)
CONSULTATION & DISPENSING OF SERVICES

Dispensing medications capture of drug dispensing data and print out


drug labels (I or II)

Dispensing laboratory tests and other services with space for


writing the results at a later date (II or III)

Diagnosis entry (I or II)

MCs, letters of referral, reports (II or III) would be good to exploit


the computer since the data is stored inside

Electronic notification (I, II or III)

EMR (or EHR) from scratch pad (I) to use of templates to record symptoms (II or III),
data capture of displayable serial data (II or III) & graphic displays of serial data (II or III)
BILLING & FINANCIAL MANAGEMENT

Consultation charges

Drugs charges

Other services lab, physiotherapy, nutrition counselling that are dispensed

Bills generation
INVENTORY MANAGEMENT

Drugs and pharmaceuticals (I, II, III)

Expendables e.g., gauze, syringes (I, II, III)


MANAGEMENT REPORTS

Services provided (II or III)

Workload (II or III)

Audit reports (II or III)


COMMUNICATION & CONTENT ACQUISITION

Email (I, II)

Internet (I)
ADMINISTRATION AND OTHER FUNCTIONS

Wordprocessing for document production

Spreadsheets for financial related work

Powerpoint for presentations

SPSS Windows for statistical and research work

Desktop publishing for developing patient information materials

One way of staging the computerization process is to decide which are the category I
clinic work processes (essential work processes e.g. patient register management); the
category II work processes (good to have work processes e.g. appointment scheduling);
and the category III work processes (nice to have work processes e.g. graphic display of
patient blood glucose or HBA1C readings). Of course, the priorities may change
depending on the practice case mix. For example, a clinic seeing a large number of
chronic medical conditions may well regard having a capability to graph HbA1c results,
BP results to be essential (category I) instead of nice to have (category III).

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Levels of Computerisation and Configurations


The levels of computerization and computer configurations that can be implemented in
the clinic are the standalone, peer-to-peer network and client server network.
The peer-to-peer network is ideal for linking a small number of computers together. The
key feature of such a network is that all computers connected to it can be considered
equal. Any hardware attached to one computer - such as a printer, CD ROM drive, or fax
modem - can be made available to all computers on the network. Furthermore, users
can, if they wish, easily share data stored on their hard disks with one another. Peer to
peer networks are very easy to set up, requiring only a network card in each computer
and network cable to join them together. If you are setting up a peer-to-peer network
with modern computers, Windows for workgroups and Windows 98 both contain all the
software that you need (Millman et al, 1995).
The advantage of a peer-to-peer network is shown in Table 2. Integration of consultation
related work real-time is made possible with a peer-to-peer network. For example, both
the doctor and clinic staff can see the patient queue, the doctor can do online
dispensing if he wishes to, and he may also enter patient related data into the same
patient database. This is of course assuming that the clinic management software is
configured for multi-user capability.
Table 2. Advantages of Networking

Sharing of data and programs


Sharing of computer peripherals (such as printers, modems, CD ROMs)
Email and faxing from each computer
Allows access to network via a telephone line
Cost effectiveness since resources like licensed software programs can
be shared

Source: Millman et al, 1995 (BMJ 1995:311:938-941)

The Personal Digital Assistant ( PDA)


The personal digital assistant or PDA as it is commonly called, has become an excellent
tool for managing clinical information and accessing information at the point of care.
Unlike laptop computers, most PDAs are models of simplicity. They represent, for the first
time, a readily available, useful computer tool that is pocket-sized, unobtrusive, ultralight, wireless. The PDA performs only a few functions but does them very well. Many
useful applications for the PDA are available for purchase or free download from the
World Wide Web.
Internet Resources for the PDA
Singapore Palm User Group http://www.spug.org.sg
National Medical Library http://www.medical-library.org Many ebooks such as
Outpatient Medicine and Family Medicine etc can be downloaded into the PDA.
Handheld med http://www.handheldmed.com Reference textbooks such as
Harrisons Principles Of Internal Medicine can be purchased at this site.
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Mobipocket http://www.mobipocket.com The software allows you to download


and read newspapers such as the Financial Times on your PDA. Books can also be purchased
or downloaded for free at this site. Many medical textbooks in the Palm format can also be
purchased here. Working demos of these books can also be downloaded for free.
Fphandheld http://www.fphandheld.com
Emedicine http://www.emedicine.com The Disaster and Trauma medicine ebook
can be downloaded for free but it requires registration.
This list is a start. Many of these sites provide links to other application sites.
Further Reading
1. Andrew Millman, Nicholas Lee, Andrew Brooke. ABC Of Medical Computing: COMPUTERS IN GENERAL
PRACTICEI. BMJ 1995;311:800-802 (23 September)
2. Andrew Millman, Nicholas Lee, Andrew Brooke. ABC Of Medical Computing: COMPUTERS IN GENERAL
PRACTICEII. BMJ 1995;311:864-867 (23 September)
3. Bergeron BP. How To Safeguard Your Clinical Data. Postgraduate Medicine 1999; 105:1
4. Andrew Millman. ABC Of Medical Computing: KEEPING YOUR COMPUTER HEALTHY AND LEGAL.
BMJ 1995;311:1289-1293 (11 November)
5. Daniel Silver. Doing away with paper (part 2). Australian Family Physician, 31:6: 527-531.
6. Bush J. Looking for a Good Electronic Medical Records System? Family Practice Management, Feb 2002.
7. Smith PD. Implementing an EMR System: One Clinics Experience. Family Practice Management, May 2003.
8. Ng JM. A Hitchhikers Guide To The World Of Cyberpalmistry. March 2002; 28(1)
9. Bergeron BP. Personal digital assistants. Postgraduate Med Jun 1998; 103:6

CHAPTER 4

MANAGING FINANCES,
INCLUDING MANAGED CARE

Outline
Financial management defined
Income, expenses and profit
Financial records
Helping the practice accountant
Financial statements
Accounting controls
Financial audits
Financial planning
Understanding managed care

FINANCIAL MANAGEMENT DEFINED


Financial management consists of:

keeping proper records of income, expenditure and profit.


preparing financial statements at the end of accounting period.
analysing financial statements and taking the necessary actions.
implementing inventory and stock control processes.
acting on discrepancies.
ensuring that financial records are audited.
developing financial plans.
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INCOME, EXPENSES AND PROFIT


Income Sources of income for a sole practitioner or a partnership could include:

consultation.
sale of medicines.
fees for services such as vaccination, medical reports.
housecalls.
investments from surplus revenue (an important source of income in the later years of
the doctors career).

Expenses Expenses are largely under the control of the practice and may include:

staff cost such as salaries, bonuses, CPF contributions, workmen compensation insurance.
occupancy cost such as rents, rates, repairs, insurance, telephones, utilities.
drug costs such as cost of drugs and pharmaceuticals and instruments.
other costs and expenses such as books and journals, equipment, postage, printing &
stationery, and travelling. This could also include car expenses where house visits
are included.

Profit The difference between the income and the expenses would be a profit.
Maintaining a low expenses level is a surer way to profit than through high income.

FINANCIAL RECORDS
It is essential to have accurate knowledge of the financial status of the practice in order to
plan ahead. This is in turn dependent on keeping proper records for income, expenditure
and profit.
It is also cheaper to carry out checks and analysis within the practice than to hand
everything over to an accountant. The accountant should be used as a financial adviser
rather than a financial clerk.
Revenue (Income). Income is recorded in a cash analysis book and subsequently posted
to a general ledger. Receipt book entries, bank and other income statements are source
documents relating to income and must be kept up to-date and in order.
Expenditure. Expenditures are also recorded in the cash analysis book and later
transferred to the general ledger. Supporting documents of invoices, receipts should be
kept and in order in a file.
Bank Overdraft. In the initial phase of setting up practice, one can apply to his/her bank
for an overdraft to meet the expenses for establishing the clinic and to pay for the
furniture and fittings.
Cash Receipts. It is advisable to institute periodic checks in the clinic. Where possible, it
is wise to have the bank deposits made out by the persons other than the cashier or have
it checked by another person.
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Cash book. A common tool to monitor the cashflow is the use of the cash book. It is
recommended that two separate cash books be kept, namely, one for receipts and one
from payments (expenses).
Day books. The most important day books are those used for purchases, sales, returns
inwards (sales returns) and returns outwards (purchase returns).
Petty Cash Records. Most work places find it convenient to have some petty cash.
Examples of items paid with petty cash are (a) transport, (b) postage, (c) cleaning needs,
(d) office needs, and (e) sundries. A proper record must be kept of petty cash
disimbursements.

HELPING THE PRACTICE ACCOUNTANT


It is important to recognize that it is to the advantage of the practice to help the
accountant do a better job. A disordered mass of papers and figures is undesirable. The
following are areas where the practice staff should be trained to be proficient to help the
practice accountant:

Keep neat and accurate cash analysis book of income and expenditure.
Ensure that figures add up and balances are correct and correspond to bank statements
Keep a file of documents about money paid in, e.g., statements.
Keep invoices of money paid out in date order.
Have full practice accounts ready for the accountant as soon as possible after the end
of the tax year.
Send all original documents to the accountant, that is, check counterfoils, bank
statements and cash-analysis book.
Where the account books may be needed before the accountant has returned them, a
photocopy should be made.
Answer accountants queries promptly and in writing.
Inform accountant of impending changes in practice, e.g., new staff, purchase of
equipment etc.

FINANCIAL STATEMENTS
Financial statements are summaries of the financial activities of an organisation. They
contain information useful to management. The two statements commonly used are the
profit and loss statement and the balance sheet.
Profit and loss statement. A profit and loss (P & L) statement (what the Americans call
the income statement) is a summary of the companys activities for a particular period.
The basic purpose of a P & L statement is to show whether the organisation has made a
profit or loss. It summarises the sources of income of the organisation and the expenses
incurred to run the organisation. The format of a P & L statement varies with the type of
business, but it generally contains figures on sales, cost of the goods sold, gross profit,
the various types of expenses and the net profit.

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Balance sheet. The balance sheet shows the companys financial condition on a specific
day, e.g. 31st December. It shows the assets or things of value owned by the organisation
and its liabilities or debts on a particular date e.g. at 31st December 2003. An
examination of an organisations balance sheet provides an excellent indication of the
financial stability of the business. An organisation that shows a profit on its P & L
statement can still fail if its current liabilities exceed its current assets and creditors cannot
be paid on time. Usually, high inventories or trade debtors are signals of potential
problems, since inventories cannot always be sold quickly and debtors may not always
have the funds to pay their debts when due.
The data in the P & L statement and the balance sheet give us some indication of the
organisations performance and its stability. However, greater insight can be obtained by
calculating certain financial ratios.

ACCOUNTING CONTROLS
The accounting controls for income and expenditure that need to be set up are
given below:
Systems approach set up system accountability, have a system that runs by itself, use
computer software that works and forecast your income and expenditures.
Income needs accounting control numbered prescription slips, cash collection rules,
cheque bank-in rule and regular review of the cash receipts can avoid misappropriations.
Expenditure needs counting control ask if it is justifiable expenditure or not, cost
control needed for drugs, stationery and equipment, inventory and stock taking are
important and schedule payment / monthly cash flow.

FINANCIAL AUDITS
The purpose of financial audits is to ensure accountability in the use of financial and
material resources. Financial audits may be external or internal.
External audits. External audits are conducted by experts, usually Chartered Public
Accountants, who are not employees of the organization. They are extremely thorough in
seeking to document the authenticity of every item on a firms financial statements.
Internal audits. Internal audits serve a similar purpose. The main difference is that they
are conducted by company personnel and are intended to answer managements need
for authentication as much as that of external groups.

FINANCIAL PLANNING
One key activity of financial planning is the development of the organisations budgets.
Organisation budgets are of two kinds: Operating budgets and financial budgets.

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Operating Budgets
Operating budgets indicate the goods and services the organisation expects to
consume in the budget period: they usually list both physical quantities and cost figures.
The most common types of operating budgets are: expense budget, revenue budget, and
profit budget.
An expense budget describes the labour and material costs of production of each item
of product or service produced, including estimated overhead costs.
A revenue budget describes the expected quantity of sales multiplied by the expected
unit selling price of each product or service.
A profit budget (or master budget) combines cost and revenue budgets in one
statement. It is used by managers who have responsibility for both the expenses and
revenues of their units. It consists of a set of projected financial statements and
schedules for the coming year. Thus, it serves as an annual profit plan.

Financial Budgets
Financial budgets spell out in detail the money the organisation intends to spend in the
same time period and where the money will come from.
Financial budgets which are prepared with information developed from the revenue and
expense budgets serve 3 purposes:
to justify the financial expenditure with respect to results to be obtained.
to reveal financial actions to ensure adequate cash flow for the execution of its
operating budgets.
to indicate in what way the organisations operating plans need to be modified in the
light of cash flow availability.
There are four types of financial budgets:
Capital expenditure Capital expenditure budgets indicate future investments to be
made in buildings, equipment and other physical assets of the organisation.
Cash budgets Cash budgets combine the estimates for revenues, expenses and
new capital expenditures.
Financing budgets These are budget statements developed to assure the
organisation of the availability of funds to meet the shortfalls of revenues relative to
expenses in the short run and to schedule medium- and longer-term borrowing or
financing. This budget is developed in conjunction with the cash budget to provide the
organisation with the funds it needs at times it needs them.
Balance sheet budget (or pro forma balance sheet) Balance sheet budget (or
pro forma balance sheet) bring together all of the other budgets to project how the
balance sheet will look at the end of the period if actual results conform to planned
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results. Analysis of the balance sheet budget may suggest problems or opportunities
that will require managers to alter some of the other budgets e.g., reduction in
planned borrowing and reduced capital expenditures.
Zero based Budgeting
In the normal budgeting process, the previous years spending is used as a starting point.
The task of individuals preparing the new budget is to decide what activities and funds
should be dropped and more often, what activities and funds should be added. Such a
process creates a built-in bias towards continuing the same activities year after year
long after their relevance and usefulness may have been lost because of environmental
changes or changes in the organisations objectives.
Zero-base budgeting (ZBB), in contrast, enables the organisation to look at its activities
and priorities afresh. The previous years resource allocations are not automatically
considered the basis of this years resource allocations. Instead, each manager has to
justify anew his or her entire budget request, using a cost-benefit analysis of each of the
organisations major activities. Theory zero-based budgets lead to better prioritisation of
budget items and more efficient organisations. In practice, the paper work generated
may be too formidable.
Budgetary Controls
Budgetary controls are the periodic comparison between actual expenditure and
budgeted figures. The difference is the variance. If the variance is beyond the margin
allowed, as for example, 10-15% difference, then the situation needs to be reviewed. In
this way, changes in the clinic revenue and expenditure can be monitored more closely
and action taken early when the variance shows that things are not going on
as expected.

UNDERSTANDING MANAGED CARE


Managed care refers to a variety of techniques for influencing the clinical behavior of
health care providers and/or patients, often by integrating the payment and delivery
of health care. The overall aim of managed care is to place administrative control over
cost of, quality of, or access to health care services in a specific population of
covered enrollees.
Managed Care Systems
The prototype managed care system is the health maintenance organization (HMO)
where a capitation system of payment is a key feature. Capitation involves paying
physicians a fixed, prospective amount for each patient regardless of the cost of caring
for the patient.
Over time, other models of managed care have arisen. Preferred provider organizations
(PPOs) involve arrangements between physicians and purchasers in which physicians
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agree to offer discounts from their usual charges or fees in exchange for providing health
care for a group of patients. Other examples of managed care include individual practice
associations (IPOs), physician/hospital associations, and exclusive provider organizations
(EPOs). See Figure 1.

Capitation is one example of managed care practices that seek to control costs of health
care. Some managed care practices seek to impact the quality of care. For instance,
clinical guidelines that aim to alter the clinical management of specific health concerns
(e.g., treatment of hypertension) are also common managed care practices.
Encouraging Cost Effective Practice and Its Limits
Managed care is structured around a variety of incentives to encourage the practice of
cost-effective medicine, and to minimize variation in clinical practice patterns. In its ideal
state, money is saved through several mechanisms: (a) standardization of fees, (b)
reduced variations of care, (c) cheaper alternatives without undue sacrifice of quality or
convenience, (d) exclusion of non-effective treatment, and (e) reduction of unnecessary
tests and treatments.
Standardisation of fees Standardisation of fees for a given item of service or
product also helps to reduce costs of provision by excluding the extra payment for the
outlier fees. What needs to be confirmed is the quality of that service.
Reduced variations of care Spending resources only for those items of care that
make a difference to the care will be cost saving. This is where clinical practice guidelines
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and evidence-based medicine can provide some direction for reducing the variation of
care. What needs to be recognized also is medicine is an in-exact science and some
leeway should be allowed in good faith. For example, should a particular sprained ankle
be X-rayed? Clinical judgment coupled with some rules of thumb e.g. the ankle rules
help to resolve the dilemma. Also, if uncertainty exists, there can be negotiation that the
X-rays be deferred pending observation of the improvement that takes place over the
next 2-3 days.
Cheaper alternatives without undue sacrifice of quality or convenience The
latest additions to the pharmacopoeia or available services are likely to more expensive
than existing alternatives. What is important is that the extra expense may not be worth
the money spent. Also, whilst cheaper alternatives may be less convenient to use e.g.
requiring more than once daily dosage, the inconvenience may be acceptable. The choice
should revolve on effectiveness for the money spent. Better still if the cheaper alternative
is of equivalent effectiveness compared to the more expensive alternative, the decision
would be of no dilemma. A large part of the savings of managed care will come from
therapeutic choices; it is also an area of unhappiness of the patient and doctor because
there is now a limitation of choice. The limits of decisions of this nature should be the
idea that equivalent effectiveness is not compromised.
Exclusion of non-effective treatment This is one further step towards spending
money cost-effectively. Some products and services may be found over time to be not
effective and should therefore be dropped. One example is ketotifen hydrogen fumarate
(zaditen) which has been promoted as an oral asthma prophylactic and antiallergic agent.
Research has now disproved its claims.
Reduction of unnecessary tests and treatments This is logical decision making.
What is less certain in practice is sometimes extra tests may be needed just to be sure
things are all right. The limits of such reduction should be determined by the difference in
decision making that this test would make. If there will be no difference then it should
not be ordered.
The drive in managed care should not be on cost savings alone but also quality and
effectiveness. Effectiveness here means providing a product, in this case health care,
while minimizing resources used, most often dollars. Most often, efficiency is maximized
by increasing productivity while fixing cost. Hence, managed care may create pressure to
do more with less: less time per patient, less costly medicines, and fewer costly diagnostic
tests and treatments.
Current Thoughts on Managed Care
For managed care to work, there is a need for common alignment of incentives and
desire for the system to be effective. There needs to be a common alignment of
incentives to keep costs down without sacrificing the quality of care. For managed care to
be sustainable as a healthcare financing system each stakeholder in the system the user,
the provider, the managed care organization and the payor has to play his/her part.

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Adequate premium and adequate quality assurance An adequate premium


needs to be collected and providers reimbursed equitably if managed health is to realise
its primary goal of cost containment without sacrifice of quality. Experience from the US
suggests the need for insistence on quality as a means for checking poor care. The
following paragraph from a paper on the US experience (Dudley & Luft, April 2001) ably
sums up the situation.
The future of managed care remains uncertain, however. If employers and federal and
state governments continue to emphasise the quality of care, and especially if medical
groups and medical societies support these efforts, physicians may be able to spend
more time caring for their patients and less time arguing with insurers. This might also
help patients regain confidence in a system they have lost trust in. An appropriately
design system of prepayment with rates that are high enough to cover all appropriate
care and costs of treating catastrophic illness, as well as incentives for providers to plan
for the future could facilitate the co-ordination of care, which has traditionally been
fragmented. On the other hand, medical costs are on the rise again, and if the primary
focus of the policy debate returns to financial considerations, efforts to improve the
quality of care may be postponed.
Provider incentives At the bottom of it all, any system whether it is fee-for-service
or fixed salaries or capitation and the variants thereof can be abused. The same doctors
who over-treat or over-bill on the fee-for-service can under-treat or under-provide on
fixed salary. Inefficiencies can be found in either end of the spectrum. Doctors, because
they make the key decisions about hospitalisation, surgery, referrals, diagnostic tests, and
the prescribing of drugs and procedures, are important determinants of health care costs.
Therefore, apart from giving incentives to corporations and individuals to take up
managed care plans, it is equally, if not more, important to find the right incentives for
providers to deliver health care services cost-effectively. In searching for cost containing
incentives, it is essential to ensure that managed care organisations do not end up
compromising quality of care, as it has been found that certain incentives, in particular
the financial ones, do have an adverse effect on the quality. The system must be able to
cater for legitimate exceptions, such as payment for additional drugs where these are
clearly indicated.
Quality of care Several techniques used by managed care firms, such as guidelines
based on clinical best practices, quality report cards that provide information on provider
and health plan performance, and evidence-based medicine that incorporates the latest
clinical findings and cost-effectiveness data, are steps towards improving the quality of
health care services. Although to individual physicians the application of guidelines may
be intrusive, wide variations in treatment patterns for the same diseases indicate the
need for sharing best practices on how to treat particular illnesses. Clinical protocols
developed by providers in integrated HMOs have had a positive effect in reducing
variation and improving quality. Both physicians and patients can be brought into the
discussion of the benefits of the information in improving treatment decisions
(Sekhri, 2000).

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Aligning incentives of users To prevent unnecessary use of medical benefits, there


must be co-payment by individual which should be substantial enough to align incentives
for cost containment by the user. Users also need to be adequately briefed on what their
plans cover and do not cover. The introduction of a co-payment on prescription drugs has
also been found to be effective in the US. The quantum effect was almost as effective
as is switching physician payment from fee-for-service to a capitated risk payment
(Sekhri, 2000)
Users role The user needs to understand what the scheme pays for and his or her
responsibility to keep it viable by reducing unnecessary demands. Communication
between the managed care organization and the user is important to clarify what should
be the role of the user.
Provider and professions roles Providers can exercise voluntary cost control (within
limits) this will reduce the need and desire for external control. Level up to provide
quality care within budget this will win public trust and increase willingness to pay for
what is needed; doctors will eventually be able to be less dissatisfied professionally. The
profession can prevent major unscrupulous for-profit MCOs surfacing The profession
needs to provides the necessary leadership, professional will and ombudsmen role to
prevent exploitation of doctors. Maintain a surveillance system to monitor the quality of
care of for-profit managed care systems Provide leadership on what is good clinical
practice, and reasonable consultation cost or premium Meet government to present the
professions stand whenever the opportunity occurs.
Enhancing cohesiveness amongst the stakeholders Mutual trust and support
between the Government, the managed care provider, the doctor and the patient are
necessary. There is a need to translate to everyone that managed care is not about the
different stakeholders taking advantage of one another, trying to exploit or abuse the
system to gain the most benefits for oneself. It is all about working together and forming
a win-win situation for everyone.
Evolution of Managed Care in the United States
America is the home of the concept development of managed care. Managed care in
America went through several phases. The trend is that schemes that are increasingly less
restrictive have sprung side by side with the older ones. See Figure 1. The
different phases
Group or staff model HMOs (1942) Kaiser-Permanente and Group Health
Cooperative of Puget Sound. Socially motivated. Affordable care for the immigrants.
(R Adams Dudley & Harold S Luft.
Managed Care in transition. NEJM 2001, 1590) HMOs and IPAs (1960s and 1970s)
Policy makers and employers alike began to consider prepayment as an alternative to
fee-for-service system of payment.
PPOs (1980s) California passed legislation to permit contracts with selected providers.

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Networks of PPOs were formed. PPOs and POS (1990s) The response to employees
wanting less restricted service. Copayments for services of doctors outside
the network.
Multi-tiered plans presently Employees can choose between (a) HMO scheme,
(b) PPO scheme with some copayment, or (C) PPOs with POS scheme with even more
copayment. Different coverage for employees of different salaries in the same
company The plan most desired by the user and most expensive to the payer will be
the traditional indemnity where the patient is free to choose what he or she wants
and the doctor is free to charge what he feels is due to him i.e. the incentives for cost
control of provider and user are not aligned. Such a benevolent payor cannot be
found. In the real world, some restriction is imposed by the payor as an in-house selfmanaged system or through a managed care organization. Other attempts to align
incentives are patient co-payment to reduce unnecessary patient demand, and a cooperative set-up where both providers and users share common objectives of an
affordable health care system. This latter phenomenon explains the sustainability of
managed care plans like that of Kaiser-Permanente.
Can Managed Care Work?
Managed care can be made to work by paying attention to the interest of the stakeholders:
Provider interests adequate premium, motivation, incentives and empowerment to
practise professionally.
User interests alignment of incentives not to over-use services, clear understanding
of the services to be provided by the scheme, and the stake-holder role of keeping the
system sustainable.
MCO interests alignment of incentives not only for cost control and profit
maximization but also quality assurance; ombudsman mechanism to ensure doctors
are not unduly exploited.
All the stake-holders need to share common incentives and mutual trust for managed
care to be sustainable. This is the challenge to leaders in the medical profession to
foster the development of such a climate of healthcare delivery.
FURTHER READING
1. JK Iglehart, NEJM 1994;331:1167-71
2. R Adams Dudley & Harold S Luft. Managed Care in transition. NEJM 2001, 344:1087-1092
3. Sekhri N. Managed Care: the US experience. Bulletin of the World Health Org 2000;78(6):830-844.
4. Teo W & Goh LG. Singapore Managed Health Care. Sing Fam Physician 1998:13-16

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CHAPTER 5

MANAGING QUALITY

Outline
Quality and quality assurance
Continuing improvement
Quality assurance cycle
Self-audit project

QUALITY AND QUALITY ASSURANCE


Quality in health care may be simply defined as care that meets or exceeds expectations.
There are two aspects to quality the technical and patient satisfaction. The quality of
healthcare delivery may be evaluated by structure, process and outcome indicators. Based on
the results of these indicators, we can implement improvement programmes to close the
quality gaps. This is an ongoing endeavour and results in a better standard of medical care.
Quality assurance is an attempt to protect and enhance quality. It is concerned with
patient care that is high in professional quality, and satisfying to the patient. Quality holds
the promise of being able to :
deliver the most appropriate and up-to-date medical care.
reduce the chance of unsuitable treatment and care, and an inappropriate variation in
care between doctors.
encourage accountability between providers, consumers and founders of health care .
save unnecessary costs by reducing waste, duplication and increasing efficiency.

CONTINUING IMPROVEMENT
The central concept is that, to be effective, quality assurance should be seen - by
consumers, providers of healthcare and administrators and funding agencies - as an
exercise of continuing improvement rather than an inspection for bad apples. Berwicks
paper on continuous improvement as an ideal in health care expresses the attitude that
should be fostered if quality assurance is truly to succeed. For the health-care system in
general, a few small steps are needed:
its leaders must hold to a shared vision of a health-care system that is undergoing
continuous improvement.
substantial investments in managerial capital, time and expertise will be required for
quality improvement.
respect must be established for health-care workers involved in complex tasks in a
complex system.
those served (the customers) and those serving (the suppliers) must carefully maintain
an open dialogue.
modern technical, theoretically grounded tools must be applied to health-care settings
health-care regulations must be more sensitive to the cost and ineffectiveness of
relying on inspection to improve quality.
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professionals must take part in specifying preferred methods of care that exceed
minimalist standards.
individual physicians must actively participate in the effort for continuous
improvement.

QUALITY ASSURANCE CYCLE


Implementation of continuing improvement is done through quality assurance cycles of
activity. Each quality assurance cycle is made up of four steps:
Step 1: Select Or Review The Topic The quality assurance process begins with
setting standards for the topic under review. The following are suggested guides for
setting standards:

Keep the standards simple.


Limit the number of standards.
Include only essential items.
Include items proved effective.
Exclude dangerous and ineffective items.
Exclude excessive and unnecessary items.
Allow the best adoption of provider and patient resources.
Be sure the content is up to date.

Step 2: Observe Practice In this step, data is collected from the practice. Collecting
data broadly consists of the following:
Selection of indicators: selecting essential elements which will reflect correctly the
quality of care. For example, in the care of non-insulin dependent diabetes (Type II)
patients, this might be a blood glucose value (measured every third month), the
occurrence of complications, and the health status of patients.
Selection of collection method. Data collection methods for quality assurance must
meet the criteria of validity, reliability, feasibility, and acceptability.
data analysis. The data collected on actual performance need to be compared with
data from other practices or with implicit or explicit criteria or guidelines, in order to
achieve good quality and to come to conclusions about strong points, gaps
and needs.
It should look at essential aspects of care, be multi-dimensional (covering structure,
process and outcome aspects), use simple, understandable methods of collecting and
analysing data, and make use of practice staff.
Data to be collected must be valid, reliable, feasible, and acceptable to all.
Step 3: Compare Practice With Explicit Standards The comparison between
practice and explicit standards gives information on the gap to be closed. This is
sometimes referred to as gap analysis. This leads to the fourth step.

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Step 4: Implement Change Changing medical practice to improve patient care is the
most complex step in the quality assurance process. Change is a stepwise process.
Barriers to change can occur in one or more of the steps in the process of change.
Problems with achieving change do not depend on people alone. Very often the work
setting or the organizational system is also part of the problem. Change is achieved most
effectively with a variety and combination of methods and interventions on several levels,
directed to specific barriers to change.
Follow-Up The completion of change brings us to the new cycle of quality assurance.
This is the follow-up. It consists of new data collection, evaluation and feedback and
further changes as necessary. For example, if a family doctor had collected data on
prescribing patterns and instituted changes, the changes should be monitored by
further data collection. His second scrutiny of prescribing may be more focused than the
first, since the quality assurance process need only concentrate on those aspects
requiring change.

SELF-AUDIT PROJECT
Each quality assurance cycle can be a self-audit project to assess the level of quality of
service delivery. Audits can be simple, short, inexpensive and rewarding. Make sure that
the audits are short enough to be completed within the time available. Keep them simple
- at least at first. Think of taking a snapshot of one aspect of health care delivery e.g.,
hypertension control, remembering the quality assurance cycle, and the need for a
further snapshot at a later date when you again review the practice.
How to Audit
In general, the following need to be considered once your topic of audit is decided:

Your objective(s) and boundaries.


Your standard against which to measure your topic of audit.
Where and how would you collect your data case records, lab results etc.
How many patients should you include for the audit.
Design a form to record your findings.
How to perform a gap analysis.
Conclusions and decision of what needs to be improved.
How the improvement process will be implemented and followed-up.

Further Reading
Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med. 1989 Jan 5;320(1):53-6.

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1 The Consultation Process


2 Communication Skills
3 Counselling Skills
4 Changing Behaviour
5 Disease Management Skills
6 Emergency Care Skills

SECTION 05

CONSULTATION SKILLS

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SECTION 05

SECTION 05 CONSULTATION SKILLS

CHAPTER 1

THE CONSULTATION PROCESS

Outline
The consultation and referral defined
Steps of an effective consultation
Initiating the consultation
Approaches to problem solving
Understanding why patient came
Hypothetico-deductive method of problem solving
Referral to a specialist

THE CONSULTATION AND REFERRAL DEFINED


The consultation is a situation when a patient seeks medical information, advice and
treatment from a doctor. In general practice, the family physician is able to deal with
some 90% of the problems presented to him. For the remainder, he needs to refer his
patient to a consultant or specialist to seek an expert opinion.
The referral is a situation when a family physician refers his patient to a specialist for his
expert opinion, treatment or both. The consultant specialist takes over the management
of this referred patient and subsequently refers the patient back to the family physician
after the treatment has been completed.

STEPS OF AN EFFECTIVE CONSULTATION


The steps of an effective consultation has been described by Pendleton in the 1980s.
The family physician needs to complete the following seven steps or tasks:
(1) Find out why the patient has come, also called the reason for encounter (rfe) and from
there go on to take a history which covers the following:
(a) the nature and history of the problem.
(b) the patient's ideas, concerns and expectations.
(c) the effects of the problem on the patient and significant others.
(2) Consider the other problems that the patient may have:
(a) continuing problems.
(b) risk factors.
(3) Choose with the patient as appropriate action for each problem. In general practice,
there is a need to prioritise the action to take if the patient has more than one problem.
(4) Achieve a shared understanding of the problems with the patient.
(5) Involve the patient in the management and encourage him to accept appropriate responsibility,
(6) Use time and resources to good advantage.

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(7) Establish or maintain a relationship with the patient that helps to achieve other tasks.
Steps (1) and (2) together correspond to what we sometimes refer to as the approach to
the problem and the remaining steps (3) to (7) correspond to the management of the
patient and his problem. Note the steps (3), (4) and (5). These are crucial steps that form
the cornerstone of the patients compliance to the doctors management plan.

INITIATING THE CONSULTATION


When your patient enters your consultation room, the first minute is very important.
(a) Make your patient feel welcomed, relatives included. Greet all of them.
(b) Show him his chair, make him comfortable and make him feel at ease.
(c) Your opening remarks are also important. They are different depending on whether
the patient is new, a recent follow-up patient or an old patient making a reappearance.
(d) Strike a good rapport.
(e) Eye contact is essential. Having a computer in front of you may be a distraction.
Use it discreetly.
(f) Body language tells the patient your attitude. The patient can tell whether you have
a sincere interest in him and his problems.

APPROACHES TO PROBLEM SOLVING


The method of problem solving taught in the hospital setting is the inductive method
where a full history is taken, a full examination is done and also investigations are ordered
to arrive at the diagnosis. Such an approach is suitable for medical conditions which are
diagnostic problems or where the extent of disease is not clear. An example of the first
category is the fever for investigation or Pyrexia of Unknown Origin (PUO) and an
example of the second category is the staging required for assess the extent of spread of
a cancer.
Notwithstanding such situations, the initial approach to problem solving either in the
hospital setting and the ambulatory care setting is the hypothetico-deductive approach in
problem solving where based on cues from appearance and/or history, a short list of
possibilities are considered and these are narrowed down by considering relevant features
in the history, confirmation with more selective history taking and selective physical
examination is done to arrive at a working diagnosis.
Although the general principles of problem-solving are the same in all fields of medicine,
each discipline applies them differently. The problem-solving strategies of family physicians have evolved because of the unique features of family practice. These are:
Patients present with early, undifferentiated complaints, which include psychological
and social factors.
Problems and complaints may be expressed in indirect or non-verbal language.
Much of the information presented by the patient is not useful ("noise") in solving
his problem.
Symptoms change as the illness advances, and may have different diagnostic value in
different stages of the illness.
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Problems are often not presented in order of priority.


Physical signs may be minimal or absent.
The illness or problem is often a complex mix of physical, psychological and
socio-economic elements.
One patient may present with multiple illnesses or problems.
There is a high incidence of acute, short-term illness, much of it transient and
self-limiting.
The family physician can use, by his continuous relationship with the patient his
personal and close knowledge of his patients to diagnose or understand the
patients' problems.
Often, the family physician cannot make a "formal diagnosis" (pathological condition) or
put a diagnostic label (illness-centred diagnosis), as students are taught in hospitals.
More often he makes a patient-oriented comprehensive diagnosis, comprising details of
the patient as a person, his lifestyle, his family, and his environment, and of the specific
anxieties (of the patient or his family) connected with his symptoms and physical signs.
This is actually a definition of the patient's problems.
The family physician's decisions have to be made under pressure of the short time
available for each consultation; he has to separate, in the early stage of illnesses, the
serious and life-threatening conditions from the transient and minor. However with his
continuing contact with the patient, he can use (observation over) time as a tool for
diagnosis (and even for management).
Thus the family physician must have a high degree of suspicion, with a wide perspective
(by study) and experience (based on his knowledge of the epidemiology of diseases, the
natural history of common illnesses, and of the normal status of his patients).
His problem-solving strategies must be aimed at ascertaining and dealing with the
patient's main problem (with a plan for longer-term assessment and management of the
problem), and at putting the patient's other problems in priority order (with a similar plan
for their longer-term assessment and management).
Family physicians in solving problems must be particularly aware of the patients
perspective of his or her illness and its management including the environment-social,
psychological, economic, etc in which the patient lives. All the above elements interact,
making problem solving more difficult. Very often, the family physician, even after the
physical examination and history taking is unable to come to a diagnosis, i.e. he is dealing
with an unknown diagnosis. Here, it is important that, as primary care doctors, if the
symptoms could indicate a potentially lethal condition, such as perforated peptic ulcer,
ectopic pregnancy, or a myocardial infarct, prevarication is inadmissible and specialist
referral or hospital admission must be arranged. Thus, by always considering and
identifying any serious life threatening disease presenting at an early stage and in so
doing prevent serious morbidity or mortality.
After excluding any serious pathology, the family physician is then faced with a wide
variety of symptoms to which he must then address the following questions:
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What is the real motive behind the symptoms that has prompted the consultation?
What is the significance of the problem or disease to this particular patient?
Are there other factors present that should be considered when solving or managing
the patients problems?

UNDERSTANDING WHY DOES THE PATIENT COME


Reason for Encounter
The consultation is more likely to be effective if it seeks out why the patient came which
is also called the reason for encounter (RFE), and his views, concerns and expectations
(ICE) of the problem he is experiencing.
It is easy to make wrong assumptions why the patient came:
(a) It may be assumed that the patient has come to the doctor because of the symptoms;
but for every patient who presents there are many more who are coping with similar
symptoms themselves and not seeking help. Thus, it is not sufficient to know what
symptoms have been experienced; we need to know what sense the patient has made
of the symptoms in order to know why he or she has come.
(b) It is often assumed that the patient has come for treatment, but what he is looking for
may be an assurance that something more serious is not going on, simply because he
has seen someone with a serious problem having similar symptoms. His concern is
that he may have the same problem.
Patient can come to see the doctor for a variety of reasons.
The symptom(s) given by the patient may be explicit of his reason for seeing the doctor or
it may be the "ticket of entry" for something that troubles the patient but which he finds
difficulty for some reason to express directly (the so-called hidden agenda of the patient).
The following is one classification of possible reasons for encounter.
Pain or other symptoms:
Most medical encounters would concern physical complaints. The patient presents
because his limit of tolerance has been reached. The symptoms are causing pain,
discomfort or disability.
Continuity of care/Continuing care:
A family physician has a role to play in both acute and chronic care. In an acute
situation he may not be able to make a diagnosis on first encounter e.g. PUO. He may
then extend his consultation by inviting his patient to return whereby the illness would
undoubtedly unfold thereby enabling him to institute the appropriate management.
In the care of chronic illness such as diabetes, hypertension, asthma and epilepsy, the
family physician has much to do in clinical management. He however also co-ordinates

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the activities of other members of the primary health care team e.g. nurse practitioners,
DAC nurse, dietitians and therapists in providing holistic care for his patient.
Prevention of disease:
The patient may request for some form of prevention in health such as (a) well person
care e.g. well-child or well-woman clinics, (b)& utine immunizations, (c) pre-employment/
retirement checkups or (d) periodic health examinations. This may result in multi-phase
screening. A point to note is that this request may have arisen out of anxiety and it is
important for the family physician to pick this up.
Opportunistic screening is another method which family physicians can adopt to
detect disease at an early stage.
Accident and emergency:
The physical nature will be obvious. In dealing with a specific emergency, the doctor
adopts a different approach. Instead of taking a history and performing an examination
in the usual way, he replaces this with a technique of rapid assessment and immediate
management. You are expected to have knowledge about the patient's illness which
gives rise to emergencies, but in addition will be expected to know the immediate
steps on diagnosis and management which are required on the road side, in the home
or consulting room. The anxiety and fear of the patient or close ones that may
accompany the situation may require management.
Problems with living:
These can arise as a result of:
personality disorders
family related situations
work related situations
the community

e.g.
e.g.
e.g.
e.g.

hypochondriasis, alcoholism and drug addiction


the empty nest syndrome, bereavement
unemployment, shiftwork
the problems of a minority race, immigrants
and social delinquents

Seeking of reassurance:
Patients whose real need is reassurance frequently, if not usually, present their
symptoms rather than express their fears. And in response to these symptoms, the
physician may achieve a diagnosis and proceed to treatment without recognising the
patient's major problem. Cartwright has shown that in Britain patients interviewed at
the end of consultations had seldom received adequate reassurance, and many of
them had found their experience alarming rather than comforting.
Need to legitimise sick role:
Society has given doctors a statutory role in the certification of illness. The patients
who wish to take up the sick-role are by no means confined to those who want to be
excused from work; the school child wishing to avoid school and the housewife who
desires to manipulate her environment are almost as common.
Ideas, Concerns and Expectations
The motivation to see the doctor is driven by the patients ideas, concerns and expections.
The patient attaches a meaning to his symptoms which is coloured by what he has
observed or learnt about the symptom from others around him. What is apparently trivial
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to the doctor may be of great worry to the patient. Our job as effective doctors is to elicit
if the symptom has a special meaning and concern to the patient. Only then could we
begin to help the patient.

History taking
How much history should be taken? There is a need to evaluate each symptom. Beyond
that, the depth of questioning will depend on what is perceived to be the problem.
Symptom presentation in ambulatory care is often early and undifferentiated. Hence the
doctor should develop a systematic approach to evaluate each symptom presented by
the patient. In ambulatory care, ninety percent of diagnosis is made on the basis of
history alone.
The meaning of the symptom will have to extend beyond biomedical possibilities.
The value of the symptom as a marker of biomedical disease may also be different from
that encountered in the hospital patient.
It is important to include in the history taking, the effect of illness on the patient, his work
and his family.

Selective physical examination


How does the history guide the doctor on how much to examine? What do you see as
the purpose of the physical examination in general practice?
When should a comprehensive physical examination be conducted in the outpatient setting?

Selective investigations
How is the decision made on how many investigations to order for the patient?
What in-house investigations should be available?
Management Options
To treat or to refer:
When should a referral be done?
Can you describe what a referral letter should contain?
Therapeutic interventions:
How would you attempt to convince the patient if you think that medication is not
necessary? What would you do if the patient remains unconvinced?
What surgical and medical procedures could be done in the FAMILY Physicians clinic?
Patient education:
At the end of the posting can you describe the opportunities and difficulties
encountered in patient education?

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Follow-up and staggered consultations:


When should the patient come back for follow up?
What is meant by using time as a tool?
Can you describe a staggered consultation and its use in general practice?
Family as a resource:
At the end of the posting you should be able to list the various ways and give examples
of how the family can be a resource to the patient in health and illness.
Achieving Satisfactory Outcomes
Knowing the patient's concerns and expectations, the doctor will be in a better position
to bring about outcomes they want. At the conclusion of the consultation, we should like
to have reduced the patient's concerns as far as possible, and to have explained matters
sufficiently clearly for the patient to understand and remember all what has been said and
be committed to the management planned.
Common barriers to a satisfactory consultation process:
(a) Poor eye contact.
(b) Over reliance on notes.
(c) Lack of clarification.
(d) Misinterpretation.
(e) Insensitivity to Language/cultural difference.
(f) Omitting to ask what the patient thinks of his illness.

HYPOTHETICO-DEDUCTIVE APPROACH OF PROBLEM SOLVING


We are now ready to put the elements of the GP consultation into the hypotheticodeductive approach. It consists of the following steps:
(1) Gathers subject/objective data (CUES)
symptom cues, sign cues, behavioural cues (from patients behaviour or from his own
subjective sensations) and contextual cues (some incongruity that he senses in the
whole pattern of the consultation).
(2) Combines this with his prior knowledge (BACKGROUND CUES) of:
the patient and his family.
the patients past medial (physical, psychological and social) history.
the patient as a person.
the environmental factors that affect this patient.
past experience (his own or other doctors) of other similar events.
(3) Makes ELIMINATIVE DIAGNOSIS:
e.g. urgent or non-urgent
acute or chronic
pregnant or not pregnant
bacterial or viral infection
psychological or organic
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(4) Lists the diagnostic probabilities in a priority order (HYPOTHESES).


These will reflect the community morbidity (incidence and prevalence of disease in
family practice) and the doctors personal knowledge of his patients; will comprise a
large amount of chronic and transient illness; and will be very different from that in
specialist or hospital practice. Higher priority will be given to serious (even if infrequent)
and to treatable conditions.
(5) Asks questions and looks for physical signs (FURTHER CUES) to confirm or exclude one
or more of the hypotheses.
The extent of gathering will depend on the objective of the consultation i.e. it will be
less if the object is simply to exclude serious illness, and more comprehensive if a
precise etiological or pathological diagnosis is required, or if the cues are obscure.
These further cues include pathological and radiological investigations.
(6) Makes a PRESUMPTIVE DIAGNOSIS or DEFINITION OF THE PROBLEM(S) if a hypothesis
is validated. This is probabilistic statement about what is wrong with the patient.
(7) If all initial hypotheses are invalidated, revises the hypotheses and formulates new
ones, followed by further cues till another presumptive diagnosis or definition of
problems are made.
As indicated by the feedback loop, the process is a cyclical one, the physician
constantly revising, testing and further revising his hypothesis until he has refined it to
the point at which he feels justified in making management decisions. Even after this
point, he will still be prepared to revise his hypothesis if the progress of the patient is
not as predicted.
(8) Makes and implements MANAGEMENT DECISIONS.
A decision is made by taking the probabilistic statement and integrating it with a large
number of other variables, e.g., the patient's wishes, the main problem. The patient's
other problems, prognosis, personality and life situation of the patient (including fears
or skepticism), the risks and benefits of the decision alternatives, the family's wishes,
ethical issues and financial factors.
Management decisions would include any one or combination of the following:
Liquidation of the problem as a problem - by reassurance, or by leaving along
(self-limiting condition).
Elimination of the underlying cause - by treatment of disease.
Elimination of a behavioral pattern - by counselling/advice.
Adjustment of the patient's own (physical or psychosocial) environment.
Referral to specialist, physiotherapist, social worker etc - for treatment (or even
for diagnosis).

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REFERRAL TO A SPECIALIST
This may sometimes be necessary. There are several tasks that must be done:
(1) Explain to your patient and accompanying relatives your reasons for seeking a second
opinion or for requesting a specific treatment.
Prepare them mentally and financially especially when surgery is contemplated.
Try to match the skill and expertise of the specialist to the condition, personality and
financial capability of the patient.
Do not refer your patient to a close friend or relative without the above consideration.
Try to make the appointment for your patient.
Write a good referral letter: Brief and to the point, include relevant history, lab results,
X-rays, ultrasound, CT scan results and treatment and give your opinion, ask
specific questions
Phone directly for urgent conditions and early appointments.
Reference
Pendleton D. Consultation analysis. Update Jan 1989:803-807

CHAPTER 2

COMMUNICATION SKILLS

Outline
Scope of communication
Communication in medicine
Analysing the verbal communication process
Understanding non-verbal communication
Written communication
The communication part of the consultation
Overcoming problems of communication
Breaking bad news

THE SCOPE OF COMMUNICATION IN PATIENT CARE


Listening and talking to patients is an essential skill. In the healthcare setting, such
communication is an admixture of spoken words (verbal communication), non-verbal
communication and sometimes supplemented by written communication. The ability to
exchange information and feelings correctly needs to be given due attention.

COMMUNICATION IN MEDICINE
Communication in medicine differs from communication in any other field in three
important aspects:
It deals with the essential aspect of living, called health. People in all walks of life and
all ages have a vested interest in what you are communicating as a doctor. They take
what you say seriously.

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Society allows the medical and nursing professional to touch the patient, and not only
allows, but encourages such activity. In all other professions touching the recipient,
apart from shaking hands, is disallowed and may be misinterpreted. Notwithstanding
this, it is important to make sure such an activity is not misinterpreted by the patient.
This can be done by announcing what you intend to do. I am going to examine your
abdomen to make sure it is normal., I am going to listen to your chest to hear if
there is any abnormal sounds coming from your lungs.
There is a great deal more of a personal and emotional nature in medical communication
than in any other types of communication.

ANALYSING THE VERBAL COMMUNICATION PROCESS


The doctor needs to be able to analyse his communication efforts before he is able to
make stepwise improvements. This should be an ongoing and almost subconscious effort
throughout this professional career.
There are three approaches (models) that the doctor can use for such a self appraisal.
Each model by itself yields helpful but only partial information. When the models are used
together they provide a fuller understanding of the communication process.
Component Analysis
The component analysis model pays attention to factors in the speaker, message and
listener that are barriers to communication.
Sender barriers:
negative image - diffident, defensive, not looking at listener.
distracting behaviour - head scratching, twirling pencil.
aggressive behaviour - staring, mocking.
judgemental behaviour.
uncaring, insensitive.
Message barriers:
information overload.
long words and long sentences in the message.
not being specific enough.
Receiver barriers:
emotional distress.
judgemental reactions.
visual or hearing disability.
different frame of reference.
Transactional Analysis (TA)
Communication may also be regarded as a transaction between personality states.
The transactional model pays attention to these states and the aim of analysis is the
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appropriateness of personality states that are transacted. In TA theory, persons are said to
normally exhibit three personality states regardless of their age:
parent (P) - scolding tone, authoritarian attitude : uses words shouldn't, never, always
adult (A) - logical : uses words "important that ...", "consider the ...."
child (C)
- demanding : use words "I want", "I can't", "I need"
Transaction that are adult-to-adult, child-to-parent, parent-to-child are uncrossed. If the
transactions are crossed as for example child-to-adult or parent-to-adult, then problems
of communication will arise.
Transaction analysis is useful in analysing communications that seek to elicit a particular
action in the receiver. A statement can be made that reflects the personality state of the
speaker; some statements are better than others.
Example 1: There are different ways the doctor can tell the patient to stop smoking.
Doctor: It is important that you give up smoking (adult) or
Doctor: You must stop smoking (parent) or
Doctor: I want you to stop smoking (child)
Which statement is the best for the doctor to use?
The statements made by the doctor is picked up by the patient and the response will in
term depend on the personality state of receiver and this too can be analysed:
Example 2: Different kinds of response
Doctor: It is important that you give up smoking (adult)
The patient's reply (amongst other things said) can be:
Patient: I can't (child), or
Patient: I know it is difficult but I'try (adult), or
Patient: You should leave me to decide for myself (parent).
What response will each elicit in you if you are the doctor who receives such a reply.
Life-Space Analysis
Each of us lives within a particular life-space or context. Our context is the world as we
know it. There are six major areas that make up our world : (a) vocational, (b) family,
(c) social, (d) spiritual, (e) physical, (f) financial. Communication efforts will fail unless
the sender understands the life-space of the receiver. The ongoing self-appraisal and
improvement will be the ability to recognise the context of these six areas in a patient and
the appropriate response that will be necessary.
Take the vocational area for example. We will need to recognise what being a taxi-driver
mean in terms of the demands of the job, the daily struggles that he goes through to be

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able to have the empathy and appropriate response when he complains of backache or
headache. Is his presenting problem therefore physical, social or emotional?

UNDERSTANDING NON-VERBAL COMMUNICATION


It has been estimated that more than half of the content in a communication is done
through non-verbal communication. Some understanding of its importance in the process
of doctor-patient communication is therefore necessary. Spoken communication in the
clinical setting generally deals with facts. Feelings, emotions, values, wants and interest/
disinterest are usually communicated non-verbally.
Its Importance
(a) The ability of the doctor to respond to cues to the patient's feelings and emotions is as
important in establishing rapport as the ability to understand the facts about his illness.
From the non-verbal cues the doctor can read a lot about the patient's anxieties
and concerns.
(b) Non-verbal communication may be intentional (e.g., a nod to indicate understanding),
but is often unintentional. Cues to dissatisfaction, "yes" or "no" are often unintentionally
displayed. Observing these cues can be a great help in knowing what the patient
actually wants. Non-verbal cues are more reliable than spoken words.
(c) Non-verbal cues can give one's disinterest. Patients can read such non-verbal cues.
They are quite sharp in deciding whether the doctor is interested in listening to what
they have to say.
Classifying Non-Verbal Communication
Classifying the different categories of non-verbal communication allows us to understand
the different components of the phenonmenon called non-verbal communication.
There are seven categories. These are:
(a) Proxemics e.g., personal space, seating arrangement at meetings, distance between
individuals while in conversation, and time.
(b) Artifacts, e.g., clothing, make-up, eye glasses, jewellery.
(c) Kinesics (body language), e.g., hand gestures, body postures, facial expressions and
eye movements, gait.
(d) Paralanguage, e.g., vocal pitch and emphasis, intonation, expressions such "uh huh",
"well", "you know".
(e) Touch, e.g., handshake, skill at which physical examination is done.
(f) Environment, e.g., furniture, room decorations.
(g) Physical characteristics, e.g., state of health, body shape, skin colour, skin, deformities,
characteristic body odours (diabetic ketosis, uraemia and alcohol consumption).
A brief description of each follows:

Proxemics
This is concerned with space, position and time.
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Space and position. People maintain certain distances during conversations. The way
family members sit as a group can tell much about relationships amongst one another.
A good consultation position is to sit on adjacent sides of a table. Sitting across the table
puts a barrier between the doctor and the patient. Some may find it more emotionally
comfortable to keep it that way.
Time. The doctor may give the impression that he is very busy if he appears hurried,
impatient, time-conscious and attending to many things at the same time. The patient
may feel that he should not waste the doctor's time and go away dissatisfied. It is possible
to project a different impression that the doctor has time through the use of non-verbal
communication: listening to the unhurried patient, speed and unhurried tone of speech,
use pauses for the patient to reply without hurrying and not allowing interruptions, e.g.,
from the telephone.

Artifacts
Clothes bias positively or negatively the doctor-patient communication; being appropriately dressed is therefore important.

Kinesics (body language)


Kinesics tell us about people's level of interest, acceptance, agreement, satisfaction and
feelings of anxiety, depression or fear.
Face. The face is a carrier of emotions (e.g., anger, joy, happiness).
Shoulders. They are raised if tensed; lowered if relaxed.
Head position. Raised if showing openness, interest and control over situation; lowered
if in doubt, defeated, in fear or insecure; tilted sideways if interested.
Body posture. Upright posture indicates confidence, upright and backward leaning
indicates defensive or reticent frame of mind.
Hand gestures. Fear or uncertainty is expressed by hand-to-nose gesture. Hand over
mouth indicates doubt of what is being said. Steepling (joining hands, with fingers
extended and fingertips touching) indicates confidence and assurance in the comments
being made.
Folded arms. Folded arms are a nature position of comfort; however, they can also
communicate messages of defensiveness, disagreement or insecurity.
Legs. Sitting forward in the chair with feet placed in the "ready to run"position
indicates disinterest.

Paralanguage
Emphasis. The emphasis on different parts of the sentence conveys the meaning of the
message. Thus, it is important to note not only what is said but how it is said.
Rate of speaking. Fast speaking occurs in anger, joy or excitement; slow speaking occurs
in sadness.
Tone. A soft voice, low pitch and irregular pauses are some of the vocal characteristics
associated with depression. Anger or irritation is also displayed through the tone
of voice.
Non-fluences. Slips of the tongue indicate anxiety, discomfort evoked by the situation;
"er", "ah", "um" may indicate being unsure of what is being said.
Pause. Being a good listener is rated very highly as an attribute. It appears that one of
the factors involved is the ability to use pauses and hesitations.
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Touch
Touch is the most important of the areas of non-verbal communication and especially so
for the healing professions. The "laying of hands", "the healing touch" tells us of the
value of touch as part of the consultation. Notwithstanding this, one has to guard
against the risk of misinterpretation of intentions. For touch to be effective, it must (a) be
acceptable to the patient, (b) be acceptable to the doctor, and (c) recognised that it has
an unique meaning for each patient. It is important to get the patient's consent before
one carries out a physical examination ("Shall I examine you?" or "Please get on the
couch, let's see what you have got").

WRITTEN COMMUNICATION
Written communication is necessary in (a) as proof of a decision (e.g., consent for
operation), (b) to eliminate confusion, and (c) to aid comprehension and retention of
information given. Clarity and simplicity in written communication is the essence of good
doctor-patient communication.

THE COMMUNICATION PART OF THE CONSULTATION


Byrne and Long (1976) studied 1,000 audio recordings of consultations and found that 6
phases can be identified:
(a) the doctor establishes a relationship with the patient.
(b) the doctor attempts to discuss, or actually discusses, the reason for the patient's
attendance; that is, he finds out the reason for encounter.
(c) the doctor conducts a verbal or physical examination, or both.
(d) the doctor, or the doctor and the patient, or the patient (in that order of probability)
discusses the patient's condition.
(e) the doctor or occasionally the patient, details treatment or further investigations, and;
(f) the doctor makes arrangement for follow-up care and the consultation is terminated
and, usually by the doctor.
The communication part of a consultation thus can seen to consist of two parts:
(A)the clinical interview to find out what is troubling the patient which covers phases (a),
(b) and (c).
(B) the exposition in which the doctor explains his diagnosis and what is to be done about
it immediately and as a follow-up which covers phases (d) and (e).
The Clinical Interview
How can we conduct it effectively? The following are points to take note of:

(a)

Start the interview right


It is important to start the interview right.
(1) Greet the patient - to show that you welcome the patient and wish to put him
at ease.
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(2) The first question must always be open: "What has brought you to see me today?"
In the hospital, when the patient comes with a doctor's letter, the opening
question can be: "Your doctor has written to me, but I want you to tell me about
it all yourself." In the ambulatory care setting, the opening question can be:
Good morning, Mr Tan, what has brought you to see me this morning?
(3) Many patients first offer a symptom that may not be what they really want to
discuss, so they must always be encouraged to say what is really troubling them
by a question "Is there anything else you would like to tell me?".
(4) The patient has trepidations in seeing the doctor. There is a need for the doctor
to be aware of how the patient is feeling, and to show this understanding and
to try to put the patient at ease by facial expression and verbally.

(b) Be patient centred


Bynre & Long found that in the 1,000 consultations study in general practice only
were patient centred, the rest were doctor centred.
(1) "Doctor centred" consultation - Here the doctor concentrates on "closed
questions", e.g., "do you sleep badly?" (as opposed to open question of "tell me
about your sleeping"); ignores or brushes aside hints of other problems so that
an organic diagnosis can be reached and a prescription given.
(2) "Patient centred" - Here the doctor listens to the patient and takes up hints of
non-organic problems, the doctor explores the patient's concern, fears
and expectations.
The "doctor centred" doctor may be good at diagnosing organic illness, but will miss
many simple opportunities of relieving anxiety, depression or psychological causes or
consequences of illness. Is that important?

(c)

Facilitation
(1) This may be verbal: "Go on, tell me about that" or non-verbal - just an
encouraging noise (paralanguage), or nodding and waiting.
(2) The proper use of silence is important and needs to be learnt. By jumping too
soon with the next question you may lost important clues.

(d) Clarification
(1) This requires direct questions about the onset of symptoms, their development,
precipitating factors and relieving factors.
(2) Avoid technical terms.
(3) Do not ask a rapid string or questions all at once.
(4) Throughout the inquiry attention must be paid to clues on unexpected emotion
which the patient may give.

(e)

Tolerance
(1) Most doctors have inhibitions or prejudice in certain areas. Interviewing however
must be dispassionate.
(2) Tolerance of emotionally disturbing things that a patient may say is needed.

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(3) A doctor has no warrant for passing judgement on what a patient tells him
however shocked he may feel.

(f)

Avoid jargon
(1) The patient and doctor may have quite different ideas of the meaning of even
simple medical terms.
(2) If there is any doubt, seek clarification or explain any technical words used.

(g) Summarising
(1) It is helpful for both doctor and patient if at the end of the interview, the doctor
summarises what he has learnt, and;
(2) The doctor asks the patient if the doctor has got it right or is there anything
more to be said.

(h) Note taking


(1) Though essential, note taking must not be allowed to spoil the interview.
(2) A doctor who never looks up from his notes cannot interview well.
(3) Writing can be done, in occasional pauses, "Just a moment, I want to make a
note of that".

(j)

Dealing with too little time


(1) Shortage of time is the commonest reason advanced for poor interviewing.
This is not entirely valid. The important facts about many patients with common
disorders may be learnt in a few minutes, a minority who may need a more
lengthy interview can also be detected quickly.
(2) Much time can also be saved by avoiding the "by the way" phenomenon.

(k)

Avoiding the "by the way" phenomenon


In the study of 1,000 consultations, Byrne and Long found 79 of them were telling
the doctor, "by the way......" in phase (e); of these 50 showed that there was no
evidence of phase (b), that is the doctor did not attempt to discuss, or actually
discuss, the reason for the patient's attendances. It appeared that even in a 5
minute consultation a short phase (b) enabled an effective consultation to take
place, and no "by the way" took place. Thus the patient should be asked if there is
anything else bothering him before going to phase (c).

The Exposition
Exposition describes the second part of a consultation, where the doctor explains his
conclusions and tells the patient about investigations, treatment, or changes in his way
of life.

(a)

Organise verbal information and ensure understanding


Studies by Ley have shown that patients' recall of what they have been told can
be improved:
-- use explicit categorisation of information
-- tell the most important first
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-- tell in simple language


-- have patient repeat the more important things told

(b) Supplement spoken with written or recorded information


This helps the patient to remember.

(c)

Encourage patient to write down their questions


Patients should be encouraged to write them down their questions before they see
their doctor the next time round.

(d) Avoid conflicting information


This often happens in hospital where patients may ask various people about their
illnesses. An "information sheet" in the case sheets of questions asked and answers
given may help. In ambulatory care where a patient doctor hops, a similar situation
may arise. A useful strategy is to find out what the patient has been told with a
starting sentence like this, Perhaps as a starting point we could review what your
doctors have told you, so we can see where are the areas I could help to
explain things.

OVERCOMING PROBLEMS OF COMMUNICATION


Physical Disabilities

(a)

Deaf patients
If they are using hearing aids make sure they are on and working.
If you have to speak very loud avoid sounding angry.
Be sure the patient is able to watch you speak so that he can lip read you.

(b) Blind patients


Blind people can hear very well.
Help your patient transfer from chair to couch; give a commentary as you go along
so that he is able to follow you.

(c)

Stroke patients
People who cannot talk freely may understand speech normally.
The handicapped are quick to non-verbal indicators of lack of concern or respect.

About Fatal Illness

(a)

The patient who has a fatal illness


There is a perpetual problem of when to tell the patient, how to tell the patient,
what to tell and how much. There are two schools of thought. One is that the
patient should be told of his fatal illness and the doctor will be accused of keeping
too much information from the patient if he does not do so. The other is to
withhold such information.

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The
(i)
(ii)
(iii)

guiding principles for not revealing too much to the patient are:
if the diagnosis is not yet definitely confirmed.
if the doctor perceives that the patient is not ready for it.
if the relatives are convinced that it will do harm than good to the patient.

At some point of time some patients may really want to know; some patients are
content to read the answer from the situation and do not ask their doctors a
direct question.
If the patient that wants to know, the unpalatable fact could be cushioned with
something that could still be done. ("It does not appear very good, but let us
concentrate on making you feel comfortable").
In some patients, the need to tell earlier may be necessary in view of their
commitments or social responsibility. ("As your medical problem is going to affect
your health substantially, I would recommend that you make the necessary
arrangements for others to look after your business, etc").

(b) Patients who think they have a fatal illness


This is easier to deal than one that indeed has a fatal illness. Nevertheless, unless
the patient is convinced otherwise, he may go through unnecessary worry. Spending
time with such patients to find out their misperception may help. Showing the
patient reports from the lab or specialist opinions to read for themselves helps to
reinforce your reassurance.

BREAKING BAD NEWS


What is Bad News?
Bad any news that drastically and negatively alters the patients view of his future
Can be: terminal illness, diagnosis of chronic illness and abnormal investigation.
ABCDE of Breaking Bad News
A helpful way to remember how to break bad news are the ABCDE checklist.
Advance preparation
Arrange for adequate time, privacy and no interruptions (turn pager off or to silent mode).
Review relevant clinical information.
Mentally rehearse, identify words or phrases to use and avoid.
Prepare yourself emotionally.
Build a therapeutic environment/relationship
Determine what and how much the patient wants to know.
Have family or support persons present.
Introduce yourself to everyone.
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Warn the patient that bad news is coming.


Use touch when appropriate.
Schedule follow-up appointments.
Communicate well
Ask what the patient or family already knows.
Be frank but compassionate; avoid euphemisms and medical jargon.
Allow for silence and tears; proceed at the patient's pace.
Have the patient describe his or her understanding of the news; repeat this
information at subsequent visits.
Allow time to answer questions; write things down and provide written information.
Deal with patient and family reactions
Assess and respond to the patient and the family's emotional reaction; repeat at
each visit.
Be empathetic.
Do not argue with or criticize colleagues.
Encourage and validate emotions
Explore what the news means to the patient.
Offer realistic hope according to the patient's goals.
Use interdisciplinary services.
Take care of your own needs bad news also has a negative impact on the messenger.
References
Byrne PS, Long BE. Doctors talking to patients. Exeter: Royal College of General Practitioners. 1976.
VandeKieft GK. Breaking bad news. Am Fam Physician 2001 Dec 15;64(12):1975-8

CHAPTER 3

COUNSELLING SKILLS

Outline
The Counselling Process
BATHE Technique
Problems Of Living
The Difficult Patient
The Angry Patient

THE COUNSELLING PROCESS


The medical consultation is a helping process. Often, the help required is not a
prescription for medicines helping the person deal with the problems at hand or
counselling. Helping sometimes needs only a one-time encounter with the person-inneed; at other times more than one session is needed. The relationship established is
specific and purposeful as it aims at dealing with the problem that is presented. In this
sense, it is a special relationship.

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Stages Of Counselling
The stages
Stage I:
Stage II:
Stage III:

of counselling can be described as a process consisting of three stages:


Relationship Building
Exploration and Understanding
Rational Discussion

Stage I: Relationship building


The first stage of counselling is relationship building. It is necessary that time be spent in
building this relationship. To make this possible the counsellor must be ready and willing
to ATTEND to the counsellee. This involves listening very carefully to him and attempting
to understand the feelings and thoughts conveyed. Structuring, paraphrasing reflecting
of feelings and summarising are the skills to use at this stage. There is no attempt to deal
with the problem as yet. The goal is to pay attention to the counsellee, and as such
develop a supportive relationship with him.

Stage II: Exploration and understanding


In this phase, the counsellor enters further into the counsellee's world. To do this, the
counsellor must attempt to gain better understanding of the person he is dealing with.
This is achieved by applying the skills of probing, information giving and clarification to
ascertain the meaning of messages and feelings that the counsellee is conveying. The aim
in this phase is to enable the counsellee to gain a better understanding of himself, his
situation and the problem he is presenting. In so doing, he is helped to deal with himself
and be motivated to engage in rational discussion for problem-solving.

Stage III : Rational discussion


The purpose of the rational discussion stage is to help the counsellee cope with the
problem in a healthy and rational way. It can be divided broadly into three phases, namely
(a) problem definition and assessment; (b) therapeutic goal setting and implementation,
and (c) termination and evaluation.
(a)

Problem definition and assessment


Defining a treatable problem is often not easy, as family practice patients present
with a wide and complex variety of complaints. Examples of defined problems are
coping with a chronic illness, grieving the death of a loved one, dealing with an
alcoholic parent, and overcoming psychological aspects of depression while also
taking antidepressants.

(b)

Therapeutic goal setting and implementation


Therapy involves eliciting as clearly and specifically as possible the patient's
expectations for improvement but often flounders on the nonobjectifiable goal of
"feeling better". Therefore it is well worth the clinician's time to define target
symptoms for improvement or specific outcomes the patient expects (hopes) to
achieve. This definition allows physician-patient negotiation to modify unrealistic
expectations and to lead to mutually agreeable goals.

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Once the goal of therapy is clarified, the next step is to establish a therapeutic
contract. Once again, being as explicit as possible at the beginning of counseling/
therapy yields a much greater probability of success and clarifies for the patient the
frequently nebulous experience of being in a counseling situation.
During this phase, the counsellor involves the patient in exploring new ways of
thinking and behaving in order to attain the therapeutic goals that have been set.
'My physician is supportive, encouraging, or confrontative depending on what s/he
perceives the patient needs. The patient frequently makes substantial changes
during this phase.
(c)

Termination and evaluation


During this phase there is a mixture of consolidation of change achieved as well
as recognition of the need to do further work or to accept unchanging/
unchangeable situations.
Each step leads to the other in sequence though it is not a matter of rigid application
that is intended. A measure of flexibility is needed. Although this is a happy guide,
it may not always be necessary to go through the sequence in helping the counsellee.

Listening

The need to listen


The first and most important step in counselling is to listen. One hears ever so often that
people do not listen to each other often enough. There are those who say that if
someone would listen to them, they would not find life and problems so difficult to cope
with. When we listen, people begin to feel at ease and feel that someone cares.
On the need to listen, Taylor Caldwell has said, "Man's real need, his most terrible need,
is for someone to listen to him - not as a 'patient' but as a human soul. He needs to tell
someone of what he thinks, of the bewilderment he encounters when he tried to
discover why he was born, how he must live, and where his destiny lies."

Usefulness of listening
When a person is allowed to talk freely to a good listener, the following happens:
there is a release of tension.
draining off of anger, aggression, frustration (like having an infection opened up so
that poison can be drained off and purified).
clarifying thinking - as the counsellee is talking, he may see the problem more clearly.
The listener can repeat what has been said, paraphrase it, mirror it and reflect it back
without introducing any new thoughts.
the counsellee is helped through a better and more realistic understanding of himself
and his situation.
sharing the burden : 'A sorrow shared is a sorrow halved'.
establishing a relationship so that loneliness is broken; the person is giving a feeling of
being worth someone's time and attention.

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Qualities of a good listener


a good listener has many positive qualities: accepting, patient, caring, sympathetic,
concerned, discreet, understanding, respectful, knowledgeable, encouraging, tolerant,
warm, kind, and trustworthy.
A good listener will try to 'be with' the person. The message : "I am with you; tell
me..." is continuously conveyed.
A good listener is sensitive to the feelings of others. He tries to understand the dynamics
of the other person, and to get an idea of 'what makes him tick'.
There is a need to sense the feelings behind the spoken words. In many cultures,
people are taught 'to put on a brave front', 'not to wear your heart on your sleeve'.
It is considered right to hide feelings. Thus words often obscure the real feelings of a
person. The good listener is one to whom the speaker can find show his true feelings
and even verbalise such statements as "You are the first person who has really listened
to me" or "You make me feel I am of some value... you seem to hear everything I say".
You know that you have been a good listener.

Barriers to good listening


Several barriers to good listening have been identified:
Impatience.
Forming premature opinions of what the person is like and how the problem can
be solved.
Making comments, implying judgement, criticisms, lack of understanding and insight;
jumping to conclusions that the person is in the wrong, disagreeing, arguing, or interrupting.
Giving advice which implies one knows the answer to the particular problem. (A
worried person will reject a glib solution given in a few minutes without the due
process of listening. He will surmise "It is ridiculous to think he knows all about it in a
few minutes he is of no help at all").
Giving the impression that one is not taking the problem seriously. ("Is that all that's
worrying you?", That's not much of a problem"). Trying to change the subject or to
get the client's mind off it is also not a solution.
Wanting to talk - perhaps being reminded by something that is said of one's own
experiences and talking about them instead of listening.
Being passive, thus appearing to say "I'm bored" or "I'm not interested" or "I'm
nearly asleep".
Inability to concentrate on person's problem or story because of pre-occupation with
one's own affairs or taking one's attention away from the person.
Interruptions - other people around are making noise. A quiet atmosphere free of
telephone rings and distractions is necessary for good listening to take place.
Lack of time or being too time conscious is a barrier. The speaker feels constrained and
is unable to express himself properly.

THE BATHE TECHNIQUE IN COUNSELLING


The busy physician can help many patients by applying Stuart and Liebermans
15-minute hour method of primary care counseling. The technique provides a structure
for counselling patients in primary care. It helps draw out the quiet patient and provides a
structure of when to move on in a talkative patient. The acronym BATHE (background,
affect, trouble, handling empathy) summarizes the methods as follows:
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B Background assessing whats the background situation


Ask about likely areas of psychological problems:
How are things at home? At work?
Whats different in your life between now and before?
A Affect the patients affect
Ask about common areas generating strong feelings:
How do you feel about your home life?
How do you feel about your work/school?
How do you feel about your life in general?
T Troubling the problem that is most troubling for the patient
Ask how much the patients problems bother him or her:
What most worries you about your life?
How stressed are you by this problem?
What do you think this problem means to you?
H Handling the manner in which the patient has been handling the problem
Problems are often mishandled life difficulties:
How are you handling the problems in your life?
What have you tried to solve the difficulty?
How much support are you getting at home/work?
Who gives you support for dealing with problems?
E Empathy response that conveys empathy
Express understanding of the patients distress:
I can understand that you would feel angry
That must have been difficult
This is a tough situation to be in
Using Soap to Bathe
Physicians can further help patients with emotional and psychological problems by talking
in therapeutic ways, summarized by the acronym SOAP (support, objectivity, acceptance,
present focus):

S Support
Normalise problems as common dilemmas:
Lots of people struggle with similar problems.
Help the patient focus on strengths:
What resources could you use to deal with this?

O Objectivity
Encourage patients to ask themselves how realistic their thoughts and feelings are
(reality tests).
Whats the worse thing that could happen?
How likely is that?
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A Acceptance
Be as non-judgmental and accepting as possible:
Thats an understandable way to feel.
Encourage patients to feel better about themselves, their parents, and other family members:
I think youve done real well considering all the stress.
Sounds like your parents did the best they could under tough circumstances that
were hard for them to survive.
Coach patients to think differently about themselves more realistically, if they are
overly self-critical:
I wonder if you are being too hard on yourself.
How much time and energy are you putting into worrying about this?
What else could you do with all that time and energy?
Urge patients to develop more of a sense of humor about their issues:
I wonder if you could see the humor in this sometimes.
Acknowledge the patients values and priorities:
It sounds like family is more important than work to you.
Acknowledge the patients readiness for changes:
Sounds like you are not quite ready to change.
Acknowledge the difficulty of making changes:
Changes is real hard, and usually pretty scary.

P Present focus
Encourage focusing more on the present, less on the past and future. Help patients
identify, explore and evaluate different attitudinal and behavioral options (including
doing nothing):
How could you cope better? (reframe problem)
What could you do different? (leave or change the situation)
What are the likely consequences of A versus B?
Express guarded optimism that the patients can and will do better. Try to set up a
positive self-fulfilling prophecy for the immediate future:
My guess is that if you set your mind to it now, you can do much better and feel a lot
better, and I think you might just do that.
Suggest a homework assignment for the patient to carry out; for example:
a. Practice sending I messages:
I think our vacation plans are too hectic.
b. Practice asking for what you want, rather than just hoping for it:
I would like more help with the children.
c. Practice telling others how you are responding to their behavior:
I feel very angry when you go on trips by yourself so often.
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PROBLEMS OF LIVING
Problems of living are life situations that affect the functioning of a person. When the
limit tolerance is reached, the person may seek medical help.
Relevance to Family Medicine
As a front-line doctor, the family doctor is likely to encounter patients with problems of
living. Not all presentations will be explicit. The depressed, the lonely or the hard-pressed
often report tiredness, lack of energy, sleeplessness, abdominal pain or headache rather
than reveal the origin of their difficulties. The patient presents his/her problem of living as
a hidden agenda because he/she perceives as not a legitimate problem to trouble the
doctor, the conversion to somatic symptoms make the problem "medical"and therefore
legitimate. The attending doctor is therefore not likely to resolve the problem that the
patient brings along, unless he explores beyond the somatic symptoms.
Satisfactory resolution of problems of living requires the ability to recognise it based on
the signature cues that are presented time to be devoted; although small in number
compared to the total number of patients seen: they take up a lot of time and effort in
the helping process some basic counselling skills, and appropriate use of teamwork &
community resources. Family doctors are urged to take up the challenge of helping the
patient deal with problems of living as part of their scope of care.
Recognising Problems of Living (Signature Cues or Signal Behaviour)
The following are a dozen of signature cues that help us recognise problems of living:
Attendances for a symptom that has been present for a long time before and until
now fairly quiescent, e.g., dyspepsia, headache. The cue is to ask the questions: "why
again?" and "why now?"
Attendances for a chronic disease that does not appear to have changed e.g.,
osteoarthritis of the knee. The cue is again to ask the questions: "why again?"and
"why now?"
Incongruity between the patient's distress and the comparatively minor nature of
the symptoms.
Symptoms that have no physiological or pathological basis. Symptoms of this kind are
also known as conversion symptoms.
An adult patient with an accompanying relative.
Failure of reassurance to satisfy the patient for more than a short period.
Frequent attendances with minor illnesses.
Frequent attendance with the same symptoms or with new symptoms

THE DIFFICULT PATIENT


Definition
A 'difficult patient' may be defined as one with whom the physician has trouble forming
an effective working relationship. However it is more appropriate to refer to difficult
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problems rather than difficult patients, it is the patients who have the problems while
doctors have the difficulties.
Characteristics of Problematic Patients
Some characteristics of problematic patients, from the doctor's perspective, include:
frequent attenders with trivial illness
multiple symptomatology
non-compliant
hostile or angry
attending multiple therapists
manipulative
taciturn and uncommunicative
all knowing
Such patients are often referred to as the 'heart-sink' patients, referring to that certain
sinking feeling on seeing them in the waiting room. They can provoke negative feelings in
us and we have to discipline ourselves to be patient, responsible and professional.
Pitfalls to Avoid
An inevitiably poor consultation will follow if we allow feelings of hostility to affect our
communication with the difficult patient. The solution is to get above these feelings.
We also need to consider the possibilities of the following disorders which may be masked:
anxiety
depression
obsessive compulsive disorder
bipolar disorder (manic depression)
drug dependency
alcohol abuse
schizophrenia
It is therefore appropriate to maintain traditional standards of care by continually
updating the data-base of the patient, integrating psychosocial aspects, carefully
evaluating new symptoms, conducting an appropriate physical examination and being
discriminating with investigations.
A 'Heart-Sink' Survival Kit
This is a model for the management of patients with somatic symptoms of emotional distress.
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 both emotional and physical aspects during the consultation. It includes

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reframing the patient's symptoms and complaints to provide insight into the link
between physical, psychological and life events.
In the third stage, 'making the link', simple patient education methods are used to
explain the causation of somatic symptoms such as the way in which stress, anxiety or
depression cafi exaggerate symptoms. It also includes projection or identification
techniques using other sufferers as examples.

THE ANGRY PATIENT


Anger in patients and their relatives is a common reaction in the emotive area of sickness
and healing. The anger, which may be concealed or overt, might be a communication of
fear and insecurity. It is important to bear in mind that many apparently calm patients
may be harbouring controlled anger.
Sources of Anger
They may have feelings of frustration and anger because they are not getting better,
disappointment at unmet expectations, crisis situations, including grief, any illness,
especially an unexpected one, the development of a fatal illness, iatrogenic illness, chronic
illness, such as asthma, financial transactions, such as high cost for services, referral to
colleagues, which is often perceived as failure, poor service, such as long waits for an
appointment, and problems with medical certificates, inappropriate doctor behaviour,
e.g. brusqueness, sarcasm, moralistic comments, aloofness, superiority.
The patient's anger may manifest as a direct confrontation with the doctor or perhaps
with the receptionist, with litigation or with public condemnation.
What is Anger?
Anger is a person's emotionat response to provocation or to a threat to his or her
equilibrium. If inappropriate, it is almost always the manifestation of a deeper fear and of
hidden insecurity. Angry abusive behaviour may be a veiled expression of frustration, fear,
self-rejection or even guilt.
On the other hand, its expression may be a defence against the threat of feeling too close
to the doctor, who could have an over familiar, patronising or overly friendly attitude
towards the patient. Some patients cannot handle this threatening feeling. Basically
anger may be a communication of fear and insecurity.
Consulting Strategies
When one feels attacked unfairly, the response is to react. This response should however
be avoided since it will damage the doctor-patient relationship further and aggravate
the problem.
The Correct Strategy
Remain calm, keep still and establish eye contact; ask the patient to sit down and try to
138

adopt a similar position (the mirroring strategy) without any aggressive pose.
Address the patient or relative with appropriate name, be it Mr or Mrs Tan or a first name.
Be interested and concerned about the patient and the problem.
Use clear, firm, non-emotive language.
Listen intently.
Allow patients to ventilate their feelings and help to relieve their burdens.
Allow patients to 'be themselves.'
Give appropriate reassurance (do not go over-board to appease the patient).
Allow time (at least 20 minutes).

Question to Uncover the True Source of Anger


The following represent some typical questions or responses that could be used during
the interview.

Rapport building
'I can appreciate how you feel,'
'It concerns me that you feel so strongly about this.'
'Tell me how I can make it easier for you.'

Confrontation
'You seem very angry.'
'It's unlike you to be like this.'
'I get the feeling that you are upset with .'
'What is it that's upsetting you?'
'What really makes you feel this way?'

Facilitation, clarification
'I find It puzzling that you are angry with me. , 'So you feel that, . . ,
'You seem to be telling me. . .'
'If I understand you correctly . . .'
Tell me more about this . , :
'I would like you to enlarge on this point, it seems important.'
Guidelines for Handling the Angry Patient
Do: Listen, be calm, be comfortable, show interest and concern, be conciliatory, give
time, arrange follow-up, allay any guilt.
Do not: meet anger with anger, touch the patient, Reject the patient, evade the
situation, talk too much, be judgmental, and be patronizing.
Completing the Consultation
A skilful consultation should provide both doctor and patient with insight into the cause
of the anger and result in a contract in which both parties to work in a therapeutic
relationship. The objective should be to come to amicable terms which, of course, may
not be possible, depending on the nature of the patient's grievance.
References
Mcculloch J, Ramesar S, And Peterson H. Psychotherapy In Primary Care: The Bathe Technique. American Family
Physician May 1, 1998

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Servan-Schreiber D, Tabas G, And Kolb Nr. Somatizing Patients: Part Ii. Practical Management. American Family
Physician March 1, 2000
(Http://www.Aafp.Org/Afp/20000301/1423.Html)
Murtagh J. Difficult, Demanding And Angry Patients. In: General Practice. Mcgraw Hill:Sydney, 1998

CHAPTER 4

CHANGING BEHAVIOUR

Outline
Changing behaviour
Stages of Behaviour Change
Smoking Cessation The Prochaska-DiClementi Model And He 5As Of Smoking Cessation
Patient Health Education On Excercise

CHANGING BEHAVIOUR
If we are to find ways to extend the benefits of good health to the most vulnerable and
promote responsible behaviour and the adopotion of lifestyles that are conducive to good
health, we in the health profession must find the most effective means of extending the
benefits of good health for all.
Prochaska and DiClemente help by indentifying four stages in the process of making
health behaviour change: (1) precontemplation (when people are not interested and are
not thinking about change); (2) contemplation (when serious consideration is given to
making a behavioural change); (3) action (the 6-month period after an overt effort to
change has been made); and (4) maintenance (the period from 6 months after a
behaviour change has been made and the behavioural problem been ameliorated).
This stages of change model is particularly useful when designing health promotion
interventions for specific target populations. It forces the practitioner to use the most
effective strategies for eliciting and sustaining behaviour change depending on which
stage of change people are in.
According to Prochaska, the majority of health promotion/disease prevention programs
are designed for the small minority of people who are in the action stage. He estimates
that among those people who were smokers in 1985, nearly 70% were not ready to take
action. Their 1986 stages were as follows: (1) precontemplation stage-35%; (2)
contemplation stage-34%; (3a) ready for action stage-15%; (3b) taking action stage12%; (4) maintenance stage-4%.
In planning, implementing, and evaluating health promotion programs, the practitioner
should know something about the stages of adoption and the diffusion curve.) It is
generally acceptedc that there are six types of individuals/groups when considering the
adoption of an innovation. These individuals range from innovators to laggards at
Opposite ends of the bell curve, with early adopters, early majority, late majority, and late
adopters falling between the two tails of the bell curve.

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It is also important for the practitioner to know the five stages of adoption: awareness,
interest, trial, decision, and adoption for innovators, early adopters, early majority, and
late majority.

STAGES OF BEHAVIOUR CHANGE IN RELATION TO SMOKING


Smoking counselling efforts should aim to move the smoker progressively through the 4
stages of behaviour change identified by Prochaska and diClemente. These stages have
been adapted for use in smoking cessation as follows:

1. Precontemplation
The smoker is not motivated to stop smoking.
Possible reasons: ignorance of harmful effects, past failed attempts to quit, fatalistic
attitude, etc.
Strategy: Create awareness about the harmful effects of smoking and benefits of
quitting. Assist in analysing reasons for past failed attempts and encourage to try again.

2. Contemplation
The smoker is motivated to stop smoking but has not set a quit date.
Strategy: Emphasise the costs of smoking and the benefits of quitting in more tangible
terms e.g. the amount of money wasted on buying cigarettes, determining the actual
number of cigarettes smoked a day, carbon monoxide testing.

3. Action
The smoker plans to stop smoking within 1 month or has already stopped for less than
a month.
Strategy: Teach specific skills in stopping smoking. Provide positive reinforcement of
efforts and specific coping mechanisms.

4. Maintenance
The smoker has stopped smoking for at least a month.
Strategy: Provide continued reinforcement of their newly acquired no-smoking status and
relapse prevention skills e.g. anticipating situations of possible relapse and planning one's
response beforehand.

5. Termination
This is defined as a stable state in which there is no temptation to smoke across all
problem situations and maximum confidence in one's ability to resist relapse across all
problem situations.
Identifying the Stages in a Smoker
(1) Have you ever thought about stopping smoking? No - Precontemplator stage; Yes - At
least Contemplator stage
(2) Would you like to stop smoking? Yes - At least Contemplator stage
(3) Do you plan to stop smoking in the next month? No - Contemplator stage; Yes Action stage
(4) How long have you stopped smoking? Less than a month - Action stage; More than a
month - Maintenance stage
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B. For the Patient Unwilling to Quit Smoking

Promoting the motivation to quit


All patients entering a health care setting should have their tobacco use status assessed
routinely. Clinicians should advise all tobacco users to quit and then assess a patient's
willingness to make a quit attempt. For patients not ready to make a quit attempt at this
time, clinicians should use a brief intervention designed to promote the motivation to quit.

PATIENT EDUCATION ON EXERCISE


Exercise: How to get Started

Why should I exercise?


Increased physical activity can lead to a longer life and improved health. Exercise helps
prevent heart disease and many other problems. Exercise builds strength, gives you more
energy and can help you reduce stress. It is also a good way to curb your appetite and
burn calories.

Who should exercise?


Increased physical activity can benefit almost everyone. Most people can begin gradual,
moderate exercise on their own. If you think there is a reason you may not be able to
exercise safely, talk with your doctor before beginning a new exercise program. In
particular, your doctor needs to know if you have heart trouble, high blood pressure or
arthritis, or if you often feel dizzy or have chest pains.

What kind of exercise should I do?


Exercises that increase your heart rate and move large muscles (such as the muscles in
your legs and arms) are best. Choose an activity that you enjoy and that you can start
slowly and increase gradually as you become used to it. Walking is very popular and does
not require special equipment. Other good exercises include swimming, biking, jogging
and dancing. Taking the stairs instead of the elevator or walking instead of driving may
also be a good way to start being more active.

How long should I exercise?


Start off exercising 3 or more times a week for 20 minutes or more, and work up to at
least 30 minutes, 4 to 6 times a week. This can include several short bouts of activity in a
day. Exercising during a lunch break or on your way to do errands may help you add
physical activity to a busy schedule. Exercising with a friend or a family member can help
make it fun, and having a partner to encourage you can help you stick to it.

Is there anything I should do before and after I exercise?


You should start an exercise session with a gradual warm-up period. During this time
(about 5 to 10 minutes), you should slowly stretch your muscles first, and then gradually
increase your level of activity. For example, begin walking slowly and then pick up the pace.

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After you are finished exercising, cool down for about 5 to 10 minutes. Again, stretch
your muscles and let your heart rate slow down gradually. You can use the same stretches
as in the warm-up period.
A number of warm-up and cool-down stretching exercises for your legs are shown at the
end of this handout. If you are going to exercise your upper body, be sure to use
stretching exercises for your arms, shoulders, chest and back.

How hard do I have to exercise?


Even small amounts of exercise are better than none at all. Start with an activity you can
do comfortably. As you become more used to exercising, try to keep your heart rate at
about 60 to 85% of your "maximum heart rate." To figure out your target heart rate,
subtract your age in years from 220 (which gives your maximum heart rate), and then
multiply that number by 0.60 or 0.85. For example, if you are 40 years old, you would
subtract 40 from 220, which would give you 180 (220 - 40=180). Then you would
multiply this number by either 0.60 or 0.85, which would give you 108 or 153 (180 x
0.60=108 and 180 x 0.85=153).
When you first start your exercise program, you may want to use the lower number (0.60)
to calculate your target heart rate. Then, as your conditioning gradually increases, you
may want to use the higher number (0.85) to calculate your target heart rate. Check your
pulse by gently resting 2 fingers on the side of your neck and counting the beats for 1
minute. Use a watch with a second hand to time the minute.

How do I avoid injuring myself?


The safest way to keep from injuring yourself during exercise is to avoid trying to do too
much too soon. Start with an activity that is fairly easy for you, such as walking. Do it for
a few minutes a day or several times a day. Then slowly increase the time and level of
activity. For example, increase how fast you walk over several weeks. If you feel tired or
sore, ease up somewhat on the level of exercise, or take a day off to rest. Try not to give
up entirely even if you don't feel great right away! Talk with your doctor if you have
questions or think you have injured yourself seriously.
WHAT ABOUT STRENGTH TRAINING?
Most kinds of exercise will help both your heart and your other muscles. Resistance
training is exercise that develops the strength and endurance of large muscle groups.
Weight lifting is an example of this type of exercise. Exercise machines can also provide
resistance training. Your doctor or a trainer at a gym can give you more information about
exercising safely with weights or machines.

Warm-up and cool-down stretches


Calf stretch
Face a wall, standing about 2 feet away from it. Keeping your heels flat and your back
straight, lean forward slowly and press your hands and forehead to the wall. You should
feel stretching in the area above your heels (this area is shaded in the picture). Hold the
stretch for 20 seconds and then relax. Repeat.
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Quad stretch
Face a wall, standing about 1 foot away from it. Support yourself by placing your right
hand against the wall. Raise your right leg behind you and grab your foot with your left
hand. Gently pull your heel up toward your buttock, stretching the muscles in the front of
your right leg for 20 seconds. Repeat the stretch with your left leg.
Groin Stretch
Squat down and put both hands on the floor in front of you. Stretch your left leg straight
out behind you. Keep your right foot flat on the floor and lean forward with your chest
into your right knee, then gradually shift weight back to your left leg, keeping it as
straight as possible. Hold the stretch for 20 seconds. Repeat the stretch with your right
leg behind you.
Hamstring stretch
Lie down with your back flat on the floor and both knees bent. Your feet should be flat
on the floor, about 6 inches apart. Bend your right knee up to your chest and grab your
right thigh with both hands behind your knee. Gradually straighten your right leg, feeling
gentle stretching in the back of your leg. Hold the stretch for 20 seconds. Repeat the
stretch with your left leg.
Diabetes and Exercise

How can exercise help my diabetes?


Exercise can help control your weight and lower your blood sugar level. It also lowers your
risk of heart disease, a condition which is common in people who have diabetes. Exercise
can also help you feel better about yourself and increase your overall health.

What kind of exercise should I do?


Talk to your doctor about what kind of exercise is right for you. The type of exercise you
can do will depend on whether you have any other health problems. Most doctors
recommend aerobic exercise, which makes you breathe more deeply and makes your
heart work harder. Examples of aerobic exercise include walking, jogging, aerobic dance
or bicycling. If you have problems with the nerves in your feet or legs, your doctor may
want you to do a type of exercise that won't put stress on your feet. These exercises
include swimming, bicycling, rowing or chair exercises.
No matter what kind of exercise you do, you should warm up before you start and cool
down when you're done. To warm up, spend 5 to 10 minutes doing a low-intensity
exercise such as walking. Then gently stretch for another 5 to 10 minutes. Repeat these
steps after exercising to cool down.
When you start an exercise program, go slowly. Then gradually increase the intensity and
length of your sessions. Talk to your doctor for specific advice.

Are there any risks to exercising for people with diabetes?


Yes, although the benefits far outweigh the risks. Exercise changes the way your body
reacts to insulin. Regular exercise makes your body more sensitive to insulin, and your
blood sugar level may get too low (called hypoglycemia) after exercising. You may need
144

to check your blood sugar level before and after exercising. Your doctor can tell you what
your blood sugar level should be before and after exercise.
If your blood sugar level is too low or too high right before you plan to exercise, it's better
to wait until the level improves. It is especially important to watch your blood sugar level
if you exercise in really hot or cold conditions, because the temperature changes how
your body absorbs insulin.

How will I know if my blood sugar is too low while I'm exercising?
Hypoglycemia usually occurs gradually, so you need to pay attention to how you're
feeling during exercise. You may feel a change in your heartbeat, suddenly sweat more,
feel shaky or anxious, or feel hungry. When you feel this way, you should stop exercising
and follow your doctor's advice about how to treat hypoglycemia. Your doctor may
suggest you keep candy or juice on hand to treat hypoglycemia.

What else should I do to exercise properly?


Many people with diabetes have problems with the nerves in their feet and legs,
sometimes without even knowing it. So it's important that you wear shoes that fit well
and have plenty of room when you exercise. Otherwise you could develop blisters or
other sores on your feet that can lead to infection and other problems. You should check
your feet before and after you exercise to make sure there are no blisters or other sores.

Should I drink more fluids during exercise?


Yes. When you're exercising, your body uses more fluid to keep you cool. By the time
you feel thirsty, you may already be getting dehydrated. Dehydration (not enough fluid
in your body) can affect your blood sugar level. Drink plenty of fluid before, during and
after exercise.

CHAPTER 5

DISEASE MANAGEMENT SKILLS

Outline
Getting Ready For A New Disease Paradigm
Getting Involved in Disease Management
The Way Ahead

GETTING READY FOR A NEW DISEASE PARADIGM


The new disease paradigm is needed for chronic disease care. The acute care model that we
are all very familiar with does not work well. Table 1 compares the differences between the
acute care model and the chronic care model that necessitate a paradigm shift.

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Table 1. Comparison of The Acute Care Model Versus Chronic Care Model
Characteristics
Main goal of care

Acute care
Cure

Chronic care
Control the progression of the condition;
Increase survival; Enhance quality of life.

Duration
Knowledge

Limited
Concentrated on health
professionals

Long term, Indefinite or Life long.


Health professionals, patients and
families share complementary knowledge

Disease management

Focused on acute & single


medical treatment

Relevant multi-drug & self-management


strategy with appropriate health system,
community and family support..
Comorbidities are usually present

Providers of care

Usually clinicians and clinical


institutions

Broad spectrum of health care


organizations, community services
and family care

Quality of care

Mostly self-contained
approaches within Institutions

Relevance of systemic quality approaches

HELPING PATIENTS TAKE CHARGE OF THEIR ILLNESSES


The doctor-relationship in the acute-care model is the do as I say model of care. The
patient is dominant and patient is passive. For chronic disease, this doctor-centred model
is focused on compliance. The doctor recognizes the patient needs to do something, but
it does not give the patient any more power. The health care professional is still very much
the authority trying to get the patient to do what is needed; the patients job is simply to
be obedient. It is a do as I say model of care.
What has been found, however, is that one cannot get patients to do anything. The
motivation to change ones behavior even to take ones medication is largely
internal. The patient is responsible and must take an active role in his or her own care.

THE PATIENT IS THE SOLUTION


Effective chronic illness care has two requirements. First, it requires a team with the
patient at the centre. Second, it requires active, involved participants especially an
active, involved patient. This model of care can be described using various terms
empowerment, informed choice, patient centered but they all have the same
underlying concept: The patient is at the centre and is actively involved in his or her own
health care.
But why cant we stick with the old models? Why does the patient need to be so
involved? There are at least three reasons.
First, most of the chronic illness care does not even involve physicians and other health
care professionals. On a day-to-day basis, the patient is in charge of his or her own health,
and the daily decisions people make have a huge impact on their own outcomes and
quality of life.
Second, we may know whats best for treating diabetes or asthma or congestive heart
failure, but that does not mean we necessarily know whats best for an individual patient.
Even in close doctor-patient relationships, we cant always know the details of our
patients lives: whats most important to them, what their other priorities are, what
motivates them, or what their financial situation is. Each patient is the expert in his or her
own life.
146

Finally, when patients are encouraged to be more involved and when their physicians
are less prescriptive, they do have better outcomes. We also know that this approach
does not take any more time but, in fact, can be more efficient because the health care
team is addressing the patients agenda first and the patients agenda is, after all, the
real reason for the visit (Nagasawa et al, 1990 in: Funnell MM, 2000).

EMPOWERMENT THROUGH EDUCATION


Its very difficult for patients to do what they dont understand, so the first step in equipping
patients to take on a more active role in their health care is to educate them. Start by
getting the message across to patients that education is as important to their health as
getting their prescriptions filled. They need to know all they can about their disease.
Patients needs should drive the education. For example, diabetes education courses can
be based entirely on questions from the audience. We can have a checklist of topics we
want to cover, but we address those topics in the context of patient questions rather than
through an impersonal lecture. Patients arent interested in their disease from an
intellectual perspective, as doctors are. They want to know about themselves. What does
this mean to me? Hows this different for me? Hows it going to affect my life?
Four important messages patients with chronic diseases need to understand (Funnel,
2000) are:
1. Their illness is serious. There are still patients out there who believe they have the
not-so-serious kind of diabetes. If they dont believe it is a problem, they will never
make changes to improve their health.
2. Their condition is essentially self-managed. Every decision patients make
throughout the day, from what they eat to whether they walk or ride the bus, has an
influence on their health. Communicate to patients that they are the most important
individuals in managing their illnesses.
3. They have options. There is rarely one perfect way to treat a condition. In the case of
diabetes, for example, patients can be treated through diet and exercise, oral medication,
insulin and so on. Patients need to understand the different treatment options available
and should be encouraged to look at the personal costs and benefits of each. Only the
patient can decide if the benefits are greater than the costs.
4. They can change their behaviour. Rarely do patients leave the doctors office and
immediately enact whatever change was recommended. The reality is that it often has to
be spread out into a series of steps. Teach patients that significant behavioral changes can
be made by setting goals, taking that first step and figuring out what you learn about
yourself along the way. This brings us to setting goals.

SETTING GOALS
In the patient-centered model of care, attention should be directed at the patients
agenda or goals related to his or her condition. Ideally, the goal should be clearly
displayed in the patients notes, and each person who handles the notes plays a part in
supporting the patient in that goal, asking, How did it go? What have you done this
week? How can we help you do better?

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Every patient has a goal. Even non-compliant patients have goals. Probably the best
definition of non-compliance is a doctor and patient working toward different goals. The
strategy is to set a goal that is in common.
The process of setting self-management goals with the patient involves essentially
two steps.
1. Start at the problem. Rather than beginning the patient encounter focused on lab
values or weight or blood pressure readings, begin by saying, Tell me what concerns you
most. Tell me what is hardest for you. Tell me what youre most distressed about and
what youd most like to change. Youll get to the lab values and other issues later, but it
will be in the context of the patients personal goal, which will make it more meaningful
for the patient.
2. Develop a collaborative goal. Once you have worked with the patient to identify
the real problem, your instinct may be to try to solve it, but dont. Dont try to fix it. Dont
just say, It will be OK. Instead, validate the patients feelings and his or her capacity to
deal with the problem, and continue asking questions that will lead the patient to his or
her own solution. Ask, What do you think would work? What have you tried in the
past? What would you like to try?

STARTING AT THE PROBLEM


Does the patient have the same goal as the doctor? Will he take the medicines you are
about to prescribe? Or the exercise that you said he should get into?
There is a need to explore the patients ideas, concerns and expectations about the
medicines to be prescribed. Specifically, we need to find out if the patient agrees that they
needed the medication, whether they want to take it at all even though he or she agrees
that it is needed. Is it because he or she thinks it will not work or is it because of worries
on side effects. The issue of affordability arose for only 10.5 percent and 14 percent of
patients in the Upjohn and American Academy of Family Medicine surveys, respectively
on non-adherence. This suggests that non-adherence arises less from financial issues than
from patients beliefs and attitudes.
Table 2. Finding the patients concerns and expectations also applies to nonpharmacological treatment.
Patient says:

Doctor responds:
(Old model)

(New model)

I hate this exercise plan.

Then try walking after


dinner every night with your
husband for 10 minutes.

What do you hate about it?


What would help you do better at it?

I dont think I can quit


smoking.

Smoking is the leading


cause of preventable death ...

Why do you think that? What


has happened in the past when
you tried to quit? What concerns
you most when you think about
trying to quit?

I havent been able to test


my blood sugar four times
a day.

Its hard at first, but just


keep trying. You really need
to keep the track of it.

What is preventing you from


doing that? Do you know what
numbers mean?

Source: Funnell MM, 2000

148

FINDING THE COLLABORATIVE GOAL


Its always more meaningful when patients find the ah ha! on their own, so give them
that chance. Encourage them to come up with ideas first, then offer your own
suggestions or additional information that they may need. You can say this works for
some people or have you tried this? or heres why I dont think thats a good idea.
The important thing is to give the patient the opportunity to make the final decision on
what goal to try.
Ultimately, at the end of the conversation, the patient should be able to tell you one step
he or she is going to take. It should be very specific. If the patient says, Im going to
exercise more, ask what that means. Will they exercise four times a week? What activity
will they be doing? How far will they walk? Help them to come up with a specific plan
that they have created for themselves. It may not be the ultimate goal you would have
chosen for the patient, but its one they are more likely to accomplish. At the next visit,
then, you can build on that.
Who actually works with patients to set their goals, whether you or the nurse or the
diabetes educator, is perhaps less important than the fact that patients are encouraged to
be more involved. The emphasis on self-management goals suggests that the visit is for
them. It is their agenda, and they are active participants in the outcome.
Adherence can be promoted by using easily learned communication skills that are part of
patient-centered medicine. They range from phrasing questions in ways that elicit
information efficiently to simply not interrupting patients while theyre talking.
Figure 1. Example of A Written Goal
Blood Pressure Goal
Actual:_________________mm/Hg
Ideal: 130/85 or lower
My goal is: ______________
A blood pressure reading has two numbers. The top number is called systolic blood pressure. This is the
amount of pressure against the blood vessel walls when your heart pumps. The bottom number is called
diastolic blood pressure. This is the amount of pressure against the blood vessel walls when your heart
relaxes, that is, between heart beats.
In general, high blood pressure means that systolic blood pressure, diastolic blood pressure or both may be
too high. For people with diabetes, high blood pressure is 130/85 or higher. High blood pressure increases
your risk for strokes, heart attacks, kidney damage and eye disease.
To lower your blood pressure you can:

Eat less salt,

Take blood pressure medicine,

Exercise,

Stop smoking,

Monitor blood pressure,

Drink less alcohol,

Maintain reasonable weight,

Other: _________________________________

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The Right Communication Processes


Communication processes that promote adherence are not difficult to acquire. There are
several steps in the communication process here:
Agree on the problem. Find out whether you and the patient agree on what the
problem is.
Negotiate reasonable goals. Once you and the patient agree on the diagnosis, set
attainable goals. If a hypertensive patient has a diastolic blood pressure of 120, you may
not want to try to bring it down below 90 immediately. You may suggest 110 as a shortterm objective. Once this has been achieved you can use that success to motivate the
patient to reduce it even more.
Generate options. Reviewing a reasonable range of treatment options, discussing
the benefits and possible side effects of each one in terms the patient can understand will
help in the patients acceptance of the treatment.
Decide on a mutually agreeable and feasible regimen. Doctor and patient can
choose a medical option that makes sense in the patients life. Dosage frequency requires
a similar discussion. Once-a-day drugs can improve adherence because they simplify
dosage. Some may be better off with a less expensive, three-times-a-day version.
Get the significant others involved. In many instances, adherence hinges both on
the patient and on his or her family. Success depended on the wifes understanding the
need and being motivated to meet it. She could undercut the program, either
inadvertently or intentionally, if she was left out of the loop.
Test the patients knowledge. It is useful to have patients repeat what theyve been
told about their illness and treatment plan. It can be, Tell me what you understand
about your illness. Likewise, ask them to explain their treatment plan, just as if they were
talking to their spouse. Its also important for patients to demonstrate any techniques
theyve been taught, such as injecting insulin or using a peak flow meter.
Screen for readiness. Ask two questions at the end of an encounter that allow him
to screen for non-adherence one more time. The first is, On a scale of 1 to 10, how
important do you think it is for you to do the things weve been talking about? The
second question is, On a scale of 1 to 10, how confident are you that you can adhere to
this treatment regiment?
Interventions

Interventions may be grouped into three strategies.


Educational: Information conveyed verbally and in writing.
Behavioural: Telephone reminders, patient contracts, skill building, drug packaging.
Affective: Counselling, home visits, family support.
In general, the more comprehensive the approach, the more adherences will be achieved.
Interventions that combined all three strategies educational, behavioural and affective
were almost twice as effective as education alone.
Keeping Patients on Course
Once a patient embarks on a course of treatment, you need to ensure that he or she stays
on course. The effective physician asks about non-adherence in a nonjudgmental way.
You can say, A lot of people find it difficult to take their pills 100 percent of the time. Tell
me about your experience. Its an open-ended question that elicits far more information
150

than just asking, Are you taking your pills? Once the patient admits to non-adherence,
you can talk about ways to get back on course. If cost is the problem, consider lower cost
medications, medical social help, or cognitive redefinition. The understanding that the
result of treatment is worth the cost may help the patient redefine the priority to be given
to medication expenses. If the patient says, I feel fine without the medicine, talk about
the long-term risks of diseases that may have no symptoms.
Offer your congratulations if you find that the patient is following the treatment plan. We
need to praise patients when theyre making any kind of progress. Likewise, doctors
should accept less-than-perfect short-term results for the sake of promoting longterm change.
References for further reading
Funnell MM. Helping Patients Take Charge of Their Chronic Illnesses Family Practice Management, March 2000.
Nagasawa M, Smith MC, Barnes JH, Fincham JE. Meta-analysis of correlates of diabetes patients compliance with
prescribed medications. Diabetes Educ. 1990;16(3):192-200.
Clark LT. Improving compliance and increasing control of hypertension: needs of special hypertensive populations.
Am Heart. 1991; 121(2):664-669.
Roter DL, Stewart M, Putnam SM, Lipkin M, Stiles W, Inui TS. Communication patterns of primary care physicians.
JAMA. 1997; 277(4):350-356

GETTING INVOLVED BY DESIGNING THE CLINIC FOR DISEASE MANAGEMENT


Designing a clinic for disease management needs to pay attention to the care
management processes of needed for chronic diseases. There are barriers to be overcome
and there are also facilitating factors that will allow the clinic to be designed to provide
optimal disease management. This is a growing area where attention to current literature
will be useful. Two papers in the current literature (Rundell at al, 2002 and Cheah, 2001)
are useful in this context and the content of this reading is based on these two papers.
Care Management Processes Needed for Disease Management
The care management processes needed for disease management have been identified by
Rundall and used as a framework to study chronic care management (Rundall et al, 2002):
practice guidelines (descriptions or statements that guide recommended treatment
based on literature and scientific review).
population disease management (a care programme that identifies the population of
patients with chronic diseases served by the medical group and provides these patients
with a symptom management plan, conditioning and drug regimen, education on the
disease, and case management by telephone).
case management (a programme to intensively manage individual patients with
uncontrolled or high cost conditions).
health promotion or disease prevention (an activity occurring outside the clinical
encounter that promotes health such as a newsletter containing advice, a series of classes
addressing a specific health risk, or screening offered in the community).
Clinical information system use of seven selected functions of a clinical information
system that support chronic disease care management namely, (1) electronic medical
record, (2) electronic recording of health history, (3) recording of tests and procedures, (4)
recording of diagnosis and treatment, (5) computerised entry of drug prescriptions, (6)
automated reminders, and (7) electronic exchange of information with patients.
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Framework for Action


Designing the clinic for continuing care requires attention to a framework for action. This
has been described by Cheah (Cheah, 2001) and consists of the following elements:
identify the chronic disease and define the target population for disease management.
organise a multidisciplinary team.
define the core components, treatment protocols, and evaluation methods; and
measure the outcomes and aim for continuous quality improvement.

Identify the chronic disease and define the target population suitable
for disease management These are conditions that have:

High prevalence.
High cost (charges per episode, high drug use, etc).
High variability in practice patterns.
Poor clinical outcomes or a high risk of negative outcomes.
Inefficient delivery systems.
Potential for changes in patients lifestyle to improve outcomes.
Availability of clinical and other expertise to develop the programme.

Organise a multidisciplinary team The importance of a multidisciplinary team in


developing and implementing a disease management programme needs to be noted. The
team should include doctors, nurses, pharmacists, therapists, case managers, and
administrators, and it is important to appoint a clinician champion to lead the team. As
well as defining the goals of the programme and deciding what needs to be done, how it
should be done, who would do it, and how much it would cost, the team must also
anticipate the barriers to change. The same team should also evaluate the success of the
programme on the basis of agreed performance and outcome indicators. Having clinician
leaders and providing them with accountability and resources is crucial to getting their
ownership and support for the programme.

Define the core components, treatment protocols, and evaluation


methods The core components will include patient education, prevention measures,
screening for complications, monitoring of compliance and clinical outcomes, behaviour
modification, and environmental interventions. The Ministry of Health has started to
develop and disseminate evidence based national clinical guidelines to all doctors.
Dissemination alone will not, however, change practice. What is needed is a structured
approach to incorporating these guidelines into everyday use.
One way of achieving the incorporation of clinical practice guidelines into everyday use is
through the use of a protocol driven clinical pathway. The pathways incorporate clinical
documentation and time based interventions and focus the team on coordinating care
across different settings. Pathways in disease management programmes can span the
continuum from acute care to chronic care and provide the necessary linkages to
coordinate clinical management and monitoring of outcomes.

Measure outcomes and aim for continuous quality improvement It is


essential to measure baseline outcomes before beginning disease management
interventions to assess their effectiveness. Measured outcomes should include a mixture
of clinical, humanistic, and financial outcomes.
152

References for Further Reading


Rundall et al. As good as it gets? Chronic care management in nine leading US physician organizations. BMJ
2002;325:958-961 ( 26 October )
Cheah J. Chronic disease management: A Singapore perspective. BMJ 2001;323:990-993 ( 27 October )

Keeping Track of Disease Management


We need to be able to keep track of the patient with chronic problems such that at a
glance we are able to make sure they are receiving the care they need. The answer lies in
the use of flow sheets. In order flow sheets work, there is a need to pay attention to
several factors. White describes what one group of doctors have found useful in the case
of flowcharts for diabetes (White, 2000). The tips can be applied in flow sheets for other
chronic conditions like hypertension or hyperlipidemia too.
The Strategies are:
Design a flow sheet that is comprehensive. The flow sheet should list all services
or measures relevant to diabetes, from patients lab values to blood pressure readings to
self-management goals to foot checks. The flow sheet wont be effective if key measures
are missing and overlooked, so dont hesitate to revise it.
Make abnormalities easy to spot. The patient data listed on the flow sheet will be
more useful if you also list the target measures or expectations so that you can
immediately know whether a patient is progressing toward the ideal. By putting the
parameters for normal lab results right on the flow sheet we do not have to wonder
whether a lab result is abnormal. Thus, targets listed on a diabetes flow sheet could
include the following: (a) two or more HbA1c checks per year, (b) with the most current
result at 7 percent or lower; (c) a retinal exam every 12 months; and (d) blood-pressure
readings at 130/85 mm Hg or lower.
Make sure the flow sheet cannot be overlooked in the chart. One way is to print
the flow sheets on coloured, heavy weight paper.
Computerize your flow sheet, if possible. While flow sheets can be easy and
effective tools even in their simplest form (paper), they become infinitely more valuable
when combined with computerized data. Computerized programs offer automatic
reminders when patients need certain services and provide an easy way to track patient
data over time.
Get Everybody to Enter the Flow Sheet. Perhaps the most difficult aspect of any
flow-sheet system is getting people to use it consistently. Filling the flow sheets seem to
work best when several people share the responsibility. For example, the person who files
the lab results in the chart can enter the lab results on the flow sheet. The nurse can be
responsible for inputting clinical data from the visit into the flow sheet. And the physician
can write in elements such as the patients self-management goal.
Set up a Review System. Follow up patients who have missed needed services.
This is where the patient register (list of patients who has a particular chronic problem)
comes in useful. If you have a diabetes patient registry (i.e., a list of your patients who
have diabetes), youll know exactly which patients to look up now that the information is
organized into a single page or two. The reviewing system is now manageable.
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Set a Goal. The point of having a goal for flow sheets, or any other aspect of
practice, is simply to spur action and encourage your practice team to work together. For
example, you can set an initial goal to have up-to-date diabetes flow sheets in 80 percent
of patients charts. Once, the goal is reached, that spirit of continuous improvement can
be continued until the ultimate goal of changing diabetes care, can be done in one step,
and for each one patient, one flow sheet that is kept up to date all the time.
Figure 2. Keeping Track of Disease Management With A Good Flow Sheet
DIABETES FLOW SHEET
NAME
DATE OF BIRTH
HbA1c <_ 7% (q 4-6 months)
DATE:
RESULT:
DATE:
RESULT:
Blood pressure < 130/85 mm Hg
DATE:
RESULT:
DATE:
RESULT:
BUN/Creatinine ratio 8-22/0.4-1.1 mg/dL (annual)
DATE:
RESULT:
Urine albumin/Creatinine 0-20 mg/L (annual)
DATE:
RESULT:
Lipids (annual)
DATE:
CHOL:
TRIG:
HDL:
LUL:
Retinal exam (annual)
DATE:

DOCTOR:

Foot screening (annual) HIGH RISK: YES/NO


DATE:
Self-management
DATE:
GOAL:
( ) DIABETES EDUCATION ( ) DIETARY COUNSELLING ( )
HOME BLOOD GLUCOSE MONITORING ( ) DSS MEMVERSHIP
CAD Status: ( ) PAST MI ( ) CABG ( ) PTCA ( ) CURRENT ANGINA ( ) NO HISTORY
Smoking Status: ( ) NONSMOKHR (SINCE _____________) ( ) SMOKER (PPD _______ )
ACE Inhibitor: ( ) YES ( ) NO ( ) MICROALBUMINURIA ( ) HYPERTFNSION
Aspirin Use: ( ) YES ( ) NO
( IF NO,SPECIFY REASON ____________________________________________)

Source: Family Practice Management Jun 2000; 61

154

This chart is copyright @ 2000 American Academy of Family Physicians. Physicians may
photocopy or adapt for use in their own patients charts; all other rights reserved by the
American Academy of Family Physicians. Use of this chart is acknowledged.
Reference and further reading
White B. Using flow sheets to improve diabetes care. Family Practice Management Sep 2000, 7(6):60-64 (Full text
at: http://www.aafp.org/fpm/20000600/60usin.html) Diabetes flow sheet in: Family Practice Management Jun
2000:61

THE WAY AHEAD


Innovative care models for chronic conditions are being formulated and implemented in
selected settings within certain developed countries. Results to date are promising,
showing improved adherence rates and clinical outcomes when the following strategies
are applied comprehensively (WHO, 2001):
Providing care that is respectful of patient preferences, and ensuring that patient
values guide all treatment decision-making.
Educating and supporting patients to self manage their conditions to the
extent possible.
Linking to resources in the broader community.
Developing and supporting health care providers to make and implement evidencebased treatment plans.
Reorganizing health systems to enhance the free flow of knowledge and information.
Coordinating care across patient conditions, health care providers, and settings
over time.
Monitoring the evaluating the quality of services and outcomes.
Reorganizing health care financing so that evidence-based care for chronic conditions
is possible and supported, and coverage of drugs is fully supported.
References and further reading
WH0. Adherence to long term therapies:policy for action, 2001 (http://www.who.int/chronic_conditions/
Adherence%20Meeting%20Report.pdf).
Bodenheimer et al. Improving Primary Care for Patients With Chronic Illness. JAMA. 2002; 288:1775-1779

Use the Plan-do-check-act (PDCA) Process. Continuing improvement is the


engine that keeps the flow sheets alive. Apply the plan-do-check-act (PDCA) process. For
any deficiency discovered that prevent flow sheets from working, get a small group of
people together and work out how it could be improved (plan). Carry out the
improvements (do). Check the results (check). If the improvement works, implement it
(act). Keep improving the flow sheets.
Finally, Be Patient. Changing your system of care isnt easy. It will take time for
physicians and staff members to experiment with the flow sheets and to find what works
best for them. Dont expect your flow sheet to be perfect the first time, but keep at it.
The more you use them and load them with data, the more useful they will become in
ensuring that patients receive the care they need.

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CHAPTER 6

EMERGENCY CARE SKILLS

Outline
Initial action
Cardiac emergencies
Respiratory emergencies
Neurological emergencies
Paediatric emergencies

INITIAL ACTION
Keep Cool, Act Swiftly and Confidently
Inform doctors and other staff.
Call ambulance at once.
Resuscitate: Administer O2, with spare cylinder nearby; Air viva taken out and ready;
Emergency trolley ready; Suction pump ready; Drip set ready, with Normal Saline and stand.
ABC
Airway Maintain head tilt, chin lift; Clear foreign body/ vomitus;
Insert oropharyngeal airway.
Breathing Look, feel & listen for breath; Assisted ventilation may be needed.
Circulation Check pulse and BP; Establish IV access.

CARDIAC EMERGENCIES
Cardiac Arrest
Recognise No carotid pulse/ respiration.
Action:
Airway Head tilt / chin lift.
Breathing Initial ventilation with 100% oxygen; 12-15 vent/min.
External Cardiac Massage (ECM) Over lower 1/2 of sternum; Depth 3-5 cm, rate
60 - 80/min; Ventilation compression ratio 1:5; Defibrillation (If available)
Check rhythm If VT/VF, serially defibrillate at 200, 200, 360 J till successful;
Lignocaine maintenance if successful.
Intubation Consider at this stage; Endotracheal tube size usually 7-8 for adults; Not
to interrupt CPR for > 20 secs.
Essential Drugs:
(IV) Adrenaline for asystole 10ml bolus of 1:10,000 (1mg).
Atropine for bradycardia 0.6mg bolus.
Lignocaine for Ventricular Tachycardia /Ventricular Fibrillation 50 mg bolus
over 1 min; Maintenance 1mg/kg/12hr.
NaHC03 if collapse prolonged; 1 ml/kg 8.4%.

156

Shock
Recognise Cold skin, tachycardia, hypotension.
Causes Hypovolaemic, septic, cardiogenic, anaphylactic, neurogenic shock.
Action:
Correct hypovolaemia (if present) Use Normal Saline or Hartmann solution.
Attend to underlying condition.
Transfer to hospital.
Acute Myocardial Infarction
Recognise Classically, anginal pain which is severe, prolonged (>_ hour), at rest, no
relief from GTN, and associated with breathlessness, sweating, vomiting, dizziness or
syncope. N.B. Beware of atypical presentation ECG may be normal in early stage.
Action:
Intranasal oxygen 6-8L/min.
S/L GTN 0.5mg stat, & Nitrodisc 10mg if available (5mg for elderly). Caution: Do not
use if hypotensive.
Slow IV Dextrose 5%.
Oral Aspirin 300mg stat.
IV morphine 2 - 5 mg slowly for pain relief, if necessary (dilute 10mg in 10ml N/
Saline). Caution: Give in 1mg aliquots till pain relief. Watch for respiratory depression
and hypotension. IV Maxolon 10 mg would alleviate nausea and vomiting.
Transfer to hospital.
Acute Pulmonary Oedema
Recognise Orthopnoea, paroxysmal nocturnal dyspnoea, history of heart disease/
hypertension/ similar episodes.
Action:
Prop upright, check BP.
Oxygen 6-8L/min.
S/L GTN 0.5mg stat.
IV Lasix 80mg bolus repeat every 15 mins till diuresis occurs.
Concurrently exclude severe hypertension (give S/L Adalat 5mg); AMI (see
previous page).
If resistant, give IV Morphine 2-5 mg slowly (dilute 10mg in 10ml N/S). Caution: Give
in 1 mg aliquots. Watch for respiratory depression and hypotension.
Consider Salbutamol Nebulisation 2:2 (2ml salbutamol:2ml normal saline) if
bronchospasm is present.
Intubate if indicated.
Transfer to hospital.
Hypertensive Encephalopathy
Recognise Severe hypertension (usually diastolic >120mmHg) associated with
headache, confusion, nausea, vomiting, focal neurological deficit, papilloedema.
Action :
S/L Adalat 5mg stat Caution: Do not give S/L Adalat to elderly patients with only
high BP reading in the absence of encephalopathy or other complications.
Set up Heparinised saline plug.
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RESPIRATORY EMERGENCIES
Acute Severe Asthma (Adult)
Recognise Restlessness, confusion, dyspnoea, inability to speak, tachycardia, pulsus
paradoxus. Cyanosis is late. N.B. A silent chest is an indication for immediate intubation.
Severe asthmatic may not complain much and may have minimal auscultatory signs.
Action:
Start Oxygen 4-6 L/min.
Salbutamol Nebulisation 2:2 (2ml salbutamol:2ml normal saline). Repeat if necessary;
Add Ipratropium Bromide (Atrovent) 20 drops (1 ml) if available.
IV Hydrocortisone 200mg stat.
IV Aminophylline 250 mg in 20ml N/S over 15 mins (Do not give loading dose if
already on oral theophylline; infuse 250mg in 500ml N/S over 12 hrs).
Monitor improvement continuously.
Intubate if patient is exhausted or somnolent.
Try S/C Adrenaline 1:1000 in dire situation where intubation cannot be expeditiously
carried out. Use insulin syringe; plaster to the skin. Give 0.3ml up to 0.5ml (0.1 ml at
a time). Caution: in the elderly and patients with IHD, give at slower rate.
Transfer to Hospital.
Breathless Patient
Causes More common: Acute Asthma, Acute exacerbation of COLD, Acute
pulmonary oedema. Less Common: Hyperventilation, Asphyxia/ Choking. Uncommon:
Pneumothorax, Massive pleural effusion / Ca Lung, Severe pneumonia, especially
in debilitated elderly, Acidotic breathing of Diabetic ketoacidosis, Acute
pulmonary embolism.
Action
Quick history (if available), quick examination.
Assess clinically for severity and cause Vital signs - tachycardia, hypotension;
Cyanosis, sweatiness; State of consciousness - restless, confused, drowsy.
Manage underlying cause immediately if it is apparent.
Start oxygen 4-6 L/min (2 L/min if COLD cannot be excluded).
Start Salbutamol Nebulisation 2:2 (2ml salbutamol:2ml normal saline).
Set up Heparinized Saline plug.
Give IV Lasix 40mg stat if unable to exclude acute pulmonary oedema.
Transfer to Hospital.
Choking
Recognise Usually occurs while patient is eating, or in children during play; Patient
often instinctively clutches throat with hands; If airway is completely obstructed, patient
is unable to speak or breathe, becomes pale, then rapidly cyanosed and finally loses
consciousness and collapses.
Action:
Do the Heimlich manoeuvre at once.

158

Adult
Executed for adults and in children older than 12 months.
Deliver 6 to 10 abdominal thrusts until the foreign body is expelled.
How to do it:
Stand behind the patient and encircle the waist with your arms. With one hand,
make a fist and place it, thumb side first, against the patients stomach slightly
above the navel.
Grasp the fist with your hand and press into the patients stomach with a quick
upward thrust.
It has to be of sufficient force and may be necessary to repeat up to 6 times to
clear the airway.

Child
How to do it:
Abdominal thrust with child supine and rescuer kneeling by childs feet.
Place heel of one hand, with the other hand on top of it over midline between
umbilicus and rib cage.
Deliver series of upward and inward thrusts.
If unsuccessful, try to visualize the oropharynx using tongue-jaw lift technique
and remove FB manually if seen. If not, repeat steps 1-4 as necessary.
If the above fails or if no spontaneous respiration occurs, commence artificial
ventilation and intubate.

Below 1 year old


How to do it:
Place child face down 60.
Administer four back blows rapidly with heel of hand high between the
shoulder blades.
If not dislodged, turn to supine position on firm surface, deliver four rapid chest
thrusts over sternum using two fingers.
If unsuccessful, try to visualize oropharynx by tongue-jaw lift technique, and if
foreign body seen, manually remove it. If not, repeat steps 1-4 as necessary.
If the above fails, commence artificial ventilation and intubate.

NEUROLOGICAL EMERGENCIES
Status Epilepticus
Recognise Recurring seizure without recovery of consciousness for 30 mins or more
Action
Protect patient from injury.
IV Diazepam 10 mg bolus over 2 mins; Repeat in 10 mins if necessary, up to maximum
of 30mg.
Maintain airway Position laterally or semiprone; Oropharyngeal airway; Give 100%
oxygen till seizure terminates; Clear pharynx of foreign body.
Transfer to Hospital.

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Eclamptic Fit
Recognise Grandmal seizure, history of pre-eclampsia; Premonitory signs: headache,
restlessness and agitation, blurring of vision, epigastric pain, hyperreflexia.
Action:
Treat as for epilepsy Protect patient from injury; Control fit with IV Diazepam.
Control hypertension IV Hydrallazine (100mg in 500ml 5% Dextrose starting with
10 dpm, increasing by 10 dpm every 15 mins till Diastolic BP 90-100 mmHg).
Transfer to hospital.
Comatose Patient
Recognise Causes: stroke, head injury, cardiovascular catastrophe, encephalopathy
(resp/ renal/ hepatic), brain infection/tumour, hyperglycemia, hypoglycemia.
Action:
Assess General state, response to verbal commands or physical stimuli; Check
pulses, BP, Chest, neurological system, and systematically rest of body; History
from relatives.
Resuscitate - Circulatory support - set drip; Respiratory support - suction, remove
dentures, oropharyngeal airway, oxygen, ventilation.
Prevent aspiration Coma position.
Obtain blood for sugar level and give 40 ml Dextrose 50% if appropriate.
Transfer to hospital.

OTHER EMERGENCIES
Anaphylaxis
Recognise Generalized urticaria, laryngeal oedema, bronchospasm, with or
without collapse.
Causes Hornet sting/ parenteral drug injection such as Penicillin/ NSAID.

Anaphylaxis with collapse


Recognise Hypotension, distress and complaint of feeling of impending death if the
patient is still conscious
Action:
IM/SC Adrenaline 1:1000 0.3-0.5ml Use insulin syringe; Repeat every 15-20 mins
as required; AVOID IV bolus (unless patient is collapsed); Caution: elderly and
ischaemic heart disease.
Assess Airway/Breathig/Circulation.
Give oxygen, intubate if necessary.
IM Promethazine 25mg stat.
IV Normal Saline - Volume correction may be needed.
IV Hydrocortisone 200mg bolus.
If bronchospasm is present, give Salbutamol Nebulisation 2:2 (2ml salbutamol:2ml
normal saline).
Continuous monitoring: General condition, BP, pulse & respiration.
Transfer to hospital.

160

Anaphylaxis without collapse


Recognise Generalized urticaria and edema of face/mucous membrane; Patient fully
conscious with no circulatory collapse.
Action:
IM Promethazine 25mg stat.
KIV Salbutamol Nebulisation (2ml salbutamol:2ml normal saline); S/C Adrenaline,
IV hydrocortisone.
Must monitor progress. Refer to A&E for observation.
Diabetic Coma
A diabetic can suffer from hyperglycaemic coma, hypoglycaemic coma and come due to
stroke, fits, infection, head injury or other causes.
Hypoglycaemia Coma
When suspected, do hypocount and collect blood sample first.
Recognise Agitation, altered mentation (may be in deeper coma), tachycardia,
sweating, anxiety; rapid onset. N.B. Unusual presentations include stroke and fits.
Causes DM on long acting sulphonylurea, missed meal, or insulin overdose.
Action:
IV 50% Dextrose 40ml stat Avoid extravasation; expect immediate improvement
(IM Glucagon 1 mg stat if IV access not obtained).
Continue 10% Dextrose drip.
Transfer to hospital.
Hyperglycaemic coma (Ketoacidosis)
Recognise Stertorous or deep breathing, severe dehydration, markedly raised blood
sugar level, urine ketone strongly positive (++); gradual onset over hours or days.
Causes Acute insulin insufficiency; failure to give insulin in known patient due to
misconception, e.g. during intercurrent illness.
Action:
Volume replacement with initially 1L N/S /hr ;If hyperosmotic non-ketotic diabetic
coma suspected, use 0.45% Saline for volume replacement.
IV/IM Soluble Insulin 5 u stat.
Transfer to hospital.
Multiple Injuries
Recognise: Hight index of suspicion in the following situations: (a) more than trivial road
traffic accident, (b) fall from height, (c) more than trivial assaults, (d) explosions.
Action:
Remove patient from area of danger.
If patient is unconscious and extent of injuries cannot be adequately ascertained,
move patient in one piece, ie as a log (may require splints, sandbags and
cervical collar).
Assess vital signs: AIRWAY, BREATHING, CIRCULATION.
(If neck injury suspected, apply cervical collar before assessing airway).
Arrest haemorrhage: direct - pressure dressings; indirect - pressure points compression.
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Establish intravenous lines with large bore venula in large veins: more than 1 usually
necessary if bleeding or in circulatory collapse; Use normal saline/ Hartmann.
Assess systematically from head to toe.
Conscious level, pupils.
Pupil size and position; eye movements.
Face/Head intubation may be necessary for severe facial injuries with bleeding
` (to prevent aspiration).
Neck gentle palpation; Do NOT perform passive range of movements of the
neck if the patient is unconscious; Apply cervical collar if in doubt.
Chest Observe respiratory movements carefully for flail chest, pneumo/
haemothorax; Palpate for tenderness, chest compression.
Abdomen Distension, bruising, tenderness.
Spine Palpate for tenderness; use minimal movement while doing so.
Hips Swelling, deformity. Pelvic compression.
Limbs Swelling, deformity; Support with splints if fracture suspected.
Constantly monitor vital signs and consciousness level.
Transfer to Hospital.
Violent Patient
Recognise Have high index of suspicion that the following types of patients may
become violent: (a) the mentally disturbed, (b) the delirious patient, (c) the very angry
patient, (d) the patient under influence of alcohol or drugs.
Action:
Protect yourself, other staff and the patient: Ensure open exit; Do not try to restrain
patient; Summon for help (including police).
Doctor should Allow patient to ventilate feelings; Maintain adequate distance from
the patient; Avoid antagonising the patient by provocative remarks; Avoid direct eye
contact; Be decisive.
If restraint needed (for unarmed patient) Use maximum force available; Act swiftly;
Have one person to direct the restraining process.
Medication IM Haloperidol 5 mg (half dose for elderly) OR IM Largactil 50 mg
(beware of hypotension).
If hypoglycaemia suspected, do hypocount.
Transfer to appropriate custody and care (a) A&E if medical condition present,
including intoxication; beware of unsuspected head injury in such patient, (b) mental
hospital if psyciatric condition present, (c) Police if medical condition unlikely.
Renal Colic
Recognise Loin to groin pain, may be severe enough to cause nausea/ vomiting; Check
BP, femoral pulses (remember dissecting aortic aneurysm).
Action:
IM Pethidine 50-75 mg stat.
IM Buscopan 2cc stat.
IM Stemetil 12.5 mg / Maxolon 10mg if nausea and vomiting is severe.

162

PAEDIATRIC EMERGENCIES
Collapsed Child and CPR
Begin with the ABC of resuscitation before organising a more coordinated team action.
Pay attention to ECM technique.
Initial Steps
Establish absence of breathing: (a) Head tilt/ chin lift, (b) Look for chest movement,
(c) Listen and feel over nose and mouth, (d) Clear pharynx if necessary.
Improve airway patency: (a) head tilt and chin lift (Avoid hyperextension of head),
(b) Bag and mask if necessary.
Palpate for brachial pulse.
Further Action
If foreign body suspected, invert child and apply back blows. Heimlich Manoeuvre
can be applied to children over 1 year old.
Bag and mask to ventilate, 15-30 breaths/min according to size of child.
External Cardiac Massage (ECM) over junction of lower and middle third of
sternum. Compression Ventilation Ratio 5:1.
Intubate, but if repeated attempts unsuccessful, bag and mask and oxygenate. Note:
adequate ECM produces palpable pulse. Adequate ventilation causes the chest to rise.
Establish IV Access (Paed Dext/Saline) - use microdrip set for small children.
Monitor BP, heart and respiration.
ECM Techniques
Baby Use thumbs encircling the babys chest in both hands; Rate 120/min; Depth
1 - 1.5cm.
Toddlers/small children Use tips of 2 fingers; Rate 100/min; Depth 2 - 3cm.
Larger child Use heel of hand; Rate 60 - 100/min; Depth 3 - 5cm.
All doses are expressed as volumes (ml), and to be given intravenously unless
stated otherwise.
Note:
*
May be given by the endotracheal route at the same dose
**
Use microdrip set for small children below 25 kg
Acute Severe Asthma (Child)
Recognise Marked respiratory distress and use of accessory muscles; Prolonged
expiration; Cyanosis (late); Silent chest (very late); Others: PEFR < 50% of predicted value
after nebuliser.
Action:
Give oxygen 4-6L/min by face mask.
Ventolin Solution 0.03 ml/kg/dose diluted to 2 ml with N/Saline, nebulized by O2. Add
Ipratropium -Bromide (Atrovent) if available (10 drops for child below 1 year, 20 drops
for above 1 year).
Review and if necessary, repeat Vent Nebulizer up to a total of 3 doses.
If child is still very dyspnoeic: give IV aminophylline 5mg/kg in Paediatric 0.45% Saline
Infusion over 6 hrs (safer than loading dose over 20 mins).
163

SECTION 05 CONSULTATION SKILLS

IV Hydrocortisone 4mg/kg stat.


S/C adrenaline (1:1000) 0.1-0.3 ml (0.01ml/kg) may be used in dire emergency where
intubation cannot be expeditiously carried out. Contraindication: Cardiac failure
or hypertension.
Transfer to hospital.
Stridor
Recognise The typical inspiratory sound: May be both inspiratory and expiratory
Causes The 4 conditions that present as emergency are: (a) Acute Epiglottitis, (b)
Foreign Body inhalation, (c) Acute Angioneurotic Oedema / Anaphylaxis, (d) Severe Acute
Laryngotracheobronchitis (Viral Croup)
Acute Epiglottitis
Recognise Severe respiratory distress, sudden onset, usually 1-5 yrs old, toxic, febrile,
tachycardia, forward sitting posture with drooling of saliva; Sweatiness and cyanosis imminent respiratory arrest.
Action:
DO NOT ATTEMPT TO EXAMINE THE THROAT if acute epiglottitis is suspected.
If child is not cyanosed: Rapid transfer to hospital (with 02 and intubation set standby).
If child is severely ill: (a) Adminster oxygen by mask, (b) Minimal disturbance, (c)
Intubate if respiratory arrest, (d) Immediate transfer to hospital.
Inhaled Foreign Body
Recognise Suspect in all cases of stridor: ask for h/o choking, may only hear wheezing
if foreign body is in bronchus or beyond.
Action
Do Heimlich Manoeuvre. See under choking.
Acute Angioneurotic Oedema / Anaphylaxis
Recognise An acute allergic reaction associated with facial or neck swelling
Action:
Oxygen by mask.
S/C Adrenaline (1:1000) - 0.01 ml/kg up to 0.3-0.5ml (can be repeated every 4 hrs
if necessary).
IV access (Paed Dextrose/Saline).
IV hydrocortisone 5-10 mg/kg stat.
IM Promethazine 0.5 mg/kg stat.
If bronchospasm is present, give Salbutamol Nebulisation 0.03ml/kg/dose diluted to 2
ml N/S. If brochospasm persists, consider IV aminophylline 5mg/kg in IV Paediatric
0.45% Saline infusion over 6 hrs (SAFER than loading dose over 20 mins).
May need to intubate. Do NOT delay if indicated. Restlessness is an indication of
severity and the possible need for intubation.
Acute Laryngotracheobronchitis (Viral croup)
Recognise Usually not as severe as acute epiglottitis; Onset insidious, usual age 3 mths
- 4 yrs; Less toxic, but severe cases may present as emergencies
164

Action:
Give humidified oxygen if available.
IV access (Paed Dextrose/Saline infusion).
Transfer to hospital.
Fits in a Child
Causes Febrile fit; Others - epilepsy, meningitis, metabolic, anoxia, cerebral injury
Action:
Clear airway, suck secretions, loosen clothing around neck; Turn to one side (to
prevent aspiration).
Oxygen during convulsions or if cyanosed.
Protect from injury. (Forcing object into mouth may cause more damage than good;
use padded gag between teeth to prevent biting of tongue only if jaw is relaxed.).
Reduce fever.
Tepid sponging.
Rectal Panadol < 3 yrs old
- 1/4 supp (62.5mg)
3 to 6 yrs
- 1/2 supp (125mg)
7 to 12 yrs
- 1 supp (250mg)
If fits persist or recur:
IV Diazepam 0.3 mg/kg
- rough guide: 1mg/yr of life
- repeat after 20 mins if necessary
- Maximum dose: <5 yrs
- 10 mg
5-12 yrs - 15 mg
Caution: Apnoea/ cardiac depression/ hypotension
Rectal Diazepam if IV access not obtained (5 mg in 2.5 ml)
>3yrs 10mg
<3yrs 5mg
<1yr 0.5 to 0.75mg/kg
After fits controlled, do full neurological examination and check BP.
Transfer to Hospital.
Paediatric Emergency Drugs
Tables 1 and 2 show the dosages of important Paediatric emergency drugs.
Table 1. Modified Reference Chart For Paediatric Resuscitation
Maximum Age (Year
unless indicated)

2
mths

6
mths

3.5

10

13

14

Maximum Length (cm)

55

70

75

90

115

135

155

160

Maximum Weight (kg)


Endotracheal Tube

7.5

10

15

20

30

40

50

Internal diameter (mm)


Length(cm)

3
10

3.5
12

4
13

5
14

5.5
15

6.5
17

7.5
18

8
21

Adrenaline (1:10,000)*

0.5

0.75

1.5

Atropine (600ug/ml)*

0.2

0.25

0.3

0.5

0.7

165

SECTION 05 CONSULTATION SKILLS

Table 1. Modified Reference Chart For Paediatric Resuscitation - Contd


Na Bicarbonate (8.4%)

7.5

10

15

20

30

40

50

Calcium Chloride (1mmol/m)

1.5

10

0.4
0.75

0.5
1

0.75
1.5

1
2

1.5
-

2
-

2
50

Diazepam (5mg/ml): Intraveneously 0.25


Per rectum
0.5
Glucose (50%)

15

20

30

40

Glucose (25%)

10

15

20

Lignocaine (1%=10mg/ml)*

0.5

0.75

1.5

Salbutamol (50ug/ml)
Initial Fluid Bp;us (ml)
Colloid
Paed Dext/Saline **

0.5

0.75

1.5

50
100

75
150

100
200

150
300

200
400

300
600

400
800

500
1000

10

15

20

30

40

60

80

100

Initial DC defibrillation (J)

Table 2. Paediatric Emergency Drugs


CONDITION

DRUG/ DOSAGE FORM

DOSAGE

FIT

IV DIAZEPAM
(10MG/2ML)

0.3 mg/kg/dose slowly


Maximum dose:
<5 yrs
10 mg
5-12
15 mg
Caution: apnoea

Supp DIAZEPAM
(5mg/2.5ml)

SEVERE ASTHMA

IV AMINOPHYLLINE
(250mg/10ml)

IV HYDROCORTISONE
(100mg/vial)
SC/IM ADRENALINE
(1:1000)

<3 yrs
5 mg
>3
10 mg
<1 0.5 - 0.75 mg/kg
5mg/kg by infusion
over 6 hrs
Loading dose: 5mg/kg over
20 mins
5mg/kg stat
then 6 hrly
0.01 ml/kg
max 0.5ml
Rpt 4Hr prn

CONGESTIVE
CARDIAC FAILURE

IV LASIX
(20mg/vial)

0.5mg/kg/dose

RESPIRATORY
DEPRESSION

IV NALOXONE
(400 mg/vial)

10 mg/kg
Rpt in 2 mins

Reference
MOH, COFM & CFPS. Emergencies. In:Handbook for Primary Care Doctors. Singapore:MOH, 1996

166

1 Fatique
2 Weight Loss
3 Fever
4 Dyspesia
5 Breathlessness
6 Cough
7 Sore Throat
8 Chest Pain
9 Diarrhoea
10 Constipation
11 Vomiting
12 Abdominal Pain
13 Skin Rash
14 Backache
15 Joint Pain
16 Dizziness
17 Headache
18 Insomnia
19 Persistently Crying Baby
20 Red Eye

SECTION 06

COMMON SYMPTOMS IN AMBULATORY CARE

SECTION 06

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

CHAPTER 1

FATIGUE

DEFINITION
Fatigue may be defined as "weakness on exertion, continued tiredness or the inability to
get going". Patients may use different words to express it.

RELEVANCE TO GENERAL PRACTICE


Everyone is occasionally tired. For some, the tiredness may be severe enough to
prompt a visit to the primary care physician.
Most patients bothered by being tired all the time come to the doctor looking for an
organic cause. Most studies of chronic fatigue syndrome (CFS) discover the vast
majority to have a psychological cause. Few patients initially report psychological
symptoms, and if they do, they view such symptoms as secondary to a medical illness.
Attempts by the doctor to address psychological issues may be misinterpreted by the
patient as not being taken seriously.
The tasks of the primary care physician are to pick up the patient with an organic
cause for evaluation and definitive treatment; and for the rest to provide advice
and reassurance.
Anaemia is the commonest physical cause of fatigue. Other physical causes include
hypothyroidism, cardiovascular disease, diabetes, carcinoma and post infectious
mononucleosis infection. A full blood count is therefore the single most useful test if
investigation is considered necessary.
Remember to review the patients medication as a possible contributing factor.

CAUSES
It is helpful to start by drawing up a shortlist of possible causes so that realistic diagnostic
probabilities can be considered. In those patients in whom a positive diagnosis can be
made, being tired all the time (TATT) is much more likely to arise from psychological or
social causes than physical ones. About 75% of cases may have psychological or social
causes. (See Table 1)2
Table 1. Causes of Feeling Tired all the Time
PSYCHOLOGICAL AND SOCIAL Anxiety, depression or mixed
PHYSICAL Uncommon (less than 10%) : anaemia, diabetes, hypothyroidism, side-effects of
medication, cardiovascular disease, chronic renal or hepatic disease, chronic renal or hepatic
disease, malignancy (rare -- less than 1%) and postviral fatigue syndrome
UNEXPLAINED Relatively uncommon (15%)

168

Source. Ridsdale L, Evans A, Jerret W et al. Patients with fatigue in general practice: a prospective study. BMJ
1993:307:103-6.

Psychological. Anxiety or depression, or a combination of the two, are overwhelmingly


responsible for most cases of feeling tired all the time. Such anxiety or depression is often
linked to psychological stress and usually has a clear underlying cause.
Anaemia. For anaemia to be a cause, it has to be severe, that is, 7-8gm/100ml.
Lassitude prevails, at times in association with exertional dyspnoea or with postural
hypotension when blood loss is acute.
Endocrine. Diabetes mellitus is the most common cause in this category. Less common
but should be looked out for are hypothyroidism and apathetic hyperthyroidism in
the elderly.
Pharmacological. Drugs commonly causing tiredness include antihistamines,
antihypertensives and psychotropics.
Cardiopulmonary and Other Vital Organ Dysfunction. Failure of any of the
vital organs can present as fatigue, e.g. congestive cardiac failure, chronic renal failure,
hepatocellular failure and chronic obstructive lung disease. In the diabetic patient and in
the elderly, acute myocardial infarction may present as tiredness. Chronic fatigue from
disturbed sleep due to sleep apnoea is an often overlooked etiology. Daytime sleepiness,
excessive snoring, irregular breathing, disturbed sleep, and haemoglobin desaturation are
characteristics of this condition.1
Malignancy. Occult malignancy is a much feared etiology. Although fatigue and
lassitude accompany most cancers, pancreatic carcinoma is the typical example of a
tumour that may present initially as marked fatigue with few localising symptoms. Severe
weight loss, depression and apathy may also dominate the clinical picture before other
manifestations of the malignancy become evident. Malignancies causing hypercalcemia
(e.g., breast cancer, myeloma) may present with fatigue, although the hypercalcemia is
usually a late development.1
Infections. Occult infections like tuberculosis or endocarditis, prodromal phase of
hepatitis, and acute infections can all cause fatigue. Postviral fatigue syndromes are
relatively uncommon. Fatigue due to infectious mononucleosis is well documented.2
Physiological Tiredness. Tiredness following any form of exertion, be it mental or
physical, is normal. It is unusual for patients to complain of this form of tiredness to the
doctor, unless it is used as a "ticket of entry" for another problem.

WORKUP
History
A brief perusal of the patients records should disclose past and present medical history,
include current drug therapy, and may give a clue about previous behavioural patterns
of illness.
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

It is important to ensure that the patient and the doctor are talking about the same thing.
Patients should be questioned about what they mean by "tiredness". Local muscle aches
or shortness of breath should be excluded. The initial part of the consultation should
concentrate on open questions, allowing the patient to elaborate on his or her
complaints, before focusing on specific questions designed to confirm or refute the
diagnostic hypotheses forming in the doctors mind. If a psychological cause seems likely
then it will be necessary to focus on the specific features of anxiety and /or depression
and to seek evidence of underlying social stress. If a psychological disorder seems unlikely,
then systematic questioning is needed to elucidate the problem.
General Questions

Duration of complaint is important


days -- prodromal phase of infections, recent infarct.
weeks -- underlying malignancy, chronic infections.
months, or life-long duration - psychological cause.

Periodicity
constant - organic problem.
fluctuating - functional aetiology.

Worst time of the day


in the morning, especially after a good night's sleep -- functional cause more likely.
worsens as the day progresses -- physical cause more likely.

Significant preceding event


acute - e.g. bereavement.
some time past - e.g. dental extraction resulting in subacute bacterial endocarditis.

Systems review
If a psychological disorder seems unlikely then systematic questioning, for example about
change in weight, cough, dyspnoea, polydipsia, polyuria, or a recent history of viral
illness, should help to confirm or refute possible physical diagnoses.

Exploration of possible psychological factors


A psychological cause. e.g. over-burdened life situations may cause fatigue. A grandparent
who suddenly has to look after a grandchild may well be tired out by the responsibility.
Physical Examination
The general condition of the patient is important. If the patient looks obviously well, then
a functional cause is more likely, though this does not preclude a thorough physical
examination. If the patient looks unwell, then one should look very hard for physical signs
that may be pointers to the underlying problem.

170

Investigations
Investigations may not be required if a psychological cause is clear-cut from history, and
the physical examination is normal. For those without a clear cut history, investigations
are needed.

Basic investigations
These include full blood count, ESR, blood for urea, electrolytes, glucose and calcium.
A chest X-ray should be done in the local setting to exclude tuberculosis.

Further investigations
These depend on findings from the history and clinical examination pointing to a
particular cause. They include tests of liver function, electrocardiogram, cardiac
enzymes, and thyroid function tests, to name a few.

MANAGEMENT
Specific Problems
If there is a specific problem, management is directed towards the underlying cause.
Functional Problems
- It is important to clearly separate patients who suffer from depression or anxiety
from patients who are basically normal but are not coping with excessive stress.
- Patient education and explanation as to why the patient is feeling fatigued helps
in the latter group. Showing him or her the normal investigation results also help to
reinforce the message of normality.
- Anxiolytics can be used in conjunction with advice and counselling. Improvement
can be expected in 6 weeks.
- Work situation and social considerations may need modification.
- Family support is important. Explanation and call for supportive attitude on the part
of the family members helps.

CHRONIC FATIGUE SYNDROME


A proportion of individuals with fatigue remains unexplained. The Centres for Disease
Control (CDC) in the US has defined the criteria for the diagnosis of chronic fatigue
syndrome. Their current criteria taken from the CDC website are:
In general, in order to receive a diagnosis of chronic fatigue syndrome, a patient must
satisfy two criteria:
1. Have severe chronic fatigue of six months or longer duration with other known
medical conditions excluded by clinical diagnosis, and
2. Concurrently have four or more of the following symptoms: substantial impairment in
short-term memory or concentration, sore throat, tender lymph nodes, muscle pain,
multi-joint pain without swelling or redness, headaches of a new type, pattern or
severity, unrefreshing sleep, and post-exertional malaise lasting more than 24 hours.
The symptoms must have persisted or recurred during six or more consecutive months of
illness and must not have predated the fatigue2.
171

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

References
1. Goroll AH. Evaluation of chronic fatigue. in: Goroll et al. Primary Care Medicine, 3rd ed. Philadelphia:
Lippincott, 1995: 32-37.
2. Gambrill EC and Mead M. Tired all the time. Update 1 Sep 1994:233-235.
3. Ridsdale L, Evans A, Jerret W et al. Patients with fatigue in general practice: a prospective study. BMJ
1993:307:103-6.
4. CDC. Criteria for diagnosis of chronic fatigue syndrome. http://www.cdc.gov/ncidod/diseases/cfs/publications/
index.htm

CHAPTER 2

WEIGHT LOSS

DEFINITION
An involuntary weight loss of greater than 5% within 6 months or greater or equal to
10% within a year should trigger concern.

RELEVANCE TO GENERAL PRACTICE


An organic cause need to looked for, although a substantial fraction of patients
eventually turn out to be free of any organic disease.
The task of the primary care physician is to determine at the time of initial
presentation who requires extensive medical evaluation and who can be followed
up expectantly.

CAUSES
The differential diagnosis of involuntary weight loss is extensive, but case studies indicate
cancer, depression, and disorders of the gastrointestinal tract are the most common
causes. In approximately 25% of cases, no cause of weight loss is found despite extensive
evaluation and prolonged follow-up. The main causes are shown in Table 1.

MEDICAL CAUSES
Cancer. Malignancy is probably the most common cause of weight loss, especially when
major signs and symptoms are absent. Although any cancer may present with weight
loss, the gastrointestinal tract, including the pancreas and liver, is the most frequent site
for occult tumours to be found. Lymphoma and leukemia as well as cancer of the lung,
ovaries or prostate should be searched for in such patients.
Endocrine and Metabolic Causes. Hyperthyroidism, hypothyroidism and diabetes
mellitus need to be thought of. Weight loss has been described as the most common
presenting symptom of hyperthyroidism in the elderly1. Although hypothyroidism is often
thought to cause weight gain, it may also result in anorexia and apathy resulting in
weight loss, especially in the elderly.

172

Infection. Hidden infection should be searched for in many patients with unexplained
weight loss. Tuberculosis, fungal disease, amoebic abscess and subacute bacterial
endocarditis should be considered.
Table 1. Some Important Causes of Involuntary Weight Loss
Medical causes Cancer; Endocrine and metabolic causes; Infection; Gastrointestinal disease;
Cardiac disorders; Respiratory disorders; Renal disease; Connective tissue diseases; Oral
disorders and Age-related factors
Neurologic causes Dementia; Parkinsons disease and stroke
Social causes Isolation and Economic hardship
Psychiatric and behavioural causes Depression; Anxiety; Bereavement; Alcoholis;
Sociopathy
Source: Reife. Med Clin N Am 1995 March;78:2:299-312

Gastrointestinal Disease. Patients with prior abdominal surgery may have partial
intestinal obstruction with discomfort, vomiting, and weight loss. Patients who have had
a partial gastrectomy for ulcer disease may have malabsorption and loss of weight.
Cardiac, Respiratory and Renal Disease. End-stage cardiac, respiratory and renal
diseases have varying degrees of loss of appetite which result in weight loss.
Oral disorders, Age-Related Factors. Absence of teeth, ill-fitting dentures and
pain with eating may be a cause of involuntary weight loss in the older patient. A number
of functional disabilities may make it increasingly difficult for elderly patients to shop or
prepare food; these factors include arthritis, stroke, visual impairment, cardiac disease
and dementia.

NEUROLOGIC CAUSES
Dementia. Such patients may lose the ability to eat independently. The time required to
feed these patients may overwhelm family resources or institutional staffing, and patients
may not be adequately fed.
Parkinsons Disease. Such patients with late stage disease may develop swallowing difficulties.
Stroke. Stroke may leave patients with dysphagia, weakness and depression, all of
which may cause patients to decrease food intake.

SOCIAL CAUSES
Isolation. People tend to eat more in social situations, and social isolation from any
reason may result in decreased food intake.
Economic Hardship. Economic hardship as the result of life events may result in
difficult financial choices and healthy food may not always be affordable.
173

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

PSYCHIATRIC AND BEHAVIOURAL CAUSES


Depression. Depression is an important disorder in later life. It may lead to apathy,
anorexia and weight loss.
Anxiety. Patients may be preoccupied and forget to eat. They may not have appetite.
Bereavement. Loss of a loved one may cause bereavement over an extended period of
time with loss of interest in eating entirely.
Alcoholism. The diagnosis of alcoholism can be difficult to make, and vague complaints
such as anorexia or weight loss may be the only signs of an underlying problem.
Sociopathy. As patients age, they may lose a sense of control. Food refusal may be
used as a way to gain back some degree of control and increase interaction with others.

WORKUP
A thorough history and physical examination, in most cases, reveal possible causes of
weight loss and usually yield a plan by which to begin an evaluation.
History

Documentation of weight loss


- Assess the extent of weight loss from previous weight records and change in
clothing size.
- Check that the patient is not dieting.
- Determine the time course of weight loss.

Identification of mechanisms for weight loss


Ascertain whether the appetite is good, normal or decreased.
Weight loss in the presence of increased appetite is seen in thyrotoxicosis, diabetes
mellitus and malabsorption.
Weight loss in the presence of normal or decreased appetite is seen in malignancy,
infection, inflammatory disease, malabsorption and depression.

Ask for symptoms accompanying the weight loss


Examples are: symptoms of diabetes mellitus; bulky stools in malabsorption;
symptoms of thyrotoxicosis; cough in tuberculosis.

Past history of relevance


e.g., gastrointestinal surgery, cancer surgery.

Family history of chronic diseases


Ask for diabetes mellitus, thyroid disease and malignancy.

174

Psychiatric history
Ask for symptoms suggestive of depression or anxiety.

Social history
Changes in socio-economic status or life events may be the underlying cause.
Physical Examination

Assessment of degree of weight loss


- Clinical signs to confirm weight loss e.g. loose clothing, loose skin folds.
- Accurate weight determination.

Systems check for signs of diseases


- fever, tachycardia, pallor, ecchymoses, jaundice, signs of hyperthyroidism,
hepatocellular failure.
- head and neck for glossitis, stomatitis, poor dentition, goitre, lymphadenopathy
- lungs and heart for crepitations, consolidation, effusion, cardiomegaly
and murmurs.
- abdomen for distension, tenderness, masses and ascites.
- rectum for masses, tenderness and appearance of the stool.
- neurological examination.

Examination of mental state for depression and dementia


Laboratory Investigations
Laboratory investigations should be selective, based on clues obtained from history and
physical examination.

Basic investigations
-

complete blood count and PBF.


BSR.
selected blood chemistry (calcium, albumin, protein, transaminases and blood urea).
urinalysis and culture if indicated.
chest X - ray.
This may show a pertinent abnormality like a mass, infiltrate, heart failure or
ymphadenopathy in up to 41% in one study.

Further investigations where indicated


- stools for inspection and tests for malabsorption.
- blood sugar.
- thyroid function tests.

Search for occult carcinoma


One of the most difficult diagnostic issues encountered in the workup of weight loss
concerns the possibility of occult malignancy.
175

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

Investigations for occult malignancy may need to be very extensive, and should be
considered in the light of the likelihood of finding a cause and the chance that it will
be treatable. Unfortunately, by the time that weight loss has occurred, most gastrointestinal malignancies are rather advanced. When weight loss is the only symptom,
pancreatic carcinoma may still be resectable if no other symptoms have appeared.
If an initial assessment does not identify a course; careful follow-up rather than
undirected diagnostic tests is the optimum management of the patient.

MANAGEMENT
A patient with weight loss should be assessed clinically.
Patients with no significant history and found to be normal on physical examination
can be watched and followed up. The risk of serious disease is small.

INDICATIONS FOR REFERRAL


Severe unexplained weight loss where an organic cause is suspected, such
as malignancy.
Referral to a gastroenterologist for those with symptoms of malabsorption such as
bulky and foul stools.
Referral to a psychiatrist for those suspected to have anorexia nervosa.
Continued unexplained weight loss.
References
1. Reife CM. Involuntary weight loss. Med Clin N Am 1995 March;79;2:299-312.
2. Goroll AH. Evaluation of weight loss. in: Goroll et al (ed). Primary Care Medicine, 3rd ed. Philadelphia:
Lippincott, 1995:38-42.
3. Wise GR and Craig D. Evaluation of involuntary weight loss. Postgraduate Medicine, 1995 March;
95;4:143-150

CHAPTER 3

FEVER

DEFINITION
The average normal oral body temperature is 36.7C (range 36-37.4C), or 98F (range
96.8 - 99.3F). The normal rectal or vaginal temperature is 0.5C (1F) higher than the
oral temperature, and the normal axillary temperature is correspondingly lower. Rectal
temperature is more reliable than oral temperature in patients who are mouth breathers
or who are tachypneic.

RELEVANCE TO GENERAL PRACTICE


Fever is a symptom that is most readily recognised as a sign of illness and brings the
patient quickly to the doctor.
176

In the febrile patient with a short history and who is otherwise well, symptomatic
treatment based on a presumed viral etiology is usual. The doctor uses time as a
diagnostic tool. If the fever persists, or if the condition of the patient deteriorates, the
anxiety of both patient and doctor is then quickly aroused to further action.

CAUSES
Many infectious, inflammatory, neoplastic and hypersensitivity reactions may produce
fever. Fever can be broadly divided into short lived fever and prolonged fever.

SHORT LIVED FEVER


Most acute fevers encountered in the ambulatory care setting are of obvious cause and
due to upper respiratory or urinary traction infection. Viral illness, drug allergy (especially
to antibiotics), and connective tissue disease are other important causes. Symptoms
accompanying the fever, if present, help in the diagnosis. In such cases, the fever would
have settled within a few days.

PROLONGED FEVER
For most patients with a fever lasting one or two weeks, the underlying cause is soon
discovered or the patient recovers spontaneously. In the latter case, a protracted viral
illness is usually presumed to be the source of fever.
In a small group of patients, physical examination and the basic tests do not reveal the
cause of the protracted fever. Such a patient is considered to have a fever of unknown
origin (PUO) if there has been a daily elevation in oral temperature to 38C or higher for
three weeks without an identified cause. From studies utilising this definition, the various
causes and incidence of longstanding fevers can be assessed. These are shown in Table 1.
Table 1. Causes of Fever of unknown Origin
Infection (40%) Endocarditis; Abscesses; Zoonoses (Q fever, brucella, leptospira); Epstein-Barr
virus, cytomegalovirus; Neoplasia (20%); Hodgkins disease; Other lymphomas; Hypernephroma;
Leukemia and Hepatoma
Immune-mediated (20%) Systemic lupus erythromatosus; Polymyalgia rheumatica;
Polyarteritis nodosa; Stills disease and Idiopathic vasculitis
Miscellaneous (20%) No diagnosis; Drug fever (gold, phenytoin, penicillin) and
Granulomatous disease (sarcoid, Crohns)
Source: Whitby M. The febrile patient. Aust Fam Physician 1993 Oct;22:10:1753-1761

The following conditions are particularly important causes of fever in general practice,
either because they are relatively common, or because they are easily treated or because
they have particularly unfortunate consequences if the diagnosis is missed or delayed. In all
these conditions the essential step in the diagnosis is to have thought of the possibility.
INFECTIONS
Meningitis. This has to be considered in acute fevers if there is neck stiffness,
photophobic or vomiting. Lumbar puncture is necessary for confirmation. The prognosis
is made worse if bacterial meningitis is not promptly diagnosed.
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Urinary tract infection. At any age this is a common and easily missed cause of fever.
Perhaps it is particularly in young children that this condition commonly presents as a PUO,
often with vomiting and irritability, but without any obvious urinary symptoms. The
microscopic examination of the urine is an essential diagnostic procedure in the investigation
of a PUO and the earlier it is done the better. The presence of pus cells in a fresh spun
specimen establishes the diagnosis which can be confirmed by culture. Its diagnosis is often
made more difficult by antibiotic therapy given in the absence of a diagnosis.
Hidden pus. This is often a cause of PUO. The three most likely sites are under the
diaphragm, in the pelvis, or round the kidney.
Subacute bacterial endocarditis. This is another cause of PUO. It may not be a
common disease but must be thought of. Increasingly it tends to occur in an older agegroup, to attack valves damaged by arteriosclerotic degeneration as well as rheumatic
fever, and to be a complication of abdominal or pelvic surgery or instrumentation of the
urinary tract, as well as dental work.
Septicaemia. This is a possibility that should always be in the doctor's mind; if it is
suspected, a blood culture is obligatory.
Pneumonia. Segmental pneumonia can cause fever with few symptoms or clear diagnostic
signs. In the elderly, particularly when they are ill and are lying in bed, pneumonia may be
hard to diagnose and the physical signs in the chest difficult to interpret.

Enteric fever (typhoid and paratyphoid).


In the early stages of the disease, there is fever without localising signs or symptoms.
The diagnosis is best made on a blood culture.
Gall-bladder infection. Cholecystitis, empyema of the gall-bladder and ascending
cholangitis can present as fever without any convincing local symptoms or signs. The
patient may be very ill. Blood cultures may be positive.
Diverticulitis. This is common in the elderly and may cause fever without any clear
localizing signs. Abscesses, either paracolic or pelvic, may occur.
Infectious diseases associated with travel. The ease of modern travel has made
certain diseases a real diagnostic possibility in any case of PUO. Specific enquiry must be
made about recent travel and to name the countries travelled to. One has to be aware of
conditions endemic to specific countries.
Malaria. The most dangerous condition to leave untreated in a traveller is malaria and
every doctor should be prepared to take a thick blood film for examination by the
laboratory in patients presenting with high fever in which malaria is a possibility. Enteric
fevers and hepatitis have also to be considered.
Viral diseases. There is a group of viral diseases, or diseases of possible viral etiology
which may present as an obscure fever.
178

Infective hepatitis. This can present with a fever which may last for four or five days
before jaundice becomes clinically evident. Anorexia and nausea are likely to be prominent
symptoms. Enlargement of the liver may be noticed before the jaundice appears.
Urobilinogen in the urine precedes the appearance of jaundice and of bile in the urine.
Infectious mononucleosis (glandular fever). This can present with prolonged fever.
Non-infectious diseases
Fever does not, of course, always mean infection and there are some relatively common
causes of fever from non-infectious diseases that should be in the doctor's mind. As a
general principle, the longer the fever persists, the less likely a diagnosis of infection
becomes. The more common causes of such fever are:
Malignant disease, including leukaemia and Hodgkin's disease. These can present
as fever of unknown origin for several weeks.
Auto-immune disorders. Auto-immune disorders such as systemic lupus
erythematosus, are rare but possible causes of prolonged fever. Rheumatoid arthritis
causes fever but the local joint signs are likely to make the diagnosis clear.
Miscellaneous Causes
Dehydration. Dehydration can cause fever. It is particularly important to think of this
possibility in the elderly and in the infant.
Drugs. Drugs must always be suspected as a possible cause of fever. Even drugs taken
for long periods without any ill-effect can still cause fever unexpectedly, e.g.,
sulphonamides. Self- prescribed drugs as well as those given by doctors may be the cause
of fever. Careful enquiry must be made about all forms of medication.
Venous thrombosis. Venous thrombosis may cause fever without any dramatic local
symptoms. Examination of the calves should be a routine in the physical examination of
patients with fever, but it should be remembered that thrombosis may affect veins not
accessible to external physical examination.

WORKUP
The acutely febrile patient presents a common but demanding problem in differential
diagnosis. In most cases, a careful history and physical examination will reveal the
diagnostic clues, so that laboratory studies can be used selectively.
The evaluation of persistent fever can be more demanding. The initial office evaluation should
help determine the proper pace of diagnostic testing and the need for therapeutic intervention.
If the patient is a compromised host, or if he is acutely ill and toxic, several immediate
diagnostic studies are needed such as blood counts and blood cultures to confirm an
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infective cause and treatment may even be required such as antibiotics given empirically
before all the results are available. Hospitalisation is usually necessary in such cases.
If the patient is not toxic and clinically stable, the workup can be less rushed. The
diagnostic use of time is an essential problem-solving method for the general practitioner.
Certain safeguards, however, are required.
The patient must understand that the doctor needs to know if the illness changes in a
significant way or if his general condition deteriorates unexpectedly. Patients do
sometimes conclude that because no treatment has been given the doctor considers
the illness insignificant. Developments of importance either for diagnosis or
management may then not be communicated to the doctor. The patient should
understand what is happening, when the doctor is going to see him again, and under
what circumstances he should seek advice before that time.
The doctor must be available so that it is possible for his patient to find him in case of
unexpected or worrying developments, or, if this is impossible, the patient must have
clear instructions about whom to contact.
In the modern organization of general practice it often happens that the patient who
calls unexpectedly has to be seen by another doctor. This makes it important that the
clinical record should make clear the diagnostic and management plans of the original
doctor so that any other person who has to take over responsibility for the patient can
understand them, and integrate his own actions in line with them. For instance, if the
presence of fever and a heart murmur in an elderly patient makes the original doctor
think that he should exclude the possibility of bacterial endocarditis, this should be
clearly stated in the notes. If not, a second doctor called in unexpectedly is quite likely
to prescribe an antibiotic without perhaps considering that a blood culture might
be required.
History
Duration and progression of fever, accompanying symptoms, chills and rigors if any,
recent travel, similar cases at home, drugs taken so far, and the number of other doctors
consulted should be asked.
Physical Examination
Where the site of infection is obvious e.g., a URTI or UTI, a selective examination
may suffice.
For the rest, a more extensive examination of the chest, abdomen, CNS and neck
stiffness will be needed noting in particular, if any skin rash is present.
INVESTIGATIONS
If the history and physical examination provide strong indications of an infectious process,
laboratory studies can be used selectively to confirm or refute the clinical diagnosis.
180

Initial investigations may not be necessary if the cause is obvious e.g., a URTI.
However, if pneumonia is a possibility then a chest X-ray and complete blood count
would be necessary.
Urine FEME, blood film for malaria parasite may be indicated based on the history.
In other patients, more extensive tests are needed to establish the diagnosis when the
cause of fever remains unknown. Although such studies must be individualised, the
approach to diagnosis would include the following:
- complete blood count, differential total white and sedimentation rate.
- urinalysis. Isolated hematuria may be a clue to underlying glomerular disease or
urinary tract malignancy.
- chest X-ray may detect infiltrates, effusions or masses even in the absence of
abnormalities on physical examination; a KUB and upright abdominal films can
disclose air-fluid levels in the bowel; ultrasound or CAT study may be needed if
there is a suspicion of a mass lesion, such as an abscess or a tumour.
- blood chemistry: liver function tests are useful in helping to define obscure sources
of fever. For example, transaminase elevation suggests hepatitis, and isolated rises
in alkaline phosphatase point to infiltration of the liver.
- blood cultures: if the patient has a heart murmur or a prosthetic heart valve or
appears seriously ill.
- serological tests: Widal and Weil Felix tests may help to confirm typhoid fever.

MANAGEMENT
Initial Routine Management
- symptomatic relief of fever.
- antibiotics if bacterial infection is thought likely.
- advice on fluid intake.
- advise further action to report back if fever does not settle in a day or two or there
are new developments e.g., rash, patient becomes more ill.
- ill patients are referred for admission.
Prevention of Complications
The complications of fever likely to be seen in general practice are dehydration and febrile
convulsions in childhood, and confusional states in the elderly. Old people also become
easily dehydrated when febrile and ill.
Dehydration in children occurs more quickly than in adults and children may fail to
drink when ill. Their parents need clear instructions about maintaining an adequate
fluid intake.
In the elderly, fever, dehydration and confusion are interrelated problems. Confusion
results in failure to drink and dehydration increases the confusion. It is just not enough to
leave a jug of water beside the bed. At least 1 1/2 litres of urine should be passed daily
and this requires a fluid intake of 2 to 3 litres. If doubt exists a regular routine fluid intake
should be organised and the intake recorded.
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Febrile convulsions deserve a special word. They occur chiefly between the ages of 1 and
3 years. There is often a family history. The most important principle in the management
of febrile convulsions is control of the temperature. The parents must be taught to do this
with confidence.
For the patient having the first febrile fit, admission for observation and investigation will
be needed. In a patient with a known history of febrile fits, a single febrile convulsion is
not a reason for admission to hospital but, if the fits continue or recur, or if there is any
clinical suspicion of meningitis, the child must be in hospital, since a lumbar puncture is
the only certain way to exclude meningitis.
Subsequent Management
The initial wait-and-see diagnostic period where the presumptive diagnosis is a viral
infection commonly lasts from two to five days. During that time it is useful to have in
mind the expected times for the appearance of the rashes of specific fevers.
Chickenpox appears on the first day, rubella on the second or third, and measles on the
fourth. If by the end of the fifth day no rash has appeared, measles can usually be
excluded. Most viral illnesses will have run their course by that time.
Beyond this period, both doctors and patients begin to feel that something more must be
done. It is often not until then that the doctor feels obliged to treat the situation more
seriously and the diagnostic label tends to change from a presumed viral illness to pyrexia
of uncertain origin. This is not in fact a common situation in general practice but it is a
worrying one for the general practitioner, and an important one for the patient.

INDICATIONS FOR REFERRAL


The ill patient.
Clinically diagnosed serious conditions: meningitis, pneumonia, cholecystitis, to name
a few.
The patient whose fever persists beyond a week and the cause is still uncertain.
References
1. Whitby M. The febrile patient. Aust Fam Physician 1993 Oct;22:10:1753-1761.
2. Simon HB. Evaluation of fever. in: Goroll et al. Primary Care Medicine. 3rd ed. Philadelphia: Lippincott; 1995;
48-53.

182

CHAPTER 4

DYSPEPSIA

DEFINITION
Dyspepsia is defined as upper abdominal discomfort which could have various combinations of nausea, vomiting, heartburn and epigastric fullness.

RELEVANCE TO GENERAL PRACTICE


Dyspepsia is a common presenting complaint in general practice.
The majority of patients who complain of dyspepsia do not have serious disease and
will respond to symptomatic treatment.
Vigilance is needed to pick out the alarm features of serious disease in the minority
of patients.

CAUSES
The causes of dyspepsia are shown in Table 1.
Table 1. Causes of Dyspepsia
Common causes simple dietary indiscretion; non-ulcer dyspepsia and gastric erosions due to drugs
Less common causes peptic ulcer and gastro-esophageal reflux oesophagitis
Important not to miss Carcinoma of stomach and Ischaemic heart disease.

Simple Dietary Indiscretion. These are acute episodes of epigastric distress due to
excessive dietary or alcohol intake. They respond to symptomatic treatment.
Non-Ulcer Dyspepsia
A diagnosis of non-ulcer dyspepsia is made if on endoscopy there is no focal lesion. It can
present in one of the following ways:
Gastro-esophageal reflux-like dyspepsia heartburn, burning epigastric pain
or regurgitation.
Dysmotility-like dyspepsia this overlaps with irritable bowel syndrome (IBS) and is
associated with flatulence, bloatedness, distension, nausea, early satiety.
Ulcer-like dyspepsia well-localised epigastric pain, nocturnal in nature and relieved
by antacids.
Aerophagia repetitive bulging or bloating. Repeat by swallows and gulping. It is
most frequently postprandial and may be related to stress.
Idiopathic dyspepsia no specific features. Anxiety neurosis with increase or decrease
acid secretions resulting in anorexia and fullness of abdomen or sensation of
"bloated feeling".

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Gastric Erosions Due to Drugs. NSAIDs cause acute gastric and duodenal damage
in 30% users. It should be remembered as a possible cause.
Chronic Peptic Ulceration. Approximately 20% of patients with dyspepsia
presenting in general practice have a chronic peptic ulcer. The three major causes are
Helicobacter pylori gastritis, NSAIDs and the rare Zollinger-Ellison syndrome. Helicobacter
pylori infection is confirmed by endoscopic gastric biopsy.
Gastro-Esophageal Reflux. Reflux of gastric contents into the esophagus is very
common in the general population. A diagnosis can be made on the basis of typical
symptom of heartburn.
Gastric Cancer. Advanced cancer, which is not curable by resection, causes dyspepsia as
well as anorexia and weight loss. Early gastric cancer may cause vague abdominal
symptoms. Gastric cancer should be considered in any patient over the age of 45 years
who presents with a history of dyspepsia for the first time.
Ischaemic Heart Disease. Ischaemic heart disease can masquerade as a dyspepsia. A
high index of suspicion in an elderly patient is required.

WORKUP
History
Ask for:
- dietary cause.
- alarm features: malaise, loss of weight and appetite suggest cancer of stomach.
- number of recurrences and the past treatment given may support diagnosis of
peptic ulcer disease.
- drug history especially NSAIDs for arthritic complaints.
Physical Examination
This should be done systematically.
- General: anaemia, recent weight loss suggest an organic cause.
- Abdominal examination: mass, supraclavicular node.
- Other systems: cardiovascular disease, lung disease.
Investigations
Taking a specific history will determine if immediate testing is warranted. Most cases of
dyspeptic symptoms are relieved by symptomatic treatment.
Baseline investigations - This depends on the diagnosis, e.g. an ECG is needed if one
suspects the dyspepsia to be of cardiac origin. A chest X-ray would be useful to
provide baseline information.

184

Barium studies (including swallow and meal) or gastroscopy - either can be used
to exclude a gastric cancer. The advantage of the latter is the ability to a biopsy to
be taken.
Should all Dyspeptic Patients be Investigated?
Definitely necessary (high-risk)
- > 45 years with recent onset of dyspeptic complaints, history of gastrointestinal bleed.
- anorexia.
- weight loss.
- non-responders to treatment in younger patients:
- no improvement after 7-10 days of symptomatic treatment.
- no resolution of symptoms after 4-6 weeks of H2 blocker therapy.
- frequent relapses i.e. more than 3 attacks in a year.
- obviously unwell.
- anaemia.
Unnecessary to investigate at first consultation (low risk)
- young < 45 years.
- supporting history of overeating, alcoholic intake.
- presence of family/social problems.
- previous negative investigation.
- long history with preservation of good health.

MANAGEMENT
Low-risk Group/First Presentation
The initial treatment is symptomatic if no serious disease is found or suspected:
Antacids for pain, metoclopamide for dysmotility - like symptoms and mild
tranquilisers if stress is a factor.
Dietary advice - bland food, avoidance of alcohol and cigarettes.
Counselling and advice on life's stresses and family problems where indicated.
Stop/reduce dose of ulcerogenic drugs e.g., NSAIDs.
High-Risk Group/Recurrent Episodes (>3 times a year)
If patient has never investigated before:
- refer for investigations (endoscopy or barium meal).
- meanwhile give antacids only, do not give H2 blockers.
If a patient has been previously investigated fully and a diagnosis made (e.g. functional
dyspepsia, oesophagitis), then the patient should be considered to have a relapse of
the condition and treated appropriately.

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Chronic Peptic Ulcer


- If Helicobacter pylori is present, a two weeks course of omeprazole 20mg 12 hourly,
amoxicillin 500mg 6 hourly and metronidazole 400mg is warranted.
- Follow-up of H pylori treated ulcers is not routine to confirm cure of the infection,
unless the ulcer has previously bled or perforated.
- Follow-up of infection status requires either an endoscopic biopsy or the non-invasive
urea breath test rather than serology. The Urea Breath Test is probably the best way to
assess eradication. It is important to wait at least 4 weeks after completion of
eradication therapies as there may be a transient decrease in bacteria numbers
without full clearance.
NSAID Ulcers
- Ulceration due to NSAIDs should be treated with an anti-ulcer drug e.g. cimetidine or
ranitidine and if at all possible, the NSAIDs should be stopped and the therapy given
for 8-12 weeks.
- Ulcers that are associated with both NSAIDs and H pylori should be treated as for H
pylori ulcers, and the NSAIDs should be stopped.
Non-ulcer Dyspepsia
- Investigations may need to be done to rule out organic disease and to provide a basis
for reassurance of the patient.
- Treat with antacids alone first.
- Add prokinetics according to presenting complaints.
- H2 blockers are probably of modest value only.
Drug Therapy

Antacids
-

Useful in both ulcer and non-ulcer dyspepsia.


Give 10-30 mls, four or more times per day, between meals and at bedtime.
Liquids more effective than solid preparations.
Compound proprietary preparations have no clear advantage over simpler
preparations.
- Antacids should not be taken at same time as other drugs because the absorption of
the latter may be impaired.
- Avoid high sodium preparations e.g. sodium bicarbonate mixtures or mist. magnesium
trisilicate in salt-restricted patients.

Prokinetic agents
- Examples are metoclopramide and domperidone.
- Short term use of metoclopramide in non-ulcer dyspepsia has been helpful.
Unfortunately, long term use is associated with tardive dyskinesia.

186

H2 blockers

- Has a place in ulcer therapy.


- Impaired metabolism caused by cimetidine and ranitidine of warfarin, theophylline,
phenytoin, carbamazepine, propranolol, nifedipine, imipramine, metronidazole will
result in raised serum levels of these drugs.
- Cimetidine and ranitidine decrease the absorption of ketoconazole due to elevation of
gastric pH.
- Magnesium and aluminium hydroxide antacids
reduce by 30-40 percent the bioavailability of cimetidine and ranitidine. Thus if an
antacid is used concurrently with an H2 blocker, the antacid should ideally be given at
least two hours either before or after the H2 blocker.

Indications for maintenance H2 blocker therapy

This is indicated under the following circumstances


- Peptic ulcer.
- history of complications e.g. bleeding, perforation, outlet obstruction.
- rapid relapse after previous treatment.
- frequent relapses (3 or more times a year).
- difficult to heal.
- elderly (> 65 years).
- intercurrent illness (where risk of bleed can jeopardise life).
- continued NSAID use.
- Zollinger-Ellison syndrome.

Hydrogen-potassium-ATPase inhibitor
- Omeprazole (Losec) is capable of almost completely eliminating gastric acid secretion.
It would be useful for treatment of refractory peptic ulcer disease at a dose
of 20mg/day.

INDICATIONS FOR REFERRAL


Initially, if organic disease is present or suspected:
- carcinoma stomach (based on age, anaemia, weight loss and anorexia)
- chronic peptic ulcer.
Patient requiring confirmation of non-ulcer dyspepsia by endoscopy
Patients request.
References
1. Tally NJ. Modern management of dyspepsia. Aust Fam Physician Jan 1996; 25:1:47-52.
2. Goroll AH, May LA & Mulley AG. Primary care medicine. Third ed. Philadelphia: Lippincott, 1995;431-2.
3. Kurup B. Dyspepsia and peptic ulcer. in:Ling SL. Handbook for primary care doctors. Singapore: MOH: 77-83.
4. Reynolds RPE. Diagnosis and managing non-ulcer dyspepsia. Can Fam. Physician. March 1992;38:541-545.
5. Dickenson RJ. Management of Non-Specific Dyspepsia. Update 1 August 1991;43:142-148.
6. Tally NJ. Drug treatment of functional dyspepsia. Scand J Gastroenterol Suppl 1991;182:47-60.
7. Feldman M and Burton ME. Histamine2 receptor antagonists. Two parts. New Engl J Med 1990;323:24:1672
1680 and New Engl J Med 1990; 323:24:1749-1755.

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CHAPTER 5

BREATHLESSNESS

DEFINITION
Breathlessness (dyspnea) may be defined as the sensation of being out of breath.
It implies difficult or uncomfortable breathing.

RELEVANCE TO GENERAL PRACTICE


Shortness of breath may be physiological or pathological. Accurate diagnosis depends
on a carefully taken history and clinical examination.
Acute shortness of breath requires prompt assessment and appropriate
emergency treatment.
Management of chronic breathlessness centres on management of the
underlying cause.

CAUSES
An approach to the causes of breathlessness is to classify them based on the mode of
onset. See Table 1.
Sudden Onset; Patient Previously not Short of Breath. Acute and severe
shortness of breath is a medical emergency and, although treatment directed to its relief
must be given with the least possible delay, it is still all-important to attempt to reach a
diagnosis of its cause.
Sudden Onset; Patient had Similar Attacks. The only two conditions which
commonly give rise to recurrent attacks of sudden shortness of breath are left ventricular
failure and bronchial asthma.
Insidious Onset; Within few days or weeks
Cardiac causes The causes under this group are congestive cardiac failure and other
cardiac causes of pulmonary venous congestion (mitral stenosis and mitral regurgitation).
Respiratory causes Respiratory causes of chronic dyspnoea are: chronic obstructive
pulmonary disease, pulmonary parenchymal disease, pulmonary hypertension, severe
kyphoscoliosis, large pleural effusion, and chronic asthma.
Severe chronic anaemia This causes breathlessness from tissue anoxia.
Psychological The cue may be the way patients describe their shortness of breath.
Often there is an admitted fear of lung disease which may have originated from
knowledge of a close acquaintance in whom a serious lung disease has recently been
diagnosed or has caused death.

188

Table 1. Causes of Breathlessness


Sudden onset; patient previously not short of breath

Cardiovascular acute heart failure e.g. AMI.

Severe respiratory infections pneumonia; acute epiglottitis (children) and acute


bronchiolitis (children).

Respiratory disorders inhaled foreign body, upper airways obstruction, pneumothorax


and atelectasis.

Acute anaphylaxis.

Metabolic acidosis e.g. diabetic ketosis.

Psychogenic disorders anxiety with hyperventilation and panic attack.


Sudden onset; patient had similar attacks acute left ventricular failure and bronchial asthma
Insidious onset; within few days or weeks Cardiac causes; Respiratory causes; Severe
chronic anaemia and Psychological

WORKUP
History
The most difficult task in the evaluation of acute dyspnoea is differentiating dyspnoea
due to cardiac disease from that resulting from pulmonary pathology. Both etiologies
share a number of clinical features. In general, a past history dominated by chronic
cough, sputum production, recurrent respiratory functions, occupational exposure, or
heavy smoking points more to a lung rather than to a cardiac disease.
Dyspnoea that is a manifestation of a chronic anxiety state may superficially mimic
cardiopulmonary disease and cause some confusion. Onset at rest in conjunction with
a sense of chest tightness, suffocation, or inability to take in air are characteristic
features of the history.
It is helpful to define as precisely as possible the degree of activity that precipitates the
sensation of dispense, in order to estimate the severity of disease, determine the
extent of disability, and detect changes over time. One means of achieving these
objectives is to relate symptoms to the patient's daily activities and interpret the degree
of restriction in terms of the expected endurance of a patient of similar age.
The occupational history is particularly important, as the relationships between
exposures and lung disease are becoming evident.
Physical Examination
General examination fever, anaemia, tachypnoea, tachycardia, respiratory efforts,
pedal edema and phlebitis.
Respiratory system air flow obstruction, percussion note, breath sounds.
Cardiac examination raised JVP, third heart sound, cardiac murmurs, and carotid
pulse abnormalities. It should be recognised that many of the signs of right sided
failure may be a consequence of longstanding pulmonary disease and therefore are
not specific for a cardiac pathology.
Abdomen ascites, and hepatojugular reflux.
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MANAGEMENT
Acute Breathlessness
This should be managed as an emergency.
Foreign body - acute onset with stridor should immediately suggest its site and cause.
A history of having swallowed a foreign body is likely to be elicited. An attempt should
be made to dislodge it by the finger or by tipping the patient upside down and
vigorously thumping his back. If these measures fail, a tracheotomy must be
undertaken as a life-saving emergency.
Acute left ventricular failure and status asthmaticus - if the differential diagnosis is in
doubt, intravenous aminophylline and a diuretic such as frusemide, are safe to give in
either condition. The patient should be admitted after emergency treatment.
Croup - in a young child, the presence of cyanosis, restlessness or exhaustion requires
urgent hospitalisation.
Acute asthma - nebuliser treatment with salbutamol has replaced the need for
subcutaneous adrenaline. Re-examination for improvement is done after such
treatment. If relieved, bronchodilator therapy, and antibiotics with adequate
explanation of the need for continuing treatment and follow-up follows.
Chronic Breathlessness
Treatment depends on the underlying cause which may be established after a careful
history examination and appropriate investigations, including chest x-rays and lung
function tests.
Anxiety Induced Breathlessness
The neurotic patient with anxiety-induced dyspnoea often benefits from having a chest
film and simple pulmonary function tests; the confirmation of a well-functioning
respiratory system may provide some reassurance and lessen concern over bodily
symptoms. At times, a walk with the patient up and down a few flights of stairs is just as
convincing for both the physician and patient. One must however, remember that the
patient with Guillain Barre syndrome with respiratory muscle paralysis may be misdiagnosed as anxiety induced breathlessness.

INDICATIONS FOR REFERRAL


Bronchial asthma - cyanosis, patient exhaustion, a quiet chest, marked tachycardia,
pulsus paradoxus, obvious use of accessory muscles of respiration, failure to respond
to full non-steroidal therapy, and subjective report of severe difficulty in breathing.
Referral for further workup in the patient with insidious onset of breathlessness may
be needed.
References
1. Goroll AH. Evaluation of Chronic Dyspnoea. in:Goroll et al. Primary Care Medicine, 3rd ed., Philadelphia:
Lippincott, 1995:227-231.
2. Murtagh J. Accident and emergency medicine Unit 6. Acute dyspnoea. Aust Fam Physician 1995 April;
24;4:663-669.

190

CHAPTER 6

COUGH

RELEVANCE TO GENERAL PRACTICE


Cough is the commonest single symptom presented to the general practitioner.
Cough in general practice can mean a problem that is acute and serious, non-acute
but serious, acute and self-limiting or a persistent or recurring disease. It could be also
be a ticket of entry for another problem.
Cough can be grouped into acute or chronic. Just like the acute cough, the
chronic cough can have etiologies that range from trivial conditions to lifethreatening illnesses.

CAUSES
Cough is a reflex act occurring in response to irritation of the lining of the respiratory
tract. There are several ways that causes of cough can be classified. The traditional
approach to classification by pathological process used in the hospital setting is also
useful Infections underlie most of the cough and cold seen in general practice. The majority of
these are viral. Most viruses are associated with short-lived illnesses but a number are
associated with bacterial superinfection, especially in patients with asthma or chronic
bronchitis, and this must not be overlooked in prolonged or recurrent episodes of cough. The
respiratory syncytial virus (RSV) is a common cause of more severe respiratory illness in children
as is influenza A virus in adults, and persisting cough during epidemics of these infections
requires careful reassessment. Occasionally, the causal agent may be mycoplasma or fungal.
Coliform and staphylococcal infections are normally found in debilitated patients or in
patients with bronchiectasis or recent hospital infection.
Physical and Chemical. The effect of cold and of smoke (especially from tobacco) in
aggravating, prolonging or causing cough is well known.
Cardiac Failure. Particularly in the elderly, a persistent dry cough may be found in the early
stages of heart failure. Although confirmatory physical signs may be absent, the response to
diuretics. The prompt relief from a short course of diuretics confirms the diagnosis.
Allergic. Cough, in particular night cough, may occur in patients with an allergic
tendency with or without asthma.
Medications. Several medications can cause an acute, disruptive cough. The
angiotensin-converting enzyme (ACE) inhibitors cause a dry, hacking cough in more than
15% of patients taking these medications, possibly by stimulating C fibres in the airways
and activating the cough reflex arc. After discontinuation of the causative drug, the
cough usually resolves within 1 to 14 days. Beta blockers can cause cough as a result of
drug induced bronchospasm. Inhaled medications, such as beta agonists, disodium
cromoglycate (Intal) and corticosteroids have also been found to sometimes cause a dry
hacking cough, apparently by local irritation.

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Psychological. Psychological or social problems may present as a habit cough as a form


of nervous tic.
Neoplastic. Low in the order of frequency but high in the list of fatal causes of cough is
bronchial carcinoma.
Other Causes. Inhaled foreign body should also be thought of.

WORKUP
History
The first priority is to determine the seriousness and time scale of the illness. The
possibility that the presentation of the symptom is an excuse to discuss a psychological
issue exists (ticket of entry) but will not be developed in detail here.
There is widespread agreement that a brief history and carrying out a chest examination
is normally sufficient. The taking of an extensive history and the carrying out of a more
complete respiratory or other general examination are usually restricted to patients who
are very young, are looking ill, or are failing to make the normal progress to recovery
which would be expected. Clearly patients with coexisting symptoms suggesting greater
probability of serious disease (e.g., hemoptysis or weight loss) will also be handled in a
manner different from the normal, including the use of specialised investigations.
Acute serious disease. The history may indicate a specific diagnosis. In acute cough with
associated symptoms such as fever, hoarseness of voice and nasal catarrh, the diagnosis is
not difficult. Cough associated with generalised wheezing may be produced by
bronchospasm. Illnesses in this group are usually associated with restlessness and distress
physical and emotional and signs of fatigue.
Non-acute serious disease. Non-acute serious illness is suggested by the continuation of
cough beyond the normal natural history of acute treated bacterial or viral illness in the
absence of a history suggesting obstructive or allergic respiratory disease.
Acute self-limiting disease. Acute self-limiting illness is characterized by a history
compatible with an acute infective process (coryza, influenza) and the absence of the
general signs of serious illness. The patient may have the headache, myalgia and malaise
of the acute underlying process or may have passed from that early stage to one in which
cough is the only significant complaint. Here the history taking normally aims to identify
any tendency to chest trouble (asthma and chronic bronchitis in particular) and the nature
and colour of any sputum being produced. Chest examination will allow exclusion of
signs of localized infection but the management decision is usually established on the
basis of the history alone. Mothers expect their children's chests to be examined and, if
for no other reason, this is a wise policy. The elderly often barricaded in by layers of
clothing may seem happier not to be examined but the frequency with which basal
crepitations are recognized justifies overruling this wish.

192

Persisting or relapsing illness. Among these, particular mention should be made of


three common 'coughing syndromes': namely night cough in children, often associated
with the catarrhal child syndrome; 'whooping-cough', again usually a childhood
complaint; the 'smoker's cough' with its inescapable and often unnoticed progress to
chronic bronchitis.
The child with persistent or recurrent episodes of cough, worse at night, is a common
cause of anxiety, especially to young parents. The child is often at the stage of attending
school or play-group for the first time and may have a past history of croup or eczema. A
family history of allergic respiratory illness may coexist. The common pattern is one of
recurrent bouts of acute wheezy respiratory infections interspersed by periods of
comparative health often, however, including nights interrupted by persisting dry cough.
The tendency for the child to be well and free of abnormal signs when seen by the doctor
may create the unfair impression of fussing parents. Careful history taking will identify the
syndrome, and the possible additional precipitating causes of animal or plant allergy may
be identified on specific questioning or a home visit.
Physical Examination
A selective examination of the upper respiratory tract, cervical lymph nodes and the
lungs, (not forgetting to note down the temperature and the pulse), is usually sufficient in
cases of upper respiratory tract infection causing cough.
In cases where the history indicates that the cause may be more complex, a more
thorough examination is warranted. Acute serious illness is normally suggested by
breathlessness, complaint of chest pain or the general condition of the patient. The
presence of cyanosis or ashen pallor is more worrying than the flushing caused by fever.
The absence of rhonchi with decreased air entry in a breathless patient indicates a more
severe form of airway obstruction than when rhonchi are heard.
Carious teeth, infected gums, tonsillar disease or sinusitis are often associated with
bronchiectasis and lung abscess. An inspiratory stridor may be due to upper airway
obstruction from various causes. One should look out for scars of previous surgery e.g.
tracheostomy, thoracotomy. Localised inspiratory and expiratory wheeze may indicate a
major airway obstructive lesion. Localised areas of dullness on percussion of the chest
may indicate consolidation, pleural effusion or atelectasis. Finally, non-acute serious
diseases may not have much definitive physical signs.
Investigations
Investigations are not indicated in cases of self-limiting, acute cough, unless one wants to
determine the aetiology for management purposes, e.g. in streptococcal infections.
Chronic cough should be thoroughly investigated. Some of the investigations can be
initiated by the general practitioner.
Sputum examination. Sputum examination in cases of productive cough may yield
much information as to the aetiological cause. Culture may be necessary.

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Radiology. The chest X-ray is essential in the workup of any patient with chronic cough.
Two views may be necessary to give a better anatomical assessment. Oblique views,
tomograms and bronchography may occasionally be needed.
Pulmonary function tests. Pulmonary function tests may be useful in diagnosing early or
mild bronchial asthma in patients who present with chronic cough as the sole symptom.
Bronchoscopy. Bronchoscopy should be considered in any patient in whom the cause of
a chronic cough is not clear.

MANAGEMENT
Symptomatic treatment with or without antibiotics as the case may be is usually
sufficient in patients with acute cough.
Patient education and explanation are necessary in patients with recurrent cough due
to bronchial asthma.
Management of chronic cough will depend on the cause.

INDICATIONS FOR REFERRAL


In acute severe cough associated with symptoms such as dyspnoea and cyanosis,
in-patient management may be necessary.
Referral may be needed to investigate a prolonged cough.
References
1. Howie JGR, The Patient Complaining of Cough, in: Practice - a Handbook of Primary Medical Care. London:
Kluwer, 1984.
2. Braunwald E et al, Harrison's Principles of Internal Medicine, 11th Edition, New York: McGraw-Hill, 1987.
3. Zervanos NJ. Acute disruptive cough. Postgraduate Medicine 1994 March; 95:4:153-168.

CHAPTER 7

SORE THROAT

RELEVANCE TO GENERAL PRACTICE


One of the most common presenting symptoms in general practice.
The task of the primary care physician is to exclude serious causes of sore throat, have
a rational approach to the use of antibiotics and provide symptomatic and expectant
management for those not initially requiring antibiotics.

CAUSES
It has been estimated that about a third of the sorethroats are caused by bacterial
infections, a third by viral and other microorganisms and the remaining one third by noninfective causes.

194

BACTERIAL INFECTIONS
Group A Beta Hemolytic Streptococcus. This is isolated in 10-15% of throat
cultures done in adults. It is important to recognise, treat early and adequately such
infections with penicillin or erythromycin because this prevents the occurrence of acute
rheumatic fever, a non-suppurative complication. Unfortunately, only some 15% present
with the triad of fever, pharyngeal exudate and tender anterior cervical adenopathy so
diagnosis may not be so easy in the remaining 85% of cases.
Non-Group A Streptococcus. Rarely produces non-suppurative complications.
Haemophilus Influenzae. Haemophilus influenzae causes a painful sore throat and it
may be complicated by acute otitis media.
Corynaebacterium Diphtheriae. Almost never seen today because of early
immunisation. It must however be thought of in a patient not immunised against
diphtheria for some reason. The white adherent membrane over the tonsil is diagnostic.
Gonococci. This is uncommon in the local setting.

VIRAL CAUSES
A viral aetiology is found in 17-25% of adults and children over 2 years of age. The most
common viral causes are:
"Respiratory" Viruses Namely rhinovirus, influenza virus, parainfluenza virus,
adenovirus and others. Symptoms may include rhinitis, cough, fever, body aches and malaise.
Coxsackie and Herpes Simplex May cause painful ulcers in the oral mucosa and
oro-pharynx.
Epstein-Barr Virus Causes the infectious mononucleosis syndrome. The sorethroat
may be prolonged and constitutional upset prominent.

OTHER MICROORGANISMS
Chlamydia Trachomatis and Mycoplasma Pneumoniae. These are found to be quite
common, contrary to what is previously known.
Candida. Especially in immunocompromised individuals, and may be an early sign of
acquired immunodeficiency syndrome (AIDS).
Non-Infectious Causes. There are a number of such causes: referred pain; drying of
pharyngeal epithelium from mouth breathing; chemical irritation from smoking or other
toxic inhalation; and cancer of pharynx or tongue which may present as persistent sore
throat but this is uncommon.

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WORKUP
History
The presence of accompanying running nose suggests a viral cause. Knowledge of family
members being similarly affected and presence of an epidemic helps in the diagnosis. Use
of medications should be asked e.g., carbimazole.
Physical Examination
A general examination, examination of the oro-pharyngitis, anterior cervical nodes and
selectively other systems is required.

General examination
This includes the temperature, presence of jaundice (jaundice is present in 5-10% of
patients with infectious mononucleosis).

Examination of the oro-pharynx


Posterior mouth ulcers are typically caused by Coxsackie viruses whilst herpes simplex
ulcers are found only in the anterior parts of the mouth and lips. Candidiasis is
characterised by white, curdy exudates.
Acute epiglottitis should be suspected in patients with high fever, hoarseness of voice and
stridor in a child or adult. The enlarged and inflamed epiglottis may be visible on
inspection. Do not attempt to examine in detail lest a spasm of the oro-pharynx is
provoked. Though rare, it is important to pick up this condition as it is potentially lifethreatening. The patient should be admitted as an emergency.
Enlarged tonsils may be streptococcal or viral in origin. Drooling and pain on opening
mouth should lead the doctor to suspect the presence of peritonsillar or retropharyngeal
abscess; unilateral erythema of the soft palate accompanied by deviation of the uvula
confirms the diagnosis.
Palatine petechiae are sometimes found in patients with infectious mononucleosis.
Exudates are seen in streptococcal sore throat, infectious mononucleosis and diphtheria.
The latter is suspected if the tonsils and pharyngeal wall are covered by a gray
membranous exudate that bleeds easily on removal.

Systemic Examination
- Anterior cervical lymph nodes are usually found in patients with streptococcal
sore throat.
- Posterior cervical lymph nodes are enlarged in 90% of patients with infectious
mononucleosis in the first week.
- Generalised lymphadenopathy, hepatic tenderness and splenomegaly further indicate
infectious mononucleosis. Most children (up to 80%) with glandular fever will have
splenomegaly at some time during the illness, but this is found less commonly in
adults2.
196

Laboratory Investigations

Throat culture
This is not needed in every case. Patients with no clinical evidence of streptococcal
infection, and with typical signs and symptoms of viral upper respiratory tract infection,
do not warrant a throat culture. Culture is indicated in patients with special risk factors
for streptococcal disease.

Useful Investigations
TWDC. Atypical lymphocytes, if constituting >20% of total white cells, indicate infectious
mononucleosis.

Specific Investigations
- Anti-streptolysin O Titre. Lack of a four fold rise in titre of convalescing serum
indicates carrier status, estimated to comprise 20-30% of positive throat cultures.
- Rapid office diagnosis. Latex agglutination and ELISA techniques.
- Tests to confirm EBV. Paul-Bunnel or Monospot test.
Investigations to identify specific causative agents are done only if the illness is prolonged.

MANAGEMENT
Symptomatic Treatment
This is sufficient when a viral cause is suspected. Antipyretics, antihistamines, decongestants and lozenges are prescribed where indicated. Rest and sufficient fluid intake should
be stressed. Symptomatic treatment is also indicated in infectious mononucleosis, as no
definite antiviral therapy is as yet available.
Streptococcal Pharyngitis
Recommended treatment regimens are as follows:
Penicillin G, benzathine (Bacillin) 1.2 million units i/m in one single dose, or Penicillin V
250 mg q.i.d. for 10 days, or Erythromycin 250 mg q.i.d. for 10 days, in patients sensitive
to penicillin.
Other Infections
A trial of 10-day course of erythromycin or tetracycline 250 mg q.i.d. is probably justified
in prolonged sore throat, to eradicate any mycoplasma present. Treat other rarer forms of
pharyngitis according to the specific treatment regimens for the particular organism.

INDICATIONS FOR REFERRAL


Suppurative e.g. peritonsillar or retropharyngeal abscess
Life-threatening conditions e.g. acute epiglottis.
References
1. Kiselica D. Group A Beta-Hemolytic Streptococcal Pharyngitis: Current Clinical Concepts. Am Fam Physician,
1994 April;1147-1154.
2. Englund JA. The many faces of Epstein-Barr virus. Postgrad Med 1988;83:167-78.
3. Gorroll AH et al. Approach to the patient with pharyngitis. in:Primary Care Medicine, 2nd ed. 1987; 885-889.

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CHAPTER 8

CHEST PAIN

RELEVANCE TO GENERAL PRACTICE


Chest pain is taken seriously by the patient.
In general practice, it is common to find that chest pain is of muscular origin or
psychogenic origin.
The important tasks of the primary care physician are first to distinguish between
cardiac and non-cardiac pain, and then to decide whether this is serious or not serious,
whether urgent or not urgent.

CAUSES
Chest pain may be classified according to anatomical structures, e.g. chest wall pain,
visceral pain and referred pain. It is more useful in practice to classify the causes into acute
and chronic or intermittent chest pain and within each of these categories, serious and
non-serious causes of chest pain.
Acute Chest Pain. Serious causes of acute chest pain arise from (1) the heart, (2) the
lungs and (3) the aorta. As these are potentially life-threatening, and it is important that
the diagnosis be made early. Once these causes are excluded, there is less urgency in
diagnosis and management.
Serious Causes

Common
Ischaemic cardiac pain. There is increased likelihood of ischaemic cardiac pain in the
presence of cardiovascular risk factors. Pain of infarction is more severe; usually occurs at
rest; lasts longer than 20 minutes; is typically associated with sweating and vomiting; is not
relieved by glyceryl trinitrate tablets.
Gallstones and peptic ulcer. Gallstones and peptic ulcer may present with chest pain
and be mistaken for myocardial infarction. Hypotension, tachycardia and extrasystoles
may also occur if there is bleeding from the gastrointestinal tract. Melaena or
haemetemesis if present differentiates the diagnosis.

Less common
Pericardial pain. Common causes of pericardial pain are Viral young person, presence
of systemic symptoms of viral illness; and Myocardial infarction within a few hours, or
after 1-2 weeks (Dresslers syndrome). This should be suspected when pain is worse on
lying down, and patient prefers to sit up and lean forward. Pericardial rub is diagnostic.
Pneumothorax. Most cases of pneumothorax are idiopathic. Known causes of
pneumothorax are asthma, bullous emphysema and interstitial lung disease.
198

Pleural pain. Pleural pain can be a feature of bacterial pneumonias, viral infections and
connective tissue diseases. There may be associated with cough, haemoptysis and
dyspnoea. If a pleural rub is present, this will be diagnostic.

UNCOMMON
Rare causes include pulmonary embolism and dissecting aortic aneurysm. Patient is
usually ill and needs immediate referral.
Non-Serious Causes

Common
Reflux oesophagitis. This is commonly described as indigestion. It is related to eating,
exacerbated by bending down, relieved by antacids. Nocturnal pain may be experienced.
As its prevalence is 30-40 % of the population, it may coexist with other causes of chest
pain. It may also be relieved by nitroglycerin, further confusing it with angina.
Musculoskeletal pain. Musculoskeletal pain is common. It can be result of strain
involving muscles of the neck, shoulder, thorax; rib and sternal pain of various causes.
Such chest wall pain is usually superficial, localised, and can be reproduced or aggravated
by pressure applied to the affected area, or with movement.
Viral illnesses can cause intercostal myalgia. Tietzes syndrome an idiopathic
costochondritis is diagnosed by tenderness at a particular costochondral junction.
Psychogenic chest pain. Psychogenic causes may be due to anxiety, depression, or the
means to secondary gain, e.g. malingering, financial compensation, sympathy. Nature of
pain variable. Usually described as sharp, stabbing and intermittent. In hyperventilation
syndrome, the patient is usually a young female presenting with diaphoresis and acute
respiratory distress. Carpopedal spasm helps to confirm the diagnosis.

Less common
Oesophageal spasm. A motility disorder that is sometimes seen in diabetes
mellitus. Patient complains of severe chest pain on swallowing a large bolus of
food or cold drinks. This may be relieved by nitroglycerin, and may hence be
further confused with angina. Diagnosis by fluoroscopy during barium meal.
Neurovascular. Herpes zoster infection can cause chest wall pain (a radiculitis) before
the onset of the rash, which is diagnostic. Post-herpetic neuralgia may persist for weeks
after the acute episode. Degenerative changes in the spine, metastatic tumours to the
spine, can impinge on the dorsal nerve root and cause chest pain.
Chronic or intermittent chest pain. Chronic or intermittent chest pain may be due to
repeated attacks of acute pain, e.g. angina, reflux oesophagitis, musculoskeletal
problems. The term nonspecific chest pain is used to describe chest pain when ischaemic
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heart disease is unlikely and no other cause can be found. A middle-aged man may also
have non-specific chest pain. Distinguishing features are listed in Table 1.
Table 1. Differential Diagnosis of Chest Pain

Anginal pain
Described as a discomfort or ache

Occurs in the centre of chest. Radiation to


jaw and neck diagnostic. Commonly also
radiates to the arms, L > R, and to the back.

Nonspecific pain
Patient complains of pain, rather than
discomfort, stabbing in nature, lasting a
few seconds.
Pain radiates down left arm, but not to neck
or jaw.

Pain induced by exercise, and after a meal.


Pain induced by sexual inter-course.

Apparent relationship with exercise, but pain


usually comes on at the end of a busy day,
and not after exercise.

Pain improves with rest.

Pain not relieved by rest.

Relieved by sublingual nitrates within


seconds or within 2 minutes.

Patient often claims that nitrates are helpful,


but only after 20-30 minutes.

Adapted from Hampton J, The patient with chest pain and breathlessness. Medicine International 1989, 3:2723.

WORKUP
History
History taking should be directed towards confirming or disproving the serious causes of
chest pain. Cardiac pain is located in the front of the chest, mid or upper sternum
radiating to the left arm or both arms, round the chest or into the jaw. The duration is
rarely of more than 30 minutes, unless a coronary thrombosis has occurred. The words
used to describe it are: tight, heavy, constricting, crushing, numbing or burning.
Pneumothorax is a condition seen off and on in general practice. Pulmonary embolism is
uncommon. Pleurisy, mediastinitis and pneumomediastinum are rare but serious causes
of chest pain. The pain of pneumothorax is described as stabbing, sudden in onset,
localised; associated with dyspnoea, sometimes giddiness and fainting. Pulmonary
embolism is also associated with sudden onset chest pain and dyspnoea.
Dissecting aortic aneurysm usually causes excruciating pain radiating down the back.
The patient may be in shock or hemiplegic.
Past history, family history, a history of social habits, life style and current medications
need to be asked for.

200

Physical Examination
The physical examination further helps distinguish the serious from the not serious causes
of chest pain. It should be approached systematically.
General. Is the patient distressed, pale, sweating, dyspnoeic or tachypnoeic? Check the
vital signs. Abnormalities in any suggest an unstable, urgent condition. Palpate the
pulses. Unequal pulses may mean aortic dissection.
Examination of the Heart and Lungs. Murmurs, abnormal heart sounds, rhythm
abnormalities especially bradycardia, crepitations in the lungs and poor air entry all
indicate a pathological cause for the chest pain. Raised jugular venous pressure, the
presence of 3rd or 4th heart sounds, pericardial rub are other abnormal signs.
Pnuemothorax result in increased percussion resonance and diminished breath sounds on
the affected side.
Examination of the Other Systems. Examination of the musculoskeletal system
may point to the anatomical site of musculoskeletal chest pain. One should remember to
examine the breast and the abdomen. Examination of the patient's mental state is also
important if serious causes of chest pain are not suspected.
Investigations
The extent of initial investigations is guided by the urgency of the presenting problem.
If the patient is very ill, minimal investigations necessary are done in the physician's office
before urgent referral. If the patient's general condition is well, and especially if the cause
is still unclear after history and physical examination, then further investigations should
be done.

Electrocardiogram
In establishing a diagnosis of ischaemic cardiac pain, a resting ECG should be done to
detect presence of ischaemic changes.
- If ECG shows evidence of ischaemic heart disease / old infarction, it is not necessary to
proceed further.
- If ECG is normal, then a treadmill test is required.
The ECG is useful to diagnose the type of arrhythmia if one is suspected clinically.
An exercise ECG may be considered. A normal stress ECG reduces considerably the
chance that ischaemic heart disease is a cause of chest pain.
In pericarditis, the ECG is not very helpful unless ST segments are present.

Radiology/Echocardiography
A chest X-ray is a useful adjunct in the diagnosis of cardiac and pulmonary causes.
In may show a widened cardiac silhouette in pericardial effusion but this may not be
obvious. Chest X-ray may be normal, or show pleural thickening or effusion. Chest Xrays are diagnostic in pneumothorax.
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Radionuclide
angiocardiography,
coronary
arteriography,
lung
scans,
echocardiography may be helpful in pulmonary embolism. Echocardiography is helpful
in diagnosis of pericardial effusion.
Barium studies, X-ray cervical spine may need to be done if the suspected cause of
chest pain is outside the chest.
Laboratory Investigations
Biochemical cardiac markers are now avaliable for early diagnosis of ischoemic heart
disease causing chest pain. Troponins, CK-MB, and Myoglobin elevation will
be confirmatory.

MANAGEMENT
A decision is made on the likelihood of an acute, life-threatening conditions. If this is
not likely, symptomatic and expectant management is given; these are patients who
diagnosis of musculoskeletal chest pain is clear from history, examination with or without
simple investigations.
Where a psychogenic cause is clear, the physician should delve further into the family and
social background and enlist help from these quarters in the management of the patient
if necessary.

INDICATIONS FOR REFERRAL


In acute, life-threatening conditions, referral for hospital management should be made
urgently, after having stabilised the patient in whatever emergency measure available,
e.g. setting up an intravenous infusion.
Where diagnosis is in doubt, or where the investigative procedures are required, the
patient should be referred to the appropriate specialists for further management. The
threshold for referral is reduced in a patient with multiple risk factors.
Where the chest pain does not improve with symptomatic and expectant treatment or
becomes more often, a review and referral should be made.
Recurrent Chest Pain without Coronary Artery Disease
- Repeated evaluation may be worthwhile.
- If chest pain is stress-related, exploring cause/s of stress may be helpful.
- Angina in the presence of normal coronary angiogram may be due to coronary artery
spasm, and may respond to coronary vasodilators.
References
1. Rakel RE, Textbook of Family Practice, 4th Edition, Philadelphia: WB Saunders, 1990; 874-882
2. Hampton J. The patient with chest pain and breathlessness. Medicine International 1989;3:2720-5.
3. Lewis PS. How to manage chest pain. Update 1993;859-65.

202

CHAPTER 9

DIARRHOEA

DIARRHOEA IN ADULTS
RELEVANCE TO GENERAL PRACTICE
Diarrhoea is an affliction familiar to everyone. Most episodes are brief, self-limited and
well-tolerated without need for medical attention.
Diarrhoea being a self-limiting complaint, it is useful to find out why for this episode,
the patient needs to see the doctor.
Symptomatic treatment is often all that is necessary for acute diarrhoea. However, one
should be alert for the occasional serious cause.

WORKUP
History
Onset. It is important to establish whether the diarrhoea is an acute problem of a few
days duration or a chronic one spanning some time.
Timing. One should ask when the diarrhoea usually occurs. Diarrhoea occurring at night is
always pathological.
Nature of stools. Watery stools constitute diarrhoea whereas loosely formed stools do not
and may indicate a different pathology like irritable bowel syndrome. It is also important
to ask whether the stools are mucoid, blood stained or foul smelling and floating.
Travel. Recent travel overseas may be etiologically important.
Foods taken. Although it is often difficult to establish the source of the diarrhoea,
a history of the types of food taken within the last 24 hours may be helpful. Milk and
diary products can cause loose stools in the susceptible adult. If an epidemic of food
poisoning occurs, information on the type of food eaten and the place where it was
served will help the Ministry of Environment in its investigations.
Associated symptoms. Vomiting, nausea, dizziness, colicky abdominal pain, fever, thirst
indicate that a bacterial infective cause for the diarrhoea is likely.
Physical Examination
Assessing dehydration. One should look at the tongue and mucous membranes as well
as the turgor of the patient's skin. A dry tongue and mucous membrane with or without
a rapid pulse rate indicate that dehydration needs to be corrected.

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Abdomen. An examination of the abdomen for tenderness and bowel sounds is


warranted to reassure the patient that there is nothing more serious. A rectal examination
is indicated if bloody diarrhoea is present.
Other systems. If a systemic cause for the diarrhoea is suspected, a full examination
should be done.
Investigations
These are not necessary for the majority of mild acute diarrhoeas. Chronic cases will
require a workup or hospital referral.
Stool culture and smear for cysts and organisms are useful if giardiasis or amoebiasis
is suspected.
Endoscopy, barium enema or barium meal may be needed for the evaluation of a
chronic diarrhoea.
Other investigations: Thyroid function tests, glucose tolerance tests and other
endocrine tests may be necessary.

MANAGEMENT
The Adult Patient
Most acute cases need only symptomatic treatment. These are:
- Bed rest if diarrhoea is severe or frequent.
- Adequate fluid and electrolyte replacement.
- Drugs like kaolin, charcoal which have some absorptive properties may be prescribed.
- Anti-cholinergics like Lomotil or opiates like codeine phosphate may help to relieve the
symptoms if diarrhoea is severe.
- Antibiotics and Flagyl are rarely indicated unless the responsible organism is identified
as being bacterial or amoebic respectively.
- Anti-emetics may be useful if vomiting is severe.
Indications for Referral
Referrals may be indicated for the following :
- Severe cases which may be infectious or warranting IV fluid replacement.
- Chronic cases for diagnosis and treatment.
- Cases where the diagnosis is not clear.

DIARRHOEA IN INFANTS AND CHILDREN


RELEVANCE TO GENERAL PRACTICE
Diarrhoea in a child has to be attended to promptly as the patient is more prone to
suffer from dehydration and its consequences.
Parents may have their incorrect views of diarrhoea in their child; thus teething does
not cause diarrhoea, contrary to what is often believed by mothers.
Fully breast-fed babies may have loose stools. Their stools are explosive, contain curd
204

and may be bright green in colour. These babies should not be treated for diarrhoea.
Starvation stools should not be confused with diarrhoea.

COMMON CAUSES
Milk Formula and Improper Feeding
Infants vary widely in tolerance to quantity and quality of food. The contents of protein,
fat and carbohydrate affect the volume of stools. Formulas high in polyunsaturated fats
have looser stools than those on formula containing greater percentage of saturated fats.
Also if sugar content in formula is greater than 7.2% weight per volume, stools tend to
be soft and watery. With age the gut matures and tolerance to food content improves.
Breastfed babies may have frequent loose stools. This is normal.
Infections
Infection as a cause of diarrhoea is common. It may be enteral or parental. Rotavirus is the
commonest cause. If blood is associated with diarrhoea, Shigella or Salmonella should be
suspected. Cholera produces profuse rice water stools. Stool culture should be done if a
bacterial cause is suspected, such as dysentery, typhoid or cholera.

MANAGEMENT
Management begins with assessment of the severity of the diarrhoea and degree of
dehydration (see Table 32.1).
Children above Age of One Year

Mild diarrhoea (< 4 stools per day)


- Continue breastfeeding if child is breastfed.
- Establish cause of diarrhoea, e.g. overfeeding, dietary indiscretion, viral upper
respiratory tract infection, systemic infection and food allergy.
- Treat the underlying cause. If mild dehydration and child is able to retain fluids treat
as outpatient.

Moderate diarrhoea (4-10 stools per day)


- Off solid diet.
- Half strength milk.
- Oral rehydration fluids, e.g. rice-water or dextrose saline solution. Oral rehydration
from tablet (Servidrat): 1 tablet in 4 ounces of water, or commercially available
solutions (e.g. Oralyte, Paedialyte). Give 50 to 100 mls after each stool.

Severe diarrhoea (>10 stools per day)


- Off solids and off milk. Only Oral Rehydration Solution (ORS).
- If diarrhoea not better (consistency of stools not improved) after ORS for 2 days
change to soya formula.
- Must continue till at least 3 consecutive stools of normal frequency and consistency
before reverting back to milk formula.
- If diarrhoea recurs on restarting milk gradually, suspect lactose intolerance (usually
temporary). May need to continue on soy formula for a longer duration before
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attempting to switch back to milk.


- Refer to hospital if no improvement or symptoms deteriorate.

Infants
Mild diarrhoea. not more than 1 stool every 2 hours, give 10-15 ml/ kg/hour ORS until
diarrhoea stops (approximately 1 dissolved tablet of Servidrat for each liquid stool). If
breastfed, continue breastfeeding.
Moderate diarrhoea. > 1 liquid stool every 2 hours. Give 10-15 ml/ kg/hour ORS until
diarrhoea becomes mild (approximately 1 dissolved tablet every hour or as much as
patient will accept). If breastfed continue breastfeeding. Solutions should be given slowly,
in sips at short intervals to reduce vomiting and improve absorption.
Severe diarrhoea. refer to the hospital.
References
1. Richter JM. Evaluation and management of diarrhoea. in: Goroll et al. Primary Care Medicine, 3rd ed. Phil5adelphia: Lippincott, 1995: 357-368.
2. Goepp JG, Katz SA. Pral rehydration therapy. American Family Physician 1993;47:4: 843-848.
3. Haffezee IE. Nutritional manageent during acute infantile diarrhoea. Maternal and Child Health. June 1992:
175-179.
4. WHO. Treatment and prevention of dehydration in diarrhoeal diseases - a guide at primary care level. WHO:
Geneva, 1976.
5. Biloo AG. Infantile diarrhoea: management with oral rehydration. Medical Progress Feb 1986: 15-24.
6. Barnes G. The Child with diarrhoea. In: Robinson MJ, ed. Practical Paediatrics. Chruchhill Livingstone, 1990:
505-513.

206

207

Treat

6. DECIDE

Treat

Weight loss of 25-100g for


each kg of weight

Sunken (in infants)

Faster than normal

Pinch, goes back very slowly

Faster than normal

Dry

Sunken

Unwell, drowsy or irritable

Small amount, dark coloured

More than normal

Some

Moderate
4 liquid stools per day

Refer patient to hospital speedily

Fever more than 39C (102F)

Weight loss of more than 100g for each


kg of weight

Very sunken

Very fast, weak, or cannot be felt

Pinch, goes back quickly

Very fast and deep

Very dry

Very sleepy, floppy, unconscious,


having fits or seizures
Very dry and sunken

No urine for 6 hours

Unable to drink

Severe
More than 10 stools per
day, with or without blood
and/or mucus
Very frequent

References
1. Richter JM. Evaluation and management of diarrhoea. in: Goroll et al. Primary Care Medicine, 3rd ed. Philadelphia: Lippincott, 1995: 357-368.
2. Goepp JG, Katz SA. Oral rehydration therapy. American Family Physician 1993;47:4: 843-848.
3. Haffezee IE. Nutritional management during acute infantile diarrhoea. Maternal and Child Health. June 1992:175-179.
4. WHO. Treatment and prevention of dehydration in diarrhoeal diseases - a guide at primary care level. WHO: Geneva, 1976.
5. Biloo AG. Infantile diarrhoea: management with oral rehydration. Medical Progress Feb 1986:15-24.
6. Barnes G. The Child with diarrhoea. In: Robinson MJ, ed. Practical Paediatrics. Churchill Livingstone, 1990:505-513.

5. TAKE TEMPERATURE

Normal

FONTANELLE
No weight loss

Normal

PULSE

Normal

BREATHING
Pinch, goes back slowly

Wet

MOUTH and
TONGUE

SKIN

Normal

Normal

URINE

EYES

Normal

THIRST

Well, alert

None or small amount

VOMITING

CONDITION

Mild
Less than 4-10 liquid
stools per day

DIARRHOEA

4.WEIGHT

3.FEEL

2. LOOK

1. ASK

Table 1. How Severe is the Dehydration

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

CHAPTER 10

CONSTIPATION

DEFINITION
There is no uniform definition of constipation. To some it means movements that are too
infrequent or stools that are too hard. Others complain of incomplete or difficult
evacuation. Among normal people, bowel habits vary widely, and there are diverse
perceptions of what is normal. Population studies show that most normal people have
more than three bowel movements per week.

CONSTIPATION IN THE ADULT


RELEVANCE TO GENERAL PRACTICE
Constipation is a common symptom in general practice. It is among the most frequent
reasons for self-medication and is particularly troublesome in the elderly.
There is a need to clarify what the patient means by constipation and what is the
normal bowel habit for that patient.
The primary care doctor must be able to uncover any underlying pathology and to
provide symptomatic relief to those without a structural lesion.

CAUSES
The common causes of constipation in the adult are shown in Table 1.
Simple constipation due to inadequate fluid intake, dietary intake and inactivity is the
commonest cause seen in general practice.
In the sedentary adult, constipation is often compounded by a hectic schedule - repeated
failure to respond to nature's call and lack of regular bowel timing.
In the bedridden elderly, the inability to indicate bowel evacuation needs may lead to
faecal impaction. In extreme constipation, it may also result in faecal soiling and a
spurious diarrhoea.
Drugs are an important cause of constipation that may be overlooked, e.g. cough
mixtures containing opiates, antacids containing calcium and aluminium, anticholinergics and anti-depressants.
Specific medical conditions may also result in constipation. Depression and hypothyroidism are common examples.

208

Table 1. Causes of Constipation


General Poor fluid intake; Inadequate dietary fibrel Inconvenience
toilet access and Inactivity
Specific pathology Depression; Hypothyroidism; Abdominal tumour
large bowel cancer, external compression and Spinal cord compression
Drugs Opiates; Anticholinergics; Tricyclic antidepressants;
Phenothiazines, haloperidol; Antacids containing calcium or
aluminiumand Iron

WORKUP
History
The presence of associated symptoms is sought to define any underlying cause, which
may be serious.
Abdominal pain, recurring and colicky - suggests mechanical obstruction.
Peri-anal pain - suggests anal fissure or abscess.
Alternating diarrhoea and constipation, with or without blood in stools - suggest
colonic carcinoma.
Symptoms that alert the possibility of depression such as low mood, negative feelings
and fatigue.
Symptoms suggestive of hypothyroidism such as the observation of family members
that the patient shows a slowing of physical and mental activities, weight gain and
cold intolerance.
Physical Examination
A selective physical examination includes an observation of the general health of the
patient, mental state, abdominal examination for faecal masses and other masses,
abdominal distension and tenderness. Rectal examination is useful to detect peri-anal
conditions, faecal impaction, and also to obtain a sample of stools for inspection and
occult blood testing.
The hypothyroid patient has characteristic facies and delayed relaxation of deep
tendon reflexes.
Investigations
Investigations are unnecessary where a cause of constipation can be found. A barium
enema may be considered if a large bowel carcinoma is suspected.

MANAGEMENT
Simple Constipation
Attend to patient's concerns about constipation.
Advice to increase

209

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

- fluid intake.
- fibre intake e.g. at least 1-2 servings of vegetables for lunch and dinner; include
fruits in the diet if not already done.
Advice to increase physical activity.
Laxatives or suppositories as a temporary measure.
Faecal Impaction in the Bedridden Elderly
Manual evacuation followed by regular enemas and laxatives may be necessary.
Advice to increase fibre and fluid intake but bearing in mind the problems of eating in
the elderly. Fruits like bananas, papaya are suitable and the making purees of
vegetables will be necessary.

INDICATIONS FOR REFERRAL


Further assessment is indicated where a colonic carcinoma is suspected.

CONSTIPATION IN THE CHILD


RELEVANCE TO GENERAL PRACTICE
Breast-fed infants tend to have frequent loose stools, whereas bottle-fed infants tend
to have less frequent hard stools.
Some older Children may normally have a bowel movement as seldom as once or
twice a week.
Parents often worry about whether their childs bowel movements are normal.

CAUSES
The diet is the commonest cause: inadequate fluid and fibre intake; and excessively
concentrated formula milk in the younger child. The child fearful of defecation or crying
after defecation, and blood in stools point to the presence of a peri-anal fissure.

Serious Causes are Rare:


Hypothyroidism in a child may present as persistent constipation in the neonate.
Acute intestinal obstruction would present with associated abdominal pain or a
persistently crying baby.
Stubborn constipation (obstipation) with failure to thrive is present in Hirschsprung's
disease (very rare).

WORKUP
History
A detailed history is important. It should cover age of onset; precipitating events such as
diet changes, toilet-training problems, pain and bleeding with defeacation; abdominal
pain; bowel routine; behavioural problems; previous treatment including punitive measures; and medications for other reasons.
210

Physical Examination
An observation is made of the childs well-being and general health, growth and
development. Children with the rare serious causes like Hirschsprungs disease and
hypothyroidism frequently fail to thrive.
Abdominal palpation often reveals faecal masses. Peri-anal inspection may reveal
a fissure.

MANAGEMENT
For simple constipation:
Allay parental anxiety and concern about constipation and advice on bowel training
where necessary.
Advice about bottle feeding, increasing fluid and fibre intake e.g. water and fruit juices
for the older infant.
A laxative may be prescribed: Liquid paraffin (Agarol) or Microlax (sodium citrate and
sodium lauryl sulfoacetate).

INDICATIONS FOR REFERRAL


Referral is indicated for intestinal obstruction, anal fissure.
References
1. Goroll AH. Approach to the patient with constipation. in: Goroll et al. Primary Care Medicine, 3rd ed.
Philadelphia: Lippincott, 1995: 369-372.
2. Ebelt VJ. Constipation in childhood. Can Fam Physician 1992 September 38;2167-2174.

CHAPTER 11

VOMITING

RELEVANCE TO GENERAL PRACTICE


Vomiting is a relatively common presenting symptom in general practice and is twice
as common in children as in adults.
It is a non-specific symptom covering a wide range of possible causes which will be
identified only by piecing together other clinical features of the illness presented.

CAUSES
There are many possible causes of nausea and vomiting and it requires time, observation,
clinical experience and awareness to decide on the cause of the problem and the correct
management. Nausea and vomiting may result from local, central or general causes.

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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

Local Causes "Acute gastritis" (a useful label for the syndrome of vomiting abdominal
pain and malaise). This may be caused by an infective agent (e.g., viral) or some other
ingested gastric irritant (in particular, excessive alcohol consumption).
Central Causes Acute vertigo associated with nausea and vomiting (as in Meniere's
syndrome or acute labyrinthitis), motion sickness, migraine and rarer conditions like
vestibular neuronitis and tumours.
General Causes Reactions to drugs (e.g., digoxin and aspirin), uraemia, diabetic
ketoacidosis, and rarities like Addison's disease.

WORKUP
History
The history will give guidance to a likely diagnosis. Systematic enquiry should be made on
how the symptoms began and how long they have been present. Any nausea and/or
vomiting that goes on longer than three to four days, in the absence of pregnancy, must
raise possibilities of an underlying cause.
The timing of the vomiting may be noteworthy. Vomiting of relatively unaltered food
soon after a meal suggests an oesophageal obstruction. Pyloric stenosis is associated with
large offensive vomitus but with no evidence of bile. A gastro-colic fistula characteristically produces faeculent vomit.
The possibility of nausea and vomiting being part of a psychiatric disturbance is unlikely.
They are not features of an anxiety state or depression. In anorexia nervosa, although
refusal of and abstention from eating are the main symptoms there may also be
induced vomiting.
Examination
The many possible causes of vomiting make it necessary to carry out a full physical
examination of patients presenting with this symptom. Associated symptoms, however,
may direct particular attention to certain areas.

The child patient


The pyrexial infant or child who presents with vomiting will lead the practitioner to
look particularly for neck stiffness, signs of inflammation in the ears and throat, and
abdominal tenderness. In the presence of respiratory distress or cough he will try to
elicit signs of pulmonary infection. In the absence of any abnormalities in these
systems he will examine a mid-stream specimen of urine bacteriologically.
Very often vomiting in infancy is caused by mild gastroenteritis, when the practitioner's
main concern will be with eliciting signs of dehydration, in the absence of which rapid
recovery may be expected. A question about the frequency with which the infant is
wetting his nappies is a useful guide to impending dehydration.
212

In the apyrexial infant in the first few weeks of life pyloric stenosis may be suspected by
the presence of projectile vomiting and the doctor will then examine the infant during
a feed in order to identify a pyloric tumour.

The adult patient


The apyrexial adult presenting with vomiting associated with colicky abdominal pain
and possibly diarrhoea is almost certainly suffering from an acute dietary indiscretion
or gastro-intestinal infection. In these cases it is always wise to examine the abdomen
for localized tenderness to exclude appendicitis.
Nausea and vomiting associated with vertigo or headache should lead to a careful
neurological examination with particular examination of the optic fundi for signs of
raised intracranial pressure, eye movements for nystagmus, and for signs of ataxia in
the limbs. The ears should also be examined.
Nausea and vomiting of gradual onset will draw special attention to the gastrointestinal tract. The practitioner should look for signs of weight loss, abdominal
masses, visible peristalsis and abdominal distension and should carry out a
rectal examination.
In the young adult infective hepatitis often presents with nausea, and jaundice and
liver tenderness should be looked for.
In a young woman pregnancy is a common cause of nausea. This may be confirmed
by a urine pregnancy test.
Investigations
These will depend on the history and examination. In the vast majority of patients
presenting in general practice with vomiting they will add nothing to the diagnosis. In the
second half of life, patients presenting with nausea and vomiting of gradual onset will
require a full investigation to exclude organic bowel disease.

MANAGEMENT
In selecting the treatment for patients presenting with nausea and vomiting, the first
priority is to make a correct diagnosis.

The child patient


In the infant and child most cases will be due to feeding problems, gastro-intestinal
infections or infections of the upper respiratory tract. Feeding problems are most
commonly due to faulty technique rather than faults in the content of the feed. They
require time for diagnosis and not only must a careful history be taken, the mother
must be observed feeding her infant.

213

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

In treating acute gastro-intestinal infections in the child, (and adult), the most
important step is to stop all solid food and to ensure an adequate intake of simple
fluids, of which water is the most appropriate. In the infant dehydration may occur
rapidly. The mother should be instructed to give 30 to 120 ml of water every two
hours, the amount depending on the size of the infant. In most cases this will maintain
hydration and vomiting will cease.
Probably more harm than good comes from administering electrolyte solutions to
infants in general practice. As vomiting ceases, the child should be slowly weaned
back on to a normal diet. Should electrolyte replacement become necessary the child
should be admitted to hospital.
Acute infections in childhood other than gastro-intestinal should be treated with an
appropriate antibiotic. In the vomiting child this should normally be administered by
intramuscular injection. Parents in this situation should be particularly warned not to
use aspirin which may exacerbate the gastro-intestinal upset.

The adult patient


In the adult patient the most common cause of vomiting is a dietary indiscretion or
gastro-intestinal infection. Treatment consists of bed rest, withdrawal of all solid food
and adequate simple fluids. Very commonly diarrhoea follows the gastric symptoms
and may be relieved by a kaolin mixture or codeine phosphate, 30 mg four hourly,
Lomotil 2 tab tds or Imodium 2 tab tds.
Some of the specific causes of nausea and vomiting may be treated with more specific
remedies. Thus, vestibular disorders, including motion sickness, vestibular neuronitis
and Meniere's disease, may be helped by the use of hyoscine hydrobromide, 0.1 to 0.5
mg or one of the anti-emetic antihistamines, e.g. diphenhydramine 50 mg or
prochlorperazine maleate 5mg. Transdermal.
Scopolamine is also effective for prevention of motion sickness. The major side-effects
are dry mouth and lightheadedness. A single patch lasts up to 72 hours.
Vomiting in pregnancy will usually resolve without specific treatment but with
reassurance and advice about taking something by mouth before rising in the
morning, and small frequent snacks, rather than large meals, during the day. The more
resistant case may be helped by use of meclozine hydrochloride, 25mg, or diphenhy
dramine 50 mg which has stood the test of time and for which there is no evidence
of teratogenicity.
Vomiting may be a troublesome symptom in migraine. It may be prevented by the
administration of ergotamine tartrate, 2 mg, early in an attack and in some proprietary
preparations this drug is combined with an anti-emetic antihistamine. In the
established attack, suppositories of prochlorperazine maleate may be useful.
In terminal illness, particularly that due to gastrointestinal neoplasms, vomiting may be
troublesome. The use of morphine for pain relief may exacerbate this symptom. In
214

such cases dia-morphine should be preferred and this may be combined with
chlorpromazine or prochlorperazine.

INDICATIONS FOR REFERRAL


The child with more than mild dehydration.
The patient with serious organic gastrointestinal disease. Referral for surgical
treatment may be required urgently.
The patient with hyperemesis gravidarum. Give nothing by mouth for 48 hours, and
maintain hydration and electrolyte balance by giving appropriate parenteral fluids and
vitamin supplements as indicated.
References
1. Fry J. The patient complaining of nausea and vomiting. in: Cormack J, Marinker M and Morrell D. Practice:
A handbook of primary medical care. London:Kluwer, 1982;436-441.
2. Goroll AH. Evaluation of Nausea and Vomiting. in:Goroll AH, May LA and Mulley AG. Primary Care Medicine.
2nd ed. Philadelphia:Lippincott, 1987; 270-274.

CHAPTER 12

ABDOMINAL PAIN

RELEVANCE TO GENERAL PRACTICE


The causes of abdominal pain in general practice cover a wide clinical spectrum.
Although most cases may not be dramatic, the GP must be vigilant for the occasional
patient with serious physical pathology.
A careful history followed by appropriate examination helps to clarify the cause.
The probability of various diseases depends on the age group. A practical classification
of abdominal pain in general practice is according to the mode of onset.
The patient with acute abdominal pain requires a careful early assessment. Non-acute
abdominal pain allows the doctor more time to think and act but a systematic
approach is essential in the history, examination and investigation.

CAUSES
Abdominal pain may be divided chronologically into acute and less acute pain.
Acute Abdominal Pain
A useful classification of acute onset of abdominal pain is summarised in Table 1.
- Group A causes are life-threatening which require surgical intervention except for
acute pancreatitis.
- Group B causes are managed medically initially.
- Group C causes are the commonest causes which may upset the patient or family
tremendously, but are not life-threatening.

215

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

Other causes to keep in mind are:


- acute myocardial infarction.
- pneumonia.
- diabetic ketoacidosis.
- herpes zoster (pre-rash stage).
- ruptured aortic aneurysm (rare).
- Munchausen syndrome.
Less-Acute Abdominal Pain
- Organic. any intra-abdominal organic disease can present as a less acute or even have
an insidious onset of abdominal pain, e.g. appendicitis
- Functional. irritable bowel syndrome and periodic syndrome are common conditions
in young adults and children respectively.
Table 1. Causes of Acute Abdominal Pain
Group A. Life-threatening conditions which must be excluded Appendicitis; Acute
obstruction; Perforated peptic ulcer; Liver abscess; Acute pancreatitis; Ectopic pregnancy;
Twisted ovarian cyst and Obstructed hernia.
Group B. Less urgent but important conditions Acute cholecystitis; Biliary colic; Hepatitis;
Renal colic; Pelvic inflammatory.
Group C. Common causes Gastritis / Dyspepsia; Mesenteric adenitis; Dietary indiscretion;
Gastro-enteritis; Alcohol abuse; Migraine and Constipation.

The likely diagnoses vary with age:


- Age related conditions are:
In infancy
- intussusception.
In children
- periodic syndrome, any febrile illness.
Young adults - gastritis, peptic ulcer, hepatitis, irritable bowel syndrome,
dysmen orrhoea.
Middle age - peptic ulcer, gall bladder disease, irritable bowel syndrome,
carcinoma of stomach, colon, pancreas, or liver.
Elderly
- gastric ulcers, gall bladder disease, neoplasms, obstructed hernia.
Acute appendicitis and acute intestinal obstruction are important causes to exclude in
all age groups (although acute appendicitis is most common in young children and
young adults). Acute gastroenteritis is a common cause in all age groups.

WORKUP
Three Questions to Answer
The questions facing the general practitioner presented with a patient with abdominal
pain are:

216

Is there a surgical or a medical cause of pain?


If not surgical, should the patient be admitted or managed at home?
Is this an acute abdomen?
If not clearly an acute abdomen should the patient be admitted for observation?
If managed at home, what should be done?

ACUTE ABDOMINAL PAIN


History
A good history may reveal as much, if not more (about the likely cause), than the
physical examination.
- It is helpful to assess and manage the patient and family in the context of past
knowledge of their demeanour, attitudes and beliefs. Nevertheless, it is wise to
remember that even the most neurotic, anxious and depressed patients may suffer
from serious abdominal diseases at times.
- Any relevant history of previous abdominal diseases and operations should be noted.
A family history for major diseases e.g. carcinoma of colon, should also be recorded.
- Clarify the features of the abdominal pain:
- duration.
- site and radiation.
- character: colicky or dull ache.
- onset and progression: constant, intermittent, increasingly severe, recurrent.
- severity: dull ache or agonising pain.
- aggravating and relieving factors.
- Look for associated features:
- nausea and vomiting.
- loss of appetite.
- change in bowel habits.
- delayed or current menstruation.
- frequency, dysuria or haematuria.
Examination

General
-

the patients general demeanour.


appearance, pallor or jaundice.
temperature.
pulse.
character of respiration.
tongue; and
skin turgor.

The abdomen
- Observe any obvious distension, movement with respiration, and any obvious skin
signs e.g. an occasional case of herpes zoster.
217

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

- Palpate all quadrants of the abdomen carefully; note any masses and tenderness
(any deep tenderness in area of pain?). Search specifically for right iliac fossa pain of
appendicitis, Murphys sign of cholecystitis and renal angle tenderness of pyelonephritis.
- Auscultate: a silent or a very noisy abdomen may be highly significant in the context of
suspected ileus or intestinal obstruction.

Other examination
If the diagnosis is in doubt, the examination may be extended to include the chest, back
and central nervous system. Frequently a rectal and/or vaginal examination will be
necessary to clarify the diagnosis or exclude disease in the pelvis.
Cardinal features of some major causes of an acute abdomen are shown in Table 2.
Table 2. Cardinal Feature of Major Causes of Acute Abdomen
Cause
Colic

Features
Arise from viscera - exaggerated peristalsis
(pain typically waxes and wanes)

Renal colic

Site loin
Radiation - loin to groin
Associated features - vomiting, dysuria and haematuria

Biliary colic

Site - right hypochondral or epigastric region


Tenderness maximum in right hypochondrium

Appendicitis

Site
- early stages periumbilical
- right iliac fossa pain and tenderness classically
- pain worse on coughing
Vomiting
Guarding if perforated
Mild fever, none in early stages
Constipation or diarrhoea may be a presentation
Rectal tenderness

Peritonitis

Associated with perforated peptic ulcer, ruptured


appendix or ruptured ectopic pregnancy
Rebound tenderness and boardlike rigidity

Peptic ulcer

Site - epigastrium
History of drug intake - NSAIDs, steroids
Relation to meals - night pains in duodenal ulcer and
postprandial pain in gastric ulcer

Pancreatitis

Site - epigastrium and radiating to the back


Severity out of proportion to clinical findings
May be in hypovolaemic shock
Serum amylase is markedly elevated

Investigations
No investigations will be required in the majority of patients with abdominal pain, who
suffer from relatively minor conditions of short duration.

218

Non-Acute Abdominal Pain


In such cases, there is more time to think and act, but a systematic approach is essential in
the history, examination and investigation. A relatively small number of causes of nonacute recurrent or persistent abdominal pain account for most of the symptoms. These
causes include peptic ulcers, hiatus hernia, gall-bladder disease, the irritable bowel and
new growths of the large bowel or stomach.
Relevant useful investigations available in the clinic and its support facilities include:
- urine tests for infection.
- stool examination for occult blood, ova or cysts.
- haemoglobin, total white, serum amylase and liver function tests.
- ultrasound of the liver, gall bladder, pancreas, kidneys and pelvis.
- plain X-rays, contrast radiography and CAT scan.
- endoscopic procedures.

MANAGEMENT
Acute Abdominal Pain
Where the cause is clear and minor, symptomatic and definitive treatment may be all that
is necessary. Where the decision is to observe the patient, as for example, when a
diagnosis of the mesenteric adenitis is made, the patient should be pain increase over
the next six hours. This asked to report back or to go to hospital should should be
emphasised to the patient. Hospital admission is necessary for the obvious acute
abdomen or when an acute abdomen cannot be excluded. It is better to err on the side of
caution than to take the risk of leaving a patient at home with a possible progressing
abdominal emergency.
Non-Acute Abdominal Pain
The management of the patient with a non-acute abdominal pain depends on the
underlying pathology. Psychological causes should be looked for if organic causes have
been excluded. Attention to reasons for encounter may provide useful cues. Where no
organic cause is found, the patient should be reassured and followed-up.
References
1. Goroll AH. Evaluation of chronic fatigue. in: Goroll et al. Primary Care Medicine, 3rd ed. Philadelphia:
Lippincott, 1995: 325-333.
2. Scott BR. Recurrent abdominal pain during childhood. Can Family Physician Mar 1994;40:539-547.

CHAPTER 13

SKIN RASH

RELEVANCE TO GENERAL PRACTICE


A rash accounts for 5% of all new symptoms presented in general practice.
Extent of involvement and the presence or absence of accompaniments of itch or
constitutional upset are helpful in differential diagnosis.
219

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

DEFINITIONS
It is important to define the terms commonly used to describe skin rashes.
Macule Papule Nodule Scale
Crust Vesicle Bulla
Pustule Urticaria -

A flat spot which differs in colour from the surrounding skin


A raised spot on the surface of the skin
A lump deeply set in the skin
A flake of horny cells loosened from the skin surface
Dried serum adherent to the skin
A skin bleb filled with clear fluid
A blister filled with clear or blood-stained fluid
A skin bleb filled with pus
An irregular white or pink pruritic weal

CAUSES
An approach to skin rashes is to group them into the following:
Generalised Rash of Acute Onset
- accompanied by malaise and fever
- accompanied by acute pruritis as a prominent feature
- accompanied by minimal constitutional upset or pruritis

Localised rash (at times can be widespread)


Generalised Rash of Acute Onset

Accompanied by malaise and fever


Most are due to specific infectious diseases:
Measles - This is commonly associated with cough, running nose and conjunctivitis.
The child is usually miserable. Koplik spots may be found on the oral mucosa before
the onset of the rash. The rash itself consists of dusky red macules which coalesce to
form irregular blotches. The rash remains as a brownish staining for 2-3 weeks after
the fever has subsided.
Rubella - The constitutional upset is mild compared to measles. The rash consists of
pale pink macules, and first appears on the face. It spreads rapidly over the trunk and
limbs and fades in 2-4 days. Generalised lymphadenopathy is an accompanying
feature. Enlargement of the suboccipital lymph nodes are typical.
Chicken pox - The rash appears as macules which rapidly progress to umbilicated
papules and vesicles. It appears in crops and are commonly found to be in different
stages of development on the same patient. It first appears on the trunk and has a
centripetal distribution.

220

Non-specific viral infections - These are usually accompanied by catarrhal symptoms.


The rash is commonly macular or erythematous, clinically similar to rubella, and fades
in 24-48 hours without leaving any serious sequelae.
Infectious mononucleosis - The rash, which occurs in 10% of patients, consists of an
erythematous eruption occurring on the trunk, buttocks and extensor surfaces of the
limbs. Accompanying features include membranous tonsillitis, lymphadenopathy and
splenomegaly. Patients given ampicillin will develop a widespread, maculo-papular
erythematous eruption.

Accompanied by acute pruritis as a prominent feature


The cause may be drugs, insect bites or allergens. The morphology of the rash ranges
from erythematous papules and macules to urticaria and purpura. Mucous membrane
lesions are sometimes present. The reaction may be mild, lasting several days, or may be
severe and life-threatening.

Accompanied by minimal constitutional upset or pruritis


These are not so common. Two conditions which are sometimes seen in general
practice are:
Erythema multiforme - The rash consists of slightly raised macules up to 1 cm in
diameter which may coalesce and show target lesions. Steven-Johnson Syndrome is a
more severe form, with mucous membrane involvement.
Pityriasis rosea - seen mainly in young adults. The rash consists of symmetrical ovalshaped macules, spreading over the trunk and proximal parts of the limbs. This may be
preceded by a `herald patch' several days earlier.
Localised Rash
These are usually not associated with any constitutional symptoms, and may have typical
sites of occurrence. The cause may be may be endogenous or exogenous. Exogenous
causes may be infective or non-infective.
Atopic eczema. This is part of the eczema-asthma-hay fever syndrome. Onset is
usually in the second year of life. The rash is typically located in the flexures of the
elbows and knees. It can also be found on the face, neck, wrists and buttocks. In the
infantile form, it may be generalised, but it usually persists as a recurrent flexural
eczema in older children.
Irritant dermatitis. These are produced by substances that chemically damage the
skin. Some are very powerful, and produce eczematous skin changes even with very
short contact. Examples are alkalis and certain solvents. Other irritants are `low grade',
and cause changes on prolonged, repeated contact. Detergents and soaps can be
classified under this category. The skin changes are varied, but are usually localised to
the site of contact.

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Allergic dermatitis. This occurs when the skin is in contact with a substance to which
the patient is allergic. The reaction may be localised, or may spread to other areas not
in contact with the allergen. Examples are allergy to nickel and cement.
Other eczemas. These include seborrhoeic dermatitis, which is of exudative nature,
and can be found on the hair margins, face, axillae, chest and groin; pompholyx,
which is a blistering condition occurring on the palms and soles; lichen planus and
others of uncertain aetiology classified under morphology and distribution.
Psoriasis. This presents most commonly in early adult life. The characteristic lesion is a
raised red plaque with a well-defined margin, covered with silvery scales. The lesions
occur mainly on the extensor aspects of the knees and elbows, the sacrum and the
scalp. Psoriasis may also present as guttate psoriasis which appears as small lesions
0.5-1 cm in diameter scattered over the skin surface, sometimes after a
streptococcal infection. Other forms of psoriasis include pustular and erythrodermic
forms, which are potentially serious. Nail involvement is common. Arthritis occurs in
about 10% of patients.
Skin infections. These may be bacterial or fungal.
- Bacterial infections include impetigo, which is mainly localised, and has
characteristically golden yellow crusts; folliculitis, involving the hair follicles; boils
and carbuncles.
- Fungal infections run a more chronic course, and are spread over a wider area.
Those caused by dermatophytes are classified according to the distribution, e.g. tinea
capitis, tinea cruris. The lesions are typically annular, with the outer edge as the most
active area, and central clearing. Scales may be present. Tinea versicolor is caused by a
yeast. The lesions may be hypo- or hyperpigmented. There is no characteristic
distribution. Candida albicans is an opportunistic yeast. The skin lesions are found
mainly in the warm, moist parts of the body, and consist of inflammatory reaction with
satellite lesions. Mucous membrane involvement consist of white exudative plaques.
Parasitic infestations/insect bites. Scabies is caused by the mite Sarcoptes scabiei.
The characteristic lesion is a `burrow', at the end of which the mite can sometimes be
found. The distribution is typically in the skin fold areas, between the fingers and toes,
and in the groin.
Papular urticaria represents an urticarial and vesicular response to a variety of insect
bites, including fleas, bedbugs, mites and mosquitoes. The lesions are seen mainly on
the exposed parts of the body.

WORKUP
History
One should establish the duration of illness, the site and distribution of the rash.

222

In patients presenting with skin rash of short duration, the presence of associated
symptoms should be asked for, namely, constitutional disturbance, and itch. A history of
prior unaccustomed food and drug ingestion, immunisations, allergy should be obtained.
A working diagnosis can often be reached even before the patient is examined.
In patients presenting with a more chronic rash, it is important to establish the site of
onset and mode of spread of the rash, any aggravating or relieving factors, or allergy.
Past, family, social and occupational history are also important, as for example, in atopic
eczema, in contact dermatitis.
Physical Examination
Examination of the skin should include examination of the mucous membranes and the
nails. Some conditions can be diagnosed by morphology and distribution e.g. pompholyx.
Some acute conditions have characteristic non-cutaneous physical signs, e.g. presence of
suboccipital lymph nodes in rubella, which help in narrowing down the differentials.
Look out also for signs confirming certain symptoms, e.g. excoriation marks in patients
complaining of pruritus, lichenification in long-standing rash. A magnifying glass is a
useful aid in studying the morphology of the rash.
The distribution of rashes provide a useful guide as to the differential diagnoses in rashes
of insidious onset.
Rashes affecting the hands - irritant eczema, pompholyx, scabies.
Rashes affecting the flexor aspects of the arms and legs - atopic eczema most common.
Rashes affecting the feet - tinea pedis most common, contact dermatitis due to leather
or dye from shoes also common.
Rashes affecting the extensor surfaces of the limbs - characteristic in psoriasis,
uncommonly dermatitis herpetiformis.
Rashes affecting the groin area - tinea cruris, seborrhoeic dermatitis.
Rashes affecting the axilla - Contact eczema e.g. due to deodorants, less commonly
seborrhoeic dermatitis, folliculitis and tinea.
Rashes affecting the scalp - seborrhoeic dermatitis, tinea capitis, psoriasis, impetigo.
Rashes affecting the trunk - seborrhoeic dermatitis, guttate psoriasis, tinea corporis,
tinea versicolor, pityriasis rosea, rarely secondary syphilis.
Rashes affecting the buttocks - scabies, psoriasis, napkin rash and atopic dermatitis
in infants.
Mucous membrane lesions - moniliasis, less commonly Steven-Johnson syndrome,
syphilis, lichen planus, etc.
Laboratory Investigations
Laboratory investigations are limited in the office setting. One useful procedure is skin
scraping for the diagnosis of fungal infections using potassium hydroxide. Other more
involved investigative methods e.g. biopsy and patch testing can be done if facilities
are available.
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MANAGEMENT
Management depends on the diagnosis. Acute infections of viral origin need only
symptomatic treatment. Patient education and reassurance are important.
Allergic and contact eczema are managed by identification and avoidance of the
offending agent, antihistamines, topical applications and steroids for severe cases.
Psoriasis and skin infections are treated according to specific protocols.
General guidelines regarding the vehicle for therapeutic agents of all rashes are
as follows:
- Lotions to be used for moist or weeping lesions.
- Creams for oedematous but not exudative lesions.
- Ointments for dry lichenified fissured lesions.

INDICATIONS FOR REFERRAL


For consultation where diagnosis is in doubt.
For specialised investigative procedures e.g. patch testing, or management
e.g. ultraviolet light treatment in psoriasis
In acute life threatening conditions e.g. erythrodermic psoriasis, exfoliative dermatitis,
severe allergic reactions.
References
1. Morell D. The patient complaining of a rash. in: Cormack et al. Practice: A handbook of primary health care.
London:Kluwer, 1982

224

CHAPTER 14

BACKACHE

RELEVANCE TO GENERAL PRACTICE


In over three-quarters of cases of predominant backache, symptoms disappear within
4 weeks with simple general measures and analgesia. The remaining likely serious
causes should be identified as early as possible.
Backache is also a common accompaniment of common conditions like viral fever,
urinary tract infections and multiple psychosomatic complaints.

CAUSES
The main causes of backache are shown in Table 1.
Table 1. Causes of Backache
Spondylogenic
Injury
musculo-ligamentous strain
disc prolapse
bony injuries
Structural defect
scoliosis
spondylolysis
spondylolisthesis
spinal stenosis
Infection
tuberculosis
pyogenic
Inflammatory arthritis
ankylosing spondylitis
rheumatoid arthritis

Tumor
malignancies-myeloma, secondaries
vascular malformations
Others
osteomalacia
Viscerogenic
Pyelonephritis
Pancreatitis
Dysmenorrhoea
Psychogenic
Functional overlay
Tension
Hysterical conversion
Depression

WORKUP
History
General
Age. This could indicate the likely diagnosis as many causes of backache are age related,
for example, degenerative diseases, Paget's disease and malignancy.
Occupation. This should be asked as it may reveal the main reason for consultation, i.e.
compensation, medical certification and therefore aid in the patient's management.
Trauma. A history of recent or past trauma will be helpful.
Symptoms
Duration. One should ask the duration and onset of the backache and whether it has
been recurrent.
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

Associations. Pain at rest, morning stiffness, radiation to the knees and calves, loss of
sensation in the foot should be looked into. In addition, if bowel and bladder
incontinence occurs one may have to suspect that a cauda equina lesion or central disc
prolapse is present and this constitutes an emergency.
Posture. Pain that is related to posture, episodic, made worse on movement and relieved
by rest is likely to be caused by a musculoskeletal condition.
Constitutional symptoms. The presence of other constitutional symptoms like loss of
weight, loss of appetite, malaise may be useful in diagnosis.
Referred pain. pain in the back may be referred from viscera within the chest, abdomen
or pelvis, e.g. pyelonephritis, duodenal ulcer or dysmenorrhoea.
Psychogenic backache. Low back pain can also be psychogenic or a symptom of
depression; however, other diagnosis must be excluded before hand.
Past History. A history of recurrent pain and what had been done for the patient in the
past, e.g. surgery, traction, etc would be helpful.
Physical Examination
Observation of the back. Acute disc prolapse: there may be a forward tilt
obliterating lumbar lordosis and a lateral tilt (sciatic scoliosis).
Palpation of the back. Local tenderness common in apophyseal joint, ligamentous
injury and often in acute disc prolapse. Note that acutely tender areas due to strains
may be helped by local injection.
Movements (flexion, extension, rotation, lateral flexion. Also test the sacroilia
joints). In ligamentous injuries the movements are likely to be full. In apophyseal joint
dysfunction there may be locally reduced mobility. In disc prolapse movements are
restricted by pain but one or two movements (often flexion) restricted more than others.
Straight leg raising. Reduced in prolapsed intervertebral disc with sciatic nerve irritation.
Femoral stretch test (knee flexion when prone). Positive if upper lumbar root involved.
Power. In particular movements of foot and big toe.
Sensation. Especially the saddle area, as saddle area anaesthesia may be a feature of
central protrusion.
Investigations
In many situations these may not be necessary especially if the reason for encounter or
cause can be established and symptomatic treatment can be given. In other cases, a
226

pathology like spondylosis may be present but it may be recurrent and hence
previously investigated thus eliminating the need for further investigations.
The most common investigation used for backache is the spinal x-ray either of the
thoracic or lumbar region. In the young, musculo-ligamentous strain and disc prolapse
would be expected to be common causes of backache and lumbar x-rays done may be
of limited value. In the elderly, degenerative or tumour changes may be seen on x-ray.
Oblique views may be necessary as pathologies such as spondylolysis will
become apparent.
ESR: This is often raised markedly in some tumours especially multiple myeloma.
CT Scan.
Other relevant investigations depending on the diagnosis e.g. FBC, Mantoux test in
suspected TB of the spine.
Table 2. Nerve Roots and Associated Neurological Signs
Nerve root
L2
L3
L4

L5
S1
Cauda

Change in power
Hip flexion
Weakness of the quadriceps
(knee extension)
Weakness of knee extension
and dorsiflexion of the foot
(footdrop)
Weakness of dorsiflexion of
the foot and toes (foot-drop)
Weakness of plantar flexion
(unable to stand on tip-toe)
Any or all of the above with
bladder and rectum paralysis

Reflexes
No change
Reduced or absent
knee jerk
Reduced or absent
knee jerk
No change
Absent ankle jerk
Ankle jerk lost, and equina lesion
reflexes lost

MANAGEMENT
Analgesia. Consider muscle relaxants, physiotherapy.
General back care:
- Rest - medical leave, control physical activities.
- Rest - lying rests the back; ensure there is a firm mattress.
- Avoid lifting heavy weights.
- Avoid bending the back; when lifting objects, bend at the knees keeping back
straight.
- Posture: when sitting, do not hunch; a small cushion as lumbar support is useful;
try to get a well-designed chair.
Attend to psychogenic factors.
Follow-up and referral. When conservative treatment fails,
- Review compliance.
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

- Reassess home/work environment.


- Reassess clinically, as thoroughly as on the initial examination.
- Refer to specialist assessment.

INDICATIONS FOR REFERRAL

For diagnosis.
Suspected serious disease i.e. neoplasia, TB, referred pain.
Treatment i.e. traction, surgery.
Failure of conservative therapy. This means failure of therapy after at least three
weeks' bed rest and analgesia faithfully complied with.
Emergency referral for surgery i.e. cauda equina lesion. Symptoms are:
- saddle area anaesthesia
- retention of urine/urinary symptoms
- atomic anal sphincter
- severe weakness of legs peripherally.
References
1. Boyd RJ: Evaluation of Back Pain in Primary Care Medicine, Ed. Goroll, May & Mulley, 2nd Ed. 651-659.
2. Quinet RJ and Serebro LH: Management of Regional Low Back Pain in Practical Care of the Ambulatory Patient
by Stults & Dere, WB Saunders 1989, 479-489.

CHAPTER 15

JOINT PAINS

RELEVANCE TO GENERAL PRACTICE


Although osteoarthritis accounts for many of the more obvious cases of joint pain
(particularly in the elderly), the differential diagnosis can encompass a bewildering
array of conditions, both articular and non-articular, inflammatory and non-inflammatory.
Many patients with joint pains self medicate and seek advice from friends and
alternative medicine practitioners before they consult a doctor.
Careful attention to the history and physical examination helps chart a logical course
to minimise diagnostic error and cost and maximise patient benefit.

CAUSES
These are many ways that joint pains can be classified. One way is to classify aetiologically
as in Table 1.

228

WORKUP
History
The history should address the following questions:
Is the problem articular or non-articular?
Is it inflammatory or non-inflammtory?
Is the involvement polyarticular (5 or more joints) or pauci-articular?
Are there any extra-articular manifestations?
The site of maximal tenderness establishes whether the problem is within the joint or
outside. Bursitis, tendinitis are conditions that are extra-articular. The features that
differentiate between inflammatory and non-inflammatory joint pain are shown in Table 2.
If the involvement is mono-articular, consider trauma, septic arthritis and monoarticular
stage of a polyarthritis. Of these, septic arthritis is the most important condition to be
sorted out. If the involvement is polyarticular, the distribution of joints helps to define the
underlying disorder. In rheumatoid arthritis, typically, the joints involved are the feet,
metacarpophalangeal joints, proximal interphalangeal joints and wrists. In osteoarthritis,
when the hands are involved, these joints are usually not involved.
Table 1. Causes of Joint Pains seen in General Practice
ACQUIRED CAUSES

Inflammatory
infective
non infective rheumatoid arthritis; ankylosing spondylitis; psoriatic arthritis and SLE,
inflammatory bowel disease
metabolic gout and pyrophosphate arthropathy

Degenerative Osteoarthritis, spondylosis, intervertebral disc prolapse

Trauma/ overuse Shoulder capsulitis, tendinitis, tenosynovitis, bursitis, carpel tunnel


syndrome, ligament/muscle tear, chondromalacia patellae, trigger finger, metatarsalgia,
and plantar fasciitis

Miscellaneous Psychogenic rheumatism, neoplasm


HEREDITARY (Uncommon)
Marfan's syndrome, Ehlers-Danlos, Osteogenesis imperfecta
Source: Grahame R. The Practitioner, 1986:316

Table 2. Inflammatory and Non-Inflammatory Joint Disorders


Symptoms & signs

Inflammatory

Non-inflammatory

Morning stiffness
Fatigue
With activity
With rest
Soft tissue swelling
Bony swelling

> 1 hour
Marked
Better
Worse
Yes
Uncommon

< 1 hour
Occasional
Worse
Better
Uncommon
Yes

Source: Catherine Alderice. Can Fam Physician 1990; 36:553.

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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

The presence of extra-articular manifestations helps to clinch the diagnosis. See Table 3.
Table 3. Extra-Articular Manifestations in Joint Disorders
Inflammatory arthropathy
Polyarthropathy
Rheumatoid arthritis

Systemic lupus erythematosus

Psoriatic arthritis

Chronic tophaceous gout


Oligoarthropathy
Ankylosing spondylitis
Reiters syndrome
Psoriatic arthritis
Inflammatory bowel arthropathy
Early rheumatoid arthritis

Extra-articular manifestations
Extra-articular manifestations tend to occur
later in the course of disease. Subcutaneous
nodules, sicca symptoms (dry eyes and dry
mouth); hand deformities volar subluxation,
swan neck, boutonniere deformity, ulnar
deformity of the metacar pophalangeal
joints are common
Extra-articular manifestations are usually
prominent, often preceding joint complaints:
alopecia, mouth ulcers, Raynauds
phenomenon, butterfly rash, photosensitivity
and serositis
In 15% of patients with psoriatic arthritis, the
arthritis appears first and the typical skin rash
develops months to years later. Typically the
skin lesions and nail changes clinch
the diagnosis
Tophaceous deposits found under the skin
Iritis, aortic incompetence
Conjunctivitis, keratoderma blenorraghica,
balanitis in males
skin rash, nail changes reveal the diagnosis
Ulcerative colitis and regional ileitis
subcutaneous nodules

Physical Examination
Examination may be normal or there may be redness and swelling of affected joints,
deformities and extra-articular manifestations.
Every painful joint should be examined with regard to the following:
- joint swelling and tenderness.
- synovial and capsular thickening.
- deformity.
- range of movement.
- instability.
- gait.
- muscle power.
Next consider the pattern of affliction and symmetry of the disease:
- peripheral Joints
- symmetrical pattern in RA
- asymmetrical pattern in gout (usually single joint affected)
- axial Joints (sacroiliac, spine, lower limbs)
- AS, Reiter's syndrome

230

For polyarticular disease other systems need to be examined and these should include:
- the eye e.g.conjunctiva, sclera,iris and retina.
- skin - pattern of rash, ulcers, ischaemia and infarction, nodules, nails, hair.
- mucous membranes - ulcers.
- abdomen and genito-urinary system.
- cardiac murmurs.
- muscle wasting (disuse atrophy, dermotomyositis in SLE).
Investigations
Not all joint pains require further investigations. A negative result does not necessarily
exclude the presence of the disease process.
In inflammatory polyarthropathy, initial investigations need only be confined to the
following:
Erythrocyte sedimentation rate. The erythrocyte sedimentation rate is a very useful
test of inflammatory activity, particularly in patients with rheumatoid arthritis or
polymyalgia rheumatica. In RA it is raised and very high in the acute stage. In the elderly
with polymyalgia rheumatica (PMR) a markedly raised ESR is usually present.
Complete blood count. Hb - moderate anaemia is the most common systemic
manifestation of inflammatory joint disease. Its severity reflects the activity of the disease.
- TW - Total white is raised in infection, and in gout.
- Platelets - can be raised or low.

Rheumatoid factor
Rheumatoid factor is an important test in confirming the diagnosis, but only if the
positive results correspond to the patients symptoms and current knowledge of
rheumatoid arthritis. Early in the disease, it may be negative in rheumatoid arthritis but
will normally turn positive within one year. Rheumatoid factor is used mainly to confirm a
diagnosis. It should never be used to monitor disease activity.

Anti-nuclear antibodies (ANA)


Anti-nuclear antibodies (ANA) should be approached in the same way as a positive test
for rheumatoid factor. Only if the patients symptoms strongly suggest SLE should a
positive test for ANA be taken as confirmation of the diagnosis. Like rheumatoid factor,
ANA tests are not useful to monitor disease activity.
Synovial Fluid Analysis
In oligoarthopathy and monoarthropathy, synovial fluid analysis is helpful. It is almost
diagnostic in septic arthritis and in gouty or pseudogout arthritis. By contrast, such
analysis does not help to differentiate the aetiology of polyarthropathy.

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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

Table 4. X-Ray features in Joint Disorders


Rheumatoid arthritis
Periarticular osteoporosis, and periosteal reaction
Ankylosing spondylitis
Typical diagnostic features: blurring of margins of sacro-iliac joints, erosions and squaring of
lumbar vertebrae; bamboo spine
Gouty arthritis
In late stages of disease, punched out juxta-articular erosions and degenerative joint changes
Osteoarthritis
Narrowed joint space, irregular joint space, sclerosis of subchondral bone, subchondral cyst,
osteophytes

Radiological Investigations
X-rays of joints are useful as a baseline examination and for monitoring progress. The
following should be looked for:
- soft tissue changes
- juxta-articular osteoporosis
- uniform narrowing of joint spaces
- erosions at joint margins.

MANAGEMENT
This depends on the cause and stage of the joint disease and is based on a combination of:
- physiotherapy
- local injections
- drug therapy - a wide range of drugs is available from the simplest analgesics, NSAIDs,
gold to cytotoxics.
- surgery - to joints and deformities
- aids for walking and ADL
- patient education and counselling
- social and community support/self-help groups
From the standpoint of management, patients can be divided into 3 groups:
Inflammatory Arthropathy and Physical Examination is Positive
- Patients whose history indicates inflammatory polyarthropathy and who have
objective evidence of joint involvement are usually fairly easy to manage. If gouty
arthritis or septic arthritis is present, the treatment is specific. In inflammatory
polyarthritis, the initial management is symptomatic. Self-limiting conditions,
particularly a viral illness (which can mimic rheumatoid arthritis), will resolve within
six weeks.
- If symptoms persist beyond six weeks, one must establish the most likely diagnosis
and then treat the symptoms as they occur; the need for second line drugs may
need to be sought.
Inflammatory Arthropathy but Physical Examination is Normal
- These patients probably have early arthritis like rheumatoid arthritis but may not
have yet developed recognisable features. The patient may develop new symptoms
232

over time or will have a complete resolution of their symptoms. Treatment at this
time is with NSAIDs and they should be followed up more closely than the other
two groups.
Non-Inflammatory Arthropathy
- These are patients who have no inflammatory features on physical examination of
affected joints. Advice on judicious exercise, weight reduction of the overweight is
needed.
References
1. Alderdice C. Approach to the patient with polyarthritis. Can Fam Physician 1990;36:549-551, 553-554.
2. Goroll AH, May LA and Mulley. Management of rheumatoid arthritis. in:Primary Care Medicine, 3 ed.
Philadelphia: Lippincott, 1995:790-794.
3. Dorbrand L et al. Chapter on Muscular Skeletal problems. In: Manual of clinical problems in adult ambulatory
care, 1992. Toronto: Little Brown: 283-339.
4. Stuart RA & Macedo TF. Antirheumatic drugs. Medical Progress. August 1993:11-17.
5. Soll AH, Weinstein WM, Durara J & McCarthy D. Non-steroidal anti-inflammatory drugs and peptic ulcer
disease. Ann Intern Med 1991; 114:307-19.

CHAPTER 16

DIZZINESS

RELEVANCE TO GENERAL PRACTICE


Dizziness is a common symptom and its interpretation can be difficult, made worse by
its very subjective nature and the many disorders that can cause it. Few doctors will not
feel a sense of despair when confronted with a patient whose main complaint is that
of dizziness.
A careful history including drug intake will help determine whether the Dizziness is a
true vertigo or pseudovertigo and pinpoint the diagnosis.
Important serious causes to keep in mind are cerebral tumours and cardiac dysrhythmias.

MEANING OF DIZZINESS
Dizziness is a sense of abnormal balance, and results from disturbance of one or more of
the organs maintaining balance.
When a patient complains of dizziness, he or she can be using this term to describe
many different phenomena, and hence a careful history is required to unravel the problem.1
Figure 1. Classification of Dizziness
Vertigo
Unsteadiness (tendency to fall; dysequilibrium)
Dizziness
Pseudovertigo

Lightheadedness (fainting or syncopal episodes)


Giddiness (hing-hing) nonspecific sensation

Source: Aust Fam Physician 1991; 20:10: 1484 (adapted)

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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

It is useful to try and categorise the patients symptoms into one of the following
categories in Figure 11, 2:
Vertigo -- a sense of rotation, that is either the patient or his surroundings are spinning
around. In its severest form, it may be accompanied by nausea, vomiting, pallor
and sweating.
Unsteadiness -- characterised by a tendency to fall; dysequiIbrium.
Lightheadedness -- presyncopal feeling. May be relieved by assuming a supine
position.
Giddiness (hing-hing) -- nonspecific; cannot be easily put into any recognisable pattern.
In the elderly, consider a problem of multisensory deficits. These sufferers may have
cataracts, neuropathy, limited neck movements and aging of the vestibular system.
Differentiation into these categories must be attempted despite the obvious difficulty in
doing so, because this helps in identifying the problem.

CAUSES
The causes of dizziness are shown in Table 1.
Table 1. Causes of Dizziness
Peripheral disorders
Labyrinth

Eighth nerve
Central causes
Brain stem
Cerebellum
Others

labyrinthitis
Menieres disease
benign paroxysmal positional vertigo
labyrinthine window fistula
vestibular neuronitis
acoustic neuroma
vertebro-basilar insufficiency
infarction
degeneration
tumours
hypotensive drugs, alcohol,
tranquillisers, anticonvulsants
cardiac dysrhythmias
anaemia

From the standpoint of diagnosis, it is useful to classify dizziness as with or without vertigo.
Dizziness without vertigo suggests one of the following:
Acute infection usually viral in origin. This may be associated with other symptoms
such as gastric or bowel disturbance and aches and pains in the limbs or body.
Postural hypotension. This is seen most often in young women who are otherwise
fit. This may be due to the earlier stages of pregnancy. Postural hypotension in the
known hypertensive on treatment and the diabetic with autonomic neuropathy may
also be a cause of dizziness.
Hypoglycaemia. This is associated with sweating and hunger, in a known diabetic or
in one who omits his regular meals for whatever reason.
Drugs. Drugs should not be forgotten as a cause of dizziness without vertigo.
Examples are hypotensive drugs, tranquillisers and anticonvulsants.
234

Other causes. Anaemia (often implicated but not substantiated) and cardiac disease
(e.g. aortic stenosis and regurgitation; dysrythmia) are other causes of dizziness
without vertigo.
Dizziness with vertigo may be caused by:
Meniere's disease. The attacks of vertigo may last for hours. Malaise or instability
may persist for a day or two, and there is always associated deafness, which may be
unilateral. Long periods of freedom between attacks are common.
Vestibular neuronitis. This is characterised by the acute onset of rotatory vertigo,
with systemic disturbance. The vertigo may subside spontaneously after a day or a few
hours, and may recur on sudden head movement or on postural change during the
following few weeks. This condition is usually self-limiting. A viral infection of the
labyrinth has been postulated, though there is little direct evidence for this.
Vertebro-basilar insufficiency. This may be the result of, either arteriosclerotic
narrowing of the blood vessels or narrowing of the intervertebral foramina secondary
to osteoarthrosis. As expected, it is seen most commonly seen in the elderly.
Other causes. Temporal lobe epilepsy and an acoustic neuroma. also causes dizziness
with vertigo.

WORKUP
History
When the patient present with 'light-headedness', not associated with rotation, the
history and examination will be directed towards identifying a non-vestibular complaint.
Does the patient experience the symptom after rising rapidly from the sitting position? Is
the patient receiving treatment for hypertension or diabetes mellitus? Does the patient
sweat or feel hungry during an attack, and is it relieved by eating food?
In evaluating a patient with vertigo, there may be associated symptoms of tinnitus and
impaired hearing. A patient complaining of vertigo should be asked if he has suffered
any head injury in the recent past, or about ingestion of drugs with known toxic effects
on the inner ear (such as salicylates, quinine and streptomycin). The addition of headache
to these symptoms suggests the possibility of acoustic neuroma causing raised intracranial pressure.
Physical Examination
The patient who suffers from 'light-headedness' unaccompanied by rotation is not
suffering from any disease of the labyrinth. In such a patient, the clinical examination will
be directed towards identifying a non-vestibular cause. It will include recording of the
pulse, temperature and blood pressure on lying and standing. If an infective cause for the
symptom is suggested by raised pulse and fever, then a general examination of throat,
sinuses, ears, chest and abdomen will be conducted to identify the site of the infection.

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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

Signs of early pregnancy should be looked out for in the young woman complaining of
dizziness, especially if her period is delayed.
True vertigo requires detailed examination of the ears and the function of the labyrinth.
Conductive deafness (bone conduction better than air conduction in Rinne's test) will
suggest a local middle ear cause for vertiginous symptoms. Perceptive deafness (air
conduction greater than bone conduction) will suggest the possibilities of disease of the
eight nerve or cochlear end organ.
Nystagmus should be looked out for, as it may be caused by disease of the labyrinth or its
central connections (though bearing in mind that it may occur in normal subjects on
extreme lateral gaze, or if the test object is held too close).
Benign positional vertigo is confirmed by a positive Dix-Hallpike manoeurve. This is done
with the patient sitting on the couch and suddenly lowering the patient to a position
below horizontal and with the head turned 45 degrees to the side. The patient is left in
this position for about 30 seconds before returning to the sitting position with the head
looking at the same direction for another 30 seconds. The test is then repeated with the
head turned to the other side. Severe vertigo and nystagmus occurring some seconds
(that is, with latency) after lowering the patient indicates a vertigo of peripheral origin. If
fatiguable (disappears after repeated testing) it is virtually diagnostic of benign positional
vertigo. If there is no latency and there is no fatiguability, a posterior fossa tumour has to
be excluded.
Investigations
A simple blood count, chest x-ray and electrocardiogram may be needed to further
evaluate suspected anaemia or cardiac disease.
The known diabetic requires measurement of his blood sugar level to identify
hypoglycaemia as a cause of his symptoms.
In a patient with associated deafness, audiometry will determine whether the deafness is
caused by a lesion of the cochlear end organ (e.g. Meniere's disease). This will show the
characteristic known as loudness recruitment: as the sound intensity is increased, the
subjective loudness in the affected ear progressively approximates that of the good ear.
More sophisticated tests for example computerised tomograms, cerebral arteriograms are
required only when a posterior fossa tumour is suspected.

MANAGEMENT
If the dizziness is due to a self-limiting viral infection, symptomatic treatment and fluids
are all that are needed. If the site of the infection is identified and the organism amenable
to antibiotics then appropriate antibiotics may also be required.
Vestibular neuronitis is also treated with symptomatic remedies, such as cinnarizine
or prochlorperazine.

236

The hypertensive patient with postural hypotension will require readjustment of the dose
or schedule of hypotensive agents. The hypoglycaemic attacks occurring in the known
diabetic require similar reassessment of his regime of treatment.
The elderly patient with dizzy attacks may benefit from the wearing of a cervical collar
which will restrain the movement of the cervical spine. The advice to rise slowly from the
sitting position and to avoid movements which will provoke the attack is also of help.
Prochlorperazine tablets, 5 mg twice daily, will often reduce the intensity of the attacks.
The medical treatment of Meniere's disease is at present symptomatic. Low-salt diet and
diuretics may be employed with variable degrees of success. Betahistine has had some
success in a dose of 8 mg thrice daily. Vestibular sedatives are helpful and of these
cinnarizine has been recommended.
Vertigo in the presence of middle ear infection requires an urgent opinion from an
ear specialist.
If the dizziness is caused by psychiatric illness, this may require appropriate management
by psychotherapeutic means, tranquillisers or antidepressants.

INDICATIONS FOR REFERRAL


Central vertigo - characterized by presence of neurological features. Vertebro-basilar
stroke is an emergency.
Suspected serious disease e.g. aortic stenosis, psychosis, for expert management.
When the diagnosis is not clear.
References
1. Murtagh J. Dizziness (vertigo). Aust Fam Physician 1991 Oct; 20:10:1483-1489.
2. Chong PN. Office evaluation of the dizzy patient. Sing Fam Physician 1990; 16:2:72-75.
3. Morrell, D.C, Gage, H.G and Robinson, N.A (1971) Symptoms in General Practice, Journal of the Royal College
of General Practitioners, 21-32.
4. Hodgkin, K. Towards Earlier Diagnosis. 3rd ed. Edinburgh: Churchill Livingstone, 1987.

CHAPTER 17

HEADACHE

RELEVANCE TO GENERAL PRACTICE


Headaches are a very common experience and about 90% of the population will have
had this symptom within one year. Commonly, it is an accompaniment of acute febrile
illness where the cause is clear. At other times, the causes are usually benign.
The primary care physician's most immediate task is to identify on clinical grounds the
occasional patient who requires aggressive work up. The ever-present possibility of a
serious organic cause in the minority makes it incumbent for the doctor to take a
careful history and conduct an appropriate examination in a patient with headache.
The nature of the headache is of some value in diagnosis. An occipital headache is
more likely than a frontal one to be due to an organic lesion. A headache of recent
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onset, changing character, increasing frequency or severity, persistent, or accompanied


by vomiting or behaviour change suggests an organic cause.

CAUSES
Headaches may be broadly classified as primary or secondary. Primary headaches are
those without underlying structural pathology. Secondary headaches are caused by
underlying disease. See Table 1.
A diagnosis of primary headache requires the prior exclusion of a secondary headache. A
previously diagnosed primary headache does not preclude a secondary headache
developing.

WORKUP
ACUTE HEADACHE
History
This should include inquiry into onset, severity, location, associated symptoms especially
neurologic deficits and fever. A previous history of headaches and head trauma should
also be noted.
Headache of extraordinary severity (my worst headache ever) suggests a serious
intracranial cause, namely, subarachnoid haemorrhage, raised intracranial pressure
and meningitis.
Diffuse headache in conjunction with a stiff neck and fever suggest acute meningitis.
Subarachnoid haemorrhage typically produces a sudden severe headache -- the
thunderclap headache.
When acute headache and stiff neck occur in conjunction with ataxia of gait and
profuse nausea and vomiting, a midline cerebellar haemorrhage needs to be
considered. Cerebellar haemorrhage is uncommon, but early recognition is important
because prompt treatment can be life saving.
Acute fever with fronto-orbital headache is suggestive of acute sinusitis.
Eye pain and blurred vision raise the possibility of acute glaucoma.
New onset of headache in an elderly patient requires consideration of temporal arteritis.
Acute throbbing headaches are mostly vascular in etiology: the patient needs to be
asked about fever, vasodilator use, drug withdrawal, and hypoglycaemia.

238

Migraine (common migraine and classic migraine) produces a recurrent acute headache.
- Common migraine - occurs in 80% of patients with migraine, the headache is
bilateral or shifts sides, nausea, photophobia and related symptoms usually
accompany the headache.
- Classic migraine accounts for 10 to 15 per cent of cases. It is characterized by
prodrome of transient visual, motor or sensory disturbances followed by onset of a
hemicranial throbbing headache, nausea, photophobia and sensitivity to noise.
Hypertensive encephalopathy may be heralded by diffuse headache, nausea, vomiting
and altered mental status.

TABLE 1. Causes of Headache (2004)


PRIMARY HEADACHES -- STRUCTURAL LESION ABSENT
Migraine
- common
- classical (with aura)
- migraine variants
Tension-type headache (TTH)
Cluster headache and other trigeminal autonomic cephalalgias
Other primary headaches e.g. cough headache
SECONDARY HEADACHES -- UNDERLYING LESION PRESENT
Headache attributed to:
Head and/or nect trauma
Cranial or cervical vascular disorder
Non-vascular intracranial disorder
Substance or its withdrawal
Infection
Disorder of homeostasis
Disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other cranial structures
Psychiatric disorder
Cranial neuralgias and central causes of facial pain
Other headache, cranial neuralgia, central or primary facial pain not elsewhere classified
Source: International Headache Society Headache Classificaion & Diagnostic Criteria (2004), Second edition

Physical Examination
In a patient where headache is an accompaniment of fever or an acute respiratory
infection, confirmation of the fever and selective examination of the affected part will be
all that is necessary.
Where the cause is not immediately clear, physical examination to rule out a serious cause
is necessary.
The blood pressure and temperature should be checked for any elevations.
Examination of the scalp for cranial artery tenderness; the sinuses for tenderness
to percussion.
Examination of eye:- pupils are noted for loss of reactivity and the cornea for haziness
due acute glaucoma; the disc margins for blurring from raised intracranial pressure.
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Examination of neck - neck rigidity on anterior flexion suggests meningitis or a vascular


leak from an AV malformation or an aneursym.
Neurological examination for ataxia in patient with severe, profuse vomiting
suggesting cerebellar haemorrhage; early recognition is important because prompt
treatment can be life saving.
Investigations
If the causes are obvious and benign, investigations are not needed.
Where organic neurologic cause is suspected patient should be referred to hospital for
further investigations such as lumbar puncture, CT scan etc.

CHRONIC AND RECURRENT HEADACHES


History
It is important to keep in mind that more than one kind of headache may be present; a
full description of each type of head pain must be elicited.
A dull, steady, recurrent, unilateral headache that occurs in the same area each time
and progressively worsens in frequency and severity is suggestive of an intracranial
lesion (tumour, brain abscess).
Recent head trauma and a symptom-interval between injury and onset of headache
are characteristic of subdural hematomas; patients may show only subtle personality
changes and be mistakenly thought to have a psychogenic problem.
Most throbbing, recurrent headaches are of vascular origin; migraine accounts for the
vast majority.
Headache that are variable in quality and location, or constant over weeks to months
but not relentlessly progressive in severity are likely to have a muscle contraction or
psychogenic etiology.
Physical Examination
A complete examination is necessary. The finding of a fixed focal deficit is important
evidence of intracranial pathology, especially in a patient with a headache that is
progressively worsening.

Laboratory studies
The patient with a chronic or recurrent headache that is getting worse with time deserves
consideration for CT scan.

240

MANAGEMENT
The effort taken to perform a careful history and physical examination are well worth the
time, for these methods remain the best means available for the accurate diagnosis
of headache.
For benign causes, symptomatic management like analgesics should be given. Treatment
of specific causes e.g. sinusitis, upper respiratory tract infections and migraine.
For the patient in whom headache is a manifestation of a deep-seated conflict,
psychotherapy is often necessary.

RECURRENT HEADACHES IN CHILDREN


Headache in childhood that is not typical of migraine and not due to structural
intracranial pathology is common. In some cases there is strong clinical evidence that
acute or chronic psychological stress is important in the genesis of the headache and in a
small number of children frank psychiatric illness such as depression is present. However,
in a not insignificant number of cases, the basis of the headache remains uncertain.
It is of vital importance to remember that a stressful family or school situation does not
protect the child from having significant intracranial pathology as the basis of headaches.
Headaches due to psychological stress and psychiatric illness occurs in several different
situations with quite different implications for management.

INDICATIONS FOR REFERRAL


Urgent Situations
Any patient with evidence suggesting meningeal irritation, increased intracranial
pressure, an A-V malformation or malignant hypertension obviously requires prompt
hospital admission.
Presence of symptoms suggestive of an intracranial mass lesion requires hospital referral.
The ophthalmologist needs to be consulted at once if acute glaucoma is felt to be the
cause of an acute orbital headache.
Non-Urgent Situations
Referral to neurologist for the rare case of migraine refractory to treatment, the
patient with muscle contraction or psychogenic headache that requires reassurance.
Dental consultation is indicated if temporomandibular joint problems appear refractory
to conservative therapy.
Referral for a vision check and assessment of the need for refraction.

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RECURRENT HEADACHES
May require referral for a more thorough assessment to exclude space occupying lesion.
References
1. Lane RJM. Is it migraine? The differential diagnosis. Update 1991 Nov;760-72.
2. Pruitt AA. Approach to the patient with headache. in: Primary Care Medicine, 3rd ed; Philadelphia: Lippincott,
1995:821-829.
3. Aminoff MJ. Headache. in:Current Medical Diagnosis 1991. London: Prentice-Hall; 677-680.

CHAPTER 18

INSOMNIA

DEFINITION
Insomnia is defined as the complaint of long-standing (more than 2 weeks) trouble falling
or staying asleep that is associated with compromised daytime functioning. In this
framework insomnia is the end point of disorders in the initiation and maintenance of
sleep (DIMS).
Normal Sleep
By using the polysomnogram (a continuous, all-night recording of a patient's respirations,
eye movements, electroencephalogram (EEG), muscle tone, blood oxygen saturation and
electrocardiogram), normal sleep can be divided into two basic phases: REM, or rapid eye
movement sleep, and nonREM (NREM). REM is a state of mental and physical activation.
Pulse and respiration are increased but muscle tone is diminished, so little body
movement occurs. The brain is active, and the EEG shows a pattern similar to that seen
during waking. Most dreaming occurs during REM.
In contrast, NREM is a time of deep rest. Pulse, respiration, and EEG all slow, and the
patient goes from light sleep, called stages I and 2, to deep or delta sleep, called stages 3
and 4. REM and NREM normally cycle in a reciprocal pattern, giving a typical
"architecture" to the polysomnogram. The entire cycle lasts about 90 minutes, and is
repeated smoothly four or five times during the night.
There is no polysomnographic pattern pathognomonic of insomnia. Some insomniacs
have slightly shorter than normal sleep times, some have less stages 3 and 4 sleep, but
most have normal-appearing polysomnograms. Recent data suggest that slight disruptions of the normal smooth cycling caused by frequent brief arousals may be related to
subjectively unsatisfying sleep. Other data indicate that psychological variables strongly
influence an insomniac's perceptions of the time spent in bed and its influence on
satisfaction during the day.

242

RELEVANCE TO GENERAL PRACTICE


The complaint of disordered sleep is common and it is estimated that as much as
a quarter of the adult population has sleep problems.
The elderly and those with psychiatric problems are more likely to complain
of sleep problems.
The primary care doctor needs to be skilled in the assessment and therapy of insomnia,
not because the problem is extremely common and a cause of considerable misery but
also because it is an important precipitant of excessive drug use and habituation.

CAUSES
These are shown in Table 1.

WORKUP
History
A careful clinical history, which systematically addresses the host of possible etiologies of
DIMS, is the key to the workup of insomnia.
Close attention must be given to medication, drug, and food intake, current
mental and physical status, past and family medical and psychiatric history, as well as
occupational and travel patterns.
Whenever possible, interviewing the spouse, bed partner, or family member is of great value.
The use of a sleep log, or diary, which includes time in bed, estimate of time asleep,
any awakenings, time of morning arousal, estimate of sleep quality, and comments
on unusual events, recorded by the patient directly upon getting up each morning,
should be standard procedure in every insomnia workup.
Those who are natural "short sleepers" (regularly have less than 7 hours of wellmaintained sleep and have no problems other than too much time on their hands at
night) likewise do not have insomnia.
Those who have a brief, time-limited disturbance or sleep related to stressful events in
their lives also do not have "insomnia." The same pertains to the normal elderly
patients who experience the decline in total sleep time, depth, and continuity which is
a natural part or the aging process.

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Table 1: Disorders in Intiation and Maintenance of Sleep (DIMS)


Psychiatric Disorders--50%

Affective disorders: major depression, dysthymic disorder, manic


depressive disorder.

Character disorders: Anxiety, obsessive-compulsive, borderline,


narcissistic character disorders.

Psychosis: schizophrenia.
Drug and Alcohol Abuse--10% to 15%

Sedatives: alcohol, benzodiazepines, barbiturates, narcotics.

Stimulants: caffeine and stimulant xanthines in coffee, tea, cola, and chocolate.

Anti-asthmatics, decongestants: terbutaline, aminophylline, phenyl propanolamine.

Cigarettes.
Medical/Surgical Problems--10%

Cardiovascular: nocturnal angina, orthopnoea, PND.

Respiratory: COPD.

Renal: UTI, urinary frequency.

Endocrine: hyperthyroidism and hypothyroidism.

Endocrine: hyperthyroidism and hypothyroidism.

Delirium: dementia, infection, metabolic derangement, medication toxicity


(e.g., anticholinergic delirium secondary to OTC sleep aids).
Primary Sleep Disorder--10% to 20%

Sleep apnea.

Nocturnal myoclonus.

Phase shift (night shift, jet lag)


Other--10%

Idiopathic insomnia.

Psychophysiologic, or conditioned, insomnia.

Persistent complaint without objective evidence.

Unusual polysomnographic patterns: alpha-delta sleep.


Source: Weilburg JB. in: in: Goroll et al. Primary Care Medicine, 3rd ed. Philadelphia: Lippincott, 1995: 1063.

Psychiatric disorders are believed by most experts to be the underlying cause of DlMS
in about half of all insomnia cases.
- Among the psychiatric etiologies, the affective disorders -- major depression and
dysthymic disorder (mild depression, or the old "neurotic" depression) -- account
for approximately 50% of the cases. Patients suffering from dysthymic disorder
typically complain of feeling tired. They often feel irritable, have difficulty falling
asleep, and report that they cannot get enough sleep to feel rested. Sometimes
they deny feeling sad or depressed and focus only on their physical complaints.
Indeed, insomnia may be the major presenting complaint in many of these patients.
Patients with major depression complain of either difficulty falling asleep or of
waking in the early morning and being unable to return to sleep. Diurnal variation
of mood is often noted.
- Character disorders make up about 40% of the other psychiatrically based DIMS.
Patients with anxiety and obsessive disorders frequently have great difficulty falling
asleep because they lie in bed and ruminate. They have difficulty falling asleep
because they focus on their lack of sleep as the source of all their troubles. They lie
in bed, furiously trying to make themselves sleep. Such patients may use their
insomnia as a justification for their inability to function or to improve their lives.

244

- Active psychosis of any type e.g. schizophrenia produces disturbed sleep and
accounts for the other 10% of psychiatric insomnia. The other signs and symptoms
of psychotic illness appear along with the insomnia, facilitating recognition of
this problem.
The remaining 50% of DIMS are nonpsychiatrically based. Drug and alcohol abuse are
responsible for about 10 to 15% of this group. Alcohol induces sedation, but the
resulting sleep is often shallow, fragmented, and not restorative. Alcoholics can have
prematurely "aged" sleep (i.e., shallow and short) during and for months after
cessation of drinking. Sedatives, such as most benzodiazepines and especially
barbiturates, when used on a regular, long-term basis lead to shallow, fragmented
sleep. Rebound insomnia and rebound anxiety prompt reuse, and tolerance leads to
dose escalation, so patients get caught in a vicious cycle. Sedatives and alcohol depress
respiratory function, which can lead to very poor quality sleep in patients with sleep
apnea. Stimulant drugs such as amphetamine or methylphenidate, activating
antidepressants such as phenelzine or protriptyline, and the phenylpropanolamine
found in many over-the counter decongestant, cold, and diet remedies can induce
significant difficulty falling asleep. Terbutaline, aminophylline, and other antiasthmatics can produce insomnia. The caffeine and stimulant xanthines found in tea,
coffee, cola drinks, and chocolate may produce difficulty falling asleep in most people
if used in large enough quantities, and if used at all in some who are sensitive. Finally,
the nicotine and other substances found in cigarette smoke have been shown to
disrupt sleep induction and continuity.
Medical problems of all types can cause insomnia, and make up approximately 10% of
all the DIMS. Pain, of whatever source, is a frequent cause of insomnia in the elderly.
Delirium is another frequent cause of insomnia in the elderly. Dementia, unrecognized
infection, and even medication toxicity (sometimes secondary to the anticholinergic
agents used to induce drowsiness in over-the-counter sleep remedies) are common
sources of delirium. Cardiovascular dysfunction leading to orthopnea, paroxysmal
nocturnal dyspnoea, or nocturnal angina; chronic obstructive pulmonary disease;
hyperthyroidism, and urinary frequency also can produce insomnia.
Primary sleep disorders make up approximately 10% to 20% of DIMS. Ask the
patient's bed partner for observations of cessation of respiration (sleep apnea) or
twitching of legs (nocturnal myoclonus or restless legs syndrome). These produce poor
quality sleep and lead to the complaint of "insomnia".
Physical Examination
A full examination should be conducted to exclude medical causes of insomnia.
The effects of alcoholism and addictive drugs if any, should be noted.
Investigations
These will depend on the nature of medical problems detected.
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MANAGEMENT
Patient Education
The overall promotion of good "sleep hygiene" is useful for many patients.
- Establishing a regular bed and wake time
- Avoiding any and all naps
- Having regular exercise (although not at night)
- Avoid using the bed for reading or watching TV, and getting in bed only when
ready for sleep (leaving bed if sleep is not forth-coming)
- Avoiding caffeinated foods, stimulants, cigarettes, and alcohol
- Avoid trying too hard to fall asleep
Disabusing patients of the myth that everyone must have 8 hours of sleep every night
makes many people feel relieved. Also, informing patients that much of the time they
spend in bed believing they are "only drowsy" is time spent actually, in the lighter
stages of sleep can ameliorate some patients' frustration.
Therapeutic Recommendations
If the DIMS is related to affective disorder, begin a sedating tricylic antidepressant, such
as amitriptyline 25 mg, to be taken an hour before bedtime every night for at least a
month. Increase the dose as needed.
If the DIMS is related to anxiety or other personality disorder, offer psychiatric
consultation and treatment, require close adherence to good sleep hygiene. If the
insomnia persists and daytime anxiety is also a problem, begin therapy with a beforebed dose of flurazepam (15 mg).
If the DIMS is related to drug, alcohol, or other substance use, clearly inform the
patient that improvement is based on proper substance withdrawal and the
maintenance of abstinence. Supervise withdrawal; support the patient's efforts at
maintaining abstinence. Try to avoid treating "dry" alcoholics with sedatives, as this
may rekindle their drinking.
Treat any underlying medical DIMS; a brief course of benzodiazepine therapy after
treatment can re-establish the sleep pattern and boost patient confidence.
Use reduced dose and caution when prescribing sedatives for the elderly.
Withdraw benzodiazepine therapy by slowly tapering the dose over 1 to 2 weeks
to avoid rebound insomnia if drug therapy has been used daily for more than 6 to 8
weeks.
Refer patients with primary sleep disorders, or those who are refractory to all efforts,
for evaluation by a sleep laboratory.

246

INDICATIONS FOR REFERRAL


Referral to a sleep laboratory if primary sleep disorder (sleep apnea or nocturnal
myoclonus) is suspected, or if careful workup fails to reveal the source of the DIMS.
Psychiatric consultation is indicated only when character problems interfere with
diagnosis or management, or if the nature of a suspected mental or emotional
problem is obscure.
References
1. Weilburg JB. Approach to the patient with insomnia. in: Goroll et al: Primary Care Medicine, 3rd ed, 1985;
1062-1066.
2. Fleming J A E & Warneboldt R B. Multiple Sleep Pathologies Presenting as Depression.
3. Can Fam Physician 1990, 36:1185-9.

CHAPTER 19

PERSISTENTLY CRYING BABY

RELEVANCE TO GENERAL PRACTICE


1. A persistently crying baby requires the doctors full attention to sort out what is the
underlying problem and the consequences of the crying.
2. Some mothers feel that the baby is abnormal because he cries so much; they may be
right, particularly if the baby does not normally behave like this.
3. Most of the cases seen are of benign cause but the important point is not to miss a
serious cause.
4. A persistently crying child may cause strained relationships at home. Not many parents
can stand a baby crying intermittently throughout the night. Their tolerance therefore
is often exceeded.

CAUSES
Infant and Younger Child

Crying without disease


This may be due to
- hunger, thirst
- discomfort - cold, heat,
- wet nappies - urine or soiled
- pain -- e.g., from local reactions to immunisation
- wants to be picked up - need for physical contact
- colic
- feeding problem -- e.g., hole in teat too small or too big

Crying with disease


The following needs to be considered:
- infection -- e.g., upper respiratory tract infection, meningitis, acute otitis media,
urinary tract infection
- intussusception, strangulated hernia, torsion of the testes
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

The Older Child


The older child may also cry from:
- fatigue
- hunger
- frustration
- scared of being left alone
- separation from parents
- pain
- infection

WORKUP
The parents are likely to be harassed and anxious. A sympathetic approach helps to
diffuse the tense situation.
History
Evaluation of the history should include the following:
- Clarify whether the baby normally cries a lot. If the baby does not normally cry like this
it is important to look for a physical cause. History of outbursts of crying, drawing their
knees and legs up may suggest the possibility of colic, wind or intussuception.
Enquire for symptoms of constipation, diarrhoea, vomiting, passing blood in stools
and poor feeding.
- Once serious causes have been excluded from the history, look for benign causes.
Ask systematically about feeding patterns and difficulties if any; frequency of changing
of wet nappies; and the sleeping environment. Often parents have changed types of
feed, used infant colic mixtures and made changes in the sleeping environment -all in vain.
- Finally, attention should turn to the parents if a serious cause is not likely. Allowing the
parents opportunity to vent their difficulties help in the management of the problem.
Questions like 'You must be feeling pretty desperate" or "you must find it difficult to
cope" are useful in getting them to speak up. Explore how do they feel about each
other and the baby? Are they staying alone? How do household members react to the
crying? Are they helpful, complaining or interfering? These questions will help to
uncover any social and emotional problems.
Physical Examination
A thorough physical examination is necessary.
- Is there a fever?
- Look for signs of serious illness like poor peripheral perfusion, dehydration, respiratory
embarrassment or petechial rash, or neck stiffness to suggest meningitis.
- The abdomen should be examined to exclude strangulated hernia or torsion of the
testes. Are there faecal masses?
- Examine the anus for anal fissures.
248

Observe the baby feeding. Too small a teat or wrong positioning of the feeding
bottle resulting in air swallowing and wind colic is often the cause of discomfort and
persistent crying.

MANAGEMENT
Once serious illness can be excluded and a benign cause is present, attention to this
will be all that is necessary:
Hunger: Feeding advice for babies who cry because of hunger. Some need to be fed
more than three-hourly. Feed times may need to be adjusted.
Thirst: A drink of water instead of an extra bottle may pacify the baby.
Wet nappies: Changing wet nappies more frequently may be needed.
Feeding problems: Hole in the teat may be too big or too small; wrong positioning of
the bottle so that the baby sucks in too much air is commonly overlooked.
Emotional need: Babies like to be with their mothers and like the warmth of contact;
picking them up may stop the crying. Sleeping in the same room as the mother may
have a quietening effect.
Wind, colic: Parents should be taught how to burp the child after every food,
sometime they may need to burp the child more than once.
In severe cases of infantile colic, dicyclomine hydrochloride (Infacol) may be of help.
Dosage:
- infant under 3 months -- 1 ml diluted with an equal volume of water given before
meals three to four times a day.
- infant above 3 months -- 2.5 ml before meals four times a day.
Discussion of parental concerns and coping skills should be part of management.
The natural history of persistent crying in infancy is improvement over time.
Reassurance and supportive management may be all that is necessary.
A variety of behavioural techniques have been described to help soothe the
crying baby:
- rocking the baby
- walking while holding the baby
- soothing sounds like singing or playing music
- taking the baby for a ride in the car or stroller.
None is superior over another. Each could be tried to see which works.
Where the child is unwell or where serious organic disease cannot be excluded, referral
to hospital should be done.

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INDICATIONS FOR REFERRAL


The ill child is suggested by the history of altered consciousness, respiratory distress,
bile stained vomiting, abdominal distention, bloody stools and excessive pallor.
Physical examination may provide supporting information of poor peripheral
perfusion, obvious respiratory embarrassment, petechial rash or hypotonia in
acute infections.
A child that is fretful also warrants admission for observation if serious disease cannot
be excluded.
References
1. H B Valman , The First Year of Life. Brit Med J, 1980, 71-74.
2. Field D, Harris A and Stewart A. How I treat a crying baby. The practitioner 1990; 234:317-320.
3. Parkin PC, Schwartz CJ, Manuel BA. Randomised controlled trial of three interventions in the management of
persistent crying in infancy. Paediatrics 1993 Aug 92(2):197-201.
4. Treem WR. Infant colic. A paediatric gastroenterologists perspective. Paediatric Clinic North Am 1994 Oct;
41(5):1121-38.

CHAPTER 20

RED EYE

RELEVANCE TO GENERAL PRACTICE


The red eye is the most common eye problem encountered by the primary
care physician.
Patients present with a wide range of conditions that are characterised by a red eye.
Most are fortunately self-limiting or easily treatable conditions.
There is a need to be alert for the occasional serious red eye.

CAUSES
These can be classified into lid or eye conditions and of gradual or sudden onset
(See Table 1)1.
Table 1. Causes of the Red Eye
RED EYE OF GRADUAL ONSET
Conjunctivitis
viral, bacterial or chlamydial conjunctivitis
allergic conjunctivitis
prolonged wearing of contact lens
Problems of the eye lid
blepharitis
stye
Meibomian cyst, chalazion
entropion and ectropion
dacryocystitis or dacryoadenitis
orbital cellulitis

Keratitis
viral or bacterial keratitis
marginal keratitis
Iritis and anterior uveitis
Episcleritis
RED EYE OF SUDDEN ONSET
Spontaneous subconjunctival haemorrhage
Foreign body
Arc eye
Acute glaucoma
Blunt trauma
Chemical burns

Source: Khunti K. Update Jun 1, 1995:751 (Arranged in order of frequency as seen in general practice)

250

Red Eye of Gradual Onset


Conjunctivitis. Conjunctivitis is the most common cause of a red eye.
Viral conjunctivitis. Viral conjunctivitis is characterized by watery, sometimes mucoid
discharge, often beginning in one eye but spreading to the other eye several days later. It
may be associated with fever and pharyngitis particularly in children. Periauricular
adenopathy is common.
Bacterial conjunctivitis. Bacterial conjunctivitis is characterized by a mucopurulent
discharge and usually occurs unilaterally without pre-auricular adenopathy. The eyelids
have a thick crust on them after a night's sleep. Pneumococcus, streptococcus,
staphylococcus and haemophilus are common causal agents.
Allergic conjunctivitis. Allergic or atopic conjunctivitis is characterized by itching,
tearing and redness of both eyes and may be associated with atopic dermatitis or
vasomotor rhinitis.
Contact lens conjunctivitis. This is common as the number of contact lens users are
increasing. It is usually a bacterial conjunctivitis.
Chemical keratoconjunctivitis. Chemical keratoconjunctivitis is a common industrial
injury due to a splash of an irritant solution. The conjunctiva is uniformly red, the pupil
constricted, vision decreased, the cornea may be hazy and the eye painful because of
spasm of the iris. Alkaline solutions are more dangerous than acidic ones.
Malingering. Occasionally the doctor may come across one who fakes a diseased red
eye by rubbing his eyes with irritant substances such as tobacco. The eye is red and may
have chemosis. The cue is that there is much tearing that is clear and not mucoid or
purulent; however, allergic conjunctivitis can also appear like this.
Eye lid conditions. Included are blepharitis, stye, meibomian abscess, chalazion,
ectropion and entropion and orbital cellulitis.
Blepharitis. Blepharitis is inflammation of the lid margin. In the mild squamous variety,
skin scales and grease line the lid margin which is slightly inflamed. In the ulcerative
variety, the lash follicles are inflamed and the lid margin is ulcerated.
Stye. A stye is an inflamed lash follicle.
Meibomian abscess. A meibomian abscess may form in a meibomian gland forming a
visible swelling on the eyelid.
Chalazion. After the acute inflammation in a Meibomian gland has subsided, a
Meibomian cyst may form. This is called a chalazion. Some may resolve spontaneously so
some period of observation is in order.

251

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

Entropion and ectropion. An ectropion or entropion can cause a red eye. Entropion may
do so because of the conjunctival and corneal irritation by in-turned lashes and ectropion
because the everted conjunctiva and stagnant pool of tears become secondarily infected.
Keratitis and corneal ulcers. Some conjunctivitis are associated with corneal
involvement. There are many causes of keratitis and corneal ulcers: bacterial ulcers
secondary to foreign body, blunt injury or contact lens wear, exposure secondary to facial
palsy, thyrotoxic eye disease and herpes simplex infection.
Iritis and Uveitis. This may be secondary to systemic disease or more likely, of unknown
cause. One or both eyes may be affected. Photophobia and impaired vision are prominent
complaints. There is ciliary injection, altered iris color, smaller pupillary size with sluggish
light response in the affected eye.
Episcleritis and scleritis. Episcleritis is usually a benign inflammation of superficial
episcleral vessels. Sometimes seen in association with collagen diseases, gout, allergic
conditions and psoriasis. The patient complains of tender irritated eyes, the conjunctiva
shows local raised areas of redness. Scleritis is inflammation of deeper layers of the sclera.
In most cases no specific cause is found but it may occur as a feature of systemic lupus
erythematosus, rheumatoid arthritis or polyarteritis nodosa.
Red Eye of Sudden Onset
Subconjunctival haemorrhage. The cause is a rupture of subconjunctival vessels either
spontaneously, or as the result of straining at stools or from coughing, often in an elderly
person. In patients receiving anticoagulant medications, spontaneous subconjunctival
haemorrhage may be a sign of overdose.
Foreign body. Foreign body on the bulbar conjunctiva or under either the upper or lower
lid may result in copious tearing and conjunctival injection.
Acute glaucoma. Acute glaucoma is an ocular emergency that presents as a painful, red
eye with prominent ciliary flush. The patient reports cloudy vision, coloured rings around
lights, unilateral headache, nausea and vomiting.

WORKUP
History
The patient should be asked specifically about the onset and progression of the red eye.
Key symptoms to ask are the presence if any, of visual impairment, discharge, pain,
photophobia, grittiness and itch. A past history of eye problems and any recent injury or
foreign body entry should be sought. The patient should be asked if any of the family
are affected.

252

Physical Examination
If the diagnosis is not obviously a lid problem, bilateral conjunctivitis or a subconjunctival
haemorrhage, then a complete examination of the eye using a bright light is important.
The distribution of the red eye should be noted.
The lid margins should be inspected for crusting, ulceration, ectropion or entropion
and infection as well as localised lesions such as stye, dacryocystitis or dacryoadenitis.
Bilateral eyelid edema may be caused by an allergy.
The upper and lower eyelids should be retracted to and the eye carefully examined to
exclude any foreign bodies.
The conjunctiva should be inspected for redness, ciliary flush and foreign body.
The palpebral conjunctiva should not be overlooked.
Corneal ulcers, hypopion and corneal opacity should be looked for.
The pupil size should be checked. Abnormality is seen in iritis or glaucoma.
If there is any suggestion of visual impairment or if there is any diagnostic doubt, it is
essential to measure the visual acuity.
Fundoscopy should be done if there is history of injury by a flying foreign body.
Table 2 summarises the chief features in differentiating conjunctivitis from iritis, keratitis
and acute glaucoma.
Investigations
For purulent discharges, culture and sensitivity should be done.

MANAGEMENT
The management of the patient general practitioner can provide symptomatic relief or
specific treatment for the following:
Viral conjunctivitis -- hydrocortisone or betamethasone eyedrops. Steroid eyedrops are
contraindicated if a corneal ulcer is present; consider referring such patients to the
ophthalmologist for further management.
Bacterial conjunctivitis -- antibiotic eyedrops.
Allergic conjunctivitis -- antihistamine eyedrops or mild steroid eyedrops.
Contact lens conjunctivitis -- advice on proper care of the lenses and avoid lens wear
until conjunctivitis subside.
253

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

Stye, cellulitis, meibomian inflammation -- systemic antibiotics with or without incision


and drainage may be necessary.
Superficial foreign body - dislodging and removing this with a moistened cotton bud
may be tried initially for a very superficial foreign body.
Removal of a lightly embedded foreign body may be attempted by the use of a syringe
needle tip under good lighting if one is sufficiently experienced; if that fails the patient
should be referred.

INDICATIONS FOR REFERRAL


Red eye associated with eye pain, visual disturbance, signs of acute glaucoma or iritis
should be referred immediately.
Corneal ulcer -- particularly, the dendritic ulcer should be regarded as an emergency.
Gonococcal infection of the newborn is a serious potentially blinding condition which
requires intensive treatment. It is characterised by profuse mucopurulent discharge.
Foreign bodies and
immediately referred.

more

than

superficial

eye

injuries

should

also

be

A conjunctivitis that is not recovering after initial treatment of 2-3 days or even earlier;
if in doubt, one should not hesitate to refer.
References
1. Khunti K. Eight-minute consultation: The red eye. Update 1995 Jun; 751-752.
2. Steinert RF. Evaluation of the red eye. in: Goroll et al. Primary Care Medicine, 3rd ed. Philadelphia: Lippincott,
1995:956-960.
3. Dobson PM, Harton RC. Inflammatory eye disease. Update 1989, 1003-1008.
4. Glasspool MG. Incision of eyelid cysts. Update 1985:44-47.

254

Table 2. The Red Eye


Clinical
feature

Conjunctivitis

Iritis

Keratitis
(corneal
inflammation
or foreign
body)

Acute
glaucoma

Vision

Normal or
intermittent
blurring that
clears on
blinking

Slightly
blurred

Slightly
blurred

Marked
blurring

Pain

None or
minor and
superficial

Moderately
severe and
aching

Sharp,
severe,
foreign
body
sensation

Very
severe;
frequently
nausea and
vomiting

Photophobia

Nil

++

Nil

Discharge

Usually
significant
with crusting
of eye lashes

None

None
to mild

None

Pupil size

Normal

Constricted

Normal or
constricted

Semi-dilated
and fixed

Conjunctival
injection

Diffuse

Circumcorneal

Circumcorneal

Diffuse with
predominant
circumcorneal

Cornea

Clear

Clear or

Opacification
present;
altered light
reflex;
positive
flourescein
staining

Hazy; altered
light reflex

Pupillary
response
to light

Normal

Minimal
further
constriction

Normal

Minimal or no
reaction of
dilated pupil

Anterior
chamber
depth

Normal

Normal

Normal

Shallow

255

SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE

CHAPTER 20

256

RED EYE

1 Respiratory & Cardiovacular Disorders


2 Gastrointestinal Disorders
3 Renal & Haematological Disorders
4 Psychological Disorders
5 Skin Disorders
6 Bone & Joint Disorders
7 Nervous System, Eye & Ear Disorders
8 Nutritional, Metabolic & Endocrine Disorders

SECTION 07

MEDICAL TECHNICAL SKILLS & CARE IN


SPECIFIC SITUATIONS

257

SECTION 07
SECTION 07 MEDICAL TECHNICAL SKILLS & CARE IN SPECFIC SITUATIONS

CHAPTER 1

RESPIRATORY
& CARDIOVACULAR DISORDERS

Outline
Symptoms and approach
Respiratory Infections
Non-Infective respiratory disorders
Cardiovascular disorders

SYMPTOMS AND APPROACH


Approach to breathlessness, cough, sorethroat and chest pain are dealt with under
Common Symptoms (See Section 6).

RESPIRATORY INFECTIONS
Upper Respiratory Tract Infection (URTI)
Upper respiratory tract infection can affect the pharygnx, tonsils, sinuses, and middle ear.

Pharyngitis
A clinical score to differentiate between bacterial and viral infection by using a clinical
score. The following clinical findings are weighted equally (1 point each). A total score
is computed.
Table 1. Clinical Score To Differentiate Between Viral and Bacterial Sore Throat
SCORE

CRITERIA

1 point
1 point
1 point
1 point
1 point
- 1 point

History of temperature or measured temperature >38 C


No cough
Tender anterior cervical adenopathy
Tonsillar swelling or exudates
Age 3-14 yr
Age > 45 yr

Ref: After Mclsaac et al.

Clinical significance
A score of <2 points rules out bacterial infection. Treat such patients symptomatically.
A score of 4 strongly indicates bacterial infection. Treat such patients with antibiotics.
The recommendation of a Singapore workgroup on antibiotic use in adults is that the
patient with a score of 3 should be re-assessed in 72 hours (MOH, 2000).

Influenza
Influenza can be diagnosed when the following four criteria are present: Abrupt onset of
symptoms; Fever (also a marker of severity); Constitutional and respiratory symptoms
258

especially cough; No specific localizing respiratory signs; Influenza known to be


circulating in the patients environment. It is important to look out for complications in
the following group of at-risk patients viz. immuno-compromised, cardiac and chronic
obstructive airway disease (COLD) patients. If fever persists more than 4 days with
productive cough and WBC more than 10,000 per cmm, secondary bacterial infection
should be suspected.

Epiglottitis
Acute epiglottitis should be considered in a sore throat associated with stridor or
respiratory difficulty. Urgent referral to hospital is mandatory and attempts to examine the
throat should be avoided. Epiglottitis is a disease affecting all ages. (Munro et al, 1994).

Acute Laryngitis
In adults with acute laryngitis, the cause may be bacterial or viral. If antibiotic is decided,
the drug of choice is erythromycin (Schalen et al, 1993).

Acute Sinusitis
No single symptom or sign is predictive of acute bacterial sinusitis. The five best predictors
are toothache or facial pain, poor response to decongestants, history of coloured nasal
discharge, purulent nasal secretion and abnormal transillumination results. When 2 or 3
predictors are present, a sinus radiograph helps to confirm or rule out acute sinusitis.
Amoxicillin or amoxicillin-clavulanate should be used in the first line treatment of acute
bacterial sinusitis. Second line therapy can be used if a patient is allergic or has not
responded to first line therapy. Both clarithromycin and azithromycin have been shown to
be as effective as amoxicillin.

Otitis Media
Acute otitis media is defined as the presence of fluid in the middle ear in association with
signs or symptoms of acute local or systemic illness. Accompanying signs and symptoms
that meet the criteria of otitis media include otalgia, fever, otorrhoea or a bulging yellow
or red tympanic membrane. There is no one preferred agent for all infants and children
with acute otitis media. Amoxicillin is favoured by many for initial treatment because of its
long history of safety and effectiveness. In communities where penicillin resistant
pneumococci are prevalent, larger doses of amoxicillin (i.e. 60 to 90 mg/ kg daily in 2 or 3
doses) should be effective.
References for further reading
Bent S et al. Antibitoics in acute bronchitis: a meta-analysis. AJM Jul 1999; 107(1):62-67.
Gonzales R et al. Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the
treatment of uncomplicated acute bronchitis in adults. JAMA 28 April 1999; 281(16):1512-1519.
Sethi S. Infectious etiology of acute exacerbations of chronic bronchitis. Chest May 2000; 117(5) Supplement
2:380S - 285S

Acute Bronchitis
Acute bronchitis refers to the acute or subacute onset of productive cough in a patient
with no history of chronic pulmonary disease, and without evidence of pneumonia or
sinusitis (Bent et al, 1999). Patients vary in the degree of purulence, fever and retrosternal
discomfort. There may be feeling of chest tightness. The current thinking is that in the
259

SECTION 07 MEDICAL TECHNICAL SKILLS & CARE IN SPECFIC SITUATIONS

young and otherwise fit person, antibiotics are not routinely indicated but close follow-up
is essential. In the patient who is initially unwell or do not improve over the next 24-48
hours, a bacterial cause should be considered and antibiotics be given. The choice is as for
the CAP patient in category I or category II (see table 3).
Acute Exacerbation Of Chronic Bronchitis
This is a subjective increase from baseline of one or more chronic symptoms of shortness
of breath, cough, sputum production, sputum purulence, and sputum tenacity (Sethi.
2000). Chronic bronchial disease predisposes patients to more frequent and more severe
episodes of acute bacterial bronchitis (ABE). Prompt use of antibiotics empirically in these
patients who demonstrate a fever or a change in sputum character is of benefit. Choice
of antibiotics is guided by resistance patterns. Dosing is at the upper range of
recommendations, and the chosen antibiotic should be given for a 10-14 day regimen.
Patients should be re-evaluated if symptoms and physical findings do not return to
baseline after 5-7 days. The background therapy for acute exacerbation of chronic
bronchitis is important: stop smoking, avoid polluted environment, increase fluid intake,
humidify the ambient atmosphere (if possible), obtain physiotherapy to loosen secretions,
use bronchodilators when obstruction is present, and treat any associated asthma
(Chodosh, 1991).
Community Acquired Pneumonia (CAP)
Pathogens typically associated with CAP are Streptococcus pneumoniae, group A
streptococci, Haemophilus influenzae, Moraxella catarrhalis, and, less often, Klebsiella
species. In patients recovering from viral infection and occasionally in diabetic patients,
Straphylococcus aureus infection is found.

Diagnostic Features
The diagnostic features of pneumonia are fever (> 38C), cough (+ purulent sputum) and
new infiltrate on the chest radiograph. The most valuable examination maneouvres in
detecting pneumonia were unilateral crepitations and crepitations in the lateral decubitus
position. Note that pneumonia can only be diagnosed reliably with a chest radiograph
(Wipf et al, 1999). An abnormality on the chest film consistent with infection is
mandatory for diagnosis.
The clinical chest physical examination is not sufficiently accurate on its own to confirm or
exclude the diagnosis of pneumonia (sensitivity 47%-69% and specificity 58%-75%).
Patients with fever and cough but normal chest films have either acute sinusitis or
bronchitis and may not need antibiotic treatment.

Management
The management of CAP hinges on risk stratification and appropriate antibiotics.
Risk Stratification Low-risk patients (Categories I & II) experience very good outcomes
and may be safely managed on oral antibiotics with proper follow-up and monitoring as
outpatients. These low-risk patients may constitute up to 75% of all patients with CAP.
260

Table 2. Risk Stratification Criteria and Empirical Treatment


RISK CATEGORY
& PLACE OF
TREATMENT

CRITERIA

EMPIRICAL TREATMENT

Category I
Low risk
outpatient
treatment is
adequate

Less than 60 years


Clinically mild disease
No radiological signs
of severity (multilobar
infiltrates, pleural effusion)
improved with initial
treatment.

Outpatient treatment
Initial treatment --oral
macrolide (See Table 2)
Review within 24-48 hours
to ensure they have
improved

Category II
Low risk
consider
outpatient
treatment

Less than 60 years with


co-morbidity or 60
years and older with
no co-morbidity
No physical, radiological
signs of severity;
in borderline cases do
laboratory tests (Table 3)

As for category I

Category III
Intermediate
risk

Elderly (60 years and


older with co-morbidity
and all patients who
show physical and
radiological signs of
clinical severity.
In cases of uncertainty,
presence of any of the
abnormalities in Table 3
is an indication for
hospitalisation

Hospital admission
Initial treatment - iv
b-lactam + / erythromycin or
new macrolide
or new quinolone

Category IV
High risk Intensive
care treatment

Those who did not


respond to initial therapy.
Those with high
risk features

Admit ICU
iv antibiotic combination

Source: MOH Clinical Practice Guidelines 1/2000

Antibiotics
Initial choices in empirical antibiotic treatment is summarised in Table 2. There is no
evidence to suggest that any single regimen is superior to the others. Where possible, the
least expensive treatment should be administered.
Atypical Pneumonias
The three most common nonzoonotic atypical pneumonia are: legionnaires disease (caused
by Legionella species), mycoplasma pneumonia (caused by Mycoplasma pneumoniae), and
Chlamydia pneumoniae (strain TWAR) pneumonia. The three common zoonotic atypical
pneumonia are psittacosis (caused by chlamydia psittaci), Q fever (caused by Coxiella
burnetii), and tularemia (caused by Francisella tularensis).The main problem for physicians
has been to differentiate typical bacterial from atypical community-acquired pneumonia.
This distinction is important because of therapeutic implications.

261

SECTION 07 MEDICAL TECHNICAL SKILLS & CARE IN SPECFIC SITUATIONS

Beta-lactam antibiotics are the drugs of choice for typical community-acquired


pneumonia, and doxycycline or erythromycin is used if the probable clinical diagnosis is
an atypical pneumonia. If a case could not be established as typical or atypical
pneumonia, doxycycline or erythromycin is added to the beta-lactam regimen.
Monotherapy is highly desirable, since adding a second antibiotic greatly increases the
cost of treatment as well as the risk of side effects and drug resistance.
References and further reading
MOH. Community acquired pneumonia. In: Clinical Practice Guidelines, Singapore: MOH, 1/2000.
George A. Sarosi,. Atypical pneumonia Why this term may be better left unsaid. Postgraduate Medicine 1999
Apr;105(4):131-2, 135-8
Cunha BA and Ortega AM. Atypical pneumonia. Postgraduate Medicine 1996. 99:1:123-132.

Table 3. Empirical Antibiotics For The Initial Treatment of CAP.


Categories I & II
RISK CATEGORY
OUTPATIENT
(Oral)
Category I *
Macrolide :

Category II *
Macrolide
or 2nd generation
cephalosporin
or Penicillin plus
beta-lactamase
inhibitor

ANTIBIOTIC CHOICE

DOSAGE

Erythromycin
Erythromycin ES
Clarithromycin
Azithromycin Doxycycline
or Tetracycline

500
800
250
500
200
100

mg
mg
mg
mg
mg
mg

6H x 7- 10d
bd x 7- 10d
bd x 7- 10d
x 3d
om x 7- 10d
bd x 7- 10d

(as above)
Cefuroxime

500 mg bd x 7- 10d

Amoxicillin- clavulanic acid


Ampicillin- sulbactam

375 mg tds x 7- 10d


750 mg bd x 7- 10d

Note: Outpatient treatment (Categories I & II) should cover Streptococcus pneumoniae and Mycoplasma
pneumoniae. Either macrolides or tetracycline fulfills this dual role. Source: MOH Clinical Practice Guidelines 1/2000

Tuberculosis

Public Health Importance


Tuberculosis is of public health importance because it is difficult to eliminate in any
society. Its eradication requires the combined efforts of:
The individual - he needs to have the will and motivation to complete the course
of treatment,
The health care provider - he needs to prescribe correctly and to trace defaulters, and
Political will - to care for those who are unable to afford treatment because such
people are at the greatest risk of maintaining a reservoir of infection.

Terminology
Tuberculosis infection refers to infection by M tuberculosis and is also called latent
tuberculosis infection (LTBI). The infected person is not infectious to others -- treatment
is needed to prevent it from developing into active disease.
Tuberculosis disease refers to active tuberculosis disease with symptoms and signs of
262

infection. Tubercle bacilli can be recovered from the affected tissues. Full course
treatment is needed for such patients.

Control Strategy
Identifying and treating persons who have active tuberculosis remain the first priority
in controlling the spread of the disease.
Eliciting a history of exposure is critical because patients with active tuberculosis may
be minimally symptomatic or asymptomatic until the disease is advanced.
Referring a patient suspected of having TB for a complete medical evaluation -medical history, physical examination, Mantoux tuberculin skin test, chest radiograph,
and appropriate bacteriological or histologoical examination - should be done.

History
Classical symptoms of pulmonary tuberculosis, particularly reactivation disease, are
cough (prolonged cough of duration of more than 3 weeks), fever, sweats, chills,
anorexia, weight loss and malaise.
Extrapulmonary tuberculosis may be associated with myriad symptoms, including
altered mental status (central nervous system involvement), back pain (spinal disease)
and abdominal pain (peritoneal disease).
It is important to ask persons suspected of having TB about their history of exposure to
TB, history of TB disease and information regarding any previous TB treatment
received. If a regimen was inadequate or if the patient did not adhere to therapy, TB
may recur and the disease may be drug resistant. It is also important to ask for
demographic data (country of origin, age, ethnic group, and occupation) that may
indicate increased risks of having TB.
Also, determine whether the patient has medical conditions which will increase the
risk for TB disease.

Physical examination
A physical examination cannot confirm or rule out TB. Nevertheless, it could provide
valuable information on the patients overall condition and other factors that may
affect the plan of management e.g. the presence of extrapulmonary tuberculosis.
The most common types of extrapulmonary tuberculosis, in descending order of
frequency, are pleural, lymphatic, bone and joint disease, genitourinary tract and
miliary disease, meningitis and peritonitis.

Investigations
When pulmonary tuberculosis is suspected, chest radiographs should be obtained.
In primary pulmonary tuberculosis, numerous X-ray abnormalities occur atelectasis,
parenchymal consolidation, lymphadenopathy, pleural effusion and a miliary pattern.
Any lung lobe may be affected, although lower-lobe involvement may be more common.
In contrast, reactivation tuberculosis has a predilection for upper-lobe involvement,
and cavitation occurs in approximately 50 percent of patients (McAdams et al, 1995).
Atypical radiographic findings and accompanying extrapulmonary disease are
extremely common in HIV-infected patients; the lower the CD4 count, the more likely
such findings are (Post et al, 1995).

263

SECTION 07 MEDICAL TECHNICAL SKILLS & CARE IN SPECFIC SITUATIONS

Bacteriologic evaluation is generally required to confirm the diagnosis of tuberculosis.


The overall sensitivity of three acid-fast smears for identifying active tuberculosis is
about 70 percent (LoBue et al, 1997). In HIV-infected patients, the specificity of
acid-fast smears is decreased.
Sputum cultures remain the gold standard for the diagnosis of tuberculosis. Cultures
are 81 percent sensitive and 98.5 percent specific for active disease (Levy et al, 1989).
Identification of M. tuberculosis by culture may require 10 to 14 days, and antibiotic
sensitivity reports may take 15 to 30 days. These delays limit the use of cultures in
making early treatment decisions (MMWR, 1995).

Treatment
Treatment of Latent Tuberculosis Infection Treatment of latent tuberculosis infection is
indicated, regardless of age, in patients who belong to one or more high-risk groups.
Isoniazid is given at 5 mg per kg per day to a maximum of 300 mg per day. A nine-month
regimen is now preferred over the previously suggested six-month regimen (ATS-CDC,
2000). To reduce the risk of drug-related peripheral neuropathy with isoniazid therapy,
pyridoxine in a dosage of 10 to 50 mg per day, may be co-administered in all children six
years of age and older. Pyridoxine administration should also be strongly considered in
patients who have conditions in which neuropathy is common (e.g., diabetes, alcoholism
and malnutrition), pregnant women and patients who are also taking anticonvulsant drugs.
Monthly clinical assessments are mandatory in patients taking isoniazid for latent
tuberculosis infection. Check compliance, signs and symptoms of hepatitis, anemia and
neurotoxicity. Patients should be educated about worrisome symptoms and instructed to
stop taking isoniazid and seek medical attention promptly if such symptoms occur.
Measuring baseline liver enzyme levels before the initiation of isoniazid therapy is
recommended only in patients with a condition that puts them at risk for hepatotoxicity,
such as pregnancy or postpartum status, human immunodeficiency virus infection,
alcoholism or chronic hepatitis.
Treatment of Active Tuberculosis A four-drug regimen should be initiated in all adults
with confirmed or suspected active tuberculosis, and pyridoxine in a dosage of 50 mg per
day should be administered with regimens containing isoniazid to help prevent neurotoxicity (Table 1). All adults with confirmed or suspected active tuberculosis should be treated
with a four-drug regimen until the results of mycobacterial cultures and sensitivities have
been obtained. After two months of a four-drug regimen to which the initial isolates were
sensitive, patients continue treatment with isoniazid and rifampin alone if repeat sputum
cultures are negative and the patient has improved clinically. Patients continue this dual
regimen for another four months, at which time treatment may be discontinued if
sputum cultures remain negative. Monthly evaluations by a physician, including sputum
acid-fast smears and cultures, should be performed throughout treatment.

264

Table 4. Treatment of Adults and Children with TB Disease: First Line


Medications
DOSE IN MG/KG (MAXIMUM DOSE)
DRUG

DAILY

TWICE OR
THRICE WEEKLY*

ADVERSE
REACTIONS

SPECIAL
NOTE

CHILDREN

ADULT

CHILDREN

ADULT

Isoniazid
(INH)

10
orally
or IM
(300 mg)

5
orally
or IM
(300 mg)

20-40
orally
or IM
(900 mg)

15
orally
or IM
(900 mg)

Hepatic enzyme
elevation
Hepatitis,
Peripheral
neuropathy,
Central nervous
system effects
Drug interactions

Hepatitis risk
increases
with age and
alcohol
assumption
Pyridoxine
can prevent
peripheral
neuropathy

Rifampian
(RIF)

10-20
orally
or IM
(600 mg)

10
orally
or IM
(600 mg)

10-20
orally
or IM
(600 mg)

10
orally
or IM
(600 mg)

Gastrointestinal
tract upset,
Hepatitis,
Bleeding
problems,
Flu-like
Drug interactions,
Rash

Significant
interactions
with methadone,
birth control pills,
Orange of
discoloration
symptoms,
secretions and
urine,
May permanently
discolour soft
contact lenses

Pyrazinamide
(PZA)

15-30
orally
(2 g)

Ethambutol
(EMB)

15- 25
15- 25
Not to be Not to be
given at given at
25mg/kg 25mg/kg
/day
/day
for longer for longer
than
than
2 months 2 months

Strepto
20-40
-mycin(1 g) (1 g)
SM

15-30
orally
(2 g)

15
(1.5 g)

50-70
orally
(3 g)

50-70
orally
(3 g)

Hepatitis,
Rash
Gastrointestina
tract upset,
Arthralgias
Hyperuricemia
Gout (rare)

Treat hyperuricemia
only if patient has
symptoms

25-30
(thrice
weekly)
30-50
(twice
weekly)

25-30
(thrice
weekly)
50
(twice
weekly)

Optic neuritis

Not recommended
for children too
young to be
monitored for
changes in vision
unless TB is drug
resistant

25-30
(1.5 g)

25-30
Ototoxicity
(hearing loss or
vestibular
dysfunction)
Renal toxicity

Avoid or reduce
dose in adults
more than
60 years old

Source: MOH & TTSH 2002; Jerant, 2000. Notes: * = All regimens administered intermittently should be used with
DOT; Children under 12 years old. Adjust weight-based dosages as weight changes.

265

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Table 5. Regimen Options for Preferred Initial Treatment of Children


and Adults
Option 1 (daily
treatment)

Administer isoniazid (INH), rifampin (Rifadin), pyrazinamide and


ethambutol (Myambutol) daily for 2 months; then administer
isoniazid and rifampin daily or two to three times a week (only by
directly observed therapy) for susceptible isolates.

Option 2 (twiceweekly

Administer isoniazid, rifampin, pyrazinamide and ethambutol daily


for 2 weeks; then administer the treatment) same drugs two times
a week for 6 weeks (only by directly observed therapy); subsequently
administer isoniazid and rifampin two times a week for 4 months
(only by directly observed therapy) for susceptible isolates.

Option 3 (thricetreatment)

Administer isoniazid, rifampin, pyrazinamide and weekly


ethambutol three times a week for 6 months (only by
directly observed therapy).

Source: Jerant, 2000

Table 6. Regimen Options When Pyrazinamide or Rifampicin


Is Contraindicated
INDICATION

TOTAL
DURATION

INITIAL PHASE

CONTINUATION
PHASE

REMARKS

(MONTHS)
Pulmonary &
extrapulmonary
TB in adults and
children when
PZA is
contraindicated

INH, RIF, EMB


- daily for
8 weeks

INH, RIF - daily


or twice or
thrice weekly for
28 weeks (DOT
if on twice or
thrice weekly)

EMB
should be
continued
until
susceptibility
to INH and
RIF is
demonstrated

Pulmonary &
extrapulmonary
TB in adults and
children when
RIF is
contraindicated

18-24

SM, EMB,
INH - daily
for 8 weeks

EMB, INH - daily


or twice or
thrice weekly for
16 to 22
months (DOT if
on twice or
thrice weekly)
Or
SM, IMH - 2
times/week for
16 to 22 months
(DOT)

Three drugs
should be
continued until
susceptibility to
the drugs
prescribed is
demonstrated

Source: MOH-TTSH, 2002 (adapted)

Patients With Multidrug-Resistant Tuberculosis Multidrug-resistant tuberculosis is


defined as disease that is resistant to at least isoniazid and rifampin (Bradford and Daley,
1998), Patients with multidrug-resistant tuberculosis should be treated with a regimen
that includes three or four drugs to which the tuberculosis isolate is susceptible.
Treatment is highly challenging because of the adverse effects of second-line agents and
the frequent need for prolonged therapeutic courses (12 to 24 months).

266

Table 7. Selected Regimens for Single Drug Resistance


DRUG TO WHICH INFECTION
IS RESISTANT

TREATMENT REGIMEN

DURATION OF THERAPY

Isoniazid (INH)

Rifampicin
Ethambutol
Pyrazinamide

6-9 months

Rifampicin (Rifadin)

Isonaizid
Ethambutol

18 months

Ethambutol (Myambutol),
pyrazinamide, or
streptomycin

Isoniazid
Rifampin

6-9 months

Source: Jerant, 2000

Children and Pregnant Women -- Treatment regimens in children are generally similar to
those in adults. Because of the difficulty in monitoring for ocular toxicity, streptomycin
should be substituted for ethambutol (Myambutol) in very young children. In pregnant
women, treatment of active tuberculosis in pregnancy should not be delayed until after
delivery. Women who become pregnant while on antituberculous therapy should
continue treatment. The regimen should generally include isoniazid, rifampin and
ethambutol plus pyridoxine. Use of pyrazinamide, streptomycin, kanamycin (Kantrex),
capreomycin (Capastat Sulfate), quinolones, ethionamide (Trecator-Sc) and cycloserine
(Seromycin) should generally be avoided. Once the rare but serious complication of
congenital tuberculosis is ruled out, infants born to mothers with active tuberculosis
should be given isoniazid for at least three months as treatment for latent tuberculosis
infection (Miller & Miller, 1996).
Lactating women who are being treated for tuberculosis may continue to breast-feed.
They should feed their infant before taking their medication and use bottle supplementation for the first feeding after dosing. To avoid high serum drug levels, bottle-feeding is
recommended in infants who are receiving isoniazid for latent tuberculosis infection
whose mothers are also taking this medication (Snider, 1984).
DOT Predicting noncompliance in advance is notoriously unreliable. Thus, directly
observed therapy, in which patients are observed swallowing each dose of medication,
should be strongly considered in patients with latent tuberculosis infection who are being
treated with twice- or thrice-weekly regimens and in all patients who are being treated
for active tuberculosis. When directly observed therapy is used, treatment completion
rates range from 85 to 96.5 percent (Chaulk et al, 1998) In the first two years after
directly observed therapy became more widely used, there was a 21 percent decrease in
all tuberculosis cases and a 39 percent decrease in multidrug-resistant tuberculosis cases
(Burman et al, 1997).
References and further reading
CDC. Core curriculum on tuberculosis - what the clinician should know, 4th edition, 2000. (available for
downloading from Division of Tuberculosis Eliminations Web site at http://www.cdc.gov/nchstp/tb)
Chaulk CP, Moore-Rice K, Rizzo R, Chaisson RE. Eleven years of community-based directly observed therapy for
tuberculosis. JAMA 1995;274:945-51.
Burman WJ, Dalton CB, Cohn DL, Butler JR, Reves RR. A cost-effectiveness analysis of directly observed therapy vs.
self-administered therapy for treatment of tuberculosis. Chest 1997;112:63-70.

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NON-INFECTIVE RESPIRATORY DISORDERS


Asthma in adults

Definition
Asthma is a condition characterised by recurrent or chronic wheeze and/ or cough, with
recognisable variable airway obstruction due to bronchial hyper-responsiveness (increased
broncho-constrictor response to nonspecific triggers, such as cold air or histamine) as well
as hyper-reactivity secondary to airway inflammation. It is important to recognise that
asthma is a chronic inflammatory airway disease. Asthma exacerbation may be episodic,
but airway inflammation is chronically present.

Diagnosis
Provisional diagnosis A diagnosis of asthma is based on symptoms and physical signs.
Asthma usually presents as a wheeze in both adult and children. In children nocturnal
cough should draw attention to the possibility of bronchial asthma. A careful
occupational history is important, and a work-related peak flow and symptom diary may
be useful; the patient should be referred to a specialist occupational physician if
occupational asthma is suspected.
Confirmation Reversible airflow limitation can be demonstrated by PEFR improvement
to inhaled bronchodilators in the clinic, or on home peak flow records. The diagnosis is
confirmed by one of the following:
FEV/FVC ratio rising >15% after a nebulised dose of salbutamol.
Simple peak expiratory flow rate (PEFR) monitoring over a period of 2 weeks, revealing
a variation of >20%.
Provocation testing with histamine producing a fall in FEV/FVC > 20%, where
doubt exists, particularly in the case of occupational health and fitness suitable
provocation testing.

Management
Assessment of severity The appropriate management of asthma begins with a correct
assessment of the severity of attack and the underlying severity. Table 8 shows the
parameters used to categorise the severity of asthma attacks. Table 9 shows the risk
factors for death from asthma (Ng & Tan, 1999; Abramson et al, 2001).
Table 8. Categorisation of Severity of Asthma Attacks
PARAMETER*

MILD

MODERATE

SEVERE

Breathless
Talks in
Mental status

Walking
Sentences
May be
agitated
Can lie
down
Usually
not

Talking
Phrases
Usually
agitated
Prefers
sitting
Commonly

At rest
Words
Usually
agitated
Hunched
forward
Usually

Body position
Use of
accessory
muscles &
suprasternal
retraction

268

RESPIRATORY ARREST
IMMINENT
At rest
Mute
Drowsy or confused
Hunched
forward
Paradoxical
thoracoabdominal
moverment

Table 8. Categorisation of Severity of Asthma Attacks Contd


PARAMETER*

MILD

MODERATE

SEVERE

Respiratory
rate
Pulse /min
Pulsus
paradoxus
Breath sounds

Increased

Increased
>30/min
100-120
May be
present
Loud
wheezes
throughout
expiration

Often

Children

PEF after
initial
bronchodilator
Or %
predicted
Or %
personal best

<100
Absent
<10mmHg
Moderate
wheezing
at midand endexpiration
Feeds
normally
Over 80%

RESPIRATORY ARREST
IMMINENT
Often >30/min

>120
Usually
agitated
Loud
inspiratory and
expiratory
wheezes

Relative bradycardia
Confused or drowsy

Has
difficulty
feeding

Wont feed

Wont feed

Approx
60-80%

<60%
predicted
or personal
best
(<100L/min
in adults)
Or response
to therapy
lasts <2 hr

Unable to do

Little air movement


without wheezes

Source: MOH, CPG 1/2002; NAEPP. Expert Panel Report 2: Guidelines for the Diagnosis and Management of
Asthma. National Institutes of Health Pub No 97-4051. Bethesda, MD, 1997. (*) = the presence of several
parameters, but not necessarily all, indicate the general classification of the severity of the attack. Table 2 lists risk
factors of death from asthma

Table 9. Risk Factors For Death From Asthma

Past history of sudden severe exacerbation


Prior intubation for asthma
Two or more hospitalizations for asthma in the past year
Three or more emergency care visits for asthma in the past year
Hospitalisation or an emergency care visit for asthma within the past month
Use of >2 canisters per month of inhaled short-cacting beta-agonist
Current use of systemic corticosteroids or recent withdrawal from systemic corticosteroids
Known difficulty perceiving airflow obstruction or its severity
Co-morbidity, as from cardiovascular diseases or chronic obstructive pulmonary disease
Serious psychiatric disease or psychosocial problems
Low socioceconomic status
Illicit drug use

Source: Ng & Tan, 1999; Abramson et al, 2001; MOH CPG 1/2002)

Pharmacological treatment Pharmacological treatment are based on severity


before treatment
Table 10 gives a STEP classification of the severity of asthma based on symptoms and
PEF before treatment or adequate control. This provides an objective way of defining
the treatment necessary for quick relief, long term control and education of
the patient.
Table 11 describes the appropriate drug treatment for each step of severity. Treatment
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can be stepped down on review if patients asthma control improves. On the other
hand, if control is not achieved, step up therapy is advised after reviewing patient
medication technique, compliance and environmental control.
Management of environmental triggers -- Identify and reduce exposures to allergens and
irritants and other factors that increase asthma symptoms and/or precipitate asthma
attacks: housedust mite; irritants e.g., tobacco smoke; drugs e.g., aspirin; and
occupational triggers e.g. flour induced asthma.
Table 10. STEP Classification Of Asthma Severity
DAY-TIME

NIGHT-TIME

PEAK EXPIRATOR

SYMPTOMS

SYMPTOMS

FLOW

Step 4
Severe persistent

Continuous limited
physical activity

Frequent

<60% predicted
variability 30%

Step 3
Moderate
Persistent

Daily symptoms
Use 2 agonist daily
Attacks affect daily
activities

>1 time
per week

>60%-<80%
predicted
variability >30%

Step 2
Mild Persistent

= 1 time a week but


<1 time a day

>2 times
a month

>80% predicted
variability
20-30%

Step 1
Intermittent
Adapted from
GINA (Global)

<1 time a week


Asymptomatic and
normal PEF
between attacks

=2 times
a month

>80% predicted
variability
<20%

Strategy for Asthma Management and Prevention) guideline, for children below 5 yrs PEF does
not apply. Symptoms: wheeze, dyspnoea and/or cough. The highest level of current severity
defines the STEP category for each patient.
CHECKLIST
(a) Good inhaler technique
(b) Compliance with preventive treatment
(c) Compliance with follow up visits
(d) Reinforce written asthma action plan - the contents of this card
Source: MOH, 2002; NAEPP Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma.
National Institutes of Health Pub No 97-4051. Bethesda, MD, 1997

Checklist -- A checklist providing the basic tools for quick patient review and revision of
management steps is shown in figure 1. The contents form the asthma action plan.

270

FIGURE 1. Clinic Check Box / List


Visit #

CONTACT NUMBERS:

Current treatment

Changes

Preventer Drug(s)
Quick Relief Drug(s)
Height
Days off (MC) in
past month
Daily activities stopped
Per month or week
PEFR % Best/Pred
(Optimal)

Day wheeze/cough
/SOB
(Per month or week)
Good Compliance
Yes
No
Since the last clinic
visit:
Nebulisation/EMD
/Admit
(Date/s)

Night wheeze/
cough/SOB
(Per month or week)
Good Inhaler technique
Yes
No
Follow up Weeks

ASTHMA SEVERITY

Table 11. Appropriate Drug Treatment at Each Step of Asthma Severity


in Adults
Step 4:
Severe
persistent

LONG-TERM CONTROL

QUICK RELIEF

Daily medication:

Short-acting
Step 2 and 3
broncholdilator:
actions plus:
Inhaled beta-2
Refer to individual
agonists as (>800mcg)
needed counselling
education, for
symptoms.

Inhaled
corticosteroid

Long-acting
bronchodilator:
either long-acting

inhaled beta-2 agonist


and/or sustained-release
theophylline and/or
long-acting beta-2
agonist tablets

Corticosteroid tablets
or syrup (2 mg/kg/d,
generally not to exceed
60 mg/d)

Step 3:
Moderate
persistent

Daily medication:
Anti-inflammatory:
inhaled orticosteroid
(400-800mcg)
AND, if needed

EDUCATION

Intensity of treatment
will depend
on severity
of exacerbation.
Use of short-acting
inhaled beta-2
agonists on a dail
basis, or increasing
use, indicates the
need for additional
long-term control
therapy.

Short-acting
bronchodilator:
Inhaled beta-2
agonist as needed
for symptoms, not
to exceed

Step 1 actions plus:


Teach self-monitoring
Refer to group
education if available

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SECTION 07 MEDICAL TECHNICAL SKILLS & CARE IN SPECFIC SITUATIONS

Table 12. Appropriate Drug Treatment at Each Step of Asthma Severity


in Adults Contd

Step 2:
Mild
persistent

Step 1:
Intermittent

LONG-TERM CONTROL

QUICK RELIEF

EDUCATION

Long acting
bronchodilator:
either long acting
beta-agonist,
sustained-release
theophylline, or
long-acting
beta-agonist tablets
Consider
anti-leukotrienes

3-4 times in
1 day.
Use of short-acting
inhaled beta-2
agonists on a daily
basis, or increasing
use, indicates the
need for additional
long-term control
therapy.

Review and update


self-management plan

Daily medication:
Anti-inflammatory:
Inhaled corticosteroid,
200-400 mg, with
or without sustained
release theophylline
Consider
anti-leukotrienes

Short-acting
bronchodilator:
inhaled beta-2
agonists as needed
for symptoms., not
to exceed 3-4 times
in 1 day.
Use of short-acting
Inhaled beta-2
agonists on a daily
basis, or increasing
use, indicates the
need for additional
long-term control
therapy.

Step 1 action plus:


Teach self-monitoring
Refer to group
education if available
Review and update
self-management
plan

No daily medication
needed

Short-acting
bronchodilator:
Inhaled beta-2
agonists as needed
for symptoms,
but less than once
a week.
Inhaled beta
agonist or
cromoglycate before
exercise or exposure
to allergen

Teach basic facts


about asthma
Teach inhaler/
inhalation
chamber
technique
Discuss roles
of medications
Develop selfmanagement &
action plans
Discuss appropriate
environmental
control measures

Step down: Review treatment every 3-6 months; If control is sustained for at least 3 months, a
gradual stepwise reduction in treatment may be possible.
Step up: If asthma control is not maintained, consider step up to next treatment level after
reviewing medication technique, adherence and environment control
Sources: MOH, 2002; NAEPP. Expert Panel Report 2: Guidelines for the Diagnosis and Management of asthma.
National Institutes of Health Pub No 97-4051. Bethesda, MD, 1997

Managing Asthma In Children

At home
When an acute exacerbation is expected, e. g. during an acute upper respiratory
infection, the usual medications should be stepped up:
frequent beta-2 agonist, (e. g. Salbutamol MDI 0.2-0.3 puff/ kg) preferably via a spacer
device, given at 4- hourly intervals.
272

for a few selected patients who have severe asthma or with a past history of acute
sudden severe attacks, clear instructions should be given as to when/ how a short
course of prednisolone can be used. The role of high- dose inhaled steroids in acute
asthma is uncertain.
It is strongly recommended that clear written instructions be given to the family on how
to manage acute exacerbations based on symptoms of PEFR, i.e. a written action plan.

At the clinic
Symptom assessment. It is recommended that symptom assessment and objective
measurement of severity with PEFR monitoring be used in assessment of acute asthma
whenever possible. The doctor should be cautious in the interpretation of PEFR in
young children and in those using PEFR meters for the first time.
Oxygen. All clinics attending to children with acute asthma should have the facility to
give oxygen-driven bronchodilator nebulisation when necessary.
Aggressive therapy. Studies have shown that early aggressive bronchodilator therapy
(beta-2 agonist, e.g. salbutamol or terbutaline plus an anticholinergic such as
ipratropium bromide) is crucial in preventing worsening of acute asthma and
improving the outcome. It is therefore recommended that a nebulised bronchodilator
should be given at 15- to20- minute intervals and the child reviewed thereafter.
Figure 2. Aggressive Management Of Acute Asthma At A& E / Outpatient Clinic
Assess severity
Has the patient any of the following? --Too breathless to talk/ feed, Use of accessory muscles, Sa
O2 < 92%, Silent chest, Altered conscious level, Fatigue or exhaustion, Cyanosis (a late sign)

Signs/symptoms of severity are absent -- Mild/ Moderate Asthma

One or more of signs/symptoms of severity are present -- SevereAsthma


Treatment of mild/moderate asthma

Salbutamol 0.5 ml to 1 ml or terbutaline 0.25 ml to 0.5 ml + Ipratropium bromide 0.3 ml


to 1 ml.

Reassess after 15 min.

At assessment, if no improvement treat as severe asthma.

At assessment, if totally improved discharge and follow-up

At assessment, if only some improvement repeat nebulisation once more and reassess. If
improved discharge and follow-up; if not improved, admit.
Treatment of severe asthma

High flow oxygen 40 - 60%

Salbutamol or terbutaline 0.5 ml to 1 ml + Ipratropium bromide 0.5 ml to 1 ml via oxygen


driven nebuliser

i/ v hydrocortisone 5 mg/ kg stat

Admit patient
Source: MOH Clinical Guidelines 1/98 (Adapted)

Admission
We should admit a child with any of the following:
Shows no response to a beta-2 agonist or PEFR does not improve to at least 70% of his
personal best.
Requires an inhaled beta-2 agonist more frequently than 4-hourly.
Has acute asthma and has a past history of acute life threatening asthma.
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Has chronic severe asthma with PEFR equal or less than 50% of predicted normal.

Use of Oral Prednisolone in Acute Asthma


A short course of steroids should be considered when the child meets one of the
following criteria:
Requires frequent beta-2 agonist therapy (more frequent than 3- hourly).
Requires regular nebuliser therapy (3- to 4- hourly) for more than 36 - 48 hours.
Has a past history of a severe life- threatening episode
Is on high- dose inhaled steroids or low- dose oral steroids
A dose of prednisolone of 1-2 mg/ kg per day (max 40 mg) is usually given for no longer
than 5 days. A child who has suffered from a severe acute attack and requires prolonged
oral steroids for control should be referred to a specialist for assessment of treatment.
Children who require more than 4 courses per year should be very carefully monitored
with a view to stepping up anti- inflammatory therapy.

Treatment Of Chronic Asthma In Children


Table 5 summarises the treatment of chronic asthma based on the severity. The details are:

Intermittent Asthma
Infrequent episodic asthma. This group of patients requires only intermittent
bronchodilator therapy. An inhaled beta-2 agonist (with spacer device if necessary) is
recommended.
Frequent episodic asthma. In addition to intermittent bronchodilator therapy, antiinflammatory therapy should be used here.

Persistent Asthma
Mild persistent asthma. Mild persistent asthma is treated with low- dose inhaled
steroids.
Moderate persistent asthma. In moderate persistent asthma or mild persistent asthma
not controlled by low dose steroids, high dose inhaled steroids are indicated. Highdose inhaled steroids e.g. BDP/ BUD >400 g to 800 g/ day or fluticasone 200g 400g/ day is recommended in this group of patients.
Severe persistent asthma. If symptoms are not controlled with inhaled steroids, the
persistent asthma will be considered as severe inhaled steroids may be further
increased to BDP/ BUD 2000 g/ day or fluticasone 1000 g/ day in children with
moderately severe persistent asthma.

Special Considerations
Hypersecretory asthma. In this situation, cough and excessive secretions, rather than
wheezing, are the primary problems. Anti- inflammatory therapy is most useful here.
Exercise - induced asthma (EIA). A beta-2 agonist before exercise is most effective here.
For older children who undergo physical activities throughout the day, a long- acting
beta-2 agonist may be considered. It is important to assess the condition carefully as
EIA may just be a manifestation of poor control of underlying asthma. In such cases
the asthma therapy needs to be optimised.

274

Nocturnal asthma. The control of asthma has to be carefully reviewed. Often, it is a


manifestation of poor control of asthma with inadequate anti- inflammatory therapy.
Environmental triggers, e. g. house dust mite, should be excluded. A long acting
theophylline/ beta-2 agonist is effective in the control of nocturnal asthma if the child
is otherwise well and symptom- free.
Table 12. Appropriate Drug Treatment At Each Step Of Asthma
Severity In Children
Severity:Based on
clinical features
before treatment
or adequate control

Long-Term Preventive
(Controllers)

Quick-Relief
(Relievers)

Daily medications:
Consider combination of
agonist and
moderate dose inhaled
steroids or
High dose inhaled corticosteroid
more/day, and
Long-acting bronchodilator:
either long-acting inhaled
2-agonist and/or sustainedrelease theophylline
Corticosteroid tablets as
last option

Short-acting
bronchodilator:
inhaled 2- agonist
as needed for
symptoms

Symptoms/day
symptoms/night
STEP 4
Severe
Persistent

Continual
Frequent

STEP 3
Moderate
Persistent
Daily
>1 night /week

STEP 2
Mild Persistent

> 2/week but


<1x/day
> 2nights/month

Daily medications:
Consider combination of long
acting B2-agonist and low
dose inhaled corticosteroids
Moderate dose inhaled
corticosteroid, 400-800mcg
/day AND, if needed
Long-acting bronchodilator:
either longacting B2-agonist
Consider anti-leukotrienes.
Short-acting bronchodilator:
inhaled B2-agonist as needed
for symptoms, not to exceed
3-4 times in 1 day
Daily medication:
Low dosed Inhaled corticosteroid,
200-400 mcg/day
A trial of cromoglycate or
nedocromil may be considered
Consider anti-leukotrienes
but treatment benefit has
not been established

Short-acting
bronchodilator:
inhaled 2-agonist
as needed for
symptoms, not to
exceed 3-4
times in 1 day

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SECTION 07 MEDICAL TECHNICAL SKILLS & CARE IN SPECFIC SITUATIONS

Table 12. Appropriate Drug Treatment At Each Step Of Asthma


Severity In Children
Severity:Based on
clinical features
before treatment
or adequate control

Long-Term Preventive
(Controllers)

Quick-Relief
(Relievers)

None needed except in children


with frequent episodic attacks
Cromoglycate or nedocromil as
first option, consider low dose
inhaled steroid if not improved

Short-acting
bronchodilator:
inhaled 2agonist as needed
for symptoms, but
less than once
a week
Inhaled 2agonist or sodium
cromoglycate
before exercise
or exposure
to allergen

Symptoms/day
symptoms/night
STEP 1
Intermittent
< 2/week
< 2nights/month

Source: MOH, 2002 (adapted)


Step down and step up: Treatment is reviewed every 3 to 6 months. If control is sustained for at least 3 months, a
gradual stepwise reduction in treatment may be possible. On the other hand, if control is not achieved, step up
therapy is advised after reviewing patient medication technique, compliance and environmental control.
Goals of therapy: Asthma control - Minimal or no chronic symptoms day or night; Minimal or no exacerbations; No
limitations on activitiesl no school/parents wok missed; Minimal use of short-acting inhaled beta2-agonist (<1xper
day, <1canister/month); Minimal or no adverse effects from medication (NAEPP, 2002)

Referral to Specialist
The asthmatic child should be referred to a specialist for evaluation and management
advice when he or she:
requires high- dose steroids, BDP/ BUD > 400 g/ day or fluticasone > 200
g/ day, or is on prolonged inhaled steroid therapy for more than 6 months.
has persistently abnormal pulmonary function
is not responding as expected to usual therapy
is below 3 years of age and requires steroid therapy
References and further reading
Clough Joanne. Asthma in the very young. Practitioner 1995;239:198-202
MOH. Management of Paediatric Asthma. MOH Clinical Practice Guidelines 1/98. Singapore:MOH, July 1998
MOH. Management of asthma. MOH Clinical Practice Guidelines 1/2002
NAEPP Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma - Update on Selected Topics,
2002. (http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm)

CARDIOVASCULAR DISORDERS
Angina Pectoris

Workup
Blood tests -- Serum lipid levels should be determined in all patients with suspected
276

angina. Anaemia and diabetes may also be investigated if clinically appropriate.


Electrocardiography -- During anginal episodes, the characteristic electrocardiographic
change is horizontal or downsloping ST segment depression that reverses after the
ischaemia disappears. T wave flattening or inversion may also occur. Less frequently, ST
segment elevation is observed; this finding suggests severe (transmural) ischaemia and
often occurs with coronary spasm.
Exercise Electrocardiography -- Exercise testing is the most useful noninvasive procedure
for evaluating the patient with angina. The usual electrocardiographic criterion for a
positive test is 1 mm (0.1 mV) horizontal or downsloping ST segment depression (beyond
baseline) measured 80 ms after the J point. By this criterion, 60-80% of patients with
anatomically significant coronary disease will have a positive test.
Echocardiography -- Image of the left ventricle and reveal segmental wall motion
abnormalities, which may indicate ischaemia or prior infarction. It is a convenient
technique for assessing left ventricular function, which is an important indicator of
prognosis and determinant of therapy.
Coronary Angiography -- Selective coronary arteriography is the definitive diagnostic
procedure for coronary artery disease. It can be performed with low mortality (about
0.1%) and morbidity (1-5%), but the cost is high, and with currently available
noninvasive techniques it is usually not indicated solely for diagnosis.

Classification
Table 14. New York Heart Association Functional Classification of Angina

Class I -- Angina only with unusually strenuous activity


Class II -- Angina with slightly more prolonged or slightly more vigorous activity than usual
Class III -- Angina with usual daily activity
Class IV -- Angina at rest

Medical Treatment
The acute attack Glyceryl trinitrate 600 m g tab or 300 m g (1/2 tab) sublingually (SL).
Alternatives
Isosorbide dinitrate 5 mg SL every 5 minutes ( to maximum of 3) or
Glyceryl trinitrate SL spray: 1 to 2 sprays to maximum of 3 in 15 minutes or
Nifedipine 5 mg capsule (suck or chew) if intolerant of nitrates (warn about possible
hypotension and unpleasant taste)
Tips about glyceryl trinitrate (GTN) tablets
Warn patient about headache and other side effects
Sit down to take the tablet
Take 1/2 (initially) or 1 tablet every 5 minutes
Maximum of 3 tablets in 15 minutes
Must be fresh
Discard the bottle opened for 3 months or after 2 days if carried on the person
Keep out of light (store in dark glass bottle) and heat
If pain relieved quickly, spit out residual tablet
Advise that if no relief after 3 tablets get medical advice (call an ambulance for transfer
to the nearest hospital)

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Mild stable angina Angina that is predictable, precipitated by more stressful activities
and relieved rapidly:
Aspirin 150 mg orally daily
Glyceryl trinitrate (SL or spray) prn
Consider a beta-blocker or transdermal nitrate
Moderate stable angina Regular predictable attacks precipitated by moderate exertion:
Aspirin 150 mg orally daily Glyceryl trinitrate (SL) prn plus Beta-blocker, eg. atenolol 50
to 100 mg orally once daily or metoprolol 50 to 100 mg orally daily.
Glyceryl trinitrate (ointment and patches) daily (12 to 16 hours only) or
Isosorbide mononitrate 60 mg oral SR tablets mane (12 hour span).
Unstable angina Persistent, more frequent and more severe, ie reduced exercise
tolerance, at rest or nocturnal. It is usual to add a dihydropyridine calcium channel blocker.
Nifedipine 10 to 20 mg caps orally bd or Nifedipine controlled release 30 to 60 mg
orally once daily or
Amlodipine 2.5 to 10 mg oral once daily.
If beta-blockers are contraindicated, use a non-dihyropyridine calcium channel blocker
since these slow heart rate.
Diltiazem 30 to 120 mg oral tds or Diltiazem SR 90 mg oral bd to maximum 240 mg
daily or
Verapamil 40 to 120 mg oral tds or
Verapamil SR 160 to 240 mg oral once daily.
Refractory angina This is angina that is not relieved with therapy.
Consider admission to hospital for IV GTN and IV heparin with a view for
coronary angiography.
Perhexiline maleate is recommended if unsuitable for angiography.
Important rules of thumb with Ca antagonists and beta blockers
Avoid non-dihydropyridine Ca channel blockers if patient has significant left
ventricular dysfunction.
Beware of using non-dihydropyridine Ca channel blockers with beta-blockers.
Revascularizationprocedures for patients with angina pectoris
Indications. These are:
Patients with unacceptable symptoms despite medical therapy to its tolerable limits.
Patients with left main coronary artery stenosis greater than 50% with or
without symptoms.
Patients with three-vessel disease with left ventricular dysfunction (ejection fraction
< 50% or previous transmural infarction).
Patients with unstable angina who after symptom control by medical therapy continue
to exhibit ischaemia on exercise testing or monitoring.
Post-myocardial infarction patients with continuing angina or severe ischaemia on
noninvasive testing.

Prevention Of Angina
Reduction of risk factors in those with a positive family history and unsatisfactory lifestyle.
278

Blood pressure control.


Cholesterol control.
Cigarettes No smoking.
Diabetes control.
Diet low fat diet.
Weight reduction.

Prophylactic management of angina - Aspirin.


Anti-anginals.
Exercise -- If inactive, take on an activity such as walking for 20 minutes a day; regular
exercise to the threshold of angina.
Relaxation program.
Avoid and correct precipitating factors.
References and further reading
Tierney et al. Angina Pectoris. Current Diagnosis and Medical Treatment. Singapore:McGraw Hill, 2000; 373-381.
Zanger DR et al. Contemporary Management of Angina. Part II. Medical Management of Chronic Stable Angina.
AFP Jan 2000; 61:129-38

Post Myocardial Infarction


Goals For patients discharged from the hospital following myocardial infarction are to:
Risk stratify patients by assessing residual ischaemia and left ventricular dysfunction,
and choose medications to deal with these factors.
Treat coronary disease prophylactically.
Prescribe an appropriate exercise program to maximize patients physical capability.
Address psychologic issues.
Consider revascularisation for those who will benefit.
Risk Stratify -- Increased risk of death are increased by the presence of the following:
Post-infarction angina.
Non-Q wave infarction.
Heart failure.
Left ventricular ejection less than 40%.
Exercise induced ischaemia, diagnosed by echography and scintigraphy.
Ventricular ectopy (>10 VPB/h).
Treat Coronary Heart Disease prophylactically -- Medication regimens that have been
found to be effective in reducing mortality after myocardial infarction are summarized in
Table 16A. A meta-analysis of currently available studies has clarified issues regarding the
usefulness of these drugs.
Table 16B - Medications That Reduce Mortality After Myocardial Infarction
DRUG

DOSAGE

INDICATION

APPROXIMATE RISK
REDUCTION

Beta blockers
Metoprolol (Lopressor)

All patients

20 percent

100 mg twice daily


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Table 16B - Medications That Reduce Mortality After Myocardial Infarction


DRUG

DOSAGE

INDICATION

APPROXIMATE RISK

Timolol (Blocadren)
Propranolol (Inderal)
Atenolol (Tenormin)

10 mg twice daily
60 to 80 mg
three times daily
100 mg per day

Aspirin

325 mg per day**

All patients

20 percent

ACE inhibitors
Captopril (Capoten)
or equivalent

50 mg three
times daily

Ejection fraction
<40%

20 percent

Low-density
lipoprotein
Cholesterol level
>130 mg per dL
(3.35 mmol per L)
despite dietary
modifications

>10 percent

REDUCTION

Cholesterol-lowering
drugs

* - Dosage necessary to achieve international normalized ratio of 2.0 to 3.0 or a


prothrombin time that is 1.3 to 1.5 times control.
+ - No clear benefit over aspirin for most other indications
** Currently 75 - 10 mg regarded as sufficient
Source: Havranek, 1994

Manage risk factors -- Attention to these will reduce the risk of a subsequent myocardial
infarct:
Smoking Cessation. The risk of another infarction drops to that of a nonsmoker in
approximately two years.
Lower Cholesterol Levels. The current consensus is that a reduction in the cholesterol
level improves the outcome in patients who have had a myocardial infarction.
Prescribe An Exercise Program. Exercise capacity decreases in all patients following a
myocardial infarction as a result of myocardial injury and the deconditioning that
occurs from bed rest. The exercise prescription can be based on the patients
performance on the submaximal exercise test. Sessions should initially last 20 minutes
and should gradually be increased to between 30 and 60 minutes. Activity should
be of an intensity to reach 70 percent of the maximum heart rate achieved on an
exercise test.
Return to work -- Unless patients have physically strenuous jobs, they can return to work
three to four weeks after the myocardial infarction. Many patients find it helpful to work
on a half-time basis for the first several days.

280

Maximize Level of Function -- Most patients will be able to return to the functional level
they had before the myocardial infarction. Some who lose weight and quit smoking may
improve their quality of life, and some with large infarctions may lose exercise capacity.
An important goal of care is to help patients achieve their highest possible level
of function.
Reference and further reading
Tierney et al. Postinfarction management. In:Current Medical Diagnosis and Treatment, 2000: 395-396.

Heart failure
Mild heart failure -- diuretic or ACE inhibitor (if there are no contraindications
may suffice)
Moderate to severe heart failure -- diuretic and an ACE inhibitor (if there are no
contraindications) should be given; if there is a contraindication to ACE inhibitor, a
hydrallazine-nitrate combination can be given.
Systolic and diastolic dysfunction -- If the above treatment do not suffice, digoxin may
be considered if the heart failure is due to systolic dysfunction. If the heart failure is
due to diastolic dysfunction then beta-blockers, or second generation calcium blocker
can be considered.
Non-pharmacological treatment -- In every case, attention to non-pharmacological
treatment should be remembered - salt reduction, alcohol reduction, and embark on
exercise programme.
Reference
Shamsham F & Mitchell J. Essentials of the Diagnosis of Heart Failure. Am Fam Physician March 2000;61:1319-28

CHAPTER 2

GASTROINTESTINAL DISORDERS

Outline
Gastro-intestinal symptoms
Upper gastro-intestinal disorders
Lower gastro-intestinal disorders
Liver and biliary tract disorders

GASTRO-INTESTINAL SYMPTOMS
The key symptoms of gastro-intestinal tract disorders are: dyspepsia (Section 6 Chapter
4), diarrhoea (Section 6 Chapter 9), constipation (Section 6 Chapter 10), vomiting
(Section 6 Chapter 11), abdominal pain (Section 6 Chapter 12), esophageal symptoms
(heartbum, dysphagia, and odynophagia), and gastro-intestinal bleeding.
Esophageal Symptoms
The symptoms of heartbum, dysphagia, and odynophagia virtually always indicate a
primary esophageal disorder (McQuaid, 2001).

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Heart burn. Heartburn (pyrosis) is the feeling of a substemal burning, often radiating
to the neck. It is caused by reflux of acidic (or rarely, alkaline) material into the
esophagus. It is highly specific for gastro-esophageal reflux disease (GERD).
Odynophagia. Odynophagia is a sharp substernal pain on swallowing that may limit
oral intake. It usually reflects severe erosive disease. It is most commonly associated
with infectious esophagitis due to candida, herpesviruses, or cytomegalovims, especially in immmocompromised patients. It may also be caused acutely by corrosive injury
due to caustic ingestions and by pill-induced ulcers. It may also be caused by
esophagitis from GERD.
Dysphagia. Dysphagia is a difficulty in swallowing. It may arise from problems in
transferring the food bolus from the oropharynx to the upper esophagus (oropharyngeal dysphagia) or from impaired transport of the through the length of the
esophagus (esophageal dysphagia). The history usually leads to the correct diagnosis.
Dysphagia may lead to malnutrition and nutritional support is often needed for such
patients. If the patient experiences a lump in the throat when they are not swallowing
the diagnosis is anxiety (globus hystericus). See Table 1.
Table 1. Causes of dysphagia
OROPHARYNGEAL DYSPHAGIA

ESOPHAGEAL DYSPHAGIA

Neurological disorders Brain stem cerebrovascular


accident, mass lesion;
pseudobulbar palsy
Amyotrophic lateral sclerosis
multiple scterosis, poliomyelitis
Myasthenia gravis

Mechanical obstruction Malignant stricture -- Esophageal


cancer, Oesophageal cancer, gastric cancer

Muscular disorders Myopathies, polymyositis


Hypothyroidism
Motility disorders Upper esophageal sphincter
dysfunction
Structural defects Zenkers diverticulum
Pharyngeal cancer, surgery,
radiation to oropharynx
Pharyngeal pouch

Benign stricture - Schatzkis ring, Peptic


stricture, Extrinsic pressure from lung cancer,
Retrosternal goiter, mediastinal cancers
Esophageal web - Plummer-Vinson syndrome

Motility disorder Achalasia


Diffuse esophageal spasm
Scleroderma

Source: McQuaid, 2001; Hope et al, 1998

Approach
This is shown in Table 2.
Table 2. Questions To Ask About Dysphagia
There are 5 key questions to ask in coming to a diagnosis (Hope et al, 1998):
1 Did you have difficulty swallowing fluids and solids from the start?
Yes Think of motility disorders (achalasia, diffuse esophageal spasm)
No Suspect a stricture (benign or malignant).
2 Is it difficult to make the swallowing movement?
Yes Suspect bulbar palsy, especially if he coughs on swallowing

282

Table 2. Questions To Ask About Dysphagia - Contd


3
4

Is swallowing painful (odynophagia)?


Yes Suspect esophagitis
Is the dysphagia intermittent or is it constant and getting worse
Intermittent Suspect oesophageal spasm.
Constant and worsening Suspect malignant stricture.
Does the neck bulge or gurgle on drinking?
Yes Suspect a pharyngeal pouch (food may be regurgitated).

Whenever dysphagia is reported as being high up, get an ENT opinion.

Table 3. Diagnostic Clues In Esophageal Dysphagia


Mechanical obstruction - solid foods worse than liquids
Schatzis ring - intermittent dysphagia; not progressive
Peptic stricture - chronic heartburn; progressive dysphagia
Esophageal cancer - progressive dysphagia; age over 50
Plummer-Vinson (Paterson-Brown-Kelly) syndrome oesophageal web + iron-deficiency
anaemia, and risk of oesophageal cancer.
Motility disorder - solids and liquid foods both cause dysphagia
Achalasia - progressive dysphagia; chest pain; regurgitation of old food
Diffuse esophageal spasm - intermittent; not progressive; may have chest pain
Scleroderma - chronic heartburn; Raynauds phenomenon
Source: McQuaid, 2001

Investigations
Barium swallow; endoscopy with biopsy; full blood count.
Achalasia. Barium swallow shows a grossly expanded esophagus tapering to a tight
lower sphincter. CXR shows air/fluid level behind the heart, and double right heart
border produced by the expanded esophagus.
Carcinoma. Barium swallow will show the narrowing of the esophagus.
GERD. See below.
Upper Gastrointestinal Bleeding
Bleeding the gastrointestinal tract can be difficult to manage mainly because it can be an
acute, massive and potentially life threatening emergency.

Clinical Assessment
When the presenting complaint is hemetemesis, recognition of upper GI bleeding is easy.
Altered blood that appears as vomitus resembling grounded coffee beans may simply be
reported as vomiting by patients. It is therefore important to enquire routinely about the
nature of vomitus, especially in patients at risk of developing upper GI bleeding.
Haemodynamic assessment is critical. A pale patient with altered sensorium and low
blood pressure is easy to recognize but the challenge is to detect patients at an earlier
stage. Postural hypotension and resting tachycardia sometimes occur in patients with an
active bleed who may otherwise appear well and comfortable. An early diagnosis at this
stage would greatly improve the outcome.
Assessment to ascertain the pathology of the GI bleeding is secondary to recognizing
active bleeding and correcting hemodynamic instability. Some diagnostic pointers include:
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Bleeding varices - Alcoholism, known chronic viral hepatitis, stigmata of chronic liver
disease
Mallory-Weiss tear - History of prior retching and repeated vomiting, sternal pain
Coagulopathy - History of easy bruising, family history may be present
Peptic ulcer disease - Past history of peptic ulcer disease, past history of surgery for
peptic ulcer
Drug induced GI bleeding - NSAIDs, adulterated traditional remedies, steroids,
anticoagulants
Gastrointestinal malignancy - Loss of weight, anorexia, chronic anemia
Conceptually, it is useful to think of upper gastrointestinal bleeding in 3 categories:
Non-variceal upper GI bleeding: (a) Ulceration of gastric mucosa adjacent to blood
vessel, (b) Angiodysplasia (vascular anomalies), (c) Mallory-Weiss tears of the oesophagus, (d) Gastrointestinal cancers, (e) Dieulafoys lesions;
Variceal upper GI bleeding
Small bowel bleeding: (a) Angiodysplasia, (b) Tumours, (c) Ulcers, (d) Crohns disease,
(e) Diverticula, (f) Merkels diverticulum

Management - Initial Triage


Risk assessment and resuscitation proceed simultaneously when a patient presents with
gastrointestinal hemorrhage. A preliminary assessment of risk based upon several clinical
factors aids in the resuscitation as well as the rational triage of the patient.
Very low risk - Reliable patients without serious comorbid medical illnesses or
advanced liver disease who have normal hemodynamics, no evidence of overt bleeding
(hematemesis or melena) with 48 hours, a negative nasogastric lavage, and normal
laboratory tests do not require hospital admission and can undergo further evaluation
as outpatient as deemed necessary.
High risk - Patients with active bleeding manifested by hematemesis or bright red blod
on nasogastric aspirate, an estimated loss of more than 5 units of blood, persistent
hemodynamic derangement despite fluid resuscitation, serious comorbid medical
illness, or evidence of advanced liver disease require ICU admission.
Low to moderate risk - All other patients should be admitted to a regular hospital unit
after appropriate stabilization for further evaluation and treatment. Based upon the
findings at endoscopy, patients deemed to be at low risk of rebleeding may be
discharged and followed as outpatients, whereas patients at high risks are put under
close observation.
References and further reading
Fallah M.A., Prakash C., Edmundowicz S. Acute Gastrointestinal Bleeding. Medical Clinics of North America Vol 84
No.5 Sep 2000
Stabile B., Stamos M. Surgical Management of Gastrointestinal Bleeding. Gastroenterology Clinics. Vol 29 No. 1
Mar 2000.
Farrell J.J., Friedman L. S., Gastrointestinal Bleeding in the Elderly. Gastroenterology Clinics. Vol30 No.2 Jun 2001.
McQuaid K.R. Gastrointestinal Bleeding. In: Current Medical Diagnosis & Treatment. 2001. Ed Tierney, et al. Pg 573-578.

UPPER GASTROINTESTINAL DISORDERS


Gastroesophageal reflux and disease
Gastro-esophageal reflux is seen in healthy people. Gastroesophageal reflux is thought to
284

have a multifactorial etiology rather than a single cause. Contributing factors include the
caustic materials that are refluxed, a breakdown in the defense mechanisms of the
esophagus and a functional abnormality that results in reflux.
Definition. Gastroesophageal reflux disease may be defined as symptoms or tissue
damage caused by reflux of gastric contents with or without esophageal inflammation
(Fennerty et al, 1996). However, this definition can blur the distinction between healthy
people and those with GERD because a mild degree of esophageal reflux is considered
physiologic. Other accepted definitions of GERD include reflux esophagitis identified by
endoscopic examination and histologic esophagitis identified by examination of tissue
samples (Scott and Gehlot, 1999)
Clinical Features. Typical symptoms of GERD are heartburn and regurgitation; atypical
symptoms include odynophagia, dysphagia, chest pain, cough, and reactive airway
disease. A diagnosis of functional heartburn is made when patients have symptoms of
GERD but do not have abnormal reflux on 24-hour esophageal pH testing or changes
consistent with reflux-induced injury on endoscopic examination (Kaynard & Flora, 2001).
Diagnosis. GERD can usually be diagnosed clinically based on the presentation alone of
heartburn and regurgitation, which may also include dysphagia. In the absence of classic
symptoms, GERD becomes more difficult to diagnose. Symptoms of chest pain (possible
cardiac causes), dysphagia, odynophagia and weight loss (possible esophageal stricture or
cancer), require more extensive investigation before the diagnosis of GERD can
be established.
Differential Diagnosis. The differential diagnoses are from other causes of heart burn,
dysphagia, odynophagia, and chest pain, namely, Esophageal neoplasm, Infectious
esophagitis, Caustic esophagitis, Pill esophagitis, Gastritis, Peptic ulcer disease, Nonulcer
dyspepsia, Coronary artery disease, Hepatobiliary disease, Esophageal motility disorders,
Cholelithiasis.
Figure 1. Management of GERD
Stage I: Lifestyle modifications Head of bed elevated six inches; Decreased fat intake;
Smoking cessation;Weight reduction; Avoidance of recumbency for three hours postprandially;
Avoidance of large meals and certain foods
Stage II: As-needed pharmacologic therapy Antacid and/or antacid product containing
alginic acid; Over-the-counter histamine H2 receptor blocker
Stage III: Scheduled pharmacologictherapy H2-receptor blocker or prokinetic agent for 8
to 12 weeks; For persistent symptoms, high-dose H2-receptor blocker or proton pump inhibitor
for another 8 to 12 weeks (or reconsider diagnosis); With documented erosive esophagitis, may
use a proton pump inhibitor as first-line therapy
Stage IV: Maintenance therapy Appropriate for patient with symptomatic relapse or
complicated disease; Lowest effective dosage of H2-receptor blocker or proton pump inhibltor
Stage V: Surgery May be appropriate in patient with severe symptoms, erosive esophagitis
or disease complications; Laparoscopic Nissen or Toupet fundoplication procedure

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Investigations
Radiologic Findings -- Only one third of patients with GERD have radiologic signs of
esophagitis (Chen et al, 1992). Findings include erosions and ulcerations, strictures,
hiatal hernia, thickening of mucosal folds and poor distensibility. Only a minority of
patients with documented abnormal pH have radiographically evident esophagitis.
Consequently, a radiographic study is not the test of choice for the diagnosis of GERD.
Endoscopy -- Endoscopy is not sensitive for diagnosis of GERD itself. Only 50 percent
of patients with GERD manifest macroscopic evidence on endoscopy (Schenk et al,
1997). It is useful for diagnosis of the complicated case. Indications for esophageal
endoscopy in patients with GERD are: dysphagia or odynophagia, persistent or
progressive symptoms despite therapy, Esophageal symptoms in an
immunocompromised patient presence of mass, stricture or ulcer on upper gastrointestinal barium study, Evidence of gastrointestinal bleeding or iron deficiency
anemia, and at least 10 years of GERD symptoms s (screen for Barretts esophagus).
Response to Omeprazole -- A recent study demonstrated a potential role for a proton
pump inhibitor, omeprazole (Prilosec), in the diagnosis of GERD. The response of
symptoms to omeprazole, in a dosage of 40 mg per day for 14 days, was shown to be
about as specific and sensitive for the diagnosis of GERD as the results of 24-hour pH
monitoring. Because of the efficacy of omeprazole in relieving reflux symptoms, failure
to respond to this proton pump inhibitor warrants investigation of other possible
causes for a patients symptoms.

Management
The therapeutic goals are to control symptoms, heal esophagitis and maintain remission
so that morbidity is decreased and quality of life is improved. The management of GERD
can be divided into five stages (Figure 1). Stages I through IV consist of medical
management, and stage V entails surgical intervention.
Table 4. Medications Used In The Treatment of Gastroesophageal
Reflux Disease
Antacids (liquids and tablets) - as needed
H2-receptor blockers (over-the-counter)
Nizatadine 75 mg bd as needed
Famotidine 10 mg bd as needed
Cimetidine 200 mg bd as needed
Ranitidine 75 mg bd as needed
Prokinetic agents
Cisapride (Propulsid) 75 mg bd as needed
Metoclopramide 10 mg four times daily
H2-receptor blockers
Cimetidine 400 mg twice daily; 800 mg twice daily
Famotidine 20 mg twice daily; 40 mg twice daily
Nizatadine 150 mg twice daily
Ranitidine 150 mg two to four times daily; 300 mg twice daily
Proton pump inhibitors
Lansoprazole 15 mg once daily; 30 mg once daily
Omeprazole 10 mg once daily; 20 mg once daily

286

References
Scott M, Gelhot AR. Gastroesophageal reflux disease: diagnosis and management.Am Fam Physician. 1999 Mar
1;59(5):1161-9, 1199.
Kaynard A, Flora K. Gastroesophageal reflux disease: control of symptoms, prevention of complications. Postgrad
Med 2001:110(3):42-53
Fennerty MB, Castell D, Fendrick AM, et al. The diagnosis and treatment of gastroesophageal reflux disease in a
managed care environment: suggested disease management guidelines. Arch Intern Med 1996;156(5):477-84
Richter JE. Typical and atypical presentations of gastroesophageal reflux disease: the role of esophageal testing in
diagnosis and management. Gastroenterol Clin North Am 1996;25:75-102

Helicobacter pylori Infection


The vast majority are asymptomatic and suffer no sequelae. The rest have either dyspepsia
or peptic ulcer disease. H pylori infection is strongly associated with peptic ulcer disease;
however, only 15% of people with chronic infection develop a peptic ulcer.
Investigations. Investigation for H pylori infection is definitely indicated in patients with
peptic ulcer disease and gastric MALToma, and increasingly also in patients with dyspepsia
and a family history of gastric cancer.
H pylori can be detected by a variety of invasive and non-invasive means, all of which
have greater than 90% sensitivity and specificity (McQuaid, 2001).
At endoscopy, gastric mucosal biopsies can be assessed for unrease activity by placing
them in a pH-sensitive medium. This simple, inexpensive test is the preferred method
of endoscopic diagnosis.
Two non-invasive tests which indicate active H pylori infection: 14C-urea or 13C-urea
breath tests and fecal antigen assay, both of which have sensitivities and specificities of
over 90%. these studies are the tests of choice for verifying eradication after
antibacterial therapy.
Peptic Ulcer Disease
Epigastric pain (dyspepsia), the hallmark of peptic ulcer disease, is present in 80-90% of
patients. However, this complaint is not sensitive or specific enough to serve as a reliable
diagnostic criterion for peptic ulcer disease. The clinical history cannot accurately
distinguish duodenal from gastric ulcers. Less than one-fourth of patients with dyspepsia
have ulcer disease at endoscopy. Symptoms are only the tip of the iceberg Up to 20%
of patients with ulcer complications such as bleeding have no antecedent symptoms
(silent ulcers). In patients with NSAID-induced ulcers, up to half are asymptomatic. Up
to 60% of patients with complications do not have prior symptoms.
Causes. Three major causes of peptic ulcer disease are now recognized: NSAIDs, chronic
H pylori infection, and acid hypersecretory states such as Zollinger-Ellison syndrome.
Evidence of H pylori infection or NSAID ingestion should be sought in all patients with
peptic ulcer.

Investigations
Endoscopy and follow-up endoscopy. Upper endoscopy is the procedure of choice
for the diagnosis of duodenal and gastric ulcers. Three to 5 percent of benignappearing gastric ulcers prove to be malignant. Hence, cytologic brushings and
biopsies of the ulcer margin are almost always performed. Provided that the gastric
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ulcer appears benign to the endoscopist and adequate biopsy specimens reveal no
evidence of cancer, dyspepsia, or atypia, the patient may be followed without further
endoscopy. If these conditions are not fulfilled, follow-up endoscopy should be
performed 12 weeks after the start of therapy to document complete healing;
nonhealing ulcers are suspicious for malignancy.
Imaging. Barium upper gastrointestinal series is an acceptable alternative to screening
of uncomplicated patients with dyspepsia. However, because it has limited accuracy in
distinguishing benign from malignant gastric ulcers, all gastric ulcers diagnosed by xray should be re-evaluated with endoscopy after 8-12 weeks of therapy.
H pylori Testing. Given the importance of H pylori in ulcer pathogenesis, testing for
this organism should be performed in all patients with peptic ulcers.

Medical Treatment
Lifestyle. Patient should be encouraged to eat balanced meals at regular intervals. There is
no justification for bland or restrictive diets. Smoking retards the rate of ulcer healing and
increases the frequency of recurrences and should be discouraged. Moderate alcohol
intake is not harmful (McQuaid, 2001).
Specific treatment. See Table 5.
Table 5. Treatment Options For Peptic Ulcer Disease.
ACTIVE HELICOBACTER PYLORI-ASSOCIATED ULCER:
1)

Treat with anti-H pylori regimen for 10-14 days. Treatment options:
Proton pump inhibitor twice daily1
Clarithromycin 500 mg twice daily
Amoxicillin 1 g twice daily OR metronisazole 500 mg twice daily
Proton pump inhibitor twice daily1
Bismuth subsalicylate two tablets four times daily
Tetracycline 500 mg four times daily
Metronisazole 250 mg four times daily
Ranitidine bismuth citrate 400 mg twice daily
Clarithromycin 500 mg twice daily
Amoxicillin 1g OR tetracycline 500 mg OR metronisazole 500 mg twice daily
(Proton pump inhibitors administered before meals. Avoid metronisazole regimens in areas
of known high resistance or in patients who have failed a course of treatment that included
metronidazole.)

2)

Continuing treatment After completion of 10-14 day course of H pylori eradication


therapy, continue treatment with proton pump inhibitor1 once daily or H2 receptor
antagonist (as below) for 4-8 weeks to promote healing.

ACTIVE ULCER NOT ATTRIBUTABLE TO H PYLORI:


Consider other causes: NSAIDs, Zollinger-Ellision syndrome, gastric malignancy. Treatment
options:
Proton pump inhibitor1 :
Uncomplicated duodenal ulcer: treat for 4 weeks
Uncomplica ted gastric ulcer: treat for 8 weeks

288

Table 5. Treatment Options For Peptic Ulcer Disease. - Contd


H2 receptor antagonists:
Uncomplicated duodenal ulcer: cimetidine 800 mg, ranitidine or nizatidine
300 mg, famotidine 40 mg, once daily at bedtime for 6 weeks.
Uncomplicated gastric ulcer: cimetidine 400 mg, ranitidine or nizatidine
150 mg, famotidine 20 mg, twice daily for 8 weeks
Complicated ulcers: proton pump inhibitors are preferred drugs
Prevention of ulcer relapse:
1. NSAID-induced ulcer: prophylactic therapy for high-risk patients (prior ulcer disease or
ulcer complications, use of cortico-steroids or anticoagulants, age > 70 with serious
comorbid illnesses).
2.

Chronic maintenance therapy indicated in patients with recurrent ulcers who either
are H pylori-negative or who have failed attempts at eradication therapy; once daily proton
pump inhibitor1 or H2 receptor antagonist at bedtime (cimetidine 400-800 mg, nizatidine
or ranitidine 150-300mg, famotidine 20-40 mg)

Proton pump inhibitors: omeprazole 20 mg, rabeprazole 20 mg, lansoprazole 30 mg,


pantoprazole 40 mg

Refractory Ulcers
Ulcers that are truly refractory to medical therapy are now uncommon. Less than 5% of
ulcers are unhealed after 8 weeks of therapy with proton pump inhibitors. Noncompliance is the most common cause of ulcer nonhealing. Cigarettes retard ulcer healing and
should be proscribed. NSAID and aspirin use, sometimes surreptitious, are commonly
implicated in refractory ulcers and must be stopped. H pylori eradication enhances
healing and decreases the high recurrence rates of refractory ulcers. Therefore, evidence
of H pylori infection should be sought and the infection treated, if present, in all
refractory ulcer patients.
Fasting serum gastrin levels should be obtained to exclude gastrinoma with acid
hypersecretion *Zollinger-Ellison syndrome).
Non-healing gastric ulcers raise concersn that an undiagnosed gastric malignancy may be
masquerading as benign gastric ulcer. Repeat ulcer biopsies are mandatory after 2-3
months of therapy in all non-healed gastric ulcers, and they should be followed with
serial endoscopies to verify complete healing. Almost all benign refractory ulcers heal
within 8 weeks with a proton pump inhibitor twice daily (omeprazole or rabeprazole 20
mg twice daily, lansoprazole 30 mg twice daily). Patients with persistent non-healing
ulcers should be referred for surgical therapy after careful exclusion of NSAID use and
persistent H pylori infection.
References for further reading
McQuaid K.R. Gastritis, Gastropathy and Peptic Ulcer Disease. In: Current Medical Diagnosis & Treatment. 2001. Ed
Tierney, et al. Pg 600-610

Upper Gastrointestinal Malignancies


Esophageal and gastric cancers frequently present with nonspecific complaints which
may be dismissed or treated symptomatically until it is too late. For the primary care
practitioner, the key point is maintaining a high level of suspicion, especially in the older
patient. If malignancy is suspected symptomatic therapy should not delay obtaining
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appropriate imaging studies. Treatment decisions should be individualized. The best


approach is always honest and frank discussion with the patient and family.
References for further reading
James D. Ahlgren. Gastrointestinal malignancies. Primary Care Clinics in Office Practice Sep 2001; 28 (3)
McQuaid K.R. Gastrointestinal Bleeding. In: Current Medical Diagnosis & Treatment. 2001. Ed Tierney, et al. Pg 600-618.

LOWER GASTRO-INTESTINAL DISORDERS


Irritable Bowel Syndrome
Definition. Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder
characterised by abdominal pain & bloating, constipation, and diarrhoea and is chronic in
nature. Organic disease need to be excluded if the following symptoms exist: Weight loss;
rectal bleeding; recent changes in bowel pattern; and pain or bowel movements that
wake a patient are usually attributed to organic disease, especially in older people.
History taking. The history may offer clues to organic causes of IBS symptoms such as diarrhea.
An important characteristic of IBS is that it is chronic. Therefore, a patients symptoms should be
present for longer than 3 months before a diagnosis of IBS is considered. Acute onset of
symptoms, even those typical of IBS, should be attributed to organic disease until proved
otherwise. The positive relation of symptoms to food, antibiotics, and travel will rule out IBS.
Diagnosis. To characterize IBS and establish criteria for diagnosis, the Rome II criteria have
been worked out.
Table 6. Rome II Criteria For Diagnosis Of Irritable Bowel Syndrome
At least three months of continuous or recurrent symptoms of:

Abdominal pain or discomfort:

Relieved with defecation, or

Associated with a change in frequency of stool, or

Associated with a change in consistency of stool

Two or more of the following, at least on one-fourth of occasions or days:

Altered stool frequency (for research purposes altered may be defined as more than
three bowel movements each day or less than three bowel movements each week), or

Altered stool form (lumpy/hard or loose/watery stool), or

Altered stool passage (straining, urgency, or feeling of incomplete evacuation), or

Passage of mucus, or

Bloating or feeling of abdominal distension

Investigations. There is consensus that one should not over-investigate patients with IBS
since many already suffer from a tendency towards anxiety and have a higher risk of
psychiatric disorders. Psychosocial stress is also known to aggravate IBS. Prolonged and
excessive investigation may actually negate efforts to reassure the patient in some cases.
It is generally agreed that a thorough physical examination should be conducted to
confirm the lack of physical findings. Some authorities recommend that the following
tests should be routinely done:
complete blood count;
erythrocyte sedimentation rate;
basic blood chemistries;
stool for ova, parasites, and blood;
290

flexible sigmoidoscopy; or
colonoscopy or barium enema with sigmoidoscopy if older than 50 years.
Other diagnostic studies should be minimal and will depend on the symptom subtype:
For patients with diarrhea-predominant symptoms, a small bowel radiograph to rule
out Crohns disease, or lactose/dextrose H2 breath test, and if negative, a therapeutic
trial of loperamide.
For patients with constipation-predominant symptoms, a therapeutic trial of fiber
supplement may be all that is required.
For patients with pain as the predominant symptom, a plain abdominal radiograph
during an acute episode to exclude bowel obstruction and other abdominal pathology,
and if negative, a therapeutic trial of an antispasmodic may be indicated.
Management. The treatment strategy is based on the nature and severity of the
symptoms, the degree of physiological disturbance and functional impairment, and the
presence of psychosocial difficulties affecting the course of the illness. The components
of the treatment strategy are.
General Measures -- For all patients, the physician should establish an effective
therapeutic relationship, provide patient education and reassurance, and help with
dietary and lifestyle modifications when needed.
Pain and bloating -- consider antispasmodic (anticholinergic) medication, particularly
when symptoms are exacerbated by meals, or a tricyclic (TCA) or serotonin-reuptake
inhibitor antidepressant (SSRI), particularly when pain is frequent or severe (see below).
Constipation -- Increased dietary fiber (25 g/day) is recommended for simple constipation, although its effectiveness is mixed, based on several studies in reducing pain in
patients with constipation-predominant IBS. Since symptoms are chronic, the use of
laxatives should be avoided. Promotility agents, such as cisapride (Propulsid), are
sometimes required.
Diarrhea -- Loperamide (2-4 mg, up to four times daily) can reduce loose stools,
urgency and fecal soiling, and in low doses, does not seem to have central nervous
system effects. Cholestyramine may be considered for a subgroup of patients with
cholecystectomy or who may have idiopathic bile acid malabsorption. Patients with
predominant symptoms of diarrhea also respond to fiber supplements.
Psychological Treatments -- These are initiated when symptoms are severe enough to
impair health-related quality of life. Antidepressants are recommended for severe or
refractory symptoms of pain, and may be helpful for less severe symptoms. Tricyclic
antidepressants (e.g., amitriptyline and desipramine), or SSRIs (e.g., fluoxetine,
paroxetine, sertraline) can be used. Psychotherapy may benefit a minority of patients
who do not respond to antidepressants. Anxiolytics are generally not recommended
because of weak treatment effects, a potential for physical dependence, and
interaction with other drugs and alcohol.
References and further reading
Rothstein RD. Irritable bowel syndrome. Medical Clinics of North America. Vol 84. No.5. Sep 2000.
Talley NJ, Zinsmeister AR, Melton LJ 3d. Irritable bowel syndrome in a community: symptom subgroups, risk factors,
and health care utilization. Am J Epidemiol 1995;142(1):76-83

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Colorectal Cancer
Colorectal cancer is a relatively common malignancy. The uncertainty and controversy
centers around issues of cost-effectiveness and optimal recommendations for groups of
patients with different risk levels. Conceptually we can think of the population as having
3 risk strata. The first strata comprise those with average risk of cancer. This would be the
majority. The second strata are those with increased risk. This is a complex strata as
different risk factors confer different level of risk factors. Sometimes risk factors overlap.
Recommendations must take this into consideration. Finally there are those who already
had curative resection of colorectal cancer. Table 9 is a summary of recommendations that
had been advocated.
Table 7. Screening Based On Risk Factors
RISK FACTOR

RECOMMENDATION

Average Risk

Start screening at age 50


FOBT every year
Sigmoidoscopy every 5 years
Colonoscopy when either test is positive

Optional:
Barium enema every 5 years
Colonscopy every 10 years

292

Increased Risk Family History


Sporadic Cancer

Start screening at age younger than


onset of affected relative
Colonoscopy every 5 years

Increased Risk Familial


Adenomatous Polyposis
Syndrome

Increased Risk Hereditary


Non-Polyposis Colorectal
Cancer Syndrome

Screen at age 20 to 25
Colonoscopy every 1 to 3 years

Increased Risk Inflammatory


Bowel Disease

Screen at 10 years after diagnosis


Colonoscopy every 3 years
Colonoscopy every year after 20 years of disease

Increased Risk Colonic Adenoma


2 or less, smaller than 1 cm tubular

Colonoscopy every 5 years

Increased Risk Colonic Adenoma


3 or more, large, villous change,
dysplasia

Colonoscopy every 3 years


Decrease scope frequency to
5 years if scope is negative.

Increased Risk 2 or more


adenoma removed

Colonoscope after 1 to 2 years


6 months if polyp is large and sessile

Increased Risk Known


Colorectal carcinoma after
curative resection

Colonoscope at 1 year
Increase interval to 2,3 then 5 years if
findings are negative.

Screen at age 10 or 12
Genetic counseling
Flexible sigmoidoscope every year
Prophylactic colectomy when
adenomas appear
Upper GI endoscopy every 1-3 years
for duodenal cancer

References and further reading


Borum M. L., Colorectal Screening. Primary Care Clinics in Office Practice. Vol 28 No.3 September 2001.
Rudy D. R., Update on Colorectal Cancer. American Family Physician Vol 61. No.6 March 15, 2000.

LIVER AND BILIARY TRACT DISORDERS


Acute Viral Hepatitis
The clinical picture of viral hepatitis is extremely variable, ranging from asymptomatic
infection without jaundice to a fulminating disease. The clinical characteristics of the viral
hepatitis A to E are given in Table 8.

Diagnosis
The key features for diagnosis are:
Prodrome of anorexia, nausea, vomiting, malaise, symptoms of upper respiratory
infection or flu-like syndrome, aversion to smoking.
Fever, enlarged and tender liver, jaundice.
Abnormal liver tests, especially markedly elevated aminotransferases early in the
course.
Liver biopsy will show characteristic hepatocellular necrosis and mononuclear infiltrate
This is rarely indicated.

Differential diagnosis
The overseas traveller presenting with jaundice may have:
Infection by any one of the viruses - hepatitis A, B, C, D or E. All are prevalent in
developing countries, especially in south-eastern and eastern asia, some Pacific islands
and Africa.
Other causes to consider are malaria, ascending choiangitis and drug induced hepatic
damage due to, for example, the antimalarials, including mefloquine (larium) and
Fansidar.
Table 8: Clinical Profile Of Viral Hepatitis A - E
CHARACTERISTIC

HEPATITIS A

HEPATITIS B

HEPATITIS C

HEPATITIS D

HEPATITIS E

Pseudonyms

Infectious
hepatitis

Serum
hepatitis

Parenterally
transmitted
non A non B

Delta
hepatitis

Enterically
trarsmitted
non A nonB

Transmission

Faecal-oral

Blood and
other body
fluids

Blood and
other body
fluids

Blood
and other
body fluids

Faecal-oral

Incubation

2 to 6
weeks

4 weeks

6 weeks to
6 months

3 weeks to
6 months

2 to 6 weeks to
3 months

Severity of
acute illness

Mild to
moderate;

Mild to
severe
often
subclinical

Moderate
Often
Jaundice
common
Usually
jaundiced

Moderate
to severe
subclinical
mortality

Mild to
moderate
High Often
subclinical

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Table 8: Clinical Profile Of Viral Hepatitis A - E


CHARACTERISTIC HEPATITIS A

HEPATITIS B

HEPATITIS C HEPATITIS D HEPATITIS E

Chronic liver
disease

No

Yes

Yes
Potentially
worst

Yes

No

Carrier state

No

Yes

Yes

Yes

Uncertain

Serology

IgM exposure

HBsAgdiagnosis
IgG immunity

anti HCV
(antibody)
anti hBsexposure

HBsAg+ve
HDsAg+ve
anti HDV
(antibody)

Being developed

Immunopro
phylaxis

Normal Ig
Vaccine

H B Ig
Vaccine

No vaccine

None
available

None
available

Source: Murtagh, 1991

Treatment
Bed rest -- Advisable during the acute initial phase of the disease, when symptoms are
most severe. Return to normal activity during the convalescent period should
be gradual.
Fluids -- If nausea and vomiting are pronounced or if oral intake is substantially
decreased, intravenous administration of 10% glucose solution is indicated.
Diet -- Dietary management consists of giving palatable meals as tolerated, without
overfeeding. Patients should avoid alcohol, and hepatotoxic agents.
Corticosteroids -- In controlled studies, corticosteroids have demonstrated no benefit
in patients with viral hepatitis, including those with fulminant hepatitis. Treatment of
patients with acute hepatitis C with alpha interferon appears to decrease the risk of
chronic hepatitis.
Encephalopathy or severe coagulopathy -- Suspect fulminant hepatic failure and
hospitalization is mandatory
References and further reading
Friedman LS. Viral hepatitis. In: Current Medical Diagnosis and Treatment, 39th ed, 2000:659-664.
Murtagh J. Jaundice. Aust Fam Physician Apr 1991;20:4:457-466.
Saab S, Martin P. Tests for acute and chronic viral hepatitis: finding your way through the alphabet soup of infection
and superinfection. Postgrad Med 2000;107(2):123-30

Chronic Hepatitis B infection

Serological Markers Of Hepatitis B Infection


There are 4 markers of that identify the Hepatitis B virus in the body. These are:
Surface Antigen (HBsAg) -- The gold standard for determining carrier status is the
persistence of HbsAg beyond 6 months. It is a marker of infection but not infectivity as
the surface antigen is non-infectious.
Core Antigen (HBcAg) -- This is the nuclear capsid of the virus and it is infectious. This
antigen is found only in the liver but not in the sera because it is closely complexed

294

with the anti-HBc antibody. Free HbcAg in the sera undergoes auto-digestion to
become the e Antigen.
e Antigen (HBeAg) -- The presence of this antigen represents viral replication
and infectivity.
Hepatitis B virus DNA (HBV-DNA) -- The presence of HBV-DNA is direct evidence
of active hepatitis B viral replication. This marker is more sensitive than e Antigen.
The demonstration of HBV-DNA is relevant to confirm the presence of pre-core
mutant strains.

The chronic hepatitis B carrier


The chronic hepatitis B carrier has HbsAg for longer than six months by definition. He
does not have anti-HBc IgM. However he has anti-HBc, indicating past infection. AntiHBc IgG is a serological scar of hepatitis B infection and never disappears from the body.
The clinical outcome of chronic Hepatitis B infection is variable depending on whether
there is viral replication. Some hepatitis B carriers remain well and asymptomatic. Others
develop complications. The 2 major complications of this infection are cirrhosis and
primary hepatocellular carcinoma. The challenge is to identify these patients through
screening and follow-up and institute timely intervention.
Management
The objectives of management of the patient with chronic hepatitis B are:
Preventing transmission to others
Avoiding potentially hepatotoxic agents
Monitoring for complications
Treating or slowing down the process of complication development - still experimental
Preventing of transmission to others. Patients should be warned against donating blood,
sperm, milk or organs; Toothbrushes, nail clippers and shaving equipment which may be
likely to come in contact with infectious body fluids should not be shared; Use of separate
eating utensils is unnecessary; patients should inform their doctors, dentists and healthcare
workers of their hepatitis B status so that precautions can be taken by their healthcare
providers during procedures; unprotected sex is not advisable unless partners had been
successfully vaccinated; all household contacts should have their serology done for
detection of those chronically infected as well as to vaccinate those without resistance;
Pregnant women must inform their obstetricians and the newborn baby must be given
Hepatitis B immune-globulins followed by a more rigorous schedule of vaccination.
Avoiding potentially hepatotoxic agents. Food, drugs and alcohol may potentially be
hepatotoxic and their effects is usually much worse in a liver that is already compromised
by chronic hepatitis B infection.
Monitoring for complications. There is now evidence that monitoring patients
transminase levels as well as alpha fetoprotein levels and ultrasound helps to detect flareup of hepatitis and primary hepatocellular carcinoma respectively. Initially, the HBeAg and
anti-HBe should also be checked to establish the phase of infection the patient is in.
Alpha-fetoprotein - This is a normal serum protein synthesized by fetal liver cells, by
yolk-sac cells, and in trace amounts by the fetal gastrointestinal tract. For healthy
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adults, the normal range for serum AFP is 0 to 20 ng/mL. Serum levels of 400 ng/mL
are highly suggestive of HCC. A alpha-fetoprotein level that is climbing is also a red
flag. Unfortunately, two thirds of patients with small HCCs have AFP levels less than
200 ng/mL, and up to 30% of HCCs do not produce elevated levels of AFP even in
advanced stages. Causes of false-positive results include acute and chronic hepatitis,
germ cell tumors, and pregnancy.
Hepatobiliary ultrasound (US) to screen of liver cancer - This is costly and of unknown
effectiveness. If included in a surveillance programme, the scan is done every six
months to a year.
Indications for referral for further management: (1) Increased ALT/AST - if marked
elevation For inpatient or close outpatient monitoring for possible decompensation;
if mild elevation to consider treatment. Indications: (i) HBeAg positive and persistent
elevation of ALT/AST (ii) HBeAg - and ALT/AST elevated i.e. precore mutant with
inflammation; (2) To exclude/ manage Hepatocellular carcinoma - indications: (i) AFP
elevated, despite normal U/S; (ii) Nodule found on ultrasound.
References and further reading
Management of Common Gastroenterological Problems - A Malaysia and Singapore Perspective. Havas Medi
Media 2000.
Friedman LS. Liver, Biliary Tract & Pancreas. In: Current Medical Diagnosis & Treatment, 39 ed. Ed. Tierney et al,
2000:666
Colombo M. Screening for cancer in viral hepatitis. Clinics in Liver Disease Feb 2001, 5(1)

Cholelithiasis And Cholecystitis

Asymptomatic Gallstones
There is generally no need for prophylactic cholecystectomy in an asymptomatic person
unless the gallbladder is calcified or gallstones are over 3 cm in diameter (McQuaid, 2000).

Biliary Colic (Symptomatic cholelithiasis)


Treatment is indicated for symptomatic cholelithiasis. Unless the patient is a high surgical
risk or has refused surgery, surgical treatment is the treatment of choice. Laparoscopic
cholecystectomy is the treatment of choice for symptomatic gallbladder disease if this is
available. If problems are encountered, the surgery can be converted to a conventional
open cholecystectomy. Bile duct injuries occur in 0.1% of cases done by experienced
surgeons. Persistence of symptoms after removal of gallbladder (post-cholecystectomy
syndrome) implies mistaken diagnosis, functional bowel disorder, technical error, retained
or recurrent common bile duct stone, or spasm of the sphincter of Oddi.

Gallstones in pregnancy
While a conservative approach to symptomatic gallstones during pregnancy is advised,
cholecystectomy may be indicated for repeated attacks of biliary colic or acute
cholecystitis. Surgery during the second trimester appears to be safest, and a laparoscopic
approach is feasible. (Ghumman et al, 1997)

Acute cholecystitis
Acute cholecystitis will usually subside on a conservative regimen (withholding of oral
feedings, intravenous alimentation, analgesics, and antibiotics). Because of the high risk
of recurrent attacks (up to 10% by 1 month and over 30% by I year), cholecystectomy
296

generally laparoscopically should generally be performed within 2-3 days after


hospitalization. Except for a shorter operating time, there was no difference in rates of
conversion to open cholecystectomy or complications between patients randomized to
laparoscopic cholecystectomy within 24 hours and those randomized to surgery 6-8
weeks later (Lai PBS et al, 1998). If nonsurgical treatment has been elected, the patient
(especially if diabetic or elderly) should be watched carefully for recurrent symptoms,
evidence of gangrene of the gallbladder, or cholangitis. In high-risk patients, ultrasoundguided aspiration of the gallbladder (percutaneous cholecystostomy) may postpone or
even avoid the need for surgery. Cholecystectomy is mandatory when there is evidence of
gangrene or perforation.
Pancreatic Cancer
Carcinoma is the commonest neoplasm of the pancreas. About 75% are in the head and
25% in the body and tail of the organ. Carcinomas involving the head of the pancreas,
the ampulla of Vater, the distal common bile duct, and the duodenum are considered
together, because they are usually indistinguishable clinically. Most are adenocarcinomas.
Neuroendocrine tumors account for 2-5% of pancreatic neoplasms. Cystic neoplasms
account for only 1 % of pancreatic cancers, but they are important because they are
often mistaken for pseudocysts. A cystic neoplasm should be suspected when a cystic
lesion in the pancreas is found in the absence of a history of pancreatitis.

Clinical features
The following are key features
mainly > 60 years of age.
Obstructive jaundice (may be painless).
Enlarged gallbladder in 50-75% patients (may be painful).
pain (over 75%)- epigastric region and radiation to the back.
Weight loss, and thrombophlebitis are usually late manifestations.

Treatment
Abdominal exploration is usually necessary. Radical pancreaticoduodenal (Whipple)
resection is indicated for lesions strictly limited to the head of the pancreas, periampullary
zone, and duodenum (T1, N0, MO). Five-year survival rates are 20-25% in this group and
as high as 40% in those with negative resection margins and without lymph node
involvement. Adjuvant radiation therapy and chemotherapy are of potential benefit.
When resection is not feasible, cholecystojejunostomy or endoscopic stenting of the bile
duct is performed to relieve jaundice.
References and further reading
McQuiad. Diseases of the biliary tract. In: Current Medical Diagnosis and Treatment, 39th Edition 2000 ed. Tierney
et al; 683-690.
Ahmed A, Cheung RC, and Keeffe EB. Management of Gallstones and Their Complications. Am Fam Physician
2000;61:1673-80,1687-8.
Lai PBS et al: Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg
1998;85:764.
Murtagh J. Acute Pancreatitis & Chronic Pancreatitis In:General Practice, 2nd ed, 2001:264- 265
Murtagh J.Carcinoma head of pancreas. In:General Practice, 2nd ed, 2001:543-544

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CHAPTER 3

RENAL AND HAEMATOLOGICAL


DISORDERS

Outline
Renal disorders
Haematological disorders

RENAL DISORDERS
UTI SYNDROMES IN ADULTS
The UTI syndromes are shown in Table 1. A diagnosis of UTI is based on patient history,
physical examination and laboratory findings. Risk factors for UTI such as urinary calculi,
genitourinary instrumentation, surgery and congenital defects should be identified. The
history should also consider prior episodes of UTI or urinary abnormalities, the pattern of
sexual activity, as well as chronic illnesses such as diabetes and other renal problems.
Table 1. UTI Syndromes
Lower Tract UTICystitis

Prostatitis

Upper Tract UTI


Uncomplicated UTI

Acute pyelonephritis
Absence of structural or functional abnormalities
of the urinary tract
Presence of complicating factors: Obstruction,
Calculi, Vesicoureteral reflux, Metabolic
abnormalities, Diabetes mellitus, Impairment
in host responses

Complicated UTI

Symptoms
The sypmtoms include dysuria, frequency, urgency, pressure in the lower pelvis,
haematuria, and cloudy urine. There may also be fever, nausea and vomiting.
Investigations

Urine Analysis
The confirmation of UTI requires, by definition, urine analysis for pyuria and culture for
bacterial sensitivity. A positive urine dipstick for nitrites (detects bacteria) and/or leukocyte
esterase (detects pyuria) can substitute for a formal urinalysis when initiating empirical
antibiotic therapy in patients with symptoms of UTI (MOH CPG, 2000).

Urine Culture
The diagnosis of UTI requires documentation of significant bacteriuria, which is defined
as: more than more than 103 colony forming units (cfu) per ml of urine for cystitis; more
than 104 cfu per ml of urine for pyelonephritis; or more than 105 cfu per ml of urine for
asymptomatic bacteriuria (Hooton & Stamm, 1997). While urine cultures are considered
298

unnecessary by some in the management of the first episode of uncomplicated cystitis in


young women, cultures are essential before and after treatment in the following
categories of patients (a) pregnant women; (b) those with recurrent UTI; (c)
pyelonephritis; (d) all men with UTI; and (e) all patients with complicated UTI.

Additional Investigations
Women with recurrent cystitis and pyelonephritis and all men with UTI may require
additional investigations including renal imaging with intravenous urography,
ultrasonography, voiding cysto-urethrogram, prostatic massage cultures and
other investigations.
Management Of Uncomplicated UTI

General Measures
General measures in all patients include drinking more water to increase urinary output
and an analgesic or antipyretic for relief of pain or fever.

Asymptomatic Bacteriuria
Asymptomatic bacteriuria is diagnosed upon the identification of more than 105 colony
forming units of bacteria/ml of urine in persons with no symptoms of UTI. Though any
population subgroup is at risk for asymptomatic bacteriuria, the elderly are at special risk.
Except in pregnant women, antibiotic therapy is not recommended in the management
of patients with asymptomatic bacteriuria because treatment has not been shown to
confer benefit. In the elderly too, antibiotics for asymptomatic bacteriuria is not
recommended as it does not reduce risk of subsequent complications of infection or
mortality (MOH CPG, 2000).

UTI In Women
Table 2 shows the antibiotic choice for UTI in female adults.
Table 2. Antibiotic Therapy For Urinary Tract Infections In Female Adults
Infection

First Line

Alternative

Comments

Acute cystitis
in women

PO 1st and 2nd


generation
cephalosporins e.g.

PO nitrofurantoin 50 mg
or PO fluoroquinolones e.g.
- ciprofloxacin 250 mg bd

Treat for 7 days.


Short course with
3-day course

- ofloxacin 200 mg bd,


- norfloxacin 400 mg bd
or PO TMZ 160/800 mg bd
or PO trimethoprim 100 mg bd
or PO nalidixic acid 500 mg tds

recommended
only for
trimethoprimsulphamethoxazole or
fluoroquinolones.
Caution: Allergy to
TMP-SMZ.

- cephalexin 250 mg qds or


- cefadroxil 500 mg bd or
- cefuroxime 125 mg bd

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Table 2. Antibiotic Therapy For Urinary Tract Infections In Female Adults


Contd
Infection

First Line

Alternative

Comments

Recurrent
cystitis in
women

PO trimethoprim
sulphamethoxazole
40/200 mg on

PO nitrofurantoin 50 mg on
or PO cephalexin 250 mg on
or PO trimethoprim 100mg on

Treat acute cystitis


for 7 days first,
followed by
prophylaxis for 3-6
months nightly or
post-coitally.

Asymptomatic
bacteriuria in
Pregnancy

PO nitrofurantoin 50
PO amoxicillin 250 mg tds
mg qds
or PO TMZ 160/800 mg bd
or PO 1st and 2nd
generation
cephalosporins e.g.
- cephalexin 500 mg qds or
- cefadroxil 500 mg bd or
- cefuroxime 250 mg bd

Treat for 7 days


based on cultures.
Review antibiotics
based on sensitivity.
Avoid sulphonamides
in third trimester.
Fluoroquinolones
are best avoided.

Cystitis in
pregnancy

* PO 1st and 2nd generation * PO nitrofurantoin 50 mg qds


cephalosporins e.g.
* or PO TMZ 160/800 mg bd

* Avoid sulphonamides
in third trimester.

Cystitis in
pregnancy
(contd)

- cephalexin 250 mg qds or


- cefadroxil 500 mg bd or
- cefuroxime 125 mg bd

* Check cultures
after treatment.

Acute

* IV ceftriaxone 1 gm om

pyelonephritis,
Pregnant
woman

Acute
uncomplicated
pyelonephritis in
women,
Mild illness,
Outpatient

* Pregnant women

adjusted carefully to levels (in


cephalosporin allergic patients)
* +/- IV ampicillin 500 mg 6
hourly
* or +/- TMZ
in penicillin/ cephalosporin
allergic patients

with pyelonephritis
should ideally be
hospitalized
to receive parenteral
therapy.
* Fluoroquinolones
are best avoided
in pregnancy.
* Avoid sulphonamides
in third trimester.

PO 1st and 2nd


PO fluoroquinolones e.g.
generation
- ciprofloxacin 500 mg bd
cephalosporins e.g.
- ofloxacin 400 mg bd
- cephalexin 500 mg qds or
- norfloxacin 400 mg bd
- cefadroxil 500 mg bd or
or _-lactam-_-lactamase
- cefuroxime 250 mg bd
inhibitor combinations e.g.
- PO amoxicillin-clavulanic
acid 375 mg tds
or PO TMZ 160/800 mg bd

Source: MOH CPG, 2000 (adapted)

300

* IV gentamicin with doses

Treat for 14 days.

UTI In Men
The antibiotic choice in UTI in Men are shown in Table 3.
Table 3. Antibiotic Therapy For Urinary Tract Infections In Male Adults
Infection

First Line

Alternative

Acute bacterial
prostatitis

PO TMZ 160/800 mg bd

PO fluoroquinolones e.g.
- ciprofloxacin 250 mg bd
- ofloxacin 200 mg bd
- norfloxacin 400 mg bd
or IV antibiotics as for
acute pyelonephritis
if ill & hospitalized

Treat for 4 weeks.


Need Sitz baths
for comfort.
Need prolonged
course to prevent
chronic prostatitis.
Exclude chronic
prostatitis if
recurrent.

Comments

Chronic
bacteria
prostatitis

PO TMZ 160/800 mg bd

PO fluoroquinolones e.g.
- ciprofloxacin 250 mg bd
- ofloxacin 200 mg bd
- norfloxacin 400 mg bd

Treat for 12 weeks.


If refractory or
recurrent, refer
urologist to exclude
prostatic stone.

Chronic
abacterial
prostatitis

PO doxycycline 100 mg bd

PO erythromycin 250mg qds Treat for 2 weeks.


Consider renal
imaging; Consider
chronic prostatitis.

Acute cystitis in
adult men

PO TMZ 160/800 mg bd

PO fluoroquinolones e.g.
- ciprofloxacin 250 mg bd
- ofloxacin 200 mg bd
- norfloxacin 400 mg bd

Diagnosed after
excluding prostatitis
and GU
abnormalities.
Treat for 7 14 days
Other risk factors:
intercourse with
infected female
partner, homosexuality,
uncircumcised.

Acute
pyelonephritis,
Men

IV 1st or 2nd generation


cephalosporins e.g.
- cephazolin 500 mg
6 hourly
- cefuroxime 750 mg
8 hourly plus
IV gentamicin 1 mg/kg
8 hourly

V fluoroquinolones e.g.
- ciprofloxacin 200 mg
12 hourly
- ofloxacin 400 mg
12 hourly
or IV ceftriaxone 1 gm om

IV agents are given


until the patient is
afebrile for 24 H
followed by oral
antibiotics, based on
culture and sensitivity
for 2-4 weeks.
Typically, antibiotics
that penetrate the
prostate gland are
advised as below:

Foot note: TMZ = trimethoprimsulphamethoxazole


Source: MOH CPG, 2000 (adapted)

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RENAL CALCULI
The diagnosis and initial management of urolithiasis have undergone considerable
evolution in recent years. A diagnosis of renal colic cannot be based on the clinical
findings alone. Further more, diagnostic imaging is essential to confirm the size and
location of urinary tract calculi. (Portis & Sundaram, 2001).
The management of urolithiasis is also becoming increasingly well defined. Initial
management is based on three key concepts: (1) the recognition of urgent and
emergency requirements for urologic consultation, (2) the provision of effective pain
control using a combination of narcotics and nonsteroidal anti-inflammatory drugs in
appropriate patients and (3) an understanding of the impact of stone location and size on
natural history and definitive urologic management. (Portis & Sundaram, 2001).
Presentation
Urolithiasis should always be considered in the differential diagnosis of abdominal pain.
The classic presentation of renal colic is excruciating unilateral flank or lower abdominal
pain of sudden onset that is not related to any precipitating event and is not relieved by
postural changes or nonnarcotic medications. With the exception of nausea and vomiting
secondary to stimulation of the celiac plexus, gastrointestinal symptoms are usually absent.
Table 4. Relationship Of Stone Location To Symptoms
STONE LOCATION

COMMON SYMPTOMS

Kidney
Proximal ureter
Middle section of ureter
Distal ureter

Vague flank pain, haematuria


Renal colic, flank pain, upper abdominal pain
Renal colic, anterior abdominal pain, flank pain
Renal colic, dysuria, urinary frequency, anterior
abdominal pain, flank pain

Source: Portis & Sundaram, 2001

Differential Diagnosis
Symptoms similar to those of renal colic can be caused by non-calculus conditions. In
women, gynecologic processes that must be considered include ovarian torsion, ovarian
cyst and ectopic pregnancy. In men, symptoms of testicular processes, such as a tumor,
epididymitis or prostatitis, may mimic the symptoms of distal ureteral stones.
Diagnosis
The diagnosis of urinary tract calculi begins with a focused history. Key elements include
past or family history of calculi, duration and evolution of symptoms, and signs or
symptoms of sepsis. The physical examination is often more valuable for ruling out
nonurologic disease.

302

Initial investigations
Urinalysis should be performed in all patients with suspected calculi. Urinalysis findings
consistent with urolithiasis include hematuria and limited pyuria. Aside from the typical
microhematuria, important findings to note are:
The urine pH and the presence of crystals, which may help to identify the stone
composition. Patients with uric acid stones usually present with acidic urine. Those with
stone formation resulting from infection have an alkaline urine; here identification of
bacteria is important in planning therapy, and a urine culture should be routinely performed.
Limited pyuria is a fairly common response to irritation caused by a stone and, in absence
of bacteriuria, is not generally indicative of coexistent urinary tract infection.
Further investigations
Because of the various presentations of renal colic and its broad differential diagnosis, an
organized diagnostic approach is useful (Figure 1).
Figure 1.Diagnostic Approach To Suspected Renal Colic.
PATIENT WITH ABDOMINAL PAIN HISTORY AND PHYSICAL EXAMINATION
RENAL COLIC SUSPECTED
Which Diagnostic imaging?
If patient pregnant, or cholecystitis, or gynecological disease is suspected
ultrasound examination definitive answer*
If patient has history or radio-opaque calculi plain film radiography
definitive answer*
All other patients Noncontrast helical CT is available definitive answer
All other patients Intravenous pyelonephrography if CT is not available
definitive answer*
Source: Portis & Sundaram, 2001. (CT = computed tomography); * = if clinical suspicion of urolithiasis still
present, do noncontrast helical CT

Abdominal Ultrasonography
Abdominal ultrasonography has limited use in the diagnosis and management of
urolithiasis. Although ultrasonography is readily available, quickly performed and
sensitive to renal calculi, it is virtually blind to ureteral stones (sensitivity: 19 percent),
which are far more likely to be symptomatic than renal calculi (Yilmaz et al, 1998; Portis
& Sundaram, 2001). However, if a ureteral stone is visualized by ultrasound, the finding
is reliable (specificity: 97 percent). The ultrasound examination is highly sensitive to
hydronephrosis, which may be a manifestation of ureteral obstruction, but it is frequently
limited in defining the level or nature of obstruction. It is also useful in assessing renal
parenchymal processes, which may mimic renal colic. Abdominal ultrasonography is the
preferred imaging modality for the evaluation of gynecologic pain, which is more
common than urolithiasis in women of childbearing age.

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Plain-Film Radiography
Plain-film radiography of the kidneys, ureters and bladder (KUB) may be sufficient to
document the size and location of radiopaque urinary calculi. Stones that contain
calcium, such as calcium oxalate and calcium phosphate stones, are easiest to detect by
radiography. Less radiopaque calculi, such as pure uric acid stones and stones composed
mainly of cystine or magnesium ammonium phosphate, may be difficult, if not
impossible, to detect on plain-film radiographs.
Unfortunately, even radiopaque calculi are frequently obscured by stool or bowel gas, and
ureteral stones overlying the bony pelvis or transverse processes of vertebrae are
particularly difficult to identify. Furthermore, nonurologic radiopacities, such as calcified
mesenteric lymph nodes, gallstones, stool and phleboliths (calcified pelvic veins), may be
misinterpreted as stones.

Intravenous Pyelography
Intravenous pyelography has been considered the standard imaging modality for urinary
tract calculi. The intravenous pyelogram provides useful information about the stone (size,
location, radiodensity) and its environment (calyceal anatomy, degree of obstruction), as
well as the contralateral renal unit (function, anomalies). Intravenous pyelography is widely
available, and its interpretation is well standardized. With this imaging modality, ureteral
calculi can be easily distinguished from nonurologic radiopacities.
The accuracy of intravenous pyelography can be maximized with proper bowel preparation,
and the adverse renal effects of contrast media may be minimized by ensuring that the
patient is well hydrated. Unfortunately, these preparatory steps require time and often
cannot be accomplished when a patient presents in an emergency situation.

Noncontrast Helical CT
Noncontrast helical CT is being used increasingly in the initial assessment of renal colic
(Smith et al, 1999; Portis & Sundaram, 2001). This imaging modality is fast and accurate,
and it readily identifies all stone types in all locations. Its sensitivity (95 to 100 percent)
and specificity (94 to 96 percent) suggest that it may definitively exclude stones in
patients with abdominal pain (Boulay et al, 1999; Portis & Sundaram, 2001).
Management
The management of patients with urolithiasis is becoming increasingly well defined. An
algorithm for the initial management of radiologically confirmed stones is presented in
Figure 2.
Figure 2. Initial Management Of Radiologically Confirmed Urolithiasis
RADIOLOGICALLY DEMONSTRATED STONE CONFIRMED 3 OPTIONS
Any emergency urosepsis, anuria, renal failure, urgent urological consultation.
No emergency, Hospitalisation required refractory pain, refractory nausea,
extremes of age, debilitated condition? Admision and urological consultation
No hospitalization required symptoms amenable to medical management

304

Figure 2. Initial Management Of Radiologically Confirmed Urolithiasis Contd


Symptoms amenable to medical management
renal stone or ureteral stone more than 5 mm referral to urological clinic
ureteral stone less than 5 mm trial of conservative treatment and weekly KUB
radiographs stone fails to pass within 2 to 4 weeks referral to urological clinic
Source: Portis & Sundaram, 2001. (KUB = kidney, ureters and bladder)

Emergency Situations
The first step in managing renal calculi is to identify patients who require emergency
urologic consultation. For example, sepsis in conjunction with an obstructing stone
represents a true emergency. In patients with sepsis, adequate drainage of the system
must be established with all possible speed by means of percutaneous nephrostomy or
retrograde ureteral stent insertion. Other emergency conditions are anuria and acute
renal failure secondary to bilateral obstruction, or unilateral obstruction in a patient with
a solitary functioning kidney.
Hospital admission may be required for patients who are unable to maintain oral intake
because of refractory nausea, debilitated medical status or extremes of age, or for
patients with severe pain that does not respond to outpatient narcotic therapy.
Placement of a retrograde ureteral stent or percutaneous nephrostomy tube may be a
useful temporizing measure in patients with refractory symptoms.
For all other patients, ambulatory management of renal calculi should be adequate.
Complications of urolithiasis are renal failure, ureteral stricture, infection, sepsis, uine
extravasation, perinephric abscess, xanthogranulomatous pyelonephritis. The
cornerstones of ambulatory management are adequate analgesia, timely urologic
consultation and close follow-up.

Initial Analgesia
Numerous medical strategies have been attempted to control colic, which can be
attributed to ureteral spasm. Although narcotics such as codeine, morphine and
meperidine (Demerol) are effective in suppressing pain, they do nothing to treat its
underlying cause, and they have the side effects of dependence and disorientation.
As a result of combined anti-inflammatory and spasmolytic effects, nonsteroidal antiinflammatory drugs (NSAIDs) such as aspirin, diclofenac and ibuprofen can be effective in
managing the pain of renal colic. Of these agents, ketorolac (Toradol) merits special
mention. In one emergency department study, the narcotic-like analgesic effects of this
agent were superior to the effects of meperidine (Larkin et al, 1999; Portis & Sundaram,
2001). Unfortunately, the antiplatelet effects of NSAIDs (including ketorolac) are a
contraindication to the use of extracorporeal shock wave lithotripsy, because of the
increased risk of perinephric bleeding (Schafer, 1999; Portis & Sundaram, 2001).
At present, an effective approach to outpatient management is to use both an oral
narcotic drug and an oral NSAID. Patients are instructed not to take NSAIDs for three
days before anticipated extracorporeal shock wave lithotripsy; they are also told to avoid
taking aspirin for seven days before the procedure.
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Spasmolytic medications, such as calcium channel blockers and glucagon, have no value in the
management of acute colic Caravati et al, 1989; Bahn et al, 1986; Portis & Sundaram, 2001).

Managing the stone


After emergency situations have been ruled out and adequate analgesia has been
achieved, the next step is to formulate a strategy for managing the stone. Clinical
experience with urolithiasis has been refined with statistical analysis to provide sound
principles for definitive management (Sengura et al, 1997; Portis & Sundaram, 2001). The
two major prognostic factors are stone size and location (Morse et al, 1991; Glowacki et
al, 1992; Portis & Sundaram, 2001).
Stone Size. The likelihood that a ureteral stone will pass appears to be determined by its
size (i.e., greatest diameter). Stones less than 5 mm in size should be given an
opportunity to pass. Patients can be advised that stones less than 4 mm in size generally
pass within one to two weeks. With stones of this size, 80 percent of patients require no
intervention beyond analgesia Miller & Kane, 1992).
Patients with a radiopaque ureteral stone who elect a conservative approach should be
advised to have regular follow-up KUB radiographs at one- to two-week intervals. They
should also strain their urine to capture stones or stone fragments, because stone
composition provides important information for the prevention of future stones.
Patients should be cautioned to seek immediate medical attention if they develop signs of
sepsis. The principal message should be that medical surveillance must be continued until
stone passage is documented. Although unlikely with small calculi, asymptomatic
complete ureteral obstruction may destroy renal function in as little as six to eight weeks.
Referral to a urologist is appropriate for patients with a ureteral stone more than 5 mm in
greatest diameter or a stone that has not passed after two to four weeks. /As stones
increase in size beyond 4 mm, the need for urologic intervention increases exponentially.
Referral to a urologist is indicated for patients with a stone greater than 5 mm in size.
Referral is also indicated for patients with a ureteral stone that has not passed after two
to four weeks of observation. The complication rate for ureteral calculi has been reported
to almost triple (to 20 percent) when symptomatic stones are left untreated beyond four
weeks Hubner et al, 1993; Portis & Sundaram, 2001).
Stone Location. Renal stones, which are generally asymptomatic, may be followed
conservatively. However, patients can be advised that about 50 percent of small renal
calculi become symptomatic within five years of detection (Glowacki et al, 1992; Portis &
Sundaram, 2001).
Persons in some occupations, most notably airplane pilots, are not permitted to work
with even an asymptomatic renal stone, for fear of the unpredictable onset of
incapacitating pain while they are involved in a crucial task. These patients obviously
require early definitive therapy.

306

Staghorn renal calculi, which are frequently the result of, and a persistent focus for,
chronic infection are clearly associated with renal damage (Segura et al, 1994; Portis &
Sundaram, 2001). These large stones should be treated when they are detected.
Renal calculi less than 2 cm in size can generally be treated with extracorporeal shock
wave lithotripsy. Stones in a lower pole calyx are an exception, as they are associated with
poor clearance rates after extracorporeal shock wave lithotripsy, and 1 cm is the generally
recommended upper limit for this treatment (Lingeman et al, 1994; Portis & Sundaram,
2001). Larger stones are generally amenable to percutaneous nephrolithotomy
Table 5. Treatment Modalities For Renal And Ureteral Calculi
Treatment

Indications

Limitations

Complications

Extracorporeal

Radiolucent calculi Minimally

Requires

Ureteral

Renal stone
> 2 cm
Ureteral stones
> 1 cm

invasive

spontaneous

by stone

Outpatient
procedure

passage of
fragments
Less effective in
patients with
morbid obesity
or hard stones

Perinephric
haematoma

Ureteroscopy

Ureteral stones

Definitive
Outpatient
procedure

Invasive
Commonly
requires
postoperative
ureteral stent

Ureteral stricture
or injury

Ureteroscopy

Renal stones
> 2 cm

Definitive
Outpatient
procedure

May be difficult
to clear
fragments
Commonly
requires
postoperative
ureteral stent

Ureteral stricture
or injury

Percutaneous

Renal stones
> 2 cm
Proximal ureteral
> 1 cm

Definitive

Invasive

Bleeding Injury to
collecting system
Injury to
adjacent structures

obstruction
shock wave
fragments
lithotripsy

Advantages

Source: Portis & Sundaram, 2001.

Extracorporeal shock wave lithotripsy is also effective for ureteral stones, with an upper
size limit of approximately 1 cm. Unknown ovarian effects are the basis for a relative
contraindication to the use of extracorporeal shock wave lithotripsy in women of childbearing age who have middle or distal ureteral stones. Percutaneous nephrolithotomy
remains a safe and reliable method of removing large renal and proximal ureteral stones.
Advances in ureteroscopic techniques now allow calculi that are not good candidates for
extracorporeal shock wave lithotripsy or percutaneous nephrolithotomy to be treated
virtually anywhere within the ureter or kidney (Tawfiek & Bagley, 1999; Portis &
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Sundaram, 2001). The urologists judgment and experience, with consideration of the
patients preferences, should dictate the treatment approach (Table 2).

Preventing Future Stones


The first episode of nephrolithiasis provides an opportunity to advise patients about
measures for preventing future stones. Low fluid intake and excessive intake of protein, salt
and oxalate are important modifiable risk factors for kidney stones. Calcium restriction is
not useful and may potentiate osteoporosis. Diseases such as hyperparathyroidism,
sarcoidosis and renal tubular acidosis should be considered in patients with nephrolithiasis.
A 24-hour urine collection with measurement of the important analytes is usually reserved
for use in patients with recurrent stone formation. In these patients, the major urinary risk
factors include hypercalciuria, hyperoxaluria, hypocitraturia and hyperuricosuria. Effective
preventive and treatment measures include thiazide therapy to lower the urinary calcium
level, citrate supplementation to increase the urinary citrate level and, sometimes,
allopurinol therapy to lower uric acid excretion. Uric acid stones are most often treated
with citrate supplementation. Data now support the cost-effectiveness of evaluation and
treatment of patients with recurrent stones (Goldfarb & Coe, 1999)
References for further reading
Portis AJ & Sundaram CP. Diagnosis and Initial Management of Kidney Stones. Am Fam Physician 2001;
63:1329-38. Goldfarb & Coe. Prevention of Recurrent Nephrolithiasis. Am Fam Physician 1999;60:2269-76.

HAEMATOLIGICAL DISORDERS
The haematological disorders may be grouped under anaemias, bleeding disorders, and
malignancies. Only the anaemias will be discussed in this Primer.

ANAEMIA
Anaemia is commonly encountered in general practice. It is important to recognize that this
is a symptom and treatment with iron supplements should not be given until the diagnosis
is clear. A carefully taken history, clinical examination and selected investigations are
therefore required. Anemia is present in adults if the hematocrit is less than 41 %
(hemoglobin <13.5 g/dL) in males or 37% (hemoglobin <12 g/dL) in females. The history,
clinical findings and the laboratory screening tests will help in defining its cause.
Classification Of Anaemia
Whilst a classification by pathophysiology (Table 6) gives us an understanding of the
underlying cause, from the practice standpoint, classifiying by the mean corpuscular
volume into microcytic, macrocytic, and normocytic is more useful. Table 2 gives us the
selected causes and investigations of anaemia.
Table 6. Classification of Anaemias By Pathophysiology
DECREASED PRODUCTION
(1) Hemoglobin synthesis: iron deficiency, thalassemia, anemia of chronic disease
(2) DNA synthesis: megaloblastic anemia
(3) Stem cell: aplastic anemia, myeloproliferative leukemia Bone marrow infiltration:
carcinoma, lymphoma
(4) Pure red cell aplasia
INCREASED DESTRUCTION
(1) Blood loss

308

Table 6. Classification of Anaemias By Pathophysiology Contd


INCREASED DESTRUCTION

CONTD

(2) Hemolysis (intrinsic)


Membrane hereditary spherocytosis, elliptocytosis Hemoglobin:
sickle cell, unstable hemoglobin
Glycolysis: pyruvate kinase deficiency, etc.
Oxidation: G6PD deficiency
(3) Hemolysis (extrinsic)
Immune: warm antibody, cold antibody
Microangiopathic: thrombotic thrombocytopenic purpura,
hemolytic-uremic syndrome, mechanical cardiac valve, paravalvular leak
Infection: clostridial
Hypersplenism
Source: Linker, 2003

Table 7. Selected Causes and Investigations of Anaemia


CAUSES/CLASSIFICATION

PRIMARY DIAGONOSTIC FEATURES

SECONDARY INVESTIGATIONS

Iron deficiency

SFe Dec SFerr Dec Transferrin Inc


SFe Nor SFerr Nor or In

Therapeutic trial of iron; GIT


evaluation for blood loss

Hemoglobinopathy
(e.g., thalassemia)

SFe Nor SFerr Nor or In

Haemoglobin investigation

Sideroblastic anaemia
(hereditary)

SFe Dec SFerr Nor or Inc Transferrin

Bone marrow examination

Anaemia of chronic
disease (sometimes)

SFe Dec SFerr Nor or Inc


Transferrin Dec

Specific for underlying


disorders

SB12 Dec, rcFol Nor or Inc


SB12 Nor, rcFol Dec

IF antibody assay; Schilling test


Usually none
None

Microcytic (MCV <80 fl)

Macrocytic (MCV >98fl)


With megaloblastic
changes:
Vit B12 deficiency
Folate deficiency
Cytotoxic drugs
With no megaloblastic
changes:
Liver disease/alcoholism

History; uniform macrocytosis; SB12 Liver function tests


Nor, rcFol Nor
Specific peripheral blood findings,
Bone marrow examination
SB12 Nor, rcFol Nor

Myelodysplastic disorders
(including sideroblastic
anaemia)
Normocytic (MCV 80-98 fl)
Acute blood loss/occult
blood loss

Isolated anaemia, Retic Inc


History, Retic Dec

Dictated by clinical findings


SFe Dec, SFerr Nor or Inc

Anaemia of chronic
disease
Haemolysis

Specific red cell changes, Retic Inc

SBil and SLDH Inc, SHapt Dec,


specific tests for hemolysis

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Table 7. Selected Causes and Investigations of Anaemia Contd


CAUSES/CLASSIFICATION

PRIMARY DIAGONOSTIC FEATURES

SECONDARY INVESTIGATIONS

Normocytic (MCV 80-98 fl)


Chronic renal disease
Endocrine disorders (e.g.,
hypothyroidism)

Isolated anaemia, Retic Dec


History, isolated anaemia,
Retic Dec

Renal function
Specific endocrine
investigation

Source: Murtagh, 2003. Footnotes: MCV = mean corpuscular volume; SFe = Serum iron; SFerr =SFerritin; SB12 =
Serum Vitamin B12; rcFol = red cell folate; IF = intrinsic factor; Retic = reticulocyte count; SBil = serum Bilirubin;
SLDH = serum lactate dehydrogenase; SHapt = serum haptoglobin; Nor = normal; Inc = Increased;
Dec = Decreased.

Approach To Anaemia

History
The history is important. Congenital anaemia is suggested by the patients personal and
family history. Poor diet results in folic acid deficiency and contributes to iron deficiency. A
history of heavy menses, ingestion of NSAIDs and aspirin will suggest blood loss.

Physical examination
Physical examination includes attention to signs of primary hematologic diseases
(lymphadenopathy, hepatosplenomegaly, or bone tenderness). Mucosal changes such as
a smooth tongue suggest megaloblastic anemia.

Diagnostic possibilities based on MCV size


The diagnostic possibilities are shown in Table 7.
Microcytic anaemia

Iron Deficiency Anemia


Causal factors
These are shown in Table 8.
Table 8. Causes of Iron Deficiency Anaemia

Deficient diet
Decreased absorption
Increased requirements Pregnancy, Lactation
Blood loss Gastrointestinal, Menstrual, Blood donation
Hemoglobinuria
Iron sequestration Pulmonary hemosiderosis

Clinical features
The only symptoms of iron deficiency anaemia are those of the anaemia itself (easy
fatigability, tachycardia, palpitations and tachypnea on exertion). Severe deficiency causes
skin and mucosal changes, including a smooth tongue, brittle nails, and cheilosis.
Dysphagia may be present because of the formation of esophageal webs
(Plummer-Vinson syndrome) also occurs. Many iron-deficient patients develop pica,
craving for specific foods (ice chips, lettuce, etc), often not rich in iron.
310

Laboratory investigations
Hb and iron stores. Iron deficiency develops in stages. The first is depletion of iron
stores. At this point, there is anaemia and no changes in red blood cell size. The serum
ferritin will become abnormally low. A ferritin value less than 30 gg/L is a highly reliable
indicator of iron deficiency. The serum total iron-binding capacity (TIBC) rises. After
iron stores have been depleted, red blood cell formation will continue with deficient
supplies of iron. Serum iron values decline to less than 30 pg/dL and transferrin
saturation to less than 15%.
MCV. In the early stages, the MCV remains normal. Subsequently, the MCV falls.
PBF. In the early stages, the blood smear shows hypochromic microcytic cells. With
further progression, anisocytosis (variations in red blood cell size) and poikilocytosis
(variation in shape of red cells) develop. Severe iron deficiency will produce a bizarre
peripheral blood smear, with severely hypochromic cells, target cells, hypochromic
pencil-shaped cells, and occasionally small numbers of nucleated red blood cells. The
platelet count is commonly increased.

Differential Diagnosis
Other causes of microcytic anaemia include aaemia of chronic disease, thalassemia, and
(less commonly) sideroblastic anaemia.
Anaemia of chronic disease is characterized by normal or increased iron stores in the
bone marrow and a normal or elevated ferritin level; the serum iron is low, often
drastically so; the TIBC is either normal or low.
Thalassemia produces a greater degree of microcytosis for any given level of anaemia
than does iron deficiency. Red blood cell morphology on the peripheral smear
becomes abnormal earlier in the course of thalassemia.
Treatment
To make the diagnosis of iron deficiency anaemia, one can either demonstrate an
iron-deficient state or evaluate the response to a therapeutic: trial of iron replacement.
Since the anaemia itself is rarely life-threatening, the most important part of treatment is
identification of the cause especially a source of occult blood loss.
Oral iron. There is no better treatment than ferrous sulfate, 325 mg three times daily,
which provides 180 mg of iron daily of which up to 10 mg is absorbed (though
absorption may exceed this amount in cases of severe deficiency). Compliance is
improved by introducing the medicine more slowly in a gradually escalating dose with
food. An appropriate response is a return of the hematocrit level halfway toward normal
within 3 weeks with full return to baseline after 2 months. Iron therapy should continue
for 3-6 months after restoration of normal hematologic values in order to replenish iron
stores. Failure of response to iron therapy is usually due to noncompliance, although
occasional patients may absorb iron poorly. Other reasons for failure to respond include
incorrect diagnosis (anaemia of chronic disease, thalassemia) and ongoing gastrointestinal blood loss that exceeds the rate of new erythropoiesis.
Parenteral iron. The indications are intolerance to oral iron, refractoriness to oral iron,
gastrointestinal disease (usually inflammatory bowel disease) precluding the use of oral
iron, and continued blood loss that cannot be corrected. Because of the possibility of
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anaphylactic reactions, parenteral iron therapy should be used only in cases of persistent
anaemia after a reasonable course of oral therapy.
The dose (total 1.5-2 g) may be calculated by estimating the decrease in volume of red blood
cell mass and then supplying 1 mg of iron for each millilitre of volume of red blood cells below
normal. One should then add approximately 1 g for storage iron. The entire dose may be
given as an intravenous infusion over 4-6 hours. A test dose of a dilute solution is given first,
and the patient should be observed during the entire infusion for anaphylaxis.
Normocytic anaemia

Anaemia Of Chronic Disease


Many chronic systemic diseases are associated with mild or moderate anaemia. Common
causes include chronic infection or inflammation, cancer, and liver disease. The anaemia of
chronic renal failure is somewhat different in pathophysiology and is usually more severe.
Red blood cell survival is modestly reduced, and the bone marrow fails to compensate
adequately by increasing red blood cell production. Failure to increase red cell production is
largely due to sequestration of iron within the reticuloendothelial system. Decrease in
erythropoietin is rarely an important cause of underproduction of red cells except in renal failure.
Clinical Features
The clinical features are those of the anemia, which is usually modest. The diagnosis should
be suspected in patients with known chronic diseases; it is confirmed by the findings of low
serum iron, low TIBC, and normal or increased serum ferritin (or normal or increased bone
marrow iron stores). In cases of significant anemia, coexistent iron deficiency or folic acid
deficiency should be suspected. Decreased dietary intake of folate or iron is common in
these ill patients, and many will also have ongoing gastrointestinal blood losses. Patients
undergoing hemodialysis regularly lose both iron and folate during dialysis.
Laboratory investigations
The hematocrit rarely falls below 25% (except in renal failure). The MCV is usually normal
or slightly reduced. Red blood cell morphology is nondiagnostic, and the reticulocyte
count is neither strikingly reduced nor increased. Serum iron values may be unmeasurable, and transferrin saturation may be extremely low, leading to an erroneous diagnosis
of iron deficiency. In contrast to iron deficiency, serum ferritin values should be normal or
increased. A serum ferritin value of less than 30 ltg/L should suggest coexistent iron
Treatment
In most cases no treatment is necessary. Purified recombinant erythropoietin has been shown to
be effective for treatment of the anaemia of renal failure and other secondary anaemias such as
anaemia related to cancer or inflammatory disorders (e.g. rheumatoid arthritis). In renal failure,
optimal response to erythropoietin requires adequate intensity of dialysis. Erythropoietin must be
injected subcutaneously and is very expensive. One effective schedule is 30,000 units once
weekly. This agent is used only when the patient is transfusion-dependent or when the quality of
life is clearly improved by the haematologic response.

312

Macrocytic anaemia

Vitamin B12 Deficiency


Causes of vitamin B12 deficiency are: Dietary deficiency (rare); Decreased production of
intrinsic factor in pernicious anaemia and gastrectomy; Helicobacterpylori infection;
Competition for vitamin B12 in gut seen in blind loop syndrome, fish tapeworm (rare);
Pancreatic insufficiency; Decreased ileal absorption of vitamin B12 seen in surgical
resection and Crohns disease; TrancrnhAamin II deficiency (rare). The most common
cause of vitamin B12 deficiency is that associated with pernicious anaemia. Although the
disease is hereditary, it is rare clinically before age 35. Pernicious anaemia produces a
number of clinical findings in addition to vitamin B12 deficiency. Atrophic gastritis is
invariably present and results in histamine-fast achlorhydria. These patients may also have
a number of other autoimmune diseases, including IgA deficiency, as well as
polygllandular endocrine insufficiency. The atrophic gastritis is associated with an
increased risk of gastric carcinoma.
Clinical Features
The hallmark of vitamin B12 deficiency is megaloblastic anaemia. The anaemia may be
severe, with hematocrits as low as 10-15%. The megaloblastic state also produces
changes in mucosal cells, leading to glossitis, as well as other vague gastrointestinal
disturbances such as anorexia and diarrhoea. Vitamin B12 deficiency also leads to a
complex neurologic syndrome. Peripheral nerves are usually affected first, and patients
complain initially of paresthesias. The posterior columns next become impaired, and
patients complain of difficulty with balance. In more advanced cases, cerebral function
may be altered as well, and on occasion dementia and other neuropsychiatric changes
may precede haematologic changes.
Patients are usually pale and may be mildly icteric. Neurologic examination may reveal
decreased vibration and position sense but is more commonly normal in early stages of
the disease.
Laboratory investigations
The MCV is usually strikingly elevated, between 110 and 140 fl,. However, it is possible to
have vitamin B12 deficiency with a normal MCV. The neutrophils are hypersegmented.
Typical features include a mean lobe count greater than four or the finding of six-lobed
neutrophils. The reticulocyte count is reduced. Because vitamin B12 deficiency affects all
hematopoietic cell lines, in severe cases the white blood cell count and the platelet count
are reduced, and pancytopenia is present.
Bone marrow morphology is characteristically abnormal. Marked erythroid hyperplasia is
present as a response to defective red blood cell production (ineffective erythropoiesis).
Megaloblastic changes in the erythroid series include abnormally large cell size and
asynchronous maturation of the nucleus and cytoplasm - ie, cytoplasmic maturation
continues while impaired DNA synthesis causes retarded nuclear development. In the
myeloid series, giant metamyelocytes are characteristically seen.

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The diagnosis of vitamin B12 deficiency is made by finding an abnormally low vitamin
B12 serum level. Whereas the normal vitamin B12 level is 150-350 pg/mL, most patients
with overt vitamin B12 deficiency will have serum levels less than 100 pg/mL.

DIFFERENTIAL DIAGNOSIS
Vitamin B12 deficiency should be differentiated from folic acid deficiency, the other
common cause of megaloblastic anemia, in which red blood cell folate is low while
vitamin B12 levels are normal. The distinction between vitamin B12 deficiency and
myelodysplasia (the other common cause of macrocytic anemia with abnormal
morphology) is based on the characteristic morphology and the low vitamin B12 level.
Peripheral neuropathy and dementia of other cause may be similar clinically to nonhematologic pernicious anemia.
Treatment
Patients with pernicious anemia are often treated with parenteral therapy. Intramuscular
injections of 100 ug of vitamin B12 are adequate for each dose. Replacement is usually
given daily for the first week, weekly for the first month, and then monthly for life. It is a
lifelong disorder, and if patients discontinue their monthly therapy the vitamin deficiency
will recur.
Oral cobalamin may be used instead of parenteral therapy, in a dose of 1000 ug/d and
must be continued indefinitely. Patients respond to therapy with an immediate improvement in their sense of well-being. Hypokalemia may complicate the first several days
of therapy, particularly if the anemia is severe. A brisk reticulocytosis occurs in 5-7 days,
and the haematologic picture normalizes in 2 months. Central nervous system symptoms
and signs are reversible if they are of relatively short duration (less than 6 months) but
become permanent if treatment is not initiated promptly.

FOLIC ACID DEFICIENCY


Folic acid is present in most fruits and vegetables (especially citrus fruits and green leafy
vegetables) and daily requirements of 50-100 ug/d are usually met in the diet. Total body
stores of folate are approximately 5000 ug, enough to supply requirements for 2-3 months.
Causes of folate deficiency are: Dietary deficiency; Decreased absorption seen in tropical
sprue, effect of drugs like phenytoin, sulfasalazine, trimethoprim-sulfamethoxazole;
Increased requirement seen in Chronic hemolytic anemia, Pregnancy, Exfoliative skin
disease; Loss seen in dialysis; and Inhibition of reduction to active form seen in
methotrexate therapy.
By far the most common cause of folate deficiency is inadequate dietary intake.
Alcoholics, anorectic patients, persons who do not eat fresh fruits and vegetables, and
those who overcook their food are candidates for folate deficiency. Reduced folate
absorption is rarely seen, since absorption occurs from the entire gastrointestinal tract.
However, drugs such as phenytoin, trimethoprim-sulfarrlethoxazole, or sulfasalazine may
interfere with folate absorption. Folic acid requirements are increased in pregnancy,
hemolytic anemia, and exfoliative skin disease, and in these cases the increased
requirements (five to ten times normal) may not be met by a normal diet. Patients with
increased folate requirements should receive supplementation with I mg/d of folic acid.
314

Clinical Features
The features are similar to those of vitamin B12 deficiency, with megaloblastic anemia
and megaloblastic changes in mucosa. However, there are none of the neurologic
abnormalities associated with vitamin B12 deficiency.
Laboratory investigations
The megaloblastic anemia is identical to that resulting from vitamin B12 deficiency.
However, the serum vitamin B12 level is normal. A red blood cell folate level of less than
150 ng/mL is diagnostic of folate deficiency.
Differential Diagnosis
The megaloblastic anaemia of folate deficiency should be differentiated from vitamin B12
deficiency by the finding of a normal vitamin B1, level and a reduced red blood cell folate
or serum folate level. Alcoholics, who often have folate deficiency, may also have
anaemia of liver disease. This latter macrocytic anaemia does not cause megaloblastic
morphologic changes but rather produces target cells in the peripheral blood.
Hypothyroidism is associated with mild macrocytosis but also with pernicious anaemia.
Treatment
Folic acid deficiency is treated with folic acid, I mg/d orally. The response is similar to that
seen in the treatment of vitamin B12 deficiency, with rapid improvement and a sense of
well-being., reticulocytosis in 5-7 days, and total correction of hematologic abnormalities
within 2 months. Large doses of folic acid may produce hematologic responses in cases of
vitamin B12 deficiency but will allow neurologic damage to progress.
References for further reading
Linker CA. Blood in: Current Medical Diagnosis and Treatment, 2003:469 - 477
Goddard AF et al: Guidelines for the management of iron deficiency anaemia. British Society of Gastroenterology.
Gut 2000;46(Suppl 3-4):IV1.
Goodnough LT et al: Erythropoietin, iron, and erythropoiesis. Blood 2000;96:823.

CHAPTER 4

PSYCHOLOGICAL DISORDERS

Outline
Psychiatric assessment

PSYCHIATRIC ASSESSMENT
In the outpatient setting, the pressure of time raises the question of how thorough a
psychiatric assessment should be. An awareness of a psychiatric disorder as the
underlying cause of the presentation or as a complication of a physical illness is the first
step. A screening tool such as the psychiatric review described in this reading could then
be used. History taking and examination provide the input for a working diagnosis and
management plan. A psychiatric diagnosis must be based upon positive evidence
accumulated by the above techniques. It must not be based simply on the exclusion of
organic findings.
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Scope Of Psychiatric Assessment


The psychiatric assessment needs to include the history; mental status; medical conditions
(including drugs); and pertinent social, cultural, and environmental factors impinging on
the individual. The psychiatric history should cover the following points (Eisendrath &
Lichtmacher, 2003):
(1) complaint, from the patients viewpoint;
(2) the present illness, or the evolution of the symptoms;
(3) neurovegetative signs such as libido, appetite, and sleep;
(4) previous disorders and the nature and extent of their treatment;
(5) the family history important for genetic aspects and family influences;
(6) the personal history childhood development, adolescent adjustment, level of
education, and adult coping patterns;
(7) current life functioning, with attention to vocational, social, educational, and
avocational areas; and
(8) present or past use of alcohol and other drugs.
It is often essential to obtain additional information from the family e.g. the patients
premorbid personality. Observing interactions of the patient with significant others in the
context of a family interview may give important diagnostic information e.g., relationship
problems. Physical examination (with emphasis on the neurologic examination) as well as
all necessary laboratory and other special studies may also need to be done because
physical illness may frequently present as psychiatric disease, and vice versa. A thorough
psychiatric evaluation has therapeutic as well as diagnostic value and should be expressed
in ways best understood by the patient, family, and other physicians.
Psychiatric Review Of Symptoms
Screening tools help to spot the patient with a psychiatric problem. One such useful tool
is the psychiatric review of symptoms by Carlat (Carlat, 1998). The approach begins with
a mnemonic encompassing the 8 major psychiatric disorders: depression, personality
disorders, substance abuse disorders, anxiety disorders, somatization disorder, eating
disorders, cognitive disorders and psychotic disorders.
The mnemonic Depressed Patients Seem Anxious, So Claim Psychiatrists is used to
remember these 8 psychiatric groups, as follows:
Depression and other mood disorders (major depression, bipolar disorder, dysthymia).
Personality disorders (primarily borderline personality disorder).
Substance abuse disorders.
Anxiety disorders (panic disorder with agoraphobia, obssessive-compulsive disorder).
Somatization disorder, eating disorders (these two disorders are combined because both
involve disorders of bodily perception).
Cognitive disorders (dementia, delirium).
Psychotic disorders (schizophrenia, delusional disorder and psychosis accompanying
depression, substance abuse or dementia).

316

For each category, an initial screening question is used, with a positive response leading
to more detailed diagnostic questions. The psychiatric review of symptoms is both rapid
and thorough, and can be readily incorporated into the standard history and physical
examination (Carlat, 1998).
Useful Interviewing Approaches to Psychiatric Symptoms
Useful interviewing techniques include a broad question first, normalization (phrasing a
question to convey to the patient that such behavior is normal or understandable),
symptom assumption (phrasing a question to imply that it is assumed the patient has
engaged in such behavior) and transitioning from one subject to another rather than
abruptly changing subjects.
Begin with broad screening questions As in the medical review of systems, the best
approach for the psychiatric review of symptoms to begin with broad screening questions
and proceed to specific symptoms if the patients response to the screening question is
positive. While a negative response to a given screening question decreases the likelihood
of a disorder, the sensitivity of such screening is never perfect, and answers should be
interpreted within the context of the patients entire history and physical examination.
Normalization To deal with sensitive topics like suicidality, substance abuse and
obsessive-compulsive rituals which can arouse feelings of shame, embarrassment or
despair, normalisation can be used to approach such topics in a nonthreatening manner.
This involves introducing a behavioral topic by first making a statement to let the patient
know that you consider the behavior in question to be a normal, or at least an
understandable, response to a mood or situation. For example, the topic of alcohol abuse
can be approached with a question like With all the stress youve been under, I wonder
if youve been drinking more lately?
Symptom assumption This is a similar technique in which a question is phrased in a
way that implies you already assume the patient has engaged in a particular behavior.
This technique communicates to the patient that you will not be surprised or offended by
a positive response. For example, a patient who has indicated suicidal ideation might be
asked, What kinds of ways have you thought about to hurt yourself? A patient who
abuses alcohol and is suspected of having polysubstance abuse as well might be asked,
What sort of drugs do you usually use when you drink?
Transitioning techniques These are often used in psychiatric interviewing to
facilitate a rapid series of questions on sensitive topics. Rather than abruptly switching
from topic to topic (as is appropriate in the medical review of systems), a previous topic or
a previous response is used as a jumping-off point for the next question. Thus, the topic
of suicidality might be approached with the statement, Earlier you mentioned that you
didnt know how much more of this you could take. Have you had thoughts of wanting
to escape it by dying?

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Mood Disorders
For depression, the simple question, Are you depressed? is effective. A study of
terminally ill patients revealed that this straightforward approach had a 100 percent
sensitivity and specificity in diagnosing major depression, outperforming elaborate
screening instruments such as the Beck Depression Inventory (Chochinov et al, 1997).
When depression screening is positive, the next step is to determine the presence of
neurovegetative symptoms of depression. This information is helpful not only in
confirming the diagnosis but also in identifying specific target symptoms to monitor after
antidepressant therapy is initiated.
The eight neurovegetative symptoms of depression can be easily remembered with the
mnemonic SIGECAPS (Table 1). Used by psychiatry residents at Massachusetts General
Hospital (where it was devised by Dr. Carey Gross), the mnemonic refers to a prescription
one might write for a depressed, anergic patient SIG: Energy CAPSules.
Each letter refers to one of the major diagnostic criteria for major depressive disorder, as
listed in Table 1. Rather than asking about each of the neurovegetative symptoms
separately, a more efficient approach is to ask, How has your depression affected your life
over the past couple of weeks? For example, how has it affected your sleep? Your
appetite? and so forth. For patients who seem reluctant to admit to a depressed mood (or
who have poor insight), beginning with the question, Do you have any problems
sleeping? provides a nonthreatening introduction to a discussion of depressive symptoms.
Table 1. A Mnemonic For Symptoms of Major Depression And Dysthymia
SIGECAPS=SIG + Energy + CAPSules
Sleep disorder (either increased or decreased sleep)*
Interest deficit (anhedonia)
Guilt (worthlessness,* hopelessness,* regret)
Energy deficit*
Concentration deficit*
Appetite disorder (either decreased or increased)*
Psychomotor retardation or agitation
Suicidality
Source: Carlat, 1998. Footnote To meet the diagnosis of major depression, a patient must have four of the
symptoms plus depressed mood or anhedonia, for at least two weeks. To meet the diagnosis of dysthymic disorder,
a patient must have two of the six symptoms marked with an asterisk, plus depression, for at least two years.

Suicidal Ideation. The most effective approach for assessing suicidal ideation is to
ask first about passive suicidal ideation. This sensitive area may be introduced with
the question, With all the depression youve been dealing with, have you ever had
the thought that youd be better off dead? The most common response is the
reassuring, Oh sure, the thought has crossed my mind, but Id never do anything
to hurt myself. However, if active suicidal ideation is present, one should
determine if the patient has a suicide plan in place and estimate how realistic and

318

imminent it is. A patient with a specific suicide plan should undergo urgent
psychiatric evaluation.
Dysthymia. This is a chronic depression lasting at least two years that does not
meet symptomatic criteria for major depression. The diagnosis is usually easily made
with the question, When was the last time you remember not feeling depressed?
Typically, the patient with dysthymia answers many years; indeed, the average
duration of the disorder is 16 years (Klein et al, 1993).
Bipolar Disorder. A common oversight in psychiatric screening is to neglect to ask
questions aimed specifically at diagnosing bipolar disorder. A failure to recognize
the presence of bipolar disorder can lead to serious problems, since antidepressant
therapy can precipitate manic episodes in such patients (Wehr & Goodwin, 1987).
Rapid screening for a history of mania is made challenging by the high potential for
false-positive responses. Many patients report periods of euphoria and high energy
that represent normal variations in mood rather than mania.
The following screening question is helpful: Have you had periods of feeling so
happy or energetic that your friends told you were talking too fast or that you were
too hyper? If the screen is positive, the mnemonic DIGFAST can be used to
recall the cardinal symptoms of mania (Table 2).
Table 2. Cardinal Symptoms of Mania
Distractibility
Indiscretion (DSM-IVs excessive involvement in pleasurable activities . . . )
Grandiosity
Flight of ideas
Activity increase
Sleep deficit (decreased need for sleep)
Talkativeness (pressured speech)
NOTE: A manic episode requires at least one week of elevated or irritable mood plus three of the
seven symptoms described above
Source: Carlat, 1998

Borderline Personality Disorder


An important personality disorder for the family physician to recognize is borderline
personality disorder. Patients with this disorder have high comorbidity with other
psychiatric disorders and high rates of suicidal ideation, and they cause particular
treatment difficulties, including hostility toward caregivers and low rates of treatment
compliance (Lazare, 1989).
The central feature of patients with borderline personality disorder is a morbid fear of
abandonment with consequential pathologic responses to perceived rejection (Lazare,
1989). Such patients may demand inappropriate amounts of time or support from a
primary care physician, and they may become hostile and demanding or suicidal if these

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needs are not met. While screening for borderline personality disorder is not always
practical during the initial visit, the mnemonic I DESPAIRR(Table 3) is useful for recalling
the criteria of the disorder, and some of these questions can be posed during follow-up
visits as time and circumstances allow.
Table 3. Criteria of The Borderline Personality Disorder
Identity problem Do you have trouble knowing who ________ is?
(say patients name)
Disordered affect Are you a moody person?
Empty feeling Do you often feel empty inside?
Suicidal behavior When something goes really wrong in your life, like getting rejected, do you
ever do something to hurt yourself, like cutting yourself or overdosing?
Paranoia or dissociative symptoms When youre under stress, do you feel like you lose touch with
your environment or with yourself? During those times, do you feel like people are ganging up
against you?
Abandonment terror When someone abandons you or rejects you, how do you react? (Patients
with borderline personality disorder often react with suicidal ideation or rage.)
Impulsivity Do you ever get really impulsive and do crazy things, like going on spending sprees,
having a lot of sex, driving like a maniac and so forth?
Rage What do you do when you get angrydo you hold it inside or let loose with it so
everybody knows how youre feeling? (Patients with borderline personality disorder tend to express
rage dramatically.)
Relationship instability
Source: Carlat, 1998

Do your relationships tend to be calm and stable or stormy and with lots of ups and downs?
Asking about each trait in turn is not advised, both because this approach interrupts the flow
of the interview and because it is time-consuming. Instead, these traits are best uncovered
within the context of a brief survey of a patients relationship history. Patients with borderline
personality disorder often have a lifelong trail of ruptured and stormy relationships within several
spheres, including the family, school, work, romance and marriage.
While a lengthy social history is generally not possible during an initial medical visit, the
family practitioner should be alert to the following red flags:
A history of doctor shopping.
A history of legal suits against physicians or other professionals.
A history of suicide attempts.
A history of several brief marriages or intimate relationships.
An immediate idealization of you as a wonderful doctor, especially if the patient
compares you with disappointing caregivers of the past.
Excessive interest in your personal life, eventually leading to invitations to socialize with
you. Behavior of this type implies boundary violations, and its purpose is to cement a
relationship with the physician, allaying the patients ever-present fear of abandonment.
Substance Abuse Disorders
The best and quickest screen for alcoholism remains the tried-and-true CAGE questionnaire
(Ewing, 1984) (Table 4), in which a positive response to two or more of the items implies a 95
320

percent chance of alcohol abuse or dependence. However, a recent study (Steinwed & Worth,
1993) suggests that the way in which physicians create the transition to the CAGE questions
profoundly affects the questionnaires sensitivity.
In this study, 43 confirmed alcoholics were divided into two groups. In one group, the CAGE
was introduced with an open-ended question, such as Do you have a drink now and then?
In the second group, patients were first asked to quantitate their alcohol intake with the
question, How much do you drink? The sensitivity of the CAGE questions was dramatically
higher in the first group (95 percent) than in the second group (32 percent), demonstrating
the importance of beginning the CAGE questions in a non-judgmental way.
Many physicians have been taught that the two-question drinking test (Have you ever had a
drinking problem? and When was your last drink?) is an effective rapid screen for
alcoholism. The screen is considered positive if the patient answers yes to the first question
and within the past 24 hours to the second question (Cyr & Wartman, 1988) However, a
study failed to confirm the results of the initial study, and the sensitivity of this screening tool
is probably no better than 50 percent (Schorling et al, 1995).
Abuse of other substances is common in alcohol abusers, and a positive CAGE screen should
be followed by a question about drug use. The symptom assumption technique is useful in
this setting. The possibility of drug use can be introduced with the question, Aside from
drinking, what sorts of recreational drugs do you use regularly? Cocaine? Marijuana? Speed?
Heroin? Delivered in a matter-of-fact manner, this question communicates a nonjudgmental
attitude and tends to decrease the patients shame about admitting to drug use.
Table 4. CAGE Questionnaire
1.
2.
3.
4.

Have you ever felt you ought to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves
or get rid of a hangover (Eye-opener)?
Score Two yes responses constitute a positive screening test.

Source: Carlat, 1998

Anxiety Disorders
A good general screen for all anxiety disorders is the question, Do you tend to be an
anxious or nervous person? A positive response should prompt the physician to screen
for panic disorder, agoraphobia and obsessive-compulsive disorder. Time constraints
during the history and physical examination preclude screening for all of the anxiety
disorders; panic disorder with agoraphobia is selected because it is common, and
obsessive-compulsive disorder because patients rarely divulge this information unless they
are specifically asked.
Panic Disorder with Agoraphobia. For panic disorder, the straightforward question,
Do you have anxiety or panic attacks? is useful. If the patient is confused about what is
meant by the term panic attacks, the following explanation is usually sufficient: A
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panic attack is a sudden rush of fear and nervousness that makes your heart pound and
makes you afraid youre going to die or go crazy.
Once a diagnosis of panic disorder is confirmed, questions about symptoms of
agoraphobia should be asked because agoraphobia accompanies panic in the majority of
cases (Am Psychiatric Association, 1994). The question, Have you had to limit where you
can go because of your anxiety? captures the gist of the disorder. Patients with panic
disorder often have been gradually limiting their activities, especially those that require
driving, without realizing that anxiety is the underlying cause of their self-imposed
restrictions.
Obsessive-Compulsive Disorder. A good screening question for diagnosing obsessivecompulsive disorder is, Do you have symptoms of obsessive-compulsive disorder, such as
checking things repeatedly or washing your hands over and over? A potential pitfall is a falsepositive response from healthy patients who are adaptively compulsive or perfectionistic but do not
meet the criteria for obsessive-compusive disorder. A question such as Do your compulsions
significantly interfere with your ability to live your life? helps identify a clinically significant disorder.
Somatization Disorder
Since the criteria for somatization disorder are somewhat arbitrary, the following
mnemonic may help in remembering them: Recipe 4 Pain: Convert 2 Stomachs to 1
Sex. The translation of this mnemonic is as follows: the presence of four pain symptoms
(Recipe 4 Pain), one conversion symptom (Convert), two gastrointestinal symptoms
(2 Stomachs) and one sexual symptom (1 Sex).
Eating Disorders
To elicit information about behaviour related to an eating disorder, the first question can
be, Have you ever felt like you are overweight? An unequivocal negative response
probably excludes the diagnosis of an eating disorder. A positive response should be
followed by more focused questions about the methods used to lose weight, asking the
questions in a matter-of-fact way to help defuse the patients embarrassment. For
example, the patient may be asked, Have you dieted? Used laxatives? Made yourself
throw up? A binging history can be elicited by asking the following question: Do you
go on eating binges in which you eat an unusually large amount of food within a twohour period and feel that you cant control your eating?
A common pitfall is to screen for eating disorders only in women. Studies have pointed to
a significant prevalence of these disorders in men, who constitute 10 to 15 percent of all
anorexic and bulimic patients (Carlat & Camargo, 1991). Furthermore, 40 percent of men
with bulimia are gay or bisexual, implying that screening for an eating disorder is
particularly important in this population (Carlat et al, 1997).
Dementia
Early detection of dementia is increasingly important because currently available treatment,
such as donepezil (Aricept) which is most useful in the early stages of the disease.
Unfortunately, the utility of the most popular screening instrument, the Folstein Mini322

Mental State Examination (MMSE) (Folstein et al, 1975), is hampered by high rates of falsepositive diagnosis, especially among poorly educated patients (Anthony et al, 1982). In a
large-scale study (3,513 elderly patients) of the MMSE at the Mayo Clinic, unacceptably low
positive predictive values led the researchers to conclude that the MMSE is ineffective when
it is used to screen unselected patients in a general medical practice (Tangalos et al, 1996).
For these reasons, a more reliable screening approach for the family physician is to
conduct formal cognitive testing only in patients with a history that suggests a likelihood
of cognitive impairment. Questions should directly address the possibility of short-term
and long-term memory impairment. For short-term memory, studies have demonstrated
the clinical utility of both a three-object recall and orientation to time and place
(orientation to person is a measure of long-term memory) (Hinton, 1971). For long-term
memory, clinical studies have shown that general information questions and questions
pertaining to remote personal information are most useful (Keller & Manchreck, 1989).
Poor performance on these screening tests, defined as significant disorientation to place
and date, a greater than 50 percent failure rate on general and personal information
items, and inability to remember at least two of the three words, suggests that more indepth cognitive evaluation is needed, often including formal neuropsychologic testing.
Psychotic Disorders
Psychotic symptoms such as looseness of associations, bizarre delusions and
hallucinations are generally easy to recognize, and patients manifesting these symptoms
should be referred immediately for psychiatric treatment. However, many patients present
with more subtle symptoms, which may not be discovered without some diagnostic
digging. Because of the time constraints during an initial visit, screening for psychosis
should be selective, focusing on those patients with a relatively high probability of
harboring a psychotic thought process or content. Patients at high risk of psychosis
include (1) patients with the diagnosis of major depression, substance abuse or dementia
and (2) patients who appear guarded, suspicious or otherwise odd during the interview.
Screening questions for psychosis are often piggy-backed onto transitional questions
referring to other symptoms previously described by the patient. For example, a
depressed patient might be asked, Depression sometimes causes people to have strange
experiences, like hearing voices or feeling that others are trying to harm them. Has that
happened to you? A patient with dementia might be asked, When you misplace
things, do you sometimes think that theyve been stolen? or Have you ever heard or
seen people coming into your house? For a substance-abusing patient, the approach
might be to ask Have drugs ever caused your mind to play tricks on you, like seeing
things or having paranoid ideas? Among substance abusers, psychotic ideation may
result from acute intoxication (e.g., amphetamine or cocaine abuse), chronic use (e.g.
alcoholic hallucinosis) or withdrawal (e.g., delirium tremens).
The best approach for ascertaining delusional ideation in someone suspected of active
paranoia is to adopt the patients viewpoint: Have people been harassing you or trying
to harm you? This communicates sympathy for the patients perceptions and tends to
defuse a guarded attitude.
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This rapid screen is no substitute for a complete psychiatric evaluation in patients with
more complicated or severe problems. Such patients should be referred for psychiatric
consultation, but they can often return to their family physician for ongoing
psychopharmacologic treatment.
References for further reading
Carlat DJ. The psychiatric review of symptoms: a screening tool for family physicians. Am Fam Physician 1998 Nov
1;58(7):1617-24
Eisendrath SJ, & Lichtmacher JE. Psychiatric disorders. In: Current Diagnosis & medical Treatment, 2003:10061009.

CHAPTER 5

SKIN DISORDERS

Outline
Infective dermatoses
Bacterial infections
Fungal infections

INFECTIVE DERMATOSES
Infective dermatoses are commonly encountered in general practice. The important
clinical decision is to decide if the condition can be treated at the primary care level. It
must be emphasized that a systematic attention to appearance of the patient; vital signs
including temperature; the four major skin signs of morphology, arrangement,
distribution; hair and nails, mucous membranes as well as general medical examination
will help in arriving at the correct diagnosis and the need for referral or not. Infective
dermatoses can be grouped in aetiologically into bacterial, fungal, viral, and parasitic.
Only the bacterial infections and fungal infections will be discussed in this Primer.

BACTERIAL INFECTIONS
Primary Skin Infections

Impetigo
This is the commonest bacterial skin infection in children. The disease is caused by
coagulase-positive micrococci and by betahemolytic streptococci; both organisms may be
present. The lesions can be divided into two types according to their bacterial aetiolgoy.
Streptococcal Impetigo. The golden crusted impetiginous lesions are primarily caused
by group A betahemolytic streptococci (GABHS). The earlier lesion is a tiny vesicle or
pustule that soon ruptures and is replaced by expanding crusts. Typically it has little
surrounding erythema, but local adenopathy is common. The lesions are generally
asymptomatic although pruritus may occasionally be present. They spread rapidly
wherever the child has broken the natural defence barrier of the skin.
Staphylococcal Impetigo. The typical lesions of bullous or staphylococcal impetigo are
easily separated clinically from those of crusted or traditional stretococcal infection. The
324

bullae are larger than the transient, tiny vesicles or pustules of GABHS impetigo. The thin
roof of the bulla is lost fairly quickly, and the telltale aftermath should be easily
recognizable. Once the bullae have shed their covers, they initially have erythematous,
moist bases that dry quickly, leaving a varnished or lacquered appearance. Contiguous
older lesions may be recognizable by their thin collarettes of scales. The lesions have little
or no surrounding erythema and Iymphadenopathy is usually not present. Staphylococcal
impetigo tends to spread locally unless associated as a secondary lesion in vericella or
multiple insect bites. Bullous impetigo in neonates should generate special concern since
serious secondary infections, particularly osteomyelitis, septic arthritis and pneumonia
may follow seemingly innocuous superficial infection.

Ecthyma
This condition is commonly caused by streptococca/ infection. It forms crusts and ulcers.
Often, it heals with scarring. The lesions differ from impetigo in which the crust is not as
massive and under which there is no ulcer. Attention should be aid to possible underlying
predisposing causes ea. insect bites and trauma.
Treatment of Impetigo and Ecthyma
Many physicians prefer semisynthetic penicillinase resistant penicillins or erythromycin as
systemic therapy. Bullous impetigo requires treatment with either erythromycin or
dicloxacillin. There has been concern about the increasing frequency of erythromycinresistant staphylococcal infections. Ecthyma responds nicely to penicillin but usually with
some scarring.

Cellulitis and Erysipelas


This is a spreading inflammation of loose connective tissue, and is a more serious
infection because of local and systemic spread. The overlying skin is red, tender and
warm. Regional adenopathy, Iymphangitis, and systemic signs and symptoms such as
fever and chills may be more pronounced. The cause is either a streptococcus or
a staphylococcus.
Erysipelas is a distinctive cellulitis caused by Group A beta-haemolytic streptococcus. It is
rapidly spreading with distinct, raised borders associated with prominent systemic signs,
and symptoms, Fever, chills, and prostration may be abrupt in onset, and bacteremia
is common.
Facial cellulitis is an enigmatic potentially serious infection generally affecting young
children. It requires early recognition and aggressive treatment because of the associated
high risk for other serious systemic infections, particularly meningitis, brain abscess, optic
neuritis, and cavernous sinus thrombosis.
Treatment of Cellulitis and Erysipelas
Attacks of cellulitis and erysipelas may be quickly suppressed by appropriate antibiotic
therapy. Penicillin is the agent of choice. Cloxacillin or erythromycin should be given
when staphylococcal infection is suspected. Patients should be given complete bed rest.
Local medicament is of no value. The affected part should be immobilized and elevated.
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In recurrent infection one should seek the nidus such as tinea pedis. In some instanes
systemic antibiotics given on a long-term prophylactic basis will prevent recurrences.

Other bacterial infections


Necrotizing Fasciitis (Hemolytic Streptococcus Gangrene)
This rare disease is a fulminating infection of the superficial and deep fascia resulting in
thrombosis of the subcutaneous vessels and gangrene of the underlying tissue. Usually it
follows a cutaneous injury but sometimes no portal of entry is found. The affected area
becomes hot, oedematous and red and as it gradually enlarges, a pathognomonic sign
develops between the second and the fourth days; the affected skin assumes a blue,
dusky tinge. Blisters may be present. The process advances to areas of frank, cutaneous
gangrene, with eventual sloughing. Cutaneous metastatic infections may appear.
Streptococcus may be demonstrated from the spreading border of the lesions or from
the blister fluid.
The most important part of the treatment is early incision and drainage. The involved part
is opened widely at the fascial plane and the gangrenous areas excised. Massive doses of
antibiotics are needed and all such patients require inpatient treatment. Mortality rate is
high and underlying diseases such as diabetes mellitus and severe arteriosclerosis are
not uncommon.

Folliculitis, Furunculosis, Carbuncle


Infection of the hair follicle is most commonly caused by staphylococcus. Folliculitis is a
superficial infection consisting of small, yellowish superficial pustules with a thin rim of
surrounding erythema. A central hair shaft is commonly present in the lesion. A furuncle
is a deeper infection in the follicle and is associated with more swelling and erythema.
The center of these lesions often liquefies, producing a cavity filled with a creamy
yellow pus.
The scalp, extremities, and buttocks are the most likely sites of these infections. Sycosis
barbae is similar to bacterial folliculitis over the beard areas. The lesions are deep seated.
Impetiginization also occurs.
Gram negative folliculitis mainly occurs as a superinfection in acne vulgaris patients
receiving long term systemic antibiotic therapy. These pustules are often concentrated
around the nose. The organism is found in the nostril and in the pustule in such patients.
Carbuncle may be regarded as an aggregation of furuncles. It is a larger, more
deeplyseated, infiltrated lesion which drains through a number of points to the surface.
Recurrent furunculosis can be troublesome for the patient and the physician. Obese
individuals who sweat excessively are particularly prone. In few instances systemic host
factors are responsible. Most of the carbuncles are seen in diabetics and it appears
reasonable to investigate patients with carbuncles for diabetes.
Treatment of Folliculitis, Furunculosis, Carbuncle
For folliculitis, proper cleansing and local application of topical antibiotics are effective
326

measures. Systemic antibiotics are often indicated, especially when the scalp is involved.
In treatment of recurrences the duration of antibiotic therapy should be increased.
Oral semisynethetic penicillin or penicillin is the drug of choice and should be given
parenterally in every case of carbuncles as well as in severe cases of furunculosis. Local
measures alone are indicated if there is only one boil or a few. Squeezing or too early
incision of furuncles is harmful; the lesion should be allowed to point, then gently nicked
and drainage established. Cleanliness is of paramount importance. The suppurative
discharge should be removed as it forms and not allowed to drain over the surrounding
skin. Antibiotic ointments e.g. fusidates and aminoglycosides may be applied after
compressing, though their value is open to doubt except possibly in preventing the
formation of new adjacent lesions.
Lesions about the nose and upper lip are always to be respected because of the danger
of intracranial extension with development of a venous sinus thrombosis. Vigorous
antibiotics therapy should be instituted early. Penicillins and dicloxacillins or the newer
cephalosporins are useful.
Treatment of recurrent furunculosis is difficult and disappointing. Predisposing factors
which may be uncovered should be corrected if possible: e.g. diabetes, poor hygiene,
occupational trauma, pyogenic infections in the patients family, hyperhidrosis and obesity.

Pitted Keratolysis
This is a superficial skin infection causing symtomatic pits of the stratum corneum,
usually involving the soles of the feet. It is caused by a gram positive filamentous and
coccoidal organism, belonging to a Corynebacterium species. Humidity is a frequent
aggravating factor and is often associated with hyperhidrosis. The areas most often
affected are the pressure areas of the heels, the ball, the volar pads, and the toes. They
are not infrequently seen in national servicemen, Gram stain of the ground-up stratum
corneum will demonstrate the organism.
The condition may disappear spontaneously after the patient is removed from the moist
environment. Topical broad spectrum antibacterial agents such as Whitfields ointment,
formalin and Castellanis paint are effective. In severe cases a course of oral erythromycin
may be helpful.

Erythrasma
This is a chronic superficial bacterial skin infection involving the body folds and toe webs, and
sometimes it may be generalised. The causative organism is a species of Coryne-bacterium.
Three forms of disease are recognized viz. (1) the genitocrural and axillary form
presenting with well circumscribed patches with pinkish discolouration later turning
brown; it is asymptomatic or mildly pruritic. (2) Toe web infection, the most common
manisfestation of the disease presenting with scaling, fissuring and maceration. (3) the
generalised form presenting with well defined scaly lamellated plaques on the trunk and
proximal parts of the limbs.

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Diagnosis can be confirmed by a coral red fluorescence of the lesions under Woods light
Confirmation is with Gram stain and culture.
Topical antibacterial preparations and keratolytic agents e.g. Whitfield ointment or topical
erythromycin will beneficially affect the lesions of erythrasma. In severe cases a course of
erythromycin in the dose of I gm daily for one to two weeks is curative in most cases.
Secondary Infection Of The Skin
The distinction between primary and secondary infections cannot always be rigid. The
cardinal feature of a secondary infection is that there must be some pre-existing
condition, either local or systemic, which diminishes the hosts defences. Secondary
infections usually represent complications of an antecedent cutaneous lesion e.g. cut,
burn, ulcer, contact dermatitis etc. The infection arises in the preexisting cutaneous
lesion, which serves as a portal of entry.
In secondary infections, as in primary ones, pathogenic staphylococci and
streptococci are the organisms of principal importance, and routine therapy is
directed against these.
Organisms not ordinarily considered pathogenic may be the cause of secondary
infections. The principal ones in this group are gram-negative bacilli, chiefly E. coli,
Pseudomonas, and Proteus. Gram negative organisms thrive under occulusive dressings.
They are chiefly responsible for the malodor of ulcerative or eczematous lesions which
have been occluded by fixed dressings, especially if these are covered by adhesive tape,
plaster or other relatively impermeable material.
Dog And Cat Bites
The typical signs of infection erythema, swelling, and pain occur within 24 to 72
hours of the bite. Often, animal bites are contaminated by two or more organisms. The
most common infecting bacteria are streptococci, coagulase-negative staphylococci,
some enteric bacteria, Staph aureus and Pasteurella species. Anaerobic bacteria can
usually be recovered as well. Wounds to the face, deep wounds of the hands, and heavily
contaminated wounds should be covered by prophylactic antibiotics. A combination of
penicillin V, to cover most anaerobes, streptococci and Pasterurella organisms, and a
penicillinase-resistant penicillin e.g. dicloxacilin or cephalosporin, to eliminate staph
aureus, is suitable prophylactic therapy.

FUNGAL INFECTIONS
Fungal infection of the skin is divided into: superficial fungal infections and deep fungal
infections. Deep fungal infection e.g. chromomycosis is uncommon and is difficult to
treat; often requiring systemic antifungal agents; the management of patients with such
infections is best left to the dermatologist and physician. However, recognition of the
condition is important so that early treatment can be instituted and irreversible
complications averted. In this paper only superficial fungal infections will be discussed.

328

SUPERFICIAL FUNGAL INFECTIONS


Superficial fungal infection of the skin is one of the commonest skin disease seen in
general practice. There are many effective antifungal agents (oral and topical) making
treatment of superficial fungal infection relatively easy. The problem in the management
of fungal infection is in making a correct diagnosis. Very often superficial fungal infection
is misdiagnosed as eczema and vice versa. Different fungal infection of the skin presents
differently and treatment depends on the type of fungal infection. An understanding of
the classification of fungal infection of the skin is essential.
Classification Of Superficial Fungal Infections
These include the following: Dermatophytosis (Ringworm), Tinea versicolor, and
Candidiasis (Moniliasis).
Dermatophytosis (Tinea Or Ringworm)
Dermatophytosis is probably the most common superficial fungal infection of the skin. It
is caused by a group of fungi which are capable of metabolising the keratin of human
epidermis, nails or hair. It is rare for true dermatophytes to penetrate into the dermis or
deeper body layers and when dermatophytes infections present with dermal and
subcutaneous reaction concomittent infection with other organisms, particularly bacteria
must be considered. There are 3 genera of dermatophytes causing dermatophytosis viz.
Microsporum, Trichophyton and Epidermophyton. Establishment of dermatophyte
infection of the skin depends on 2 factors viz., the virulence of the infecting fungi and
the physical condition of the skin (traumatised and macerated skin are favourable to
fungal growth).
Dermatophytosis is generally named and classified according to the site of infection e.g.
tinea capitis (scalp), tinea cruris (groin). Classification of the infection according to
reservoir e.g. animals (zoophilic), soil (geophilic) and human (anthropophilic) may be
useful in epidemiology and preventive measures against recurrent and spread of
infection e.g. An outbreak or persistence of tinea capitis due to Microsporum cants (a
zoophilic) fungi may indicate infection from a pet (like, rabbits, cats, dog) at home and
eradication of infection in the pet may be necessary to prevent relapses.

Clinical Features Of Dermatophytosis According To Site


Ringworm infections are usually classified according to the site of the lesion.

Tinea Capitis
This is cause by a variety of fungi e.g. M Audouinii, M Canis, the former is usually
contracted from other individuals and the latter from animals). Tinea capitis is a
childhood infection and is rare in adult. The penetration of the fungal hyphae down into
the hair shaft is characteristic and affects the hair and hair follicle. Patches of non
scarring scaly alopecia with broken hairs is seen. Infection due to zoophilic fungi tend to
be more inflamed and in severe infections, boggy abscess may develop (kerion). Tinea
capitis is clinically differentiated from other alopecia e.g. alopecia areata, lupus
erythematosus, lichen planus by its scaly appearance and the presence of broken hairs.
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Tinea Barbae
This is ringworm of the beard or moustache and often caused by zoophilic fungi usually
the Trichophyton genus. It is more common in the rural than urban community. It is an
infection of the adult and the lesion is usually inflamed often with resulting scarring.

Tinea Corporis and Tinea Cruris


Tinea corporis is the term given to infection at any site other than the scalp, groin, hands
or feet. Although various fungi show some preference in invading these other sites, tinea
corporis may be caused by any of the known dermatophyte species which makes the
clinical picture rather variable. The clinical picture can thus mimic a variety of
dermatological conditions e.g. Pityriasis rosea, erythrasma, secondary syphilis, psoriasis,
lichen planus, drug eruptions, contact dermatitis, discoid dermatitis etc.
Generally the lesions of tinea corporis are discrete, scaly and circular with a slowly
advancing border which may show signs of inflammation. They tend to heal towards the
centre to give a characteristic annular appearance which has been suggested as the
origin of the term ringworm.
Tinea cruris is ringworm infection of the groin. Lesions usually occur on the inner surface
of the thighs and are scaly and erythematous, usually with a vesicular border (fig. 6). T.
metagrophytes, T rubrum or E. floccosum are common causative fungi. The former tend
to produce vesicular border and the latter two less vesicular but well marginated border.

Tinea Pedis (Feet) and Tinea Manuum (Hands)


The fungi responsible are similar to that in Tinea corporis but the conditions are often
confused with eczema and bacterial infections of the hands and feet.
Tinea pedis (athletes foot) is one of the commonest and most troublesome
dermatophyte infection. Characteristically, the disease involves an area of peeling and
maceration between the toe clefts, although in extreme cases a large portion of the foot
may be involved (Fig 7). The condition is commonest in men, and it is believed to be
spread in such areas as communal showers and changing rooms where small pieces of
skin are shed free.
Tinea unguum is dermatophytic infection of the nail plate. Affected nail becomes
dystrophied, discoloured and hyperkeratotic . Onycholysis may be the initial presentation.
Special mention must be made on T rubrum infection of the palms and soles. It is also a
common fungi infecting the hands, feet and nails. The clinical picture in T rubrum
infection may not be as scaly as those of tinea corporis and may present with
keratodermatous changes. Diagnosis can be confirmed by a deep fungal scraping from
the keratodermatous lesions.
Tinea incognito is tinea infection where the classical features of an active annular
erythematous, papulo-vesicular lesions become inapparent usually following treatment
with a topical steroid. In such condition the dermatophyte continues to proliferate in the
skin with its inflammatory response being suppressed by the topical steroids. The lesion
330

appears to be responding to steroid treatment but suffers a rebound whenever the


topical steroid is discontinued.

Diagnosis Of Dermatophytosis
Ideally the diagnosis of dermatophytosis should not be made until the causative
organism has been demonstrated. This can be easily achieved by scraping scales from the
active border of the skin lesions or from plucked hair in case of tinea capitis. The scales
are heated with KOH 10/lo on a microscope slide to dissolve away the keratin and
subsequently examined under the microscope. Dermatophyte is identified as branching
hyphae or mycelium which looks like segmented spaghetti under the microscope.
Woods light can be useful in tinea capitis which fluoresces a brilliant green colour as
seen in a darkened room on infected scalp.

Treatment Of Dermatophyte Infections


Topical agents are usually adequate for limited dermatophyte infection of the skin.
Whitfield ointment (benzoic acid et salicylic acid) is the cheapest effective topical agent
here. However, it is greasy and may irritate inflamed skin. It is ineffective against candida
infection. The imidazoles are probably the most prescribed antidermatophytic agent.
There are several brands in the market e.g. Daktarin, Canestan, Pevaryl, Travogen, etc.
The efficacy of each imidazoles are generally comparable. These imidazoles are
advantageous to Whitfield as they are more acceptable and are effective against candida
species and have mild antibacterial property as well. They are more expensive. Other
antidermatophytic agents including the undecylate, tolnaftate (Tinaderm), naftifine
(Exoderil), ciclopiroxolamine (Batrafen) are also effective alternatives. Quinolines e.g.
vioform and polyenes e.g. nystatin are not effective against dermatophyte infection.
Combination creams containing immidazoles, steroids and antibiotics should be avoided
as they increase the risk of skin sensitization and skin reaction. Topical antibotics
especially neomycin and quinolines are among the common skin sensitizers in Singapore.
Imidazole in combination with a mild steroid e.g. hydrocortisone may occasionally be
useful as initial treatment for pruritic inflamed intertriginous ringworm infection.
However such combination cream should be discontinued and substituted with plain
antidermatophytes once the inflamed component clears.
Systemic treatment for dermatophytosis e.g. griseofulvin and ketoconazole are indicated in
extensive and recalcitrant dermatophyte infection and specific infection such as tinea
capitis, tinea barbae, tinea unguum. Griseofulvin is an effective and commonly used oral
agent against dermatophytosis. Griseofulvin should be taken in doses of 500 mg to 1500
mg daily depending on body weight and should be taken after meals for maximal
absorption. Side effects include gastrointestinal symptoms and photosensitivity. The
duration of therapy depends on the location of dermatophytosis. Extensive tinea corporis
usually require 4 to 6 weeks treatment and nails infection requires 6 to 18 months therapy.
Oral ketoconazole is an effective alternative. It has the added advantage of having
anticandidal property. In a comparative study of treatment of dermatophytosis with
griseofulvin and ketoconazole in Singapore, the effficacy of both were found to be

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similar but patients treated with oral ketoconazole appeared to have a slightly lower
relapse rate.
Tinea Versicolor
Tinea versicolor is a common chronic superficial fungal infection caused by Pityrosporum
species, usually P orbiculare (Malassezia furfur).
Clinical Feature
The lesions are characterized discrete or concrescent scaly discoloured or depigmented
areas mainly on the upper trunk. The colour varies from dark brown to grey and white
(Fig. 11). There is usually mild fine superficial scaliness. Occasionally the lesion may be
perifollicular. Other commonly affected sites include the arms, thighs, face and hands.
Pruritus may be troublesome especially with sweating but the condition may be
completely asymptomatic.
Differential Diagnosis
Differential diagnoses include vitiligo, melesma, idiopathic guttate hypomelanosis
pityriasis alba, pityriasis rosea and post inflammatory hypopigmentations.
Diagnosis
Diagnosis can be easily confirmed by direct examination of skin scrapings. Characteristic
spherical, thick walled yeasts and coarse mycelium (often fragmented to short filaments)
is seen. The Parker Quink Ink/ KOH staining technique and examination under the
microscope is a simple procedure to identify the fungus.

Treatment of tinea versicolor


Topical agents are the mainstay in the treatment of tinea versicolor. Recently oral
ketoconazole has been found to be useful for the treatment of severe/extensive and
tinea versicolor infection and infections recalcitrant to usual topical agents.
Common topical agents against tinea versicolor include sodium hyposulphide and
selenium sulphide containing preparations. The topical imidazoles and other wide
spectrum topical antifungal agents are as effective and cause less skin irritation and
easier to apply. However sodium hyposulphide and selinium sulphide when used as
shampoos are effective prophylaxis against relapses. Initially sodium hyposulphide and
selenium sulphide preparations should be applied nightly for 5 nights. They can be
subsequently used as prophylaxis by using them as shampoos leaving the lotion on the
scalp and skin for 10 to 15 minutes before bath once weekly or fortnightly to prevent
relapses.Propylene glycol (50% in alcohol) is a cheap effective alternative topical agent.
The imidazoles and other broad spectrum antifungals such as tolnaftate, naftifine, and
ciclopiroxolamine available as cream and gel are effective and preferred topical agents be
used for localized infection but those with extensive tinea versicolor, lotions and sprays
are easier to use.
Oral ketoconazole in doses of 200 mg daily for 2 to 4 weeks is effective in the treatment
of severe/extensive tinea versicolor infection. Various treatment regimes varying in doses
332

of 200 mg weekly to 200 mg monthly have been reported to be effective in preventing


relapse but such regime may not be as effective as reported. Great care should be taken
when prescribing oral ketoconazole for this relatively benign skin infection. Past history
of liver disease and abnormal liver function test are relative contraindications.
Fulminating hepatitis has been reported to be associated with oral ketoconazole and it
should not be used to treat mild tinea versicolor.
Post infective hypopigmentation is a common sequelae following tinea versicolor
infection and this can persist for months to years. Such post infective hypopigmentation
does not indicate infection and does not require any treatment. Recurrent tinea versicolor
infection is common in our humid, tropical climate.
Candidiasis
This is an infection caused by the yeast like fungus Candida albicans or occasionally other
species of Candida. Several clinical syndromes can be recognised.

Oral candidiasis (oral thrush)


This is characterized by sharply defined patches of creamy, crumbly, curd-like white
pseudomembranous mucosal lesions which when removed, leave an underlying
erythematous base. The buccal epithelium, the tongue, the gums or the palate may be
affected. The condition occurs most commonly in the first weeks of life and there is
significant association with vaginal candida carriage in the mother. Angular cheilitis and
candida cheilitis produce erythematous fissures.

Candidiasis of the skin and genital mucous membrane


Most cases of cutaneous candidiasis occur in the skin folds or where occlusion from
clothing or medical dressings produces abnormally moist conditions.
Candida intertrigo are typically erythematous, slightly moist lesions in skin folds (Fig 13,
14). It slowly spreads producing a characteristic fringed irregular edge and pustules
rupturing to give tiny erosions and peeling. Pustular or papular satellite lesions are
classical. Soreness, and itching may be intense. In babies the skin over the napkin areas
may be affected and occasionally associated with napkin eruption. When toe webs are
affected marked maceration with thick white horny layer is usually prominen6.
Differential diagnoses includes tinea infection, seborrhoeic dermatitis, bacterial
intertrigo, and flexural psoriasis. Skin scraping helps confirm diagnosis.
Candida vulvovaginitis and balanitis present with itching and soreness. The former
presents with thick creamy white discharge with characteristic cheesy plaques in the
vagina while the latter usually present with transient tiny papules with peeling edges.and
may be associated with soreness and irritation.

Candida paronychia
This is chiefly found among housewives and those whose hands are frequently immersed in
water. Typically, several fingers are chronically infected. The nailfold is red and swollen with
loss of cuticle and detachment of nailfold from the dorsal surface and the nail plate leading
to pocketing. Nail dystrophy with buckling of the nail plate and discoloration occur.
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Chronic muco-cutaneous candidiasis


This is an uncommon condition where the patient presents with persistent
candida infection of the mouth, the skin and the nails that are refractory to
conventional topical therapy. It may be associated with a primary defect in
immune function.
Diagnosis
Candida can be recognised on skin scrapings and smears from mucosal lesions on
potassium hydroxide mount. The presence of budding yeast cells and pseudomycelium is
evidence of active infection. The presence of spores alone is not evidence of active
infection as yeast is a common skin commensal. Candida infection can be further
confirmed by fungal cultures on Saborauds medium.
Treatment of Candidiasis
General Principle. It is important to be aware of predisposing factors which
include diabetes mellitus, anaemia, imparted immune status, malignancy, long
term oral antibiotics, oral steroids, cytotoxics, oral contraceptives, and pregnancy.
In many cases topical therapy alone is sufficient but consideration should be
given to the reduction of Candida reservoir in the mouth and gut in patients with
recurrent infections.
Topical Agents. The polyene antibiotics e.g. nystatin are highly effective against
Candida and most other yeast pathogens. The newer imidazoles eg, clotrimazole, miconazole and econazole and other broad spectrum antifungal agents such as tolnaftate,
naftifine and ciclopirox etc. are effective alternatives. These are advantageous over the
polyenes as they are available in creams and lotion preparations, are easier to apply and
less messy. The affected areas should be kept dry. The time honoured Castellani paint has
the advantage over the other anticandidal agents in affected toe webs and nail folds
where secondary bacterial infection is common. Non staining Castellani paint is more
acceptable to patients. Powders containing the newer antifungal powder e.g. imidazoles
are useful adjunct on intertriginous areas and as prophylaxis in those with recurrent
infections. Whitfield oint is ineffective against candidiasis.
Chronicity
Chronicity of the lesion should prompt a re-assessment and re-think. The possibilities are:
Wrong diagnosis.
Inadequate application of topical agents.
Griseofulvin failure may be due to:
Poor compliance
Poor absorption and tissue levels. (should be taken after meals.)
Co-existent pathology
Resistance rare
Constant reinfection
Undetected, uncorrected predisposing factors

334

References and further reading


Goh CL. Skin infection: Common bacterial infections. Singapore Family Physician 1986; 12 (1):24-30.
Goh CL. Common Skin infection: Superficial fungal infections. Singapore Family Physician 1986; 12 (2):70-74..
Buxton PK. ABC of Dermatology, 3rd ed. London: BMJ, 1998
Thomas B Fitzpatrick et al. Colour Atlas and Synopsis of Clinical Dermatology.
International Edition. Second Edition. 1992

CHAPTER 6

BONE & JOINT DISORDERS

Outline
Symptoms and approach
Use of NSAIDs & Corticosteroids

SYMPTOMS AND APPROACH


The two key symptoms of bone and joint disorders are backache (See Section 6 Chapter
14) and joint pain (See Section 6, Chapter 15).

USE OF NSAIDS & CORTICOSTEROIDS


NSAIDs and corticosteroids are useful but also have adverse effects. A clear understanding
of their role in the management of arthritis will ensure their optimal and safe use.
Non-Steroidal Anti-Inflammatory Agents (NSAIDs)
NSAIDs are widely used to relieve pain from injury, inflammation or arthritis. Among the
elderly, the prevalence of NSAID use is as high as 15% (Fennerty, 2001).

Classification
NSAIDs may be classified by its inhibition of the cyclooxgenases into non-selective
NSAIDs and Cox-2 selective NSAIDs. See Table 1.
Table 1.Classication of NSAIDS
Nnselective NSAIDs
Aspirin

Relatively COX-2selective NSAIDs


Etodolac (Lodine)

Diclofenac (Voltaren)

Meloxicam (Mobic)

Fenoprofen (Nalfon)
Ibuprofen (e.g., Advil, Motrin)

Highly COX-2selective NSAID

Indomethacin (Indocin)

Celecoxib (Celebrex)

Ketoprofen (Orudis)
Ketorolac (Toradol)
Naproxen (Naprosyn)
Nabumetone (Relafen)
Oxaprozin (Daypro)
Piroxicam (Feldene)
Tolmetin (Tolectin)
Source: Noble et al, 2000. COX = cyclooxygenase; NSAID = nonsteroidal anti-inflammatory drug.

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Mechanism Of Injury From NSAIDs


Nonselective NSAIDs predictably cause gastrointestinal mucosal injury because they
inhibit production of prostaglandins in local tissue (Scheiman, 1996 in Fennerty, 2001).
These prostaglandins are needed to ensure the following production of a protective
mucous layer, production of epithelial bicarbonate, cellular integrity or restitution, and
mucosal blood flow.
Nonselective NSAIDs indiscriminately inhibit cyclooxygenase (COX) enzymes, including
COX-1, the constitutive enzyme responsible for the production of prostaglandins in
local tissue and the resultant protective effects. While COX-1 is responsible for
prostaglandins that protect the mucosa, COX-2 is not normally found in the
gastrointestinal tract. COX-2 is an inducible enzyme that is up-regulated in areas of
inflammation and neoplasia. Inhibition of this enzyme is responsible for the antiinflammatory and analgesic effects of NSAIDs. Therefore, use of nonselective NSAIDs
inhibiting both COX-1 and COX-2 results not only in analgesia and antiinflammatory effects through the inhibition of COX-2 but also produces gastrointestinal
mucosal injury through the effect on COX-1.
Selective inhibition of COX-2 but not of COX-1 (i.e. by use of selective COX-2
inhibitors) should allow for the beneficial effects of NSAIDs without adverse
gastrointestinal effects. It needs to be remembered that the relief of pain by COX-2 is
no better compared to that by COX-1 NSAIDs.
Table 2. Pooled Relative Risks (RRs) for UGIB for Users of Individual
NSAIDs Compared With Nonusers for Studies from 1990 to 1999
INDIVIDUAL NSAID

USUAL DOSAGE (A)


FOR ADULT

336

NO. OF

RR (95% CI) (B)

STUDIES (B)

Ibuprofen overall
Low medium dose
High dose

400-800mg tds

9
3
3

1.9 (1.6 2.2)


2.1 (1.6 2.7)
5.5 (3.0 10.0)

Diclofenac overall
Low medium dose
High dose

100-200mg daily

11
3
3

3.3 (2.8 3.9)


3.1 (2.0 4.7)
3.6 (2.3 5.6)

Sulinac overall

150mg bd (max dose


400mg daily)

3.6 (2.8 4.7)

Naproxen sodium
overal
Low medium dose
High dose

275 or 550 mg bd

12
4
4

4.0 (3.5 4.6)


3.5 (2.8 4.3)
5.1 (3.8 6.9)

Indomethacin overall
Low medium dose
High dose

75 mg bd

10
3
3

4.6 (3.8 5.5)


3.0 (2.2 4.2)
6.5 (4.8 8.6)

Ketoprofen overall

100mg bd

4.6 (3.3 6.4)

Piroxicam overall
Low medium dose

20mg daily

12
3
2

6.3 (5.5 7.2


5.6 (4.7 6.7)
6.2 (4.4 - 8.7)

Table 2. Pooled Relative Risks (RRs) for UGIB for Users of Individual NSAIDs
Compared With Nonusers for Studies from 1990 to 1999 Contd
INDIVIDUAL NSAID

USUAL DOSAGE (A)

NO. OF

FOR ADULT

STUDIES (B)

Apapropazone overall

600mg bd

Celecoxib (Celebrex) (c)

100mg bd or 200mg daily


for osteoarthritis

RR (95% CI) (B)


27.5 (12.0 62.9)

RRR 47%

Sources; (a) BNF; (b) Hawkins & Hanks, 2000; (c) Fennerty, 2001

NSAID-associated Dyspepsia
NSAID-associated dyspepsia occurs in up to 50% of patients who use these drugs, and
heartburn, nausea, vomiting, and abdominal pain can also be observed (Singh, 1998 in
Fennerty, 2001). Up to 100% of patients taking nonselective NSAIDs will demonstrate
subepithelial hemorrhage, about 50% will have erosions (small, shallow breaks in the
gastrointestinal mucosa), and 20% or more will have ulceration (injury extending through
the muscular mucosa). There is no relationship, however, between NSAID-associated
dyspeptic symptoms and the presence of erosions or ulceration. Interestingly, there even
appears to be an inverse relationship: those who have ulceration are more likely to be free
of symptoms. As a result, neither the patient nor his or her physician may be aware that
the patient harbours an ulcer and is at risk for serious gastrointestinal complications.

Risk Of Side Effects


Any user of NSAID is at risk. Some are at greater risk: old age, multiple types of NSAIDs
used at the same time.
Risk of use. The pooled relative risk of upper gastrointestinal bleeding (UGIB) after
exposure to NSAIDs was 3.8 (95% confidence interval, 3.6-4.1). This means that those
exposed to NSAIDs will have nearly 4 fold risks of UGIB compared to the non-user. This
increased risk will be maintained during treatment and but will return to baseline once
treatment is stopped. (Hawkins and Hanks, 2000).

Cox2-Selective Inhibitors Their Plusses And Minuses


Cox2-selective inhibitors are not perfect NSAIDs and they are costly. The following is an
appraisal gleaned from current literature.
Advantages and limitations
Only advantage. The only advantage of COX-2 inhibitors over the conventional Cox-2
NSAIDs lies in their having a more favorable side effect profile in people with risks of
upper grastrointestinal bleeding. The decision to use the more expensive COX-2 inhibitors
should be limited to those at risk of gastrointestinal tract hemorrhage e.g., 75 years or
older, history of GI bleeding (Noble et al, 2000).
GI side effects. Cox-2 NSAIDs also have similar gastrointestinal side effects, including
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abdominal pain, dyspepsia and diarrhea when compared with non-specific NSAIDs.
Cost limitation. Cost favors the use of generic, traditional or non-selective
NSAIDs in patients who are not at high risk for bleeding (Petersen & Cryer, 1999
in Noble et al, 2000).
Not a substitute for aspirin therapy. COX-2 inhibitors do not increase bleeding time.
Studies on these agents administered in normal and higher than normal dosages for
seven to 12 days found no effect on platelet aggregation and bleeding time. Therefore,
these drugs are not a substitute for aspirin for cardiovascular protection, and they can be
used with low-dose aspirin therapy. However, concomitant use of a COX-2 inhibitor and
aspirin may increase the risk of gastrointestinal adverse events, because aspirin dosages as
low as 10 mg are capable of suppressing prostaglandin synthesis in the gastric mucosa.
Lowest effective dose and shortest duration possible recommended. The FDA
recommends that celecoxib and rofecoxib be used in the lowest effective dosage for the
shortest duration possible (in Noble et al, 2000).
Indications of Cox-2 Inhibitors
Celecoxib. The FDA has labeled celecoxib (Cerebrax), in oral dosages of 100 mg twice
daily and 200 mg once daily, for the treatment of osteoarthritis. This drug is also labeled,
in an oral dosage of 100 to 200 mg twice daily, for the treatment of rheumatoid arthritis
in adults (in Noble et al, 2000).
Meloxicam. Meloxicam, the newest COX-2 inhibitor, has been labeled by the FDA for
the treatment of osteoarthritis. The starting and maintenance dosage of this drug is 7.5
mg per day (in Noble et al, 2000).
Contraindications of Cox-2 inhibitors
Hypersensitivity. Treatment with COX-2 inhibitors is contraindicated in patients who have
hypersensitivity to these drugs, asthma, urticaria or previous anaphylactic reactions after
taking aspirin or NSAIDs.
Sulphonamide allergy. Celecoxib contains a sulfonamide group. Patients with a
demonstrated allergic reaction to sulfonamides should not take this drug (Noble et al, 2000).
Adverse Effects and Precautions in Use of Cox-2 inhibitors
GI side effects. Like traditional NSAIDs, the COX-2 inhibitors commonly cause abdominal
pain, dyspepsia and diarrhea.
Heart failure and hypertension. Because of potential aggravation of hypertension and
lower extremity edema, caution should be exercised in prescribing COX-2 inhibitors to
patients with congestive heart failure, fluid retention or hypertension.
Risk of bleeding. COX-2specific inhibitors retain some platelet thromboxane A2
338

inhibitory properties. Patients who have coagulation abnormalities or are concurrently


using COX-2 inhibitors and alcohol or anticoagulants are at increased risk for bleeding.
Rofecoxib and celecoxib have been shown to cause a slight elevation of prothrombin time
in patients who are taking warfarin (Coumadin). Thus, the International Normalized Ratio
(INR) should be monitored when celecoxib or rofecoxib is initiated or the dosage of one of
these drugs is changed in patients who are receiving concomitant warfarin therapy.
Non-Selective-NSAIDs Their Plusses And Minuses
Indications
Pain. NSAIDs are most effective when the pain is associated with symptoms and signs of
tissue inflammation, for example, as short courses in treating gout and pseudogout.
Short courses of NSAIDs can be helpful in the management of sports injuries,
postoperative pain, renal or biliary colic and dysmenrrhoea, but their therapeutic
advantage over simple analgesics for these indications is often marginal.
Osteoarthritis. Its use in osteoarthritis should be as a supplement to simple analgesics
and non-pharmacological approaches, such as the provision of walking stick or built up
shoe. In such patients, repeated short courses of NSAIDs in low dosage to supplement
regular treatment with a simple analgesic are preferable to continuous treatment with
high doses of NSAIDs.
Inflammatory disease. Prolonged NSAID treatment on the other hand is usually
required for patients with chronic inflammatory rheumatic diseases such as rheumatoid
arthritis, psoriatic arthritis or ankylosing spondylitis. It is important to explain to such
patients that NSAIDs are most likely to be effective in relieving pain and stiffness if they
are taken regularly in optimal doses. Equally, however, it is important that patients
understand that NSAIDs do not have any fundamental disease-modifying effect, so there
is no reason to continue treatment after symptoms have resolved. With rheumatoid
arthritis, the addition of a second-line, disease-modifying antirheurnatic drug always
needs to be considered in patients with persistent joint pain, swelling and stiffness, and
raised ESR despite NSAID therapy.
Pregnancy and lactation. When treatment cannot be avoided in pregnancy, drugs with
a short half-life, such as ibuprofen (Brufen), flurbiprofen (Froben) or ketoprofen (Oruvail),
should be used at maximal intervals. High-dose aspirin, and indomethacin (Indocid) are
contraindicated during lactation, but proprionic acid derivatives such as ibuprofen can be
safely given to lactating mothers.
Contraindications
Only one NSAID. Do not give two NSAIDs at the same time.
Pregnancy. NSAIDs are best avoided in pregnancy. This is particularly advised in the first
trimester because of a remote and largely theoretical risk of foetal malformation or
teratogenicity; and also in the final weeks of pregnancy when NSAIDs can delay and
prolong labour.
Adverse Effects and Precautions in Use of Nonspecific NSAIDs
NSAID Gastropathy. Under normal circumstances, prostaglandins protect the lining of
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the gastric mucosa and limit the output of gastric acid. The risk of ulcer development is
increased by approximately 15 to 20 percent in patients with rheumatoid arthritis or
osteoarthritis who are taking nonspecific NSAIDs. If first-line acetaminophen therapy is
ineffective, treatment with COX-2 inhibitors may be considered in patients with
osteoarthritis who are at high risk for gastrointestinal tract ulceration. Treatment with
COX-2 inhibitors should also be considered in patients with rheumatoid arthritis who are
at high risk for ulcers and in other at-risk patients who require NSAID therapy.
Renal Effects. NSAID inhibition of compensatory renal prostaglandins can worsen renal
function in patients with reduced renal perfusion as a result of congestive heart failure,
diabetes mellitus, dehydration or aging (Welton, 1999 in Noble et l, 2000).
Clinical Decisions In NSAID Use
Should prophylaxis with antacids and H2 receptor antagonists be given?
Routine prophylaxis is not necessary for short courses for asymptomatic
patients. The current evidence is that asymptomatic patients do not need to take
antacids and H2 receptor antagonists. Those who take these medications not only do not
have a significantly lower risk for serious GI complications than do those not taking such
medications but instead have a higher risk than those not taking these prophylactic
medications. In a study of 1921 patients, asymptomatic patients taking these prophylactic
medications had a significantly higher risk for GI complications compared with those who
did not take these medications (standardized odds ratio, 2.14; 95% confidence interval,
1.06-4.32) (Singh et al, 1996).
Whenever possible, physicians should use the lowest effective dose to reduce the UGIB
risk associated with all individual NSAIDs, especially in the subgroup of patients with the
greatest background risk.
What are the cost effective prescribing principles with NSAIDS?
There are four principles:
Decide an NSAIDs is the best choice Using acetaminophen instead of an NSAID
for noninflammatory disorders is an example; weight reduction may be as important as
a NSAID.
Choose a safer and cheaper NSAID Choose one from the safer (see Table 3) and
cheaper NSAIDs; use one agent at a time; allow sufficient time to evaluate the
therapeutic effect before changing agents and returning to the least expensive and/or
safest drug if a trial of several in succession fails to find one that is clearly better. In
choosing an NSAID, although there may be some differences in efficacy among
available drugs, these do not appear sufficient to justify using the more expensive
agents in most cases. All nonsalicylate NSAIDs share a risk of causing gastric ulcer,
upper GI bleeding, and GI perforation.
Decide if a COX-2 NSAID is needed A COX-2 will reduce the risk of UGIB in
the 75 and older and in those with history of peptic ulcer disease. It does not result
in a better control of pain compared to the non-selective NSAIDs (COX-1 NSAIDs)

340

Decide if prophylaxis is needed Routine prophylaxis with antacids and H2


receptor antagonists for asymptomatic patients is not necessary as has been pointed
out earlier.
How do you prevention NSAID-induced gastrointestinal injury?
Avoid its use unless clearly indicated The optimal method for prevention of NSAIDinduced gastrointestinal injury is to avoid the use of these agents in the first place. This
strategy can be accomplished best by using other pharmaceutical agents for analgesia.
Minimise dose If NSAIDs are necessary, minimize the NSAID dose. The maximum
analgesic effect of an NSAID is often at a much lower dose than is needed for its antiinflammatory effect. Because most patients use NSAIDs for analgesia and not for
inflammation, many are receiving a dose that unnecessarily increases the risk of
gastrointestinal injury.
Consider prophylactic therapy Prophylactic therapy may be warranted in patients at
increased risk for gastrointestinal injury or in those who would be at significant risk for
morbidity if a complication developed. (a) Concomitant use of a histamine2 (H2) receptor
antagonist in such patients decreases the risk of NSAID-induced dyspepsia and duodenal
ulcers, but it has less of an effect on the more commonly seen gastric ulcers related to
NSAID use and no effect on preventing complications from NSAIDs. Higher doses of H2
receptor antagonists may further decrease the risk of gastric ulceration (Taha et al, 1996
quoted in Fennerty, 2001). (b) Concomitant use of a proton pump inhibitor (omeprazole)
substantially decreases the risk of not only duodenal ulcers but gastric ulcers as well, and
to a much greater degree than can be accomplished with H2 receptor antagonists
(Yeomans et al, 1998, Hawkey et al, 1998 quoted in Fennerty, 2001).
What should a physician do for a patient with NSAID-induced ulceration?
First, NSAID therapy should be discontinued. If the NSAID is stopped, most ulcers heal
spontaneously, but they heal more rapidly with the addition of either an H2 receptor
antagonist or a proton pump inhibitor.
What is the place of H pylori testing in the patient receiving NSAIDs?
Most ulcers are caused by either Helicobacter pylori infection or NSAID use. However, in a
given situation, it is impossible to tell which is the causative factor. Thus, every patient
who develops an ulcer while using an NSAID should also be evaluated for H pylori
infection. If tests confirm the presence of the bacterium, then H pylori therapy needs to
be instituted in addition to the treatment outlined earlier for NSAID ulcers.
Corticosteroids In Rheumatic Disease
Corticosteroids have unparalleled efficacy in treatment of many diseases but they also
have a list of potential side effects that can involve virtually all organs. (Van
Vollenhoven, 1998).

Use them judiciously


Careful selection of the initial dose, aggressive attempts to taper doses, prescription of
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supplemental calcium and vitamin D, and consideration of steroid-sparing agents in


patients who remain dependent on corticosteroids for disease control are the foundation
of proper use.
How corticosteroids work
Corticosteroids have numerous pharmacological actions. In treatment of rheumatological
disorders, the anti-inflammatory and immunosuppressive effects are most important.
Anti-inflammatory effects. One of the main targets of the anti-inflammatory effects is
probably the neutrophil. As any clinician can affirm, the neutrophil count, both absolute
and relative, goes up after corticosteroid administration, sometimes dramatically. In large
part, this effect is due to demargination, or mobilization of neutrophils that are attached
to vessel walls at sites of inflammation.
In addition, neutrophil chemotaxis is significantly diminished, and neutrophil activation
and release of proteolytic enzymes are greatly reduced by corticosteroids. The combined
result of all these effects is a profound decrease in active inflammation within hours to
days after administration (van Vollenhoven, 1998).
Immunosuppressive effects. The immunosuppressive effects of corticosteroids have
been studied in detail, but a complete picture has not yet emerged. Lymphocytes are
depleted by long-term corticosteroid use, sometimes dramatically. T-cell function is
diminished, but only at higher doses, whereas B-cell function typically remains intact. (An
interesting exception to the latter effect is that in patients with systemic lupus
erythematosus, production of anti-DNA antibodies is suppressed very quickly and
dramatically by corticosteroids.) Thus, immunosuppressive effects of corticosteroids are
most likely to cause failure of host defenses against organisms that require T-cellmediated immunity. Consequently, among infections of most concern in patients treated
with corticosteroids are tuberculosis, Pneumocystis carinii pneumonia, and fungal disease
(van Vollenhoven, 1998).
What side effects may occur
The side effects of corticosteroids can be usefully put into three categories: immediate,
gradual, and idiosyncratic (van Vollenhoven, 1998).
Immediate. Some side effects are almost universal among patients taking
corticosteroids, even at modest doses, and they occur relatively promptly. These effects
include fluid retention, blurry vision (caused by pressure changes in the anterior chamber),
mild euphoria or other mood changes, insomnia, weight gain and redistribution of body
fat, and immunocompromise.
Gradual. Many side effects are unlikely to present in the first days to weeks of treatment
but become almost universal with more prolonged therapy. These include metabolic
effects (e.g. hyperglycemia, hypertension, osteoporosis), thinning of the skin, muscle
weakness (myopathy), acne, dyspepsia, Cushingnoid habitus, adrenal suppression,
hypertriglyceridemia, and dyslipidemia. Also included is the poorly understood
proatherogenic effect of corticosteroids, which is not fully explained by changes in levels
of low-density or high-density lipoprotein cholesterol or triglycerides.
Idiosyncratic. Some unpredictable side effects occur in patients treated with
342

corticosteroids of any dose or for any period of time, although clearly the risk increases
with longer duration and higher dose. These effects include cataract formation, avascular
necrosis, psychosis, and adrenal failure on withdrawal of therapy.
Although little can be done to prevent corticosteroid side effects, all patients should
receive what preventive therapy is available. To minimize steroid osteopenia, all patients
taking corticosteroids for more than a few days should receive supplemental calcium
(1,500 mg/day) and vitamin D (400 U/day). Whether higher levels of vitamin D can
completely prevent osteopenia remains unclear (van Vollenhoven, 1998).
What dose to use and when
High doses. High dose corticosteroids are indicated as first-line therapy for most serious
rheumatological diseases. SLE with nephritis, cerebritis, or severe cytopenia and even
those who experience severe pleurisy, pericarditis, or arthritis. Vasculitic syndromes,
including giant cell arteritis
Moderate doses. Moderate-dose corticosteroids are the mainstay of treatment for
polymyalgia rheumatica can be helpful for acute gout when nonsteroidal antiinflammatory drugs (or colchicine) are contraindicated (e.g. in patients taking oral
anticoagulants).
Rheumatoid arthritis accepted and controversial uses
Rheumatoid arthritis deserves special mention in any review of corticosteroid therapy. The
following is the current position (van Vollenhoven, 1998):
Accepted uses. Treatment of choice for severe rheumatoid vasculitis, including skin
lesions and mononeuritis multiplex, and other extra-articular features of the disease (e.g.
Feltys syndrome, rheumatoid lung, scleritis). The dosage should be at least 1 mg/kg daily.
Intra-articular administration of corticosteroids is a well-established, effective, and (when
properly done) safe treatment approach for individual inflamed joints. As bridging
therapy, corticosteroid is accepted in patients with severe rheumatoid arthritis who are
given second-line disease-modifying anti-rheumatic drugs, since response to such agents
is measured in weeks to months. The corticosteroid dose is usually kept to the minimum,
with the intention of preserving patient function, not of eliminating all pain. In many
instances, 10 mg/day can accomplish this goal; on some occasions 15 or 20 mg/day is
needed. On initiation of bridging therapy, the plan to decrease the dose and eventually
discontinue use of corticosteroids should be explained to the patient.
Controversial uses. Low-dose maintenance therapy is the most controversial issue in
use of corticosteroids for rheumatoid arthritis. Proponents argue that low-dose
corticosteroid therapy measured over 1 to 2 years may decrease progression of cartilage
and bone destruction (Cohen and Conn, 1997; Kirwan, 1995 quoted in van Vollenhoven,
1998). Opponents argue that the adverse consequences of corticosteroid therapy
become more apparent after the much longer duration of treatment faced by patients
with rheumatoid arthritis (Ramos-Remus and Russell, 1997). An important point is that
there may be profound differences between 5 mg/day of prednisone (comparable to
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physiologic levels of cortisol) and 10 mg/day (clearly above physiologic levels).


Unfortunately, most studies have lumped these levels together under the heading of lowdose therapy.
Pulse corticosteroid therapy as been advocated as a means of rapidly suppressing
immune-mediated disease with fewer side effects (Smith et al, 1988). It consists of
administration of extremely high dosages (e.g., intravenous methylprednisolone sodium
succinate [A-Methapred, Solu-Medrol], 1,000 mg/day for 3 consecutive days). In
rheumatoid arthritis, pulse therapy has been reported to achieve remission of disease for
4 to 10 weeks (Weusten et al, 1993). However, whether the overall risk-benefit ratio of
pulse therapy is better than that of daily steroid therapy remains unclear. Avascular
necrosis may be a particularly troublesome side effect of pulse corticosteroid therapy
(Felson and Andersen, 1987), It is seen more often in patients with rheumatoid arthritis or
SLE than in patients with other disorders, and