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Family Medicine Practice PDF
Family Medicine Practice PDF
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ISBN 981-04-9688-5
Sponsored by the Lee Foundation Community Abroad Assistance Fund. This publication
is not intended for commercial sale.
2
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 10
SVO Specialist Team (Family Medicine) Project Leader and Wonca Regional
President, Asia Pacific Wonca
Country Representative, Indonesia
3
MESSAGES/PREFACE
4
FOREWRD
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. WHO’s 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.
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
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.
6
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.
7
MESSAGES/PREFACE
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.
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
8
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
9
MESSAGES/PREFACE
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.
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 doctor’s 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.
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:
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
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
CHAPTER 1
SECTION 01
SECTION 01 THE PRESENT STATUS OF THE HEALTHCARE SERVICES IN INDONESIA
Outline
National health development program
Brief description of the country
National health status
Public health services
Medical care services
Financing of health services
• To enable people to maintain their own health and live a healthy and productive life
• To promote an environment conducive to the health of the people
• To promote good nutrition among the people
• To decrease morbidity and mortality
• To 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.
Indonesia is the world’s 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.
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
People’s Consultative Assembly every five years. The capital city is Jakarta, situated on the
island of Java.
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.
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
government’s 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.
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.
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.
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.
17
SECTION 01 THE PRESENT STATUS OF THE HEALTHCARE SERVICES IN INDONESIA
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.
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.
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.
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:
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.
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.
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
SECTION 01 THE PRESENT STATUS OF THE HEALTHCARE SERVICES IN INDONESIA
22
SECTION 02
FAMILY MEDICINE ORIENTED PRIMARY CARE
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
stakeholder’s 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 cost-
effectiveness. 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.
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
People’s 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 people’s needs which are to:
Family medicine is the bridge and not the solution. The 1994 Ontario, Canada
Conference Paper alluded to earlier had this to say:
“To meet people’s 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
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 people’s needs.
Closing financial gap needs to be systems oriented. There are six strategies that need to
be considered and implemented in parallel.
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.
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.
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
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.
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).
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.
• 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
• 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.
Some Observations
There are common important milestones in introducing Family Medicine into health care
systems in Singapore, Indonesia and Myanmar. These are:
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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.
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.
In recent years, men’s health too has been included as a focus of learning and teaching
too. The excess morbidity and mortality is being addressed.
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.
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.
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.
The model of care that has been developed to deal with such conditions is disease
management.
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 learner’s 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.
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
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.
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SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE
36
Table 1B. Family Medicine Syllabus Year 2 – Singapore
Period Whole person Disease mgmt Practice mgmt
One module medicine – by body systems – 1 study in
in 3 months 4 units of study – 3 units of study brackets
One module
has 8 study
units
Apr 2003 Women’s Health (2) Endocrine, metabolic & 8C: Quality assurance
– Jun 2003 8A1 – Anetnatal Nutritional Disorders
care, & 8B1 – Nutritional
drug use counselling
in 8B2 – Metabolic
pregnancy disorders
8A2 – Medical 4B3 – Endocrine
disorders in disorders
pregnancy
8A4 – Postnatal care
pregnancy
8A3 – At-risk
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SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE
Further reading
Kerjasama Depkes – IDI – Fakultas Kedokteran. Pedoman Pelatihan Dokter Keluarga, 2003
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, face-
to-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. 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
Packet B – Managing the practice – Section 4
(Each topic below can be a self-study unit)
1. Managing people and resources
2. Managing facilities and utilities
3. Managing information – medical records, confidentiality, computerisation
4. Managing finances including managed care
5. Managing quality
Packet C – Medical Technical Skills & Care in Specific Situations – C(A) Practice Skills
– Section 5 (Each topic can be a self-study unit)
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)
Packet C – Medical Technical Skills & Care in Specific Situations — C(C) Specific disorders
– Section 7 (Each topic can form 3-4 self-study units)
39
SECTION 02 FAMILY MEDICINE ORIENTED PRIMARY CARE
40
SECTION 03
CONCEPTS OF FAMILY MEDICINE
41
SECTION 03
SECTION 03 CONCEPTS OF FAMILY MEDICINE
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
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 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.
As a worldwide movement, family medicine had its prelude in the growing disenchant-
ment 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 ill-
health 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 doctor’s 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.
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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).
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 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 well-
being 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 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.
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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
The family doctor working in any community requires three types of knowledge:
46
Skills
47
SECTION 03 CONCEPTS OF FAMILY MEDICINE
48
Table 2. The Relative Frequency of Presenting Problems in Family
Practice (Singapore) - Cont’d
Paediatric Adult Overall
Earache 1.5%
Diarrhoea 1.4%
Nasal stuffiness 1.3%
Dizziness 1.2%
Dyspnoea 1.2%
Other 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.
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.
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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.
Consultation tasks
Pendleton’s 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 patient’s 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 consulta-
tions, 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.
Medical records
Proper documentation is necessary for efficient continuing care, as well as for medico-
legal purposes. Medical information should be systematically and legibly recorded, and
should reflect the patient’s 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.
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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 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 is defined as the extent to which a person’s behaviour (in terms of keeping
appointments, taking medications, and executing lifestyle changes) coincides with
medical advice. (Haynes et al)
The patient
(a) Socio-demographic characteristics e.g. age, gender, ethnic group.
(b) Attitude towards illness, health care provider, medical treatment.
(c) 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.
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
(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.
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.
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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,
Parkinson’s 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.
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 moiré (Stott and
Davies, 1979)
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.
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.
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
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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
Outline
Who forms a family?
Functions
Family Life Cycle
Developmental Tasks
Family Influence On The Individual’s Health
Functional And Dysfunctional Families
Level of Physician Involvement
Family Dynamics
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.
• 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 family’s 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.
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.
2
1. Married couples (without children).
2.5 2. Childbearing families
Yrs.
Yrs. 3.5 (oldest child, birth - 30 months).
10 to 15 + Yrs.
Years
3. Families with preschool children
1 2 (oldest child 30 months - 6 years).
8 3 4. Families with schoolchildren
7 Years
4 (oldest child 6 - 13 years).
5. Families with teenagers
5 (oldest child 13 - 20 years).
7 6. Families launching young adults
6 7 Years
(first child gone to last child leaving home).
15 + Years
7. Middle-aged parents
(empty nest to retirement).
8 Years
8. Aging family members
(retirement to death of both spouses).
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SECTION 03 CONCEPTS OF FAMILY MEDICINE
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.
• 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.
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.
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.
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 counterproduc-
tive 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.
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SECTION 03 CONCEPTS OF FAMILY MEDICINE
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 appropri-
ately. 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.
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
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).
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SECTION 03 CONCEPTS OF FAMILY MEDICINE
m 5/6/72 m 4/4/70
marriage couple marriage
with 3 children with
twin boys
b 10/21/78 b 4/13/80 b 8/1/82
b 9/17/76
oldest youngest
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
Paediatric emergencies - E.g.: persistent crying, fever, vomiting, diarrhoea and abdominal
pain, childhood injuries, fits, foreign bodies, accidental poisoning, and epistaxis.
Urogenital emergencies - Acute urinary retention, renal colic, acute testicular pain, etc.
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.
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.
63
Forensic emergencies - E.g. alleged assault or rape, death at home.
SECTION 03 CONCEPTS OF FAMILY MEDICINE
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 encoun-
tered. Clinic staff should be familiar with their roles in these protocols.
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.
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.
65
PATIENT EDUCATION
SECTION 03 CONCEPTS OF FAMILY MEDICINE
HOUSECALLS
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
66
• Good to document details of all requests for housecalls, any advice given, and whether
or not a visit was made.
Additional preparation
This can be decided after talking to the caller, and may indicate extra equipment, drugs or
clinic records.
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.
67
• Important to attend to the patient and his family members' anxieties. In many
SECTION 03 CONCEPTS OF FAMILY MEDICINE
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.
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 manage-
ment 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
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.
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.
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.
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.
Psychological Care
The family doctor must be able to cope with the dying patients' emotions and
his reactions.
69
According to Dr Kubler Ross, the patient with terminal illness undergoes five stages
SECTION 03 CONCEPTS OF FAMILY MEDICINE
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
70
Principles of Pain Management
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.
5. Consider interventions that raise the "pain threshold" including discussion of the
disease, its treatment and prognosis, counselling, relaxation techniques and
anxiolytic therapy.
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.
10.Corticosteroids may also reduce pain by modifying the disease process in brain and
nerve involvement, and reducing oedema around a tumour.
• Tumour infiltration of bone, nerve, plexus or root, visceral organs and pleura
• Infection
71
• Gastrointestinal obstruction from tumour and faeces
SECTION 03 CONCEPTS OF FAMILY MEDICINE
• 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.
• 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.
Social Care
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.
72
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.
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.
73
It is necessary to identify the one in the family who is closest to the patient, or in authority
SECTION 03 CONCEPTS OF FAMILY MEDICINE
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".
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.
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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
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.
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• Reassure family that everything reasonable was done before death supervened.
SECTION 03 CONCEPTS OF FAMILY MEDICINE
• 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.
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.
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SECTION 04
PACKAGE B – MANAGING THE FAMILY
MEDICINE PRACTICE
77
CHAPTER 1
SECTION 04
SECTION 04 MANAGING THE FAMILY MEDICINE PRACTICE
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.
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.
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.
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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.
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.
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.
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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SECTION 04 MANAGING THE FAMILY MEDICINE PRACTICE
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 person’s 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.
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.
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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 people’s leadership styles. The “managerial grid is a taxonomy of management
styles classified according to the manager’s 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.
1,9 9,9
COUNTRY CLUB MANAGEMENT TEAM MANAGEMENT
Thoughtful attention to needs of WORK accomplishment is from
people for satisfying relationships committed people;
leads to a comfortable friendly interdependence though a
organization atmosphere and “common stake” in organization
work tempo. purpose leads to relationships of
trust and respect.
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 satis-
factory level.
1,1 9,1
Impoverished Management Authority-Obedience
Exertion of minimum effort to get Efficiency in operations results
required work done is appropriate from arranging conditions of
to sustain organization work in such a way that human
membership. elements interfere to a minimum
degree.
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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.
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.
Source: Porter & Miles. in: Motivation and Management. McGuire (ed), 1974:547 (adapted)
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
staff’s 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
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working conditions. Internally generated grievances may require the counseling of the
employee or transfer to a different department or job.
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: individual’s general
state of health, distance from work and or traveling difficulties and extent of the
employee’s 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.
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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.
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.
Henri Fayol: “The plan of action facilitates the utilization of the firm’s 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.”
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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.
The following strategies are not mutually exclusive. Also, stakeholders can collaborate
and work together in one or more of the strategies.
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).
Management of Change
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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PERSONAL EFFECTIVENESS
There is a need for each of us to make a conscious effort to put our best foot forward:
Managing Paper
The ability to handle papers is a valuable skill. The points to note are:
Managing Meetings
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• Take succinct minutes.
• Send the minutes out early so that participants can act on what they have agreed
to do.
Outline
Supplies and stores management principles
Maintenance and storage
Laboratory investigations and X-rays
Managing discrepancies
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.
• 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.
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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 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.
• 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.
• 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:
MANAGING DISCREPANCIES
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.
• 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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Outline
Medical records
Confidentiality
Computerisation
MEDICAL RECORDS
Medical records are more than an aide me moiré 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.
• 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.
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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.
• 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.
• 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.
Various charts have been developed for hypertension, diabetes mellitus and asthma.
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.
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
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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.
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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.
• 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.
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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)
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)
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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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).
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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
PRACTICE—I. BMJ 1995;311:800-802 (23 September)
2. Andrew Millman, Nicholas Lee, Andrew Brooke. ABC Of Medical Computing: COMPUTERS IN GENERAL
PRACTICE—II. 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 Clinic’s 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
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
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• 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 doctor’s 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.
• 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 accountant’s queries promptly and in writing.
• Inform accountant of impending changes in practice, e.g., new staff, purchase of
equipment etc.
FINANCIAL STATEMENTS
Profit and loss statement. A profit and loss (P & L) statement (what the Americans call
the income statement) is a summary of the company’s 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 company’s 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 organisation’s 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
organisation’s 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.
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 firm’s 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 management’s need
for authentication as much as that of external groups.
FINANCIAL PLANNING
One key activity of financial planning is the development of the organisation’s 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:
• Cash budgets – Cash budgets combine the estimates for revenues, expenses and
new capital expenditures.
• 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.
In the normal budgeting process, the previous year’s 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 organisation’s objectives.
Zero-base budgeting (ZBB), in contrast, enables the organisation to look at its activities
and priorities afresh. The previous year’s resource allocations are not automatically
considered the basis of this year’s resource allocations. Instead, each manager has to
justify anew his or her entire budget request, using a cost-benefit analysis of each of the
organisation’s 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.
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.
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.
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.
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.
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.”
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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User’s 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 profession’s 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
profession’s stand whenever the opportunity occurs.
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
• 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 self-
managed system or through a managed care organization. Other attempts to align
incentives are patient co-payment to reduce unnecessary patient demand, and a co-
operative 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.
Managed care can be made to work by paying attention to the interest of the stakeholders:
• 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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MANAGING QUALITY
Outline
Quality and quality assurance
Continuing improvement
Quality assurance cycle
Self-audit project
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.
CONTINUING IMPROVEMENT
• 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.
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:
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.
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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:
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CONSULTATION SKILLS
3 Counselling Skills
4 Changing Behaviour
5 Disease Management Skills
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CHAPTER 1
SECTION 05
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 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.
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.
(5) Involve the patient in the management and encourage him to accept appropriate responsibility,
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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 patient’s compliance to the doctors management plan.
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.
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 physi-
cians 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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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).
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 patient’s problems?
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.
(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.
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).
• 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.
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.
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.
• 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 Physician’s clinic?
Patient education:
• At the end of the posting can you describe the opportunities and difficulties
encountered in patient education?
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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.
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.
We are now ready to put the elements of the GP consultation into the hypothetico-
deductive approach. It consists of the following steps:
(2) Combines this with his prior knowledge (BACKGROUND CUES) of:
• the patient and his family.
• the patient’s 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.
These will reflect the community morbidity (incidence and prevalence of disease in
family practice) and the doctor’s 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.
(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.
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.
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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
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
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
• 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.
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.
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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"
Example 1: There are different ways the doctor can tell the patient to stop smoking.
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:
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?
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.
(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.
(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).
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 appropri-
ately dressed is therefore important.
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
Byrne and Long (1976) studied 1,000 audio recordings of consultations and found that 6
phases can be identified:
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).
How can we conduct it effectively? The following are points to take note of:
(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.
(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.
(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.
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.
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Physical Disabilities
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 guiding principles for not revealing too much to the patient are:
(i) if the diagnosis is not yet definitely confirmed.
(ii) if the doctor perceives that the patient is not ready for it.
(iii) 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").
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.
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.
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.
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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.
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
Outline
The Counselling Process
BATHE Technique
Problems Of Living
The Difficult Patient
The Angry Patient
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-in-
need; 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
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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.
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
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.
The busy physician can help many patients by applying Stuart and Lieberman’s
“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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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?”
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.”
O Objectivity
Encourage patients to ask themselves how realistic their thoughts and feelings are
(reality tests).
“What’s the worse thing that could happen?”
“How likely is that?”
134
A Acceptance
Be as non-judgmental and accepting as possible:
“That’s an understandable way to feel.”
Encourage patients to feel better about themselves, their parents, and other family members:
“I think you’ve 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?”
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.
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.
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
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
136
problems rather than difficult patients, it is the patients who have the problems while
doctors have the difficulties.
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
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.
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?
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.
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.'
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
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.
140
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.
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.
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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.
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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.
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.
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.
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.
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.
Outline
Getting Ready For A New Disease Paradigm
Getting Involved in Disease Management
The Way Ahead
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Table 1. Comparison of The Acute Care Model Versus Chronic Care Model
Characteristics Acute care Chronic care
Main goal of care Cure Control the progression of the condition;
Increase survival; Enhance quality of life.
Providers of care Usually clinicians and clinical Broad spectrum of health care
institutions organizations, community services
and family care
What has been found, however, is that one cannot get patients to do anything. The
motivation to change one’s behavior — even to take one’s medication — is largely
internal. The patient is responsible and must take an active role in his or her own care.
But why can’t 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 what’s best for treating diabetes or asthma or congestive heart
failure, but that does not mean we necessarily know what’s best for an individual patient.
Even in close doctor-patient relationships, we can’t always know the details of our
patients’ lives: what’s 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.
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• 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 patient’s agenda first — and the patient’s agenda is, after all, the
real reason for the visit (Nagasawa et al, 1990 in: Funnell MM, 2000).
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 aren’t interested in their disease from an
intellectual perspective, as doctors are. They want to know about themselves. What does
this mean to me? How’s this different for me? How’s 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 don’t 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 doctor’s 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 patient’s
agenda or goals related to his or her condition. Ideally, the goal should be clearly
displayed in the patient’s 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 you’re most distressed about and
what you’d most like to change.” You’ll get to the lab values and other issues later, but it
will be in the context of the patient’s 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 don’t. Don’t try to fix it. Don’t
just say, “It will be OK.” Instead, validate the patient’s 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?”
There is a need to explore the patient’s 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 patient’s concerns and expectations also applies to non-
pharmacological treatment.
Patient says: Doctor responds:
(Old model) (New model)
“I hate this exercise plan.” “Then try walking after “What do you hate about it?
dinner every night with your What would help you do better at it?”
husband for 10 minutes.”
“I don’t think I can quit “Smoking is the leading “Why do you think that? What
smoking.” cause of preventable death ...” has happened in the past when
you tried to quit? What concerns
you most when you think about
trying to quit?
“I haven’t been able to test “It’s hard at first, but just “What is preventing you from
my blood sugar four times keep trying. You really need doing that? Do you know what
a day.” to keep the track of it.” numbers mean?”
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FINDING THE COLLABORATIVE GOAL
It’s 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 “here’s why I don’t think that’s 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, “I’m 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 it’s 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 they’re talking.
Actual:_________________mm/Hg
Ideal: 130/85 or lower
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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.
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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 they’re making any kind of progress. Likewise, doctors
should accept less-than-perfect short-term results for the sake of promoting long-
term change.
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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.
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.
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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 )
• 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 patient’s 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), you’ll 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.
Lipids (annual)
DATE:
CHOL:
TRIG:
HDL:
LUL:
Self-management
DATE:
GOAL:
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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.
• Finally, Be Patient. Changing your system of care isn’t easy. It will take time for
physicians and staff members to experiment with the flow sheets and to find what works
best for them. Don’t 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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Outline
Initial action
Cardiac emergencies
Respiratory emergencies
Neurological emergencies
Paediatric emergencies
INITIAL ACTION
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%.
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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.
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
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.
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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 patient’s stomach slightly
above the navel.
• Grasp the fist with your hand and press into the patient’s 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 child’s 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.
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.
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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.
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.
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PAEDIATRIC EMERGENCIES
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 baby’s 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
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.
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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
165
SECTION 05 CONSULTATION SKILLS
Reference
MOH, COFM & CFPS. Emergencies. In:Handbook for Primary Care Doctors. Singapore:MOH, 1996
166
SECTION 06
COMMON SYMPTOMS IN AMBULATORY CARE
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
CHAPTER 1
SECTION 06
FATIGUE
DEFINITION
• 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.
CAUSES
168
Source. Ridsdale L, Evans A, Jerret W et al. Patients with fatigue in general practice: a prospective study. BMJ
1993:307:103-6.
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.
WORKUP
History
A brief perusal of the patient’s 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 doctor’s 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
Periodicity
• constant - organic problem.
• fluctuating - functional aetiology.
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.
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.
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.
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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
DEFINITION
• 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.
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.
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.
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.
Parkinson’s 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.
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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
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
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.
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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 gastro-
intestinal 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
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 36.7°C (range 36-37.4°C), or 98°F (range
96.8 - 99.3°F). The normal rectal or vaginal temperature is 0.5°C (1°F) 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.
• 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
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 38°C 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.
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
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.
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.
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.
Miscellaneous Causes
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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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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
• 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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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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.
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 combina-
tions of nausea, vomiting, heartburn and epigastric fullness.
CAUSES
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:
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
Gastric Erosions Due to Drugs. NSAIDs cause acute gastric and duodenal damage
in 30% users. It should be remembered as a possible cause.
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.
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
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.
MANAGEMENT
• 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.
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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.
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.
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.
187
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
BREATHLESSNESS
DEFINITION
CAUSES
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.
• 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.
• 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.
Physical Examination
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MANAGEMENT
Acute Breathlessness
• 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.
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 misdiag-
nosed as anxiety induced breathlessness.
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CHAPTER 6 COUGH
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.
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Neoplastic. Low in the order of frequency but high in the list of fatal causes of cough is
bronchial carcinoma.
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.
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.
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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.
MANAGEMENT
• 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.
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 non-
infective causes.
194
BACTERIAL INFECTIONS
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:
Coxsackie and Herpes Simplex — May cause painful ulcers in the oral mucosa and
oro-pharynx.
OTHER MICROORGANISMS
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
General examination
This includes the temperature, presence of jaundice (jaundice is present in 5-10% of
patients with infectious mononucleosis).
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 life-
threatening. 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.
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, deconges-
tants 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.
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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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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 (Dressler’s 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.
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
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
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.
• Pain induced by exercise, and after a meal. • Apparent relationship with exercise, but pain
Pain induced by sexual inter-course. usually comes on at the end of a busy day,
and not after exercise.
• Relieved by sublingual nitrates within • Patient often claims that nitrates are helpful,
seconds or within 2 minutes. 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.”
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.
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 X-
rays are diagnostic in pneumothorax.
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• 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
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.
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.
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
• 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
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.
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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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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
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
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).
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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.
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
Table 1. How Severe is the Dehydration
Mild Moderate Severe
1. ASK DIARRHOEA Less than 4-10 liquid 4 liquid stools per day More than 10 stools per
stools per day day, with or without blood
and/or mucus
VOMITING None or small amount Some Very frequent
THIRST Normal More than normal Unable to drink
URINE Normal Small amount, dark coloured No urine for 6 hours
2. LOOK CONDITION Well, alert Unwell, drowsy or irritable Very sleepy, floppy, unconscious,
having fits or seizures
EYES Normal Sunken Very dry and sunken
MOUTH and Wet Dry Very dry
TONGUE
BREATHING Normal Faster than normal Very fast and deep
3.FEEL SKIN Pinch, goes back slowly Pinch, goes back very slowly Pinch, goes back quickly
PULSE Normal Faster than normal Very fast, weak, or cannot be felt
FONTANELLE Normal Sunken (in infants) Very sunken
4.WEIGHT No weight loss Weight loss of 25-100g for Weight loss of more than 100g for each
each kg of weight kg of weight
5. TAKE TEMPERATURE – – Fever more than 39°C (102°F)
6. DECIDE Treat Treat Refer patient to hospital speedily
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.
207
CHAPTER 10
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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.
CAUSES
Simple constipation due to inadequate fluid intake, dietary intake and inactivity is the
commonest cause seen in general practice.
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, anti-
cholinergics and anti-depressants.
Specific medical conditions may also result in constipation. Depression and hypothyroid-
ism 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
The hypothyroid patient has characteristic facies and delayed relaxation of deep
tendon reflexes.
Investigations
MANAGEMENT
Simple Constipation
• Attend to patient's concerns about constipation.
• Advice to increase
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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.
• 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 child’s 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.
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 mea-
sures; and medications for other reasons.
210
Physical Examination
An observation is made of the child’s well-being and general health, growth and
development. Children with the rare serious causes like Hirschsprung’s disease and
hypothyroidism frequently fail to thrive.
Abdominal palpation often reveals faecal masses. Peri-anal inspection may reveal
a fissure.
MANAGEMENT
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
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 characteristi-
cally 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 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 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 gastro-
intestinal 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.
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.
• 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.
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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.
• 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.
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.
• 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.
215
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
- Functional. irritable bowel syndrome and periodic syndrome are common conditions
in young adults and children respectively.
Group B. Less urgent but important conditions — Acute cholecystitis; Biliary colic; Hepatitis;
Renal colic; Pelvic inflammatory.
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
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?
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.
Examination
General
- the patient’s 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, Murphy’s 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.
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
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 non-
acute 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
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.
219
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
DEFINITIONS
Macule - A flat spot which differs in colour from the surrounding skin
Papule - A raised spot on the surface of the skin
Nodule - A lump deeply set in the skin
Scale - A flake of horny cells loosened from the skin surface
Crust - Dried serum adherent to the skin
Vesicle - A skin bleb filled with clear fluid
Bulla - A blister filled with clear or blood-stained fluid
Pustule - A skin bleb filled with pus
Urticaria - An irregular white or pink pruritic weal
CAUSES
• 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.
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.
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 oval-
shaped 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.
• 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.
221
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
• 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.
• 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.
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.
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.
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.
223
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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.
224
CHAPTER 14 BACKACHE
CAUSES
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.
Symptoms
Duration. One should ask the duration and onset of the backache and whether it has
been recurrent.
225
Associations. Pain at rest, morning stiffness, radiation to the knees and calves, loss of
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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.
Referred pain. pain in the back may be referred from viscera within the chest, abdomen
or pelvis, e.g. pyelonephritis, duodenal ulcer or dysmenorrhoea.
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).
• 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.
• 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.
MANAGEMENT
227
- Reassess home/work environment.
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
• 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.
• 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 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.
HEREDITARY (Uncommon)
- Marfan's syndrome, Ehlers-Danlos, Osteogenesis imperfecta
229
The presence of extra-articular manifestations helps to clinch the diagnosis. See Table 3.
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
Physical Examination
Examination may be normal or there may be redness and swelling of affected joints,
deformities and extra-articular manifestations.
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.
• Rheumatoid factor
Rheumatoid factor is an important test in confirming the diagnosis, but only if the
positive results correspond to the patient’s 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.
231
Table 4. X-Ray features in Joint Disorders
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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 combina-
tion 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:
- 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.
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
• 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
• 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
From the standpoint of diagnosis, it is useful to classify dizziness as with or without vertigo.
• 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.
• 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 intracra-
nial pressure.
Physical Examination
235
Signs of early pregnancy should be looked out for in the young woman complaining of
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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).
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.
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
• 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
237
onset, changing character, increasing frequency or severity, persistent, or accompanied
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
CAUSES
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.
• Diffuse headache in conjunction with a stiff neck and fever suggest acute meningitis.
• 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.
• Eye pain and blurred vision raise the possibility of acute glaucoma.
• 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.
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
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.
239
• Examination of neck - neck rigidity on anterior flexion suggests meningitis or a vascular
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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.
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
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.
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.
Urgent Situations
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.
241
RECURRENT HEADACHES
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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.
242
RELEVANCE TO GENERAL PRACTICE
• 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
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 well-
maintained 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.
243
Table 1: Disorders in Intiation and Maintenance of Sleep (DIMS)
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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 anti-
asthmatics 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
Investigations
245
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
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 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.
• Refer patients with primary sleep disorders, or those who are refractory to all efforts,
for evaluation by a sleep laboratory.
246
INDICATIONS FOR REFERRAL
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.
1. A persistently crying baby requires the doctor‘s 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
247
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
WORKUP
The parents are likely to be harassed and anxious. A sympathetic approach helps to
diffuse the tense situation.
History
- 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
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.
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.
• Where the child is unwell or where serious organic disease cannot be excluded, referral
to hospital should be done.
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
• 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 gastroenterologist’s perspective. Paediatric Clinic North Am 1994 Oct;
41(5):1121-38.®
• 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.
Source: Khunti K. Update Jun 1, 1995:751 (Arranged in order of frequency as seen in general practice)
250
Red Eye of Gradual Onset
Contact lens conjunctivitis. This is common as the number of contact lens users are
increasing. It is usually a bacterial conjunctivitis.
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.
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.
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
• 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.
Table 2 summarises the chief features in differentiating conjunctivitis from iritis, keratitis
and acute glaucoma.
Investigations
MANAGEMENT
The management of the patient general practitioner can provide symptomatic relief or
specific treatment for the following:
• Contact lens conjunctivitis -- advice on proper care of the lenses and avoid lens wear
until conjunctivitis subside.
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SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
• 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.
• Red eye associated with eye pain, visual disturbance, signs of acute glaucoma or iritis
should be referred immediately.
• Foreign bodies and more than superficial eye injuries should also be
immediately referred.
• 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 Conjunctivitis Iritis Keratitis Acute
feature (corneal glaucoma
inflammation
or foreign
body)
255
SECTION 06 COMMON SYMPTOMS IN AMBULATORY CARE
256
CHAPTER 20
RED EYE
SECTION 07
MEDICAL TECHNICAL SKILLS & CARE IN
SPECIFIC SITUATIONS
4 Psychological Disorders
5 Skin Disorders
6 Bone & Joint Disorders
7 Nervous System, Eye & Ear Disorders
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
Approach to breathlessness, cough, sorethroat and chest pain are dealt with under
Common Symptoms (See Section 6).
RESPIRATORY INFECTIONS
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 History of temperature or measured temperature >38 °C
1 point No cough
1 point Tender anterior cervical adenopathy
1 point Tonsillar swelling or exudates
1 point Age 3-14 yr
- 1 point Age > 45 yr
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.
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
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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).
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).
Diagnostic Features
The diagnostic features of pneumonia are fever (> 38ºC), 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 CRITERIA EMPIRICAL TREATMENT
TREATMENT
Category I • Less than 60 years • Outpatient treatment
Low risk • Clinically mild disease • Initial treatment --oral
— outpatient • No radiological signs macrolide (See Table 2)
treatment is of severity (multilobar • Review within 24-48 hours
adequate infiltrates, pleural effusion) to ensure they have
improved with initial improved
treatment.
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.
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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
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 patient’s 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).
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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.
264
Table 4. Treatment of Adults and Children with TB Disease: First Line
Medications
DOSE IN MG/KG (MAXIMUM DOSE)
May permanently
discolour soft
contact lenses
Pyrazina- 15-30 15-30 50-70 50-70 Hepatitis, Treat hyperuricemia
mide orally orally orally orally Rash only if patient has
(PZA) (2 g) (2 g) (3 g) (3 g) Gastrointestina symptoms
tract upset,
Arthralgias
Hyperuricemia
Gout (rare)
Etham- 15- 25 15- 25 25-30 25-30 Optic neuritis Not recommended
butol Not to be Not to be (thrice (thrice for children too
(EMB) given at given at weekly) weekly) young to be
25mg/kg 25mg/kg 30-50 50 monitored for
/day /day (twice (twice changes in vision
for longer for longer weekly) weekly) unless TB is drug
than than resistant
2 months 2 months
Strepto 20-40 15 25-30 25-30 Ototoxicity Avoid or reduce
-mycin(1 g) (1 g) (1.5 g) (1.5 g) (hearing loss or dose in adults
SM vestibular more than
dysfunction) 60 years old
Renal toxicity
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.
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Pulmonary & 18-24 SM, EMB, EMB, INH - daily Three drugs
extrapulmonary INH - daily or twice or should be
TB in adults and for 8 weeks thrice weekly for continued until
children when 16 to 22 susceptibility to
RIF is months (DOT if the drugs
contraindicated on twice or prescribed is
thrice weekly) demonstrated
Or
SM, IMH - 2
times/week for
16 to 22 months
(DOT)
266
Table 7. Selected Regimens for Single Drug Resistance
DRUG TO WHICH INFECTION TREATMENT REGIMEN DURATION OF THERAPY
IS RESISTANT
Isoniazid (INH) Rifampicin 6-9 months
Ethambutol
Pyrazinamide
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 supplementa-
tion 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).
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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.
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).
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Table 8. Categorisation of Severity of Asthma Attacks — Cont’d
PARAMETER* MILD MODERATE SEVERE RESPIRATORY ARREST
IMMINENT
Respiratory Increased Increased Often Often >30/min
rate >30/min
Pulse /min <100 100-120 >120 Relative bradycardia
Pulsus Absent May be Usually Confused or drowsy
paradoxus <10mmHg present agitated
Breath sounds Moderate Loud Loud Little air movement
wheezing wheezes inspiratory and without wheezes
at mid- throughout expiratory
and end- expiration wheezes
expiration
Children Feeds Has Won’t feed Won’t feed
normally difficulty
feeding
PEF after Over 80% Approx <60% Unable to do
initial 60-80% predicted
bronchodilator or personal
Or % best
predicted (<100L/min
Or % in adults)
personal best Or response
to therapy
lasts <2 hr
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
Source: Ng & Tan, 1999; Abramson et al, 2001; MOH CPG 1/2002)
269
can be stepped down on review if patient’s asthma control improves. On the other
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hand, if control is not achieved, step up therapy is advised after reviewing patient
medication technique, compliance and environmental control.
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
Preventer Drug(s)
Height
ASTHMA SEVERITY
Step 3:
Moderate Daily medication: • Short-acting Step 1 actions plus:
persistent • Anti-inflammatory: bronchodilator: • Teach self-monitoring
inhaled orticosteroid Inhaled beta-2 • Refer to group
(400-800mcg) agonist as needed education if available
AND, if needed for symptoms, not
to exceed
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Step 1:
Intermittent • No daily medication • Short-acting • Teach basic facts
needed bronchodilator: about asthma
Inhaled beta-2 • Teach inhaler/
agonists as needed inhalation
for symptoms, chamber
but less than once technique
a week. • Discuss roles
• Inhaled beta of medications
agonist or • Develop self-
cromoglycate before management &
exercise or exposure action plans
to allergen • 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
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.
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.
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.
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, anti-
inflammatory 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. High-
dose inhaled steroids e.g. BDP/ BUD >400 µg to 800 µg/ day or fluticasone 200µg -
400µg/ 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 µg/ day or fluticasone 1000 µg/ 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.
Symptoms/day
symptoms/night
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Symptoms/day
symptoms/night
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 µg/ day or fluticasone > 200
• µg/ 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
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)
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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
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.
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.
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 patient’s 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.
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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 patient’s
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.
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
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, espe-
cially 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 (oropharyn-
geal 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.
Approach
This is shown in Table 2.
282
Table 2. Questions To Ask About Dysphagia - Cont’d
3 Is swallowing painful (odynophagia)?
Yes — Suspect esophagitis
4 Is the dysphagia intermittent or is it constant and getting worse
Intermittent — Suspect oesophageal spasm.
Constant and worsening — Suspect malignant stricture.
5 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.
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.
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.
• 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
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.
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.
Stage II: As-needed pharmacologic therapy — Antacid and/or antacid product containing
alginic acid; Over-the-counter histamine H2 receptor blocker
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 gas-
trointestinal barium study, Evidence of gastrointestinal bleeding or iron deficiency
anemia, and at least 10 years of GERD symptoms s (screen for Barrett’s 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 patient’s 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.
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
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.
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 benign-
appearing 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 x-
ray 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).
(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.)
288
Table 5. Treatment Options For Peptic Ulcer Disease. - Cont’d
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
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)
1
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. Noncompli-
ance 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.
289
appropriate imaging studies. Treatment decisions should be individualized. The best
SECTION 07 MEDICAL TECHNICAL SKILLS & CARE IN SPECFIC SITUATIONS
approach is always honest and frank discussion with the patient and family.
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 patient’s 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.
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.
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 Crohn’s 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 constipa-
tion, 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.
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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.
Optional:
• Barium enema every 5 years
• Colonscopy every 10 years
292
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.
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.
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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
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.
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
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.
295
adults, the normal range for serum AFP is 0 to 20 ng/mL. Serum levels of 400 ng/mL
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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.
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).
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, ultrasound-
guided 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.
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Outline
Renal disorders
Haematological disorders
RENAL DISORDERS
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.
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.
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
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300
UTI In Men
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RENAL CALCULI
Presentation
Differential Diagnosis
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).
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
304
Figure 2. Initial Management Of Radiologically Confirmed Urolithiasis -
Cont’d
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.
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).
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.
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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
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 child-
bearing 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 urologist’s judgment and experience, with consideration of the
patient’s preferences, should dictate the treatment approach (Table 2).
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.
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Table 6. Classification of Anaemias By Pathophysiology — Cont’d
INCREASED DESTRUCTION — CONT’D
(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
Sideroblastic anaemia SFe Dec SFerr Nor or Inc Transferrin Bone marrow examination
(hereditary)
Anaemia of chronic SFe Dec SFerr Nor or Inc Specific for underlying
disease (sometimes) Transferrin Dec disorders
Anaemia of chronic Specific red cell changes, Retic Inc SBil and SLDH Inc, SHapt Dec,
disease specific tests for hemolysis
Haemolysis
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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 patient’s 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.
Microcytic anaemia
Causal factors
These are shown in Table 8.
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.
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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 gas-
trointestinal 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
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 unmeasur-
able, 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.
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Macrocytic anaemia
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.
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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 non-
hematologic 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 im-
provement 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.
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.
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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.
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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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 patient’s 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 patient’s
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.
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.
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).
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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).
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 patient’s 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 patient’s 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 you’ve been under, I wonder
if you’ve been drinking more lately?”
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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.
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 you’ve been dealing with, have you ever had
the thought that you’d be better off dead?” The most common response is the
reassuring, “Oh sure, the thought has crossed my mind, but I’d 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
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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).
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).
NOTE: A manic episode requires at least one week of elevated or irritable mood plus three of the
seven symptoms described above
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.
“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 patient’s 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 patient’s ever-present fear of abandonment.
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 questionnaire’s 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 patient’s shame about admitting to drug use.
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 you’re going to die or go crazy.”
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 patient’s 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 two-
hour period and feel that you can’t 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
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Mental State Examination (MMSE) (Folstein et al, 1975), is hampered by high rates of false-
positive 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).
Psychotic Disorders
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 they’ve 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 patient’s viewpoint: “Have people been harassing you or trying
to harm you?” This communicates sympathy for the patient’s 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.
Outline
Infective dermatoses
Bacterial infections
Fungal infections
INFECTIVE DERMATOSES
BACTERIAL 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.
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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.
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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.
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.
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.
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.
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.
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 Whitfield’s ointment,
formalin and Castellani’s 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 Wood’s 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.
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 host’s 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.
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.
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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.
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.
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.
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 (athlete’s 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
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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.
Wood’s light can be useful in tinea capitis which fluoresces a brilliant green colour as
seen in a darkened room on infected scalp.
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.
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similar but patients treated with oral ketoconazole appeared to have a slightly lower
relapse rate.
Tinea Versicolor
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.
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.
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.
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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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, mico-
nazole 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
Outline
Symptoms and approach
Use of NSAIDs & Corticosteroids
Classification
NSAIDs may be classified by its inhibition of the cyclooxgenases into non-selective
NSAIDs and Cox-2 selective NSAIDs. See Table 1.
Source: Noble et al, 2000. COX = cyclooxygenase; NSAID = nonsteroidal anti-inflammatory drug.
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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) NO. OF RR (95% CI) (B)
FOR ADULT STUDIES (B)
Ibuprofen – overall 400-800mg tds 9 1.9 (1.6 – 2.2)
Low – medium dose 3 2.1 (1.6 – 2.7)
High dose 3 5.5 (3.0 – 10.0)
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Table 2. Pooled Relative Risks (RRs) for UGIB for Users of Individual NSAIDs
Compared With Nonusers for Studies from 1990 to 1999 — Cont’d
INDIVIDUAL NSAID USUAL DOSAGE (A) NO. OF RR (95% CI) (B)
FOR ADULT STUDIES (B)
Apapropazone – overall 600mg bd 2 27.5 (12.0 – 62.9)
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 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).
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.
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).
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).
GI side effects. Like traditional NSAIDs, the COX-2 inhibitors commonly cause abdominal
pain, dyspepsia and diarrhea.
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.
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.
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).
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.
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.
Avoid its use unless clearly indicated — The optimal method for prevention of NSAID-
induced 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 anti-
inflammatory 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.
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).
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).
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.
Felty’s syndrome, rheumatoid lung, scleritis). The dosage should be at least 1 mg/kg daily.
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Which to use
How to administer
Which is more beneficial, a single daily dose or split doses? For severe disease,
prednisone, prednisolone, and methylprednisolone should be divided into at least two
344
daily doses. When disease is more stable, a single morning dose is preferable: The patient
will sleep better, and the adrenal glands may achieve a small degree of recovery before
the next dose. In addition, the natural peak of adrenal corticosteroid production occurs in
the morning, so morning dosing is more physiologically normal.
Alternate-day steroid dosing is advocated by some researchers as having efficacy equal to
daily dosing but with fewer side effects (Fauci, 1978). However, in the only controlled
study of this method (Hunder et al, 1975), alternate-day dosing did not adequately
control giant cell arteritis. Often, patients with such diseases as SLE and rheumatoid
arthritis do not tolerate alternate-day corticosteroid therapy well, because symptoms
tend to become quite severe by the end of the second day.
Alternate-day dosing is therefore of little use. The following rules of thumb to be helpful
in prescribing corticosteroids (van Vollenhoven, 1998):
Go high and go fast. The approach is the opposite of that usually recommended in
prescribing drugs (go low and go slow), because most patients who need corticosteroids
need them badly. For a few days, until the clinical picture becomes clearer, underdosing of
corticosteroids often causes greater harm than overdosing. However, once a clinical
response has been obtained, the dose can often be reduced rapidly.
Taper fast at first, more slowly later. Corticosteroid doses should be reduced
whenever possible, and the tapering curve should look “logarithmic” (e.g., 60, 40, 20,
15, 10, 7.5, 5, 2.5, 0 mg) rather than linear (e.g., 60, 50, 40, 30, 20, 10, 0 mg). Serious
diseases, such as SLE, require slower tapering and closer monitoring for disease
recurrence. In many instances, high-dose corticosteroids are prescribed in conjunction
with immunosuppressive agents; in fact, it is an interesting but largely unpublished fact
that immunosuppressive agents are ineffective without the addition of corticosteroids.
Use local or topical steroids whenever possible. Use of steroid creams for lupus rashes and
intra-articular or soft-tissue injections can decrease the need for systemic steroid therapy.
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Outline
Symptoms and approach
Foreign bodies in ear, nose & throat
The eye in systemic disease
Ear
In the ear, smooth round foreign bodies of non-organic material should always be
syringed. Attempting to remove it with a forceps may only push it further in. If difficulty is
encountered, a referral should be made to the ENT specialist.
Nose
For foreign bodies in nose (and ear) in children, attempt to remove them only if they are
easy to remove and you feel confident of success, otherwise it is safer to refer. Availability
of suitable instruments and good lighting are again emphasised. In the nose, it is best to
apply local anaesthetic prior to attempting to removal.
Throat
The commonest FB in the throat is a fish bone. Locating the site is helped by a careful
history. The commonest site is the tonsil and only the tip of a buried bone may be visible
sso search carefully.
Approach
There are four factors which would largely determine the success of the doctor trying to
remove a swallowed bone:
346
A 60W conventional spotlight or a halogen light source mounted on an angle-poised stand
will make a very practical solution to overcome this problem. Such a light source together
with a head-mirror of aperture at least 1.5cm diameter will allow good visualization of all
the pharyngeal structures using a tongue depressor and a laryngeal mirror.
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• Dysphagia in an adult or refusal to take feeds in a young child signifies that there is a
strong likelihood that the bone is in the oesophagus.
• Retrosternal chest pain after swallowing a bone should alert the attending doctor that
the bone is in the thoractic oesophagus.
Using a good light source, head mirror and topical anaesthesia if necessary, the patient’s
throat is examined systematically. The different common sites of impaction are carefully
inspected. Particularly difficult areas include the superior and inferior poles of the tonsils,
tonsillo-lingular sulcus and the valleculae, especially in a patient with very prominent
lingual tonsils. During this procedure, effective tongue depression is achieved with the
right angled tongue depressors holding down the tongue firmly at the anterior two
thirds. A pair of Tilley’s forceps can be used to retract the anterior faucial pillars which
may be obscuring the superior tonsillar pole. If no bone is found, the patient’s tongue is
held forwards with a gauze, and the tongue base, vallecula and the piriform fossae are
inspected with a laryngeal mirror. Bones in the tonsils and anterior tongue base can be
easily removed with the Tilley’s forceps. Bones in the posterior tongue base, valleculae
and piriform fossae would require the Nagashima forceps.
If at this stage no bone can be found despite a good view of the oropharynx and
hypopharynx, two clinical tests have been found useful:
• Laryngeal rocking test - during which the patient’s thyroid cartilage is rocked gently
from side to side. If a bone is impacted at the upper cervical oesophagus (the
commonest site in the cervical oesophagus), the patient will complain of pain during
this action.
• Self digital palpation test - during which the patient is asked to palpate the maximal
site of pain with his own index finger. If he can feel a sharp bone with his fingers, it will
help the doctor locate the bone so that it can be found and removed. If no bone is felt,
it is most likely that the bone is not there. This will also help convince that patient that
this is so.
Radiology
Plain lateral view x-ray of the neck is useful in confirming and locating a bone in the
cervical oesophagus. This is usually seen as a calcified vertical shadow centred at C6 level
(cricopharyngeal sphincter). This x-ray is of no use in excluding a pharyngeal fish bone.
Plain x-ray of the neck in the anteroposterior view and chest x-rays are of no value in the
diagnosis of oesophageal fish bones.
A barium swallow is indicated when the patient has definite symptoms of an oesophageal
fish bone (chest pain, dysphagia, etc) but the plain lateral neck x-ray shows negative or
equivocal findings. A bone can be seen lying in the midthoracic oesophagus.
348
When To Refer
Under the following circumstances, referral by the attending family physician is indicated:
• Inability to perform a good pharyngeal examination
• A bone is found but for various reasons, removal is not achieved
• Positive laryngeal rocking test
• An oesophageal foreign body shown on plain lateral x-ray of the neck
• Patient has chest pain and dysphagia
• A bone is shown on barium swallow
The eye may be involved in a very wide spectrum of systemic disorders. Ocular signs may
sometimes be the presenting feature in a systemic disease. Conversely, visual function
may be compromised by the underlying disease process. Primary care physicians play an
essential role in the prompt recognition of ocular complications and instituting
appropriate treatment for their patients. Visual function testing and a directed search for
relevant ocular signs should be performed in this group of patients.
The Eyelids
There are two signs of clinical significance to systemic disease, namely, ptosis and lid
retraction.
The presence of ptosis always merits further investigation. The two main differential
diagnosis are either Horner’s syndrome or a third nerve palsy. These can easily be
differentiated on the basis of the pupil examination. The pupil will be relatively miosed in
Horner’s syndrome, and usually dilated in a third nerve palsy.
Lid retraction, lid lag and exophthalmos are classical eye signs of thyroid eye disease. Lid
retraction (Dalrymple’s sign) occurs in 37% to 92% of patients with this condition.
Thyroid eye disease is characterised by inflammation, enlargement and fibrosis of orbital
tissues, particularly the extraocular muscles. It is presumed to be an autoimmune disorder
which overlaps with Graves hyperthyroidism. It is noteworthy that the eye signs may be
independent of the extent of hyperthyroidism, and may in fact be worse during the
hypothyroid phase of the disease. Consequently, all patients with thyroid eye disease
require evaluation of visual function, (including colour vision and perimetry), examination
of ocular motility, and a CT scan.
There are four major pathways in which thyroid eye disease affect the vision of a patient:
• The oedema and swelling within the orbit can cause compressive optic neuropathy
which may lead to blindness. In fact, the eye which is least proptotic may actually be at
a higher risk, because proptosis or forward displacement of the eye may lower the
intraorbital pressure.
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• These patients may develop increased intraocular pressure due to the restrictive
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myopathy or obstruction of the orbital veins with elevation of episcleral venous pressure.
• The swelling and fibrosis of the extraocular muscles often causes diplopia due to a
restrictive myopathy. The most common muscles affected are inferior rectus (causing
limitation of upward gaze) and medial rectus (causing a convergent squint).
• The cornea may develop exposure keratopathy due to inability to adequately close the
eye and the paucity of blinking.
Proptosis
Although thyroid eye disease as described above is the commonest cause of proptosis, it
is important to recall the other differentials of proptosis. Inflammatory pseudotumour or
infectious orbital cellulitis will present with proptosis, and require treatment with steroids
and antibiotics (and perhaps surgical drainage) respectively. It must also be borne in mind
that lymphomas, neoplasms (especially breast carcinoma), sarcoidosis, amyloidosis,
Wegener’s granulomatosis and vasculitis may also cause proptosis. The CT scan and
selected serological markers, e.g. ANCA etc., play an important role is sorting these
differential diagnoses.
The physician needs to provide supportive therapy to the eyes in the form of lubricants,
antibiotic prophylaxis and topical steroids in selected cases under ophthalmic supervision.
Kayser-Fleisher rings are brown or brownish blue deposits in Descemet’s membrane of the
cornea. They occur in 100% of patients with neurological manifestations of Wilson’s
disease, but unfortunately are often only visible on slit lamp examination, thus precluding
its usefulness in a general practice setting.
Dry eyes or keratoconjunctivitis sicca’ may occur with rheumatoid arthritis (15% to 25%),
primary Sjogren’s syndrome, systemic lupus erythematosis, systemic sclerosis, polyarteritis
nodosa or polymyositis. Although most cases of dry eyes are idiopathic, a high index of
350
suspicion is necessary to exclude these systemic conditions. Treatment is usually symptomatic
and consists of artificial tear preparations, acetylcysteine drops or punctal occlusion.
The more sinister manifestations of rheumatoid arthritis include corneal stromal keratitis
(with corneal opacities visible), peripheral ulcerative keratitis and scleritis (recognised by
deep boring pain and inflammation of the sclera).
Uveitis
A sterile hypopyon (pus in the anterior chamber) is a typical finding in Bechet’s disease, which
is a relapsing and remitting systemic vasculitis accompanied by oral and genital ulcers. Other
ophthalmic complications include retinal vasculitis and retinitis. Prompt recognition is essential
in order to avoid complications which include blindness and even death.
Cataracts
The vast majority of senile cataracts are idiopathic. Diabetics may develop a premature
onset of senile cataracts, and 15% to 20% of patients with Wilson’s disease may develop
a sunflower cataracts. Nevertheless, these constitute an extremely small minority, and
senile cataracts usually do not undergo extensive investigations as far as the aetiology is
concerned.
Steroid therapy also causes posterior subcapsular lenticular opacification in a dose and
duration related effect. Younger children are particularly prone to this development, and
require regular screening for the duration of the treatment.
Sixty percent of bilateral paediatric cataracts are idiopathic, with a further 30% being
hereditary. However, 5% are due to genetic, metabolic and systemic diseases and 3% due
to intrauterine infections. Consequently, a systematic search for an aetiology diagnosis in
paediatric cataracts is mandatory because it will identify other organ systems at risk (e.g.
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Retina
Diabetic retinopathy
Diabetes mellitus is by far the most important disease affecting the eye, as it is a leading
cause of irreversible blindness in developed countries Up to 90% of patients with Diabetic
retinopathy is a microangiopathy that has two basic pathophysiologic mechanisms,
namely, leakage and occlusion.
Type I (IDDM) diabetes will develop some form of retinopathy by 15 years post diagnosis,
and 50% may develop potentially blinding proliferative retinopathy by 20 years post
diagnosis. However, they usually do not develop retinopathy during the initial 5 years of
diagnosis. In patients with Type n (NIDDM) diabetes 3% may have visually threatening
macular oedema at the point of diagnosis. This difference in timing probably relates to
the lag period between onset of NIDDM and diagnosis.
Progressive capillary closure causes larger areas of ischaemic retina to produce presumed
angioproliferative factors which lead to the development of new vessels. These new
vessels may leak (causing further oedema) and bleed (causing vitreous haemorrhage).
Ultimately, proliferation of new vessels is accompanied by fibroblast proliferation which
may cause tractional retinal detachments. In addition, proliferation of new vessels on the
iris (rubeosis) causes often intractable glaucoma which leads inexorably to blindness.
352
Diabetic retinopathy may be classified clinically into the following 3 types. See Table 2.
Diabetic Maculopathy
Diabetic maculopathy may be associated with any of the above diabetic retinopathy.
Three types Maculopathy has been described:
• Cystoid maculopathy
• Exudative maculopathy
• Ischemic maculopathy
The key to managing this condition is early - detection and prompt institution of argon
laser photocoagulation which has been shown to be effective in treating oedema and
causing regression of new vessels.
When to refer?
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Autoimmune vasculitis. Apart from diabetes, the retina may also be involved in other
systemic conditions. For example, autoimmune vasculitis, like systemic lupus
erythematosis may present with retinal vasculitis. This presents with cotton wool spots,
retinal haemorrhages and exudates and disc changes. Atherosclerosis and hypertension
predispose to retinal vascular disorders like central retinal vein or artery occlusion.
CMV retinitis. The emergence of AIDS has also led to a dramatic increase in the number
of patients with retinitis due to opportunistic cytomegalovirus (CMV) reactivation. Up to
25% of patients with AIDS will develop CMV retinitis, and it may occasionally be one of
the first clinical signs of HN infection. The median survival after diagnosis of CMV retinitis
in some series of AIDS patients has been only 7-10 monthsl6. Consequently, it is a sinister
development, and any apparently healthy patient presenting with opaque retinal lesions
and blotchy retinal haemorrhage and vasculitis requires a comprehensive workup.
More recently, there has also been a series of local children who developed CMV retinitis
after organ transplants due to immunosuppression.
The eyes are affected in a very wide spectrum of systemic diseases. The primary care
physician should always be aware that eyes may sometimes pro-vide the first signs of a
systemic disease or may be compromised by the systemic disease process itself. Visual
acuity testing, and a quick exclusionary search for relevant eye signs should form part of
the assessment of any patient with a systemic disorder.
Outline
Metabolic syndrome
The Third Report of the National Cholesterol Education Program Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III [ATP III]) (NCEP III, 2001) has defined individuals with the metabolic
syndrome as having 3 or more of the criteria listed in Table 1.
354
Treatment Panel III [ATP III]) (NCEP III, 2001) has defined individuals with the metabolic
syndrome as having 3 or more of the criteria listed in Table 1.
Impact
The impact of the metabolic syndrome is clear. With the results of the West of Scotland
Coronary Prevention Study (WOSCOPS) by Sattar et al (Sattar et al, 2003). They found
that 26 percent of the men with elevated cholestrol had the metabolic syndrome. They
had 1.7 times the risk of a CHD event and 3.5 times the risk of developing diabetes
during 4.9 years of follow-up. This level of risk was similar to an increase in age of 10
years, or to the risk in smokers.
The risk increased as the number of metabolic abnormalities rose. Men with four or five
features of metabolic syndrome had 3.7 times the risk of coronary heart disease and 24.5
times the risk of diabetes compared to those with no abnormalities. Interestingly, the
cholesterol-lowering drug seemed equally beneficial for men with and without the
metabolic syndrome. It reduced the risk of CHD by 27 percent in those with metabolic
syndrome and 31 percent in those without it.
For most patients, the root causes of the metabolic syndrome are improper nutrition,
inadequate physical activity, and subsequent increases in body weight. The cornerstones
of treatment are weight loss and appropriate levels of physical activity.
Evaluation
The evaluation of patients who present with 2 or more indicators of metabolic syndrome
should include:
• Measurement of vital signs and body weight;
• Measurement of waist circumference;
• Measurement of fasting blood sugar; and
• A lipid profile (total cholesterol, HDL-C, TG, and a calculated LDL-cholesterol [LDL-C]).
Management strategy
The NCEP ATP III guidelines endorse Therapeutic Lifestyle Changes (TLCs) as an approach
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Weight Loss
Weight loss is a key therapeutic objective. All components of the metabolic syndrome are
positively affected by weight loss. Even modest weight reductions, in the range of 5% to
10% of initial body weight, are associated with significant clinical improvements in
hypertension, lipid abnormalities, and glycemic control.
A mean weight loss of 7% reduced the risk of developing type 2 diabetes by 58% (Franz,
2002). Intentional weight reduction of any amount in women 40-60 years of age who
had never smoked was associated with reduction in all-cause mortality by 20%, and
diabetes-associated mortality by 30% to 40%.
Dietary Change
Successful weight loss requires that more energy be expended than consumed on a daily
basis. All energy-restricted diets reduce weight and improve glycemic control and blood
pressure. The basis for optimizing cardiovascular health for individuals is an overall diet that
emphasizes vegetables, fruits, whole grains, fish, and low-fat dairy products, along with
regular physical activity. A recent study from the Harvard School of Public Health compared
health outcomes from the “Western” diet with those from the “Prudent” diet. Data
showed that men who consumed a typical “Western” diet were 60% more likely to
develop diabetes than those whose diets centered on vegetables, fruits, whole grains, fish,
and poultry (Van Dam et al, 2002). See Table 2 on “Western” diet and “Prudent” diet.
Exercise
The Surgeon General’s Report on Physical Activity and Health recommends that people of
all ages include a minimum of 30 minutes of physical activity of moderate intensity on
most if not all days of the week, eg, 30 minutes of brisk walking (>/=3 mph) plus
356
resistance training 3 times per week. Recent recommendations, however, have favored 60
minutes of physical activity daily. Before starting any physical fitness program, patients
with metabolic syndrome should be evaluated for readiness.
The TLC treatment model is shown in Table 3. It prescribes along diet and physical activity.
Table 3 shows the Therapeutic Lifestyle Change (TLC) model adapted for metabolic
syndrome. The TLC model includes 3 follow-up visits in the first 18 weeks, with continued
contact every 4-6 months thereafter. Risk factors measured at each visit include weight,
waist circumference, LDL, HDL-C, TG, BP, and glucose. Patients are encouraged to
increase physical activity and choose healthy foods. The nutrient composition of the TLC
diet (Table 4) mirrors the nutrient profile of the “Prudent” diet (Table 2).
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Footnotes. * = Intake of trans fatty acids, which raise LDL cholesterol, should be kept low; †=
Carbohydrates should be derived predominantly from foods rich in complex carbohydrates, especially
whole grains, fruits, and vegetables; ‡ = Daily energy expenditure should include at least moderate
physical activity (contributing approximately 200 kcal/day.).
Compared with traditional diets, meal replacements have been shown to be an effective
weight management tool both in the medical office practice and in traditional dietitian-
led group settings. It has been found that instructions on the labels of popular meal
replacement shakes and liquid diets make it easy for patients to use the products properly.
Meal replacements provide a simple way to initiate an easily structured and sensible
portion-controlled diet plan.
By substituting 2 meals a day with a shake or meal bar and eating a sensible third meal,
patients lose weight; replacing one meal a day with a shake or meal bar, they continue to
maintain their weight. Snacks (such as fruits, vegetables, or a meal bar) satisfy between-
meal hunger. In general, patients who drink plenty of water daily and exercise have
greater short- and long-term success. Structured meal plans help instil regular reating
patterns and promoted healthy modifications in the tins of food stored at home.
The longer patients remain in treatment and the higher their motivation, the more likely
healthcare practitioners are to uncover stumbling blocks and the greater the number of
opportunities to teach patients new sets of skills. Data indicate that the more contact
patients have with members of their treatment team, the longer they maintain their
weight losses. Physicians must anticipate relapse and the nature of motivational cycles.
Patients will wax and wane in their enthusiasm for the TLC program components. The
most important issues for the physicians are to maintain a supportive environment and to
keep the patient coming back. This can be done, for example, by the following:
358
• Increasing the number of patient visits;
• Reviewing food and activity logs;
• Monitoring exercise regimens; and
• Monitoring diet structure and use of portion-controlled foods and meal replacements.
If a long-term approach is taken, a successful outcome is more likely to result.
The primary care physician has a central role to play in helping patients with the metabolic
syndrome. His tasks are:
• To identify the metabolic syndrome and act as agents of change.
• To implement the goals of weight management which are (1) to ameliorate or reverse
the risk factors and comorbidities of the metabolic syndrome, (2) to promote long-
term changes in diet and physical activity based on structured meal replacements and
TLCs, and (3) to improve physical well-being and quality of life. The cornerstones of
treatment for the metabolic syndrome are dietary modification through the use of
structured meal replacements and increased physical activity via TLCs.
• To advise the patient on the dietary therapy to produce an energy deficit of 500-1000
kcal/d, leading to a weight loss of no more than 1-2 lb/wk. Use of food and activity
logs help patients create a structured diet plan based on the use of portion-controlled
foods and meal replacement products.
• To advise the paitient on the importance of exercise (aerobic and anaerobic) to
promote increased lean body mass, which leads to increased resting energy
expenditure and multiple cardiovascular benefits (eg, improved blood lipid profile,
decreased blood pressure and glucose, and improved sense of well-being).
• To help the patient in the long-term success of TLCs which depends on the frequency
and intensity of contact and support. Contact itself, whether delivered via brief
telephone calls, friends and relatives, or group therapy, appears to play a key role in
long-term weight loss maintenance.
.
References and further reading
Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA.
2001;285:2486-2497.
Wing RR, Jeffery RW. Food provision as a strategy to promote weight loss. Obes Res. 2001;9(suppl 4):271S-275S.
Sattar N, Gaw A, Scherbakova O et al. Metabolic syndrome with and without C-reactive protein as a predictor of
coronary heart disease and diabetes in the West of Scotland Coronary Prevention Study. Circulation. 2003 Jul
29;108(4):414-9.
Goldstein DJ. Beneficial health effects of a modest weight loss. Int J Obes. 1992;16:397-415.
Liese AD, Mayer-Davis EJ, Tyroler HA, et al. Development of the multiple metabolic syndrome in the ARIC cohort:
joint contribution of insulin, BMI, and WHR: atherosclerosis risk in communities. Ann Epidemiol. 1997;7:407-416.
Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment
and prevention of diabetes and related complications. Diabetes Care. 2002;25:148-198.
Bonow RO, Eckel RH. Diet, obesity, and cardiovascular Risk. N Engl J Med. 2003;348:2057-2058.
Van Dam RM, Rimm EB, Willett WC, Stampfer MJ, Hu FB. Dietary patterns and risk for type 2 diabetes mellitus in
U.S. men. Ann Intern Med. 2002;136:201-209.Perri MG, Nezu AM, Viegner BJ. Improving the Long-term
Management of Obesity: Theory Research and Clinical Guidelines. New York, NY: Wiley; 1992.
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360
CHAPTER 8
ENDOCRINE DISORDERS
NUTRITIONAL, METABOLIC AND
SECTION 08
APPLIED MEDICINE IN THE
VARIOUS AGE GROUPS
3 Men’s health
4 Health of the working adult
5 Elder’s health
6 Public health
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SECTION 08
SECTION 08 APPLIED MEDICINE IN THE VARIOUS AGE GROUPS
Outline
Approach to the child
Acute paediatrics
Developmental paediatrics
Behavioural paediatrics
Adolescent health
Good rapport with the parent and child sets the scene for easier history taking and co-
operative physical examination.
Observe carefully the parent-child interaction at all times, including in the waiting room.
The parent’s manner in talking to and handling the child can provide useful clues about
possible problems related to the parent’s ability to nurture the child adequately.
History taking
Obtaining information on
• Present history - the presenting problem (focus on this first) — allow the parents to
elaborate without interruption, be a listener and believe the story; state of health
prior to the present complaint
• Past history - general features, pregnancy and neonatal features, feeding and diet,
immunization, toilet training
• Developmental history - checklist of milestones. See Table 3.
• Family history - inherited disorders, other points of note
• Social history and psychological history -- behavioural problems, reaction to other
people and situations
• Systems review - general health, feeding and bowel habits, hearing, vision
Physical examination
• Note the growth and compare with standard developmental charts
• Note developmental milestones and note any developmental problems observed by
the parents or carer
• Note any dysmorphism (funny looking kid)
• Examine the child systematically
• Recognise serious illness in the infant - drowsiness, decreased activity, the child moves
eyes (rather than head) to follow you, weak cry, noisy breathing, cold extremities. Have
high index of suspicion for meningitis, intussuception, and septicaemia.
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ACUTE PAEDIATRICS
The infant
Vomiting In Infancy
Vomiting is common in infancy, and does not usually indicate severe illness unless there
are red flags requiring referral. See under Common Symptoms (Section 6)
Excessive Crying
A persistently or excessively crying infant can tax the nerves of the parents. See under
Common Symptoms (Section 6).
Nappy Rash
Prevention of napkin dermatitis:
• Make frequent nappy changes (5-6 times per day, i.e. when urine is voided);
• Have periods without nappies;
• Pay attention to general skin care — (a) Hygiene: at each change, wash the nappy area
with water and dry gently; (b) Local emollients e.g. aqueous cream -apply this at the
earliest sign of irritation; (c) Bath oil - use it if the skin is dry or easily irritated.
Management
Decide whether the nappy rash is ammoniacal dermatitis or is due to candida. In both
conditions, encourage the parents to allow the infant to be exposed for as long as
possible each day.
• Ammoniacal dermatitis -- Distinctive sign: redness does not extend into the creases.
Advise the parents to change the nappy even more frequently, e.g. every 2 hours if
wet; boil nappies vigorously to kill ammonia-producing bacteria; and use a barrier
cream, e.g. white soft paraffin or zinc ointment, at each nappy change.
Diagnostic Features
The features of pneumonia are fever (>38ºC), 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. It is important to 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.
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• Candida dermatitis -- Distinctive sign: redness extends deep into the creases, with
spotty satellite lesions. Prescribe a topical antifungal agent at each nappy change.
Resistant cases: check for oral candida and treat; consider an antifungal combined
with steroid.
Fever with localizing signs — Most are viral URTIs, but serious bacterial infections, for
example, bacterial meningitis, bacterial pneumonia, cellulitis, epiglottitis, osteomyelitis,
septic arthritis must not be overlooked in a sick child. Management depends on the cause
suspected. If a viral URTI is diagnosed, review the child over the next 1-2 days and
subsequently, if necessary, to monitor the progress to ensure the child is improving.
Intervene early if the child is not improving.
Fever without localizing signs — Often, at presentation, fever is present for less than one
week. A careful history and physical examination may fail to reveal a probable cause.
Watchful waiting and follow-up is the strategy. Over time, three subgroups of patients
can be recognised:
• Prodromal illness. Fever is a component of the prodromal illness before the
appearance or recognition of localizing or diagnostic signs, e.g., roseola infantum,
measles, dengue fever, or Kawasaki’s disease.
• Chronic illness. Fever is the initial manifestation of chronic illness e.g., systemic onset
juvenile chronic arthritis.
• “Occult” infection. Fever is due to ‘occult’ infection like pneumonia, urinary tract
infection and bacteremia. This is the problem that may be encountered in the child
under two. An awareness of this possibility and a high index of suspicion in the sick
child are the ways out of the pitfall. Some investigations will help here.
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Investigations for fever without localising signs
• In children between 3 months and 2 years, a full blood count, urinalysis with urine
culture, a chest X-ray will pick out the “occult infections” Blood cultures will be
needed if the fever rises above 104ºF. Occult bacteremia due to pneumococcus in
otherwise healthy children between 3 and 24 months may be transient, with serious
infection developing in a small percentage of patients. Bacteremia caused by H.
Influenzae type b and Nesseria meningitidis are less benign, and serious localising
infections such as meningitis, septic arthritis and pericarditis are possible sequelae.
• For infants younger than 3 months who are sick and all infants younger than 1 month
of age - they should be regarded at risk of bacteremia and admitted to hospital rather
than investigated. In the hospital, after blood culture, urine and CSF specimens are
obtained for culture, broad spectrum are given and monitored (Nelsen, 1998).
Fever of unknown origin — Fever is present for more than 14 days that does not suggest
an aetiology despite history, physical examination, and routine laboratory tests (Nelson,
1999). The majority of children with fever of unknown origin eventually will be found to
have some form of infection; however, a number of other conditions may present in this
way (Table 1). In up to 20% of children, no cause will be found after extensive
investigation, but the fever resolves eventually.
Management
Attention to red flags, watchful waiting and follow-up provides the best way to deal with
uncertainty. The situation should be explained to the carer and a close contact kept. The
alternative is to observe the patient in hospital. Meanwhile, symptomatic treatment with
paracetamol syrup, syrup promethazine, and advice on fluid intake will be all that is necessary.
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Second - Incubation 14-21 days. Only 2/3 have Mild disease,Keep away
German measles symptoms. Generalised maculopapular from school till recovers
Rubella virus rash, Not confluent - unlike measles; or at least 5 days after
prominent post-auricular, sub-occipital, rash begins
cervical lymphadenopathy; Infectious
for up to 10 days after onset of rash
Third - Incubation period: 10-21 (usually 15-16) Keep away from school
Chicken pox days. Prodrome: myalgia, fever, headaches until recovery, usually
Varicella zoster virus 2-3 days. Maculopapular rash with onset 7 days. Antihistamines,
of fever becoming vesicular in 24 hours - Antiviral within indicated
start with scalp and move down to face for family contacts
and trunk. 24 hours X 5 days Multiple
crops of lesions. Rash is pruritic
Fifth - Incubation period: 4-21 days. Fever, cervical Rare in this part of
Erythema lympadenopathy, and joint pains. Slapped the world
Infectiosum cheek facial rash with circumoral pallor
Parvovirus 19 and erythematous extremities with a
reticular pattern. Recrudesence in response
to sunlight, heat and exercise for some
time. During pregnancy can cause hydrops
fetalis and fetal death
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Table 2: Clinical features of exanthemas in children — Cont’d
NUMERICAL DISEASE PRODROME AND CLINICAL FEATURES MANAGEMENT
Dengue Petechie on legs. Also generalised Admit
haemorrhagic fever erythema - blanches on pressure
Kawasaki’s disease Chiefly seen in children under 3 years of Admit. Treatment with
(mucocutaneous age, most severe cases occurring below iv IgG and aspirin.
lymph node 1 year. Onset of fever of 5 or more Do not give
syndrome) days with the following features: corticosteroids as these
• bilateral conjunctivitis predispose to rupture of
• maculopapular polymorphous rash with coronary aneurysms.
or without cervical lymphadenopathy
• dryness, redness and cracking
of the lips
• erythema of the oral cavity
• erythema of palms and soles with
induration and oedema
• peeling of the skin of the finger and
to pulps some time during the illness
(a characteristic feature).
Major complication is vasculitis resulting
in coronary aneurysms in 17-31%
patients and case fatality of 0.5 - 2.8%
in the second week to second month
of illness.
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Convulsions
See under Emergencies — Section 5 Chapter 6
Enuresis
Enuresis may be defined as daytime wetting (diurnal enuresis) after age 4 years or night-
time wetting (nocturnal enuresis) after 6 years. These are primary enureses and appear to
be due to delayed maturation of achieving bladder continence. Secondary enuresis is
wetting after normal continence of at least 3 months.
Nocturnal enuresis
Nocturnal enuresis refers to the involuntary passage of urine during sleep in the absence
of any identified physical abnormality in children (or adults) at a time when control of
urine could reasonably be expected (usually the age of 5).
Aetiology.
Primary enuresis. There is no obvious cause and most of the children affected are normal
in every respect but seem to have a delay in development of bladder control. Others may
have a small bladder capacity or a sensitive bladder. It tends to be more common in boys
and has a genetic predisposition.
Investigations
After the age of 6, investigations including an intravenous urogram or ultrasound are
necessary to exclude urinary tract abnormalities.
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Management
If no cause is found, reassure the parents and child that there is no organic cause found,
and that it is a common problem that will eventually go away (spontaneous resolution
rate is 15% per year). There are some important ways of helping the child to adjust to
the problem.
• Do not scold or punish the child.
• Praise the child often, when appropriate.
• Do not stop the child drinking after the evening meal.
• Do not wake the child at night to visit the toilet.
• Use a night-light to help the child who wakes.
Enuresis clinics currently favour two trials of the alarm system and, if persistent,
desmopressin acetate nasal spray (Murtagh, 2003).
• The bed alarm. Essentially, wetting of the pants completes a circuit and the buzzer
outside the bed makes a loud noise. The child wakes, switches off the buzzer and visits
the toilet. This method works especially well in older children.
• Tricyclic antidepressants. The most widely used drug is imipramine in doses of 1-2.5
mg/kg as a single night-time dose (Jarman, 1996).
• Desmopressin acetate. This is the treatment of choice after failed trial of bed alarm.
The dose is one spray to the lower part of each nostril per night. Avoid water loading
before bed.
Urodynamic assessment. For the 1-2% of patients whose bed-wetting persists beyond
adolescence, a formal urodynamic assessment is advisable. Many of these patients also
have daytime symptoms.
Diurnal enuresis
• Urinary containment exercises: visit toilet upon urge but sit and hold urine stream for 1
minute. Then stop and start urine flow on three occasions before emptying bladder.
• Structural toilet program: the child sits on the toilet and urinates at scheduled intervals
during the day irrespective of urge. Start at 1 hour intervals, increasing to 2-3 hours as
control is obtained.
• Medication: useful short-term drugs include the anticholinergics -oxybutynin, imipramine.
Secondary enuresis
Secondary enuresis can develop at any age and should always be fully investigated. It is
often caused by urinary infection, especially in the, elderly, and may be associated with
some neurological disorders and chronic retention of urine associated with prostatic
enlargement. Treatment is directed at the cause, which may be a psychologically
traumatic event.
Reference
Murtagh J. Enuresis. In: General Practice, 3rd ed. Australia:McGrawHill, 2003:894895.
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History
Enquire if: (a) whether the child has ever been continent; (b) the frequency and nature
of the episodes; (c) the attitude of the parents and child.
Physical examination
Check for (a) the abdomen for faecal masses; (b) the anus for fissure; and (c) the rectum
for faecal masses.
If full rectum is found - The most common cause is a full, distended rectum with loss of
the urge to defecate. Liquid faeces seep around the obstruction, and the solid feces also
comes away piecemeal.
• Explain the problem to the parents and child. Normal rectal sensation will only return
once the rectum has been empty for a time.
• Empty the rectum using a stimulant laxative, e.g. senna as a syrup (2-6 years, 2.5-5ml;
7-12 years, 5-10ml, at night), increasing the dose by 5ml each week until a significant
result is achieved.
• At the same time prescribe a stool softener (e.g. lactulose 2-6 years 10ml at night, 7-
12 years 20ml at night) and increase as needed until a comfortably soft stool is passed.
Docusate is a useful alternative as combined stimulant and softener.
Reference
Khot A & Polmear A. Bladder and bowel problems. In: Practical General Practice. 4th ed. London:Elsevier, 2003:70-72.
DEVELOPMENTAL PAEDIATRICS
Developmental milestones
In a child under 5 years old, the developmental milestones should be checked at the first
visit to establish if development has been normal so far. See Table 3 for the
developmental milestones.
Specific delays in some areas, with normal development in others, raises the question of
isolated defects. For example, delayed speech in a child who is normal in other milestones
suggests a hearing loss. Delayed motor development with normal social relationships and
speech suggests a neuromuscular disorder.
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Interpretation and prediction
What is appropriate where milestones are either delayed or advanced is to say where the
child’s development is in relation to average children of that age and then help the
parents with techniques of responding appropriately to the child’s developmental age.
Unless the developmental examination is markedly abnormal, it is important to be
cautious in diagnosing abnormalities, as there is a wide variation in the attainment
of milestones.
Chin up (1 m) Coos (3 m)
Lifts head (4 m) Babbles (6 m)
Rolls-prone to supine (4 m) Da-Da-inappropriate (8 m)
Rolls-supine to prone (5 m) Da/Ma-appropriate (10 m)
Sits unsupported (8 m) First word (11 m)
Pulls to stand (9 m) Two to six words (15 m)
Cruises (10 m) Two-word phrases (21 m)
Walks alone (13 m) Speech all understandable (27 m)
Walks up stairs (20 m) Names one colour (30 m)
Kicks ball forward (24 m) Uses plurals (36 m)
Walks up stairs-alternate feet (30 m) Names four colours (42 m)
Rides tricycle (36 m) Gives first and last names (44 m)
Two-wheeler bike (36 m) Names two opposites (50 m)
Hops on one foot (60 m) Strings sentences together (60 m)
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The intellectually handicapped baby or infant will usually be behind in all areas of
development. Occasionally, sitting and walking may not be as far behind as other areas,
but the delay is usually global and would be most marked in general understanding and
language. If the developmental examination raises concerns it should be repeated later if
not initially performed under optimal conditions. Other appropriate investigations should
be performed and the child should be referred for another opinion.
Nutrition matters
Breast Feeding
Encourage the mother to breast feed the baby at least for a few months. It will bond the
mother and child. Inadequate milk supply is the most common reason put forward for
stopping breast feeding. Encourage the mother to have confidence in herself and her
abilities. All possible measures should be taken to ensure adequate lactation.
Vitamins A, D and C. These should be given to all breast-fed babies at least until the age
of 2 or until formula milks or follow-on milks have been added. They should not be given
to a child on formula or follow-on milks.
Maternal diet. The mother’s diet does not need supplementation with vitamins unless
inadequate. Very low calorie diets should be avoided.
Bottle Feeding
Formula milk should be given until the infant is at least 12 months old. Breast-fed babies
changing to bottle should take formula feeds until 12 months. Follow-on milks may be
recommended in certain situations, e.g. premature babies or where cows milk is
introduced as the main milk at 6 months. Follow-on milks are lower in protein than whole
milk and are fortified with iron and vitamins A, C and D.
Points to note
• Feed volume. The infant requires about 150ml/kg per day. This is given as 5-6 feeds a
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day, but ‘on demand’ feeding does not result in fatter babies. When a baby regularly
finishes the feed offered, this can be increased by 30ml per feed. Parents should
beware of misinterpreting hand sucking or crying as a request for a feed.
• Changing milks because the baby is ‘not satisfied’ or has ‘colic’ is of no value, and may
increase anxiety. If the baby is genuinely not satisfied, the feed volume should be
increased, or solids introduced if the baby is over 3 months old.
• Additional supplements (e.g. vitamins and fruit juices) are not necessary. Soya milks do
not protect the infant against atopy and should not be given for colic or unconfirmed
cows milk intolerance.
Weaning
Weaning is the process which begins when solids are added to the baby’s diet. It is a
gradual process over several weeks starting from about four months of age because that
is the time when milk alone may not provide enough nutrition for the baby.
Breast-feeding should be encouraged for 4-6 months, preferably longer. Earlier weaning
should be discouraged because there is an increased risk of food allergies in the very
young infants. Unless the baby does not want milk feeds entirely, starting on solids under
three months of age is discouraged. Initially, breast or formula milk still supplies the major
calories and nutrition, but as the amount of solid food increases, the volume of milk is
decreased and becomes less important as a source of nutrition.
Foods regarded as potentially allergenic should be avoided until 6 months of age, e.g.
cows milk, gluten, eggs, soya proteins, wheat and citrus fruits.
Iron. Iron deficiency not only causes anaemia, but can affect behaviour, development and
susceptibility to infection. Consider iron supplementation in children at risk of this deficiency:
• born prematurely; or
• of low birth weight; or
• who drink tea; or
• who have poor nutrition.
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Do FBC; and start on a 3-month course of iron 5mg/kg per day, as ferrous sulphate oral
paediatric solution.
Salt. Advise against adding salt to food cooked for a baby under 6 months. After 6
months the salt added should be kept to a minimum, with no added salt at the table.
Fibre. Advise against rigorously high-fibre diets, as they do not supply adequate nutrition
to a growing child and can cause diarrhoea.
From 9 to 17 months -
• Soft rice and thicker congee can be started after nine months when the child
starts teething.
• Vegetables can be added, but they should be soft and easy to chew.
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• Finger food items can be offered for the child to feed himself or herself - softer
biscuits, pieces of fruit, strips of cheese. Do not leave the child unattended while
finger-feeding in case he chokes on the food.
• Accept the child will make a mess of himself and the surroundings - that is part of
growing up.
From 18 to 24 months -
• A toddler may be able to feed himself with a baby spoon and folk.
• Prepare food in bite-sized pieces and help him along.
• He can eat with the rest of the family.
The child who won’t take lumpy foods - Encourage a combination of homogenized and
finger foods with the steady introduction of more solid foods.
When there is anxiety about a child’s growth, establish the height and weight of the child;
and the expected final adult height of the child.
Measurement of height
Correct measurement of height is essential.
• The child should not wear shoes and the heels should be against the wall with an
assistant or parent holding the feet down gently;
• With the child standing straight, the thighs and pelvis should be held gently to the wall;
• The jaw and external auditory meatus should be in a horizontal line;
• The child should be gently stretched upwards with traction under the angle of the jaw,
and the height measured.
Management
A quarter of children with a height at least 2.5 standard deviations (SD) below the mean
(which is close to the 0.4 centile) had organic disease in the Wessex growth study. Refer
the child for further assessment if he is less than 0.4 centile.
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Further reading
Voss LD et al. Poor growth in school entrance as an index of organic disease: the Wessex growth study. BMJ
1992;305:1400-2.
The child who presents with a painful limp and complains of pain in the knee should be
assumed to have a problem in the hip until proved otherwise. Depending on the age of
the child, the problem may be due to (Khot & Polmear, 2003):
• Congenital dislocation of the hip. This is painless and usually obvious once the child
begins to walk.
• Perthes’ avascular necrosis of the femoral head, which usually occurs between age 5
and 10.
• Slipping of the upper femoral epiphysis, which usually occurs between age 10 and 15.
• Acute septic arthritis and acute osteomyelitis, which can occur at any age and are
surgical emergencies.
• Transient synovitis of the hip (irritable hip) - this is the most common cause of limp due
to hip pain and is commonest between age 4 and 10. Ninety per cent resolve in 7
days, but it cannot reliably be distinguished in general practice from more serious
causes of hip pain, and all patients should be referred.
Refer to hospital urgently.
Scoliosis
This occurs more commonly in girls than in boys. Examine all children over the age of 10
years, when the opportunity arises. Examine from behind, as follows:
• Stand the child up with the feet together.
• Assess whether the hips are level (i.e. there is no compensation).
• Ask the child to touch his or her toes with the knees straight.
• Look for a ‘rib hump’. This will be most marked when the spine is flexed.
Refer to an orthopaedic surgeon if there is any suggestion of ‘rib hump’ or curvature.
BEHAVIOURAL PAEDIATRICS
In managing families who have a child with behavioural problems, the role of the family
physician is three-fold:
• Education and anticipatory guidance - explaining to parents their child’s behaviour in
its developmental context.
• Providing specific suggestions to facilitate problem solving - examples are: positive
reinforcement in the child; shared information with the child on possible solutions;
parental agreement on how to solve the child’s problem; avoiding paying attention to
negative behaviour; progressive desensitization of fears and phobias; and using the
adolescent to solve his or her problems e.g. giving him an alarm clock to be in school
on time and no bailing out by a drive if he gets up too late to take a walk or take the bus.
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• Referral - for families in need of more intensive family therapy or some practical
assistance to handle their child’s behaviour problems e.g. baby-sitting or day care services.
Two questions
In the workup on a behavioural problem, two questions need to be asked and answered.
Behavioural assessment
For any problem behaviour it is useful to identify A, B and C (Stevenson, 1987). They
stand for:
• Antecedents - what leads up to the behaviour
• Behaviour - a detailed account of the Frequency, Intensity, Duration and Severity of the
behaviour (FINDS)
• Consequences - what reinforcement the child is receiving from this behaviour.
Management
The behavioural approach works. This consists of attempting to alter the parent’s
behaviour so that the antecedents of a problem are made less frequent and trying to
change the consequences of the child’s behaviour so that reinforcement is removed.
Emphasis is also placed upon the parents carefully recording the behaviour itself so that
they can identify the effects of the changes made to antecedents and consequences.
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Temper Tantrums
The temper tantrum is the hallmark of toddlerhood or ‘the terrible twos’. These arise
when the child is thwarted, angry or has been hurt. They can occur in isolation or as part
of a wider problem. They comprise a variety of behaviours, including screaming, crying,
often resulting in collapse to the floor with the banging of the feet. The child can be
aggressive towards other people around him, but rarely injures himself. Most tantrums
‘burn themselves out’, so that specific intervention is not necessary.
Assessment
The assessment should, as usual, begin with a careful history. This serves several
purposes. Firstly, it allows the parent to ‘let off steam’ or ventilate. Secondly, it identifies
the frequency, severity and context of the tantrums. Thirdly, it can facilitate exploration of
other family stresses which may be important factors.
Management
The management of tantrums depends on the history. Reassurance can be given that the
occasional tantrum in a 2-4-year-old, while embarrassing for the parent, is commonplace
and not harmful. Diverting the child’s attention may help to abort a tantrum early in its
course.
The thing not to do is to reason with a toddler having a tantrum. In these circumstances,
the following points are useful:
• the parent is best advised to pretend to ignore the behaviour or to set a firm,
non-punitive limit.
• Minimise any additional attention to the child
• If necessary, restrain from behind by folding arms around the child’s body
• “Time out” and only respond and praise when behaviour has returned to normal.
School Refusal
Absence from school fall into three main groups: truanting; absence voluntarily withheld
by parents; and school refusers. The latter is the result for fear and it tends to occur in
three main age groups: 5-7, 11 (after changing to secondary school) and in adolescence.
Workup
Establish the source of fear. School refusal results from a fear of separation from one or
both parents or fear of school attendance. School-refusing children generally work well
at school, and are expressing an underlying neurotic disorder.
Management
• Exclude any underlying physical illness.
• Encourage the child to go back to school. This involves convincing the parents of the
importance of doing so. Even severe emotional problems can improve rapidly on re-
establishing attendance.
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References and further reading
Yves Talbot. Behaviour problems in children: A family approach to assessment and management. Can Fam
Physician Oct 1993; 29:1889-1895.
Stevenson J. The prevention of common behavioural problems in the preschool child. The Practitioner Dec
1987:231:1619-1626.
Khot A & Polmear A. School refusal. In:Practical General Practice, 4th ed. London:Elsevier, 2003:84.
ADOLESCENT HEALTH
Adolescence
Phases Of Adolescence
Three phases of development in adolescence is recognized: early (10-14 years), mid (14-
17 years) and late adolescence (17-20 years). Progression through each of these
developmental tasks is necessary if the adolescent is to establish a sense of identity and
become a healthy adult.
Early Adolescence
Predominant issues in early adolescence are the new bodily sensations of puberty and a
preoccupation with normality; the same sex peer group becomes all-important and the
desire for independence begins. In their effort to develop a separate identity from their
parents, they are often viewed as rebellious and difficult. The role of the primary care
physician is to recognize these changes and to reassure the parents that this is normal
separation behavior.
Middle Adolescence
The major conflicts in this phase relate to independence; the peer group sets behavior
standards as parents begin to exert less authority; there is enjoyment of new intellectual
powers and a rich fantasy life. Adolescents at this phase are concerned with their physical
appearance and believe that others are also concerned. Middle adolescents experience
sexual drives and aggression and must learn to control and be comfortable with their
sexuality. During this phase peer groups expand to include friends of the opposite sex.
Taking risks and experimenting with sex, drugs, alcohol, and cigarettes is common.
Late Adolescence
During this phase the emphasis is on functional role definition in terms of work, lifestyle
and relationship plans; a degree of freedom, realistic body image and a comfortable
gender role should have been established; relationships now tend to involve mutual
caring and responsibility.
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The adolescent often feels awkward in seeing a doctor. The following suggestions about
conducting an interview will make help the adolescent feel comfortable and establish a
relationship of trust:
• Be warm, sincere and non-judgmental, but be careful not to condone risky behaviour
• See the adolescent alone, at least for part of the visit, as this avoids appearing aligned
with parents and invites a more mature response.
• Assure confidentiality, but be mindful that disclosure of abuse must be reported and, if
the adolescent appears to be at significant risk, explain the need to involve parents
and/or authorities.
• Explore the young person’s agenda, listen carefully and provide non-verbal support,
for example, eye contact, head nods.
• Use an interactive rather than an interrogative style; progress from neutral to more
sensitive topics, using a third person approach for delicate subjects, for example, ‘Are
there drugs in your school? Are any of your friends involved? Do you use drugs?’
• Answer the young person’s questions simply and honestly.
• For the problematic adolescent including the obsessive compulsive, two questions that
are useful are: Do you have silly thoughts? Do you do silly things?
• Family involvement can result in additional information about and support for
adolescents and can increase adolescents’ health care compliance.
Puberty staging
Puberty is staged using the Tanner Staging System of pubertal development. This system
is based on breast, genital and pubic hair changes, with Stage 1 being prepubertal and
Stage 5 being the adult development stage (Tables 5 and 6). As well as indicating
biological stage of development, Tanner staging correlates with special events and is thus
useful in clinical assessment of normal and abnormal puberty.
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• In girls, peak height velocity (PHV) occurs early (Tanner Stage 2 or 3) while menarche is
a late event (Tanner Stage 4) and usually occurs about 2-3 years after the initial signs
of breast development.
• In boys, peak height velocity is achieved later than in girls (Tanner stage 4), while the
first ejaculation (semenarche) normally occurs around mid-puberty (Tanner Stage 3).
4 The pubic hair continues to curl and becomes The areola and papilla separate from
coarse in texture. The number of hairs the contour of the breast to form a
continues to increase. secondary mound.
Early puberty
Pubertal development before the age of 8 years in girls and 9 years in boys is unusual and
may have a pathological cause. Premature thelarche and adrenarche may also occur
in children.
Premature thelerche
This is the early onset of breast development in the absence of other clinical signs of
puberty. It is most common in girls of less than 4 years of age. Height velocity is not
increased, pubic hair is not present and skeletal maturation is not advanced. It probably
follows a transient increased secretion of oestradiol from an ovarian follicle. The child
should be reviewed at 3 and 6 months to confirm the lack of progress of the clinical signs
of puberty and normal height velocity. A left hand and wrist x-ray for bone age will
confirm the normal skeletal maturation. If there is serious concern that the child might
have precocious puberty. then a GnRH stimulation test will confirm the pre pubertal
gonadotrophin levels in premature thelarche. Thelarche tends to wax and wane and
usually disappears after 12 to 24 months.
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4 Resembles adult type in The penis grows in The testes and scrotum
being coarse and curly but width, and the glans continue to grow; the
less in quantity; adult type penis develops. scrotal skin darkens.
of distribution is attained.
5 Mature- adult distribution; Adult size and shape Mature-The testes and
spread to medial surface scrotum are adult size.
of thighs.
Premature adrenarche
This is the early appearance of pubic hair without other signs of sexual maturation. It is
associated with a moderate increase in height velocity and body weight. Skeletal
maturation may advance slightly. It is most common is children aged between 6 and 8
years. It is a result of an early increase is androgen secretion, the reason for which is
unknown. The differential diagnosis is adrenal hyperplasia or tumour. Which will cause
virilization in girls (enlargement of the clitoris) and significant sexual maturation in boys,
although the testes will remain small as they have not been stimulated by
gonadotrophins. There will also be a marked increase in height, weight and bone age.
Precocious puberty
This is more common in girls and generally no cause is found for their early pubertal
development. In contrast, 80% of the boys will be found to have a hypothalamic tumour
that has triggered their pubertal development.
In boys testicular enlargement is the clinical hallmark of precocious puberty, but in girls
the ovaries cannot be so easily felt and when there is any doubt as to the diagnosis
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(though a GnRH stimulation test should be diagnostic), abdominal ultrasound to exclude
an ovarian tumour is essentia.
Outcome
Malignant tumours have a poor prognosis. In most children, however, no cause is found,
and as long as family awes are allayed and social pressures on the child prevented, the
only long-term effect is relative short stature. In practice, a wide range of final heights
is achieved.
Sexual precocity
The commonest cause in boys is congenital adrenal hyperplasia (in girls this will cause
virilization and not sexual precocity), and in girls ovarian tumours or cysts. Other causes
are rare.
Delayed Puberty
Ninety-five percent of girls and boys have entered puberty by 13 and 14 years of age,
respectively. Delayed puberty is rare in girls but common in boys. Therefore investigation
is warranted is a girl at the age of 13 years, but can be safely left in a boy until he is 16
years or more, other things being normal.
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In boys the commonest cause is constitutional delay (also called physiological delay),
whilst in girls it is probably Turner’s syndrome. Other conditions are relatively rare.
History
Biochemical investigation is generally less helpful than the history and examination.
Constitutional delay in pubertal development is probably genetically determined and the
parents may be aware of a family history of this. It is important to know whether the child
is able to smell normally, since hyposmia or anosmia can be associated with
hypogonadotrophic hypogonadism (Kallmann’s syndrome). Short stature is a significant
feature in Turner’s syndrome. An abnormal facies may signify that the child has one of the
fairly rare dysmorphic conditions that are associated with decayed puberty (for example,
Noonan’s syndrome, Prader-Willi syndrome).
Physical examination
Careful examination of the boy’s genitals gives useful information. In conditions with low
levels of gonadotrophin, the genitalia are often significantly underdeveloped, with a flat
scrotum and a small penis and testicles. When the pubertal delay is purely physiological,
however, the scrotum is well formed and the testicles are the normal prepubertal size. In
primary testicular problems the testes are after abnormally formed and small. Pubic hair
may be full in spite of abnormalities of the hypothalamic-pituitary-gonadal axis, for it is a
reflection of adrenal androgen secretion.
Chronic ill health will cause delay in puberty, and the child will usually have obvious signs
and symptoms, e.g., that of severe asthma and renal failure. Signs of malabsorption may
be more subtle.
Investigations
If the girl is more than 14 years, and the diagnosis is uncertain, then the chromosomes
must be determined. As many girls with Tuner’s syndrome are chromosomal mosaics, the
classical, clinical signs of the syndrome (apart from short stature) may be absent. Follicle-
stimulating hormone is a sensitive indicator of gonadal damage and if raised is diagnostic
of primary gonadal failure. Prolactin, if very high, suggests a prolactinoma, a rare but
distinct cause of hypogonadism.
In a boy, an x-ray of the left hand and wrist to assess the skeletal maturation and predict
the final height is probably the only investigation required. It may be of help to the family
to know that the child’s eventual height will be satisfactory.
Management
Boys are more likely to have delayed puberty than girls. Most difficulty arises in
distinguishing those with partial hypogonadotrophic hypogonadism from those with a
simple physiological delay in puberty. In many the clinical picture of the genitalia is
diagnostic. In others a wait-and-see policy may be advisable and in practice most prove to
be normal boys.
At times there may be a great deal of pressure from the boy or his parents for some form
of treatment. As long as the boy is of adequate stature, one can hold back therapy. If the
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boy is of short stature, it is important to explain to him that treatment may increase his
bone age in excess of his height velocity and thus dwarf his final height.
In these boys with probable constitutional delay in puberty, a 3-month course of monthly
intramuscular testosterone oemathate (Primoteston) 125mg followed by 3 months with no
therapy may help. Examination of the testes will reveal whether puberty has begun. Usually,
only one 3-month course is necessary, for the purpose of the therapy is simply to promote
as increase in height velocity and sexual maturation sufficient to enhance the boy’s morale.
This is generally the case, and the boy and his family are usually delighted at the results. As
skeletal maturation and height velocity must be carefully monitored in these children, they
should be referred to a paediatrician if such therapy is seriously considered.
In girls with delayed puberty small doses of oestrogen induce breast budding and
gradually over 2 to 3 years the dose is increased. At an appropriate time a progesterone
such as norethisterone (Primolut N) 5mg daily for the first 5 days of each calendar month
will initiate regular periods.
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depression; sexual activity; and substance use [HEADSS]; any recent weight change;
exercise; medications; past medical history (especially chronic illnesses); review of
systems; and a family history, as well as an exact determination of the timing and
sequence of thelarche and adrenarche.
Further evaluation and management. Further evaluation and testing is based on the
history and physical examination. Patients with a history of normal puberty and a normal
physical examination should have a pregnancy test. If the pregnancy test is negative, do a
progesterone challenge (10mg twice a day for 5 days): A withdrawal vaginal bleeding
within 2 weeks is a positive test and indicates that the hypothalamic-pituitary-ovarian axis
and uterine function are normal. The parents can be assured that menarche will
eventually arrive.
386
ovarian failure. Patients who have not had thelarche and who have a low FSH have
some form of hypothalamic-pituitary dysfunction. Further laboratory testing should be
determined by the history and the physical examination of the patient. Initial tests may
include thyroid function tests and TSH (hypothyroidism), prolactin (pituitary adenoma),
and computed tomography or magnetic resonance imaging (pituitary or hypothalamic lesion).
Outline
Family planning
Common gynaecological symptoms
Cervical cancer screening
FAMILY PLANNING
The standard type available is the Multi-load copper 250 suitable for uterine length
sounded between 6 to 9cm. IUCDs to fit shorter length uteri are not available routinely in
clinics. Women with uterine cavities sounded larger or smaller than average may need
further investigation before IUCD insertion. Other types of IUCD commonly available
include the Copper T, the Nova T and the Lippes loop.
Contraindications of IUCD
Absolute
• Active pelvic infection (acute or subacute), including known or suspected gonorrhoea
or chlamydia
• Known or suspected pregnancy
• Undiagnosed genital bleeding
• Genital malignancy.
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Relative
• Multiple sex partners or strong likelihood that the woman will have multiple partners
during the time that IUCD is in place
• Multiple sex partners by partner of IUCD user
• Difficult to obtain emergency treatment should complications occur
• Recent or recurrent pelvic infection, postpartum endometritis, or septic abortion
within the past 3 months
• Acute or purulent cervicitis - treat first
• Menstrual bleeding disorders not yet definitely diagnosed
• History of ectopic pregnancy or conditions that predispose a woman to it
• Single episode of pelvic infection if patient desires subsequent pregnancy
• Impaired response to infection (AIDS, diabetes, corticosteroid treatment, etc)
• Blood coagulation disorders
Other contraindications
• Endometriosis
• Leiomyomata
• Endometrial polyps
• Congenital uterine abnormalities or fibroids that prevent proper placement
• Anaemia
Removal of IUCD
Removal is easier at the time of menstruation.
• Prepare the vulva, insert the speculum and cleanse the cervix. To facilitate removal, a
tenaculum should always be used to straighten the uterine axis, thereby also
minimising the risk of side arm breakages.
• Use forceps to grasp both threads of the IUCD as near to the exit from the external as
possible.
• Use steady downward traction with the tenaculum to straighten the uterine axis, the
IUCD should be able to be easily withdrawn from the uterus. No excessive force must
be used.
• If the device cannot be withdrawn by normal force or if a fragment has remained
behind, diagnostic steps should be taken to exclude perforation or embedding.
Complications
Immediate complications at insertion
• Vasovagal reaction (syncope, cervicalshock) with, very rarely, a generalised
epileptiform attack or cardiac arrest. Treatment: 1/V atropine sulphate 0.6 to 1.2 mg
diluted in sterile water; check pulse and BP
• Perforation. This usually occurs or begins at insertion. It may be accompanied by
sudden pain and/or bleeding or it may be symptomless.
Later complications
• Pelvic infection. This occurs usually within the first 4 months after insertion. When
pelvic inflammatory disease is present, remove the IUCD and treat it aggressively
(Metronidazole 200mg tds and Amoxycillin 500mg tds for 14 days).
• Increased menstrual bleeding. It is normal that periods become slightly longer and
heavier than previously.
• Dysmenorrhoea. Menstrual pain is usually increased for the first few cycles only, but
may be persistently severe in nulliparous women.
• Intermenstrual spotting. This may occur with all IUCD devices. Pain and bleeding may
occur following removal.
• Pregnancy. Pregnancy rate varies from 1-5%. When diagnosed, the IUCD should be
removed. There is 20% risk of aborting the pregnancy by removal but if left in place
there is 50% risk of spontaneous abortion, usually in the first trimester. There is an
increased risk of infection.
• Expulsion. Checking for IUCD strings should be done by the patient. If missing, the
patient should have an ultrasound done to see if it has been expelled.
• Ectopic pregnancy. Unlike other contraceptive methods, the IUCD does not protect
against ectopic pregnancy. When evaluating pelvic pain in an IUCD user, it is essential
to rule out the possibility of ectopic pregnancy.
• Tubal infertility
There is a higher risk especially with nulliparous women who use an IUCD.
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Injectables
There are two preparations
a) Depo-provera - contains medroxyprogesterone acetate 50mg/ml x 3ml
b) Implanon - 3-year system containing etonorgestrol.
Selection of patients
Patients should be
• below 45 years old and have at least 2 children.
• informed that Depo-Provera may upset their menstrual cycle, and may cause spotting,
intermenstrual bleeding and amenorrhoea. If patients are not prepared to accept
these side effects, they should be dissuaded from using this method.
• protected by another contraceptive method during the first month, e.g. condoms
and spermicide.
Work-Up
Medical History
A careful medical history is taken to exclude :
• malignancy of breast or genital organs
• abnormal vaginal bleeding of unknown cause
• thrombo-embolic disease
• liver disease or dysfunction
• suspected pregnancy
Reference
Goh LG & Thein MM. Family Planning. In: Handbook for Primary Care Doctors. MOH:Singapore, 1996:272-290
390
Oral Contraceptives
Choice Of Preparation
All patients should be adequately screened (see checklist) for possible contraindications and
counselled for possible side effects before starting on COC. There are four different regimens:
• Monophasic formulations where each active tablet contains a constant dose of
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The choice depends primarily on the progestogen component, although the dose of
oestrogen and cost should also be considered. Table I shows COCs listed according to
progestogen component. All have 21 tablets per cycle to be given with a 7-day break
between cycles. Each may be given on a Tricycle regimen - take 3 packets continuously
followed by one week break, thus reducing the breaks to 4 per year.
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Table 2. Progestogens Used In The Oral Contraceptive Pill
(EQUIVALENT DOSES IN MG WHICH SUPPRESS OVULATION)
Progestogen Dose (mg)
Norethisterone 5.0
Levonorgestrel 0.5
Ethynodiol 2.0
Desogestrel 0.6
Gestodene 0.4
OCs containing desogstrel and gestodene are called third generation OCs and those
containing levonorgestrel are second generation OCs.
• Desogestrel-containing COCs (Marvelon, Mercilon) are useful for women with acne or
hirsutism, because of their anti-androgenic properties.
• Gestodene-containing COCs (Gynera, Minulet) are useful for women who have
experienced breakthrough bleeding on other preparations, since cycle control is
particularly good.
• Norethisterone and levonergestrel-containing COCs - Pills containing low-dose
norethiseterone (Brevinor) or levonorgestrel (Ovranette, Microgynon 30, Nordette)
have been in use for many years and are cheaper than the newer COCs. However, they
do not control the cycle as well as preparations containing the newer progestogens. A
triphasic preparation (Trinordiol, Triquilar, Trinovum) remains useful for controlling
bleeding where monophasic preparations have failed.
Although triphasic formulations have the lowest total dose of progestogen per cycle, they
are not necessarily the best choice for all women. Some women develop dysmenorrhoea
for the first time when taking a triphasic formulation because there is more endometrial
proliferation than with monophasic formulations.
Drug interactions may also result in breakthrough bleeding. The well documented
common drug interactions are: All anticonvulsants except sodium valproate and
clonazepam; Griseofulvin; Rifampicin; Barbiturates; and Spironolactone. Antibiotics have
also been implicated in lowering blood concentrations of contraceptive steroids due to
effects on gut bacteria.
Other possible adverse effects include nausea, decreased libido, weight gain due to
increased appetite, depression, acne and headache. However, careful history-taking and
elicitation of other factors is important to ensure that such events are not incorrectly
ascribed to the OC pill.
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Starting COCs
Table 3 shows the time to start COC and the extra precautions.
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Table 3. Starting Combined Oral Contraceptives - Cont’d
SITUATION START EXTRA PRECAUTION*
Follow Up Schedule
• Blood Pressure : 3 months, 6 months, yearly
• Weight : 3 months, 6 months, yearly
• New Risk Factors : review at age 30, 35, 40, 45 and yearly thereafter.
• Pap smear
• Breast examination
Source: Ann McPherson. Women’s Problems in General Practice 2nd ed. 1988:144
Starting POP
The starting routines for POP is shown in Table 5. Note that POP are taken continuously
without a break, unlike COCs.
Table 5. Starting routines for POP
SITUATION START EXTRA PRECAUTION
Menstruating 1st day of menses No
Post partum
- No lactation Any time before 4th week No
- Lactation Usually 7-42 days after delivery No
Post abortion/ Same day No
miscarriage
Change from Instant switch No
COC to POP
Postcoital Contraception
Postcoital contraception may be necessary in condom bursts or any other situation where
pregnancy risk has occurred and the pregnancy is not desired. There are three methods
for post-coital contraception
• Copper-T IUD as Emergency Contraception
• High dose combined OC pills
• High dose progestin-only pill.
The copper-T intrauterine device (IUD) can be inserted up to five days after unprotected
intercourse to prevent pregnancy. Insertion of a copper-T IUD is much more effective than
use of combined emergency contraceptive pills or progestin-only pills, reducing the risk of
pregnancy following unprotected intercourse by more than 99%.
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Combined emergency contraceptive pills contain the hormones estrogen and progestin.
Combined Emergency Contraceptive pills reduces the risk of pregnancy by about 75%
(from 8 per 100 women to 2 per 100 women). Therapy is more effective the earlier it is
initiated within the 72 hour window. The treatment schedule is one dose of
ethinylestradiol of 100-120ug (e.g., 4 tablets of Nordette) within 72 hours after
unprotected intercourse, and a second dose of 100-120ug, 12 hours after the first dose.
Dysmenorrhea
Primary Dysmenorrhea
Assessment
• History clinches the diagnosis - Typically, pain occurs with onset of menstruation and
then declines.
• Examination - This is required to exclude surprises from other pathology.
• Investigations - If the history is typical and no surprises are found on examination, then
no further investigation is needed.
Treatment
• Non-steroidal anti-inflammatory agents are prostaglandin synthetase inhibitors and
will decrease pain and reduce menstrual loss.
• Oral contraceptive pill will inhibit ovulation. Primary dysmenorrhoea is usually
associated with ovulation, thus the pill by preventing ovulation, will relieve primary
dysmenorrhoea.
• If treatment fails to improve symptoms then a laparoscopy is needed to exclude a pathology.
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Secondary Dysmenorrhoea
Causes
• Endometriosis
• Adenomyosis/fibroid
• Pelvic inflammatory disease
• Psychological problems.
Assessment
• History is important. It may take time to obtain if psychosexual problems are present.
• Pelvic examination must be performed, and swabs taken if indicated. Restricted
mobility or fixed retroversion of the uterus suggests the presence of adhesions
secondary to endometriosis, pelvic inflammatory disease, or previous surgery.
• Investigations required will be guided by history, but laparoscopy is indicated in most cases.
Treatment
This depends on the cause.
Menstrual irregularities
Clinical features
Important points to take note of:
• Age group
• Drug/contraception history
• Pattern
Age Groups
• Reproductive 20-40 years - benign causes usual but look out for serious cause
• Perimenopausal - likelihood of serious cause -- refer for D&C
• Paediatric- always abnormal - refer for proper assessment, KIV EUA
Drug/Contraception History
• non-compliance with OC pill common cause of abnormal bleeding
• old, infected IUCD easily forgotten cause of bleeding
Definition
Excessive menstrual bleeding that occurs with regular or irregular cycles. Median
menstrual blood loss is 30-40 ml in total per period; > 80 mI = pathological but this is
difficult to assess objectively.
Clinical features
Menstrual bleeding can be ovulatory or anovulatory. In general, regular, painful periods
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are associated with ovulation, and irregular, painless periods with anovulation. The latter
is more common in the extremes of menstrual life. In anovulatory cycles, oestrogen and
progesterone levels are variable, causing irregular shedding of the endometrium.
Causes
The causes for menorrhagia are:
• Physiological, i.e. normal loss but interpreted as excessive. This commonly occurs in
women who stop the oral contraceptive pill. Having been used to painless, light
periods while taking the pill, they then revert to normal periods which are more
painful, and heavier.
• Dysfunctional uterine bleeding (hormonal). This is a diagnosis which is made after
pelvic pathology has been excluded.
• Traumatic, e.g. IUD.
• Infective, e.g. chronic pelvic inflammatory disease.
• Neoplastic, e.g. fibroids, endometrial polyps.
• Metabolic, e.g. thyroid dysfunction.
• Psychological factors.
• Adenomyosis.
• Blood dyscrasias.
• Iatrogenic, e.g. drug ingestion as seen in women on long-term anticoagulation.
Acyclical, heavy. Causes: classical history of metropathia haemorrhagica — usually long history
dating back to teens or when weight increased; associated with obesity, hirsutism, infertility.
Completely Irregular and heavy (Metorrhagia). History is usually shorter than anovulatory
bleeding usually dates back only a few months. Causes:
• Abnormal pregnancy states eg. threatened abortion blighted ovum missed abortion,
incomplete abortion, ectopic pregnancy, molar pregnancy, septic abortion — ask for
LNMP; ask for pain fainting spells. Do pregnancy test; check relevant findings on VE;
do Ultrasound.
• Neoplasia. Benign polyps either cervical or endometrial or fibroid; Malignant - cervix or
corpus. Uterus irregularly enlarged in fibroid.
• Adenomyosis often presents with menorrhagia, dysmenorrhoea and a uniformly
enlarged uterus of about eight to ten weeks size. As the condition responds poorly to
medical therapy, a hysterectomy is often recommended. Adenomyomectomy or
wedge excision of adenomatous tissue may be considered if there is a strong need or
desire to conserve the uterus.
• Infection
Work-up
History. History is essential to distinguish menstrual bleeding from non-menstrual bleeding.
Examination. This should include measurement of weight, a search for signs of endocrine
disturbance, and a pelvic examination, including a cervical smear if indicated.
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Treatment
Any pathology that is found should be appropriately treated. One is then left with the
treatment of dysfunctional uterine bleeding.
Anovulatory bleeding
In adolescents and premenopausal women the oral contraceptive pill can be prescribed,
making the periods lighter, regular, and less painful. Cyclical progestogens (e.g.
medroxyprogesterone acetate 10mg daily for 10 days) can be used to induce regular
withdrawal bleeds.
Likewise, in perimenopausal women, once the endometrium has been sampled, cyclical
progestogens can also be used to induce regular withdrawal bleeding. If no withdrawal
bleeding occurs, then there has been no oestrogenic stimulation of the endometrium
which indicates no ovarian function, and the ‘menopause’ has occurred. If the woman is
experiencing climacteric symptoms with menorrhagia, then it is appropriate to put her on
hormone replacement therapy, remembering that she needs progestogens for at least 12
days of each calendar month.
Acute arrest of heavy bleeding. Start with a high dose of a progestogen and decrease,
e.g. norethisterone 30mg b.d. for 3 days, 20mg b.d. for 3 days, 10mg b.d. for 3 days,
5mg b.d. for 10 days. Cessation of treatment will be followed by a withdrawal bleed.
Ovulatory bleeding
• Non-steroidal anti-inflammatory drugs. These inhibit biosynthesis of the
prostaglandins, and reduce menstrual flow by about 30% in most women with
menstrual blood loss greater than 80 ml/day. The advantage of this treatment is that it
is only taken for a few days of each cycle, i.e. during menstruation.
• Oral contraceptive pill. The absolute contraindications must be ruled out, and the
relative contraindications considered. Ovulation is suppressed, and the oestrogen
levels remain constant. This inhibits endometrial growth reducing menstrual loss.
Irregular Bleeding
• Irregular bleeding can result from pregnancy complications such as threatened
abortion, missed abortion, incomplete abortion or ectopic pregnancy. Pregnancy
should always be excluded by performing a urine or serum HCG.
• Thyrotoxicosis can also result In Irregular menstruation. Signs of thyrotoxicosis and of
hyperandrogenism (e.g. acne, hirsutism and acanthosis nigricans) should be looked for
during examination. If some of these signs are present, polycystic ovarian syndrome
(POS) should be excluded. The LH/FSH ratio will be reversed by more than two or three
400
and serum testosterone may be elevated In POS. Ultrasound scan features of POS
include an Increased ovarian volume, presence of a thickened ovarian capsule,
subcapsular cysts and a dense stroma.
• The cervix should be visualised in a sexually active woman. If any pelvic pathology is
suggested in the examination e.g., carcinoma of cervix, it should be dealt with
appropriately. An ultrasound scan can sometimes reveal hidden pathology such as
submucous fibroid.
Physiological Causes
• Normal physiological discharge or leucorrhoea is usually mucoid or white due to a
mixture of cells. The quality and quantity of the discharge may vary considerably
throughout the menstrual cycle. It is maximal during mid-cycle at the time of
ovulation, premenstrually, when using an Intrauterine contraceptive device or during
sexual excitement.
• During coitus, there is an increase in cervical and vaginal discharge and semen.
• During pregnancy, under the Influence of oestrogens, the mucus-secreting columnar
epithelium everts into the ectocervix and secretes mucoid fluid, resulting in an increase
in vaginal discharge.
• In the female neonate, a self-limiting vaginal discharge may occur due to the Influence
of maternal oestrogens in utero.
Pathological Causes
Although there may be an overlap, in general the commoner causes in the premenarchal
years, reproductive years and in peri-postmenopausal women are different:
• Premenarchal years - Poor hygiene; Foreign bodies, either organic or Inorganic;
Threadworms; Sexual abuse.
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Work-Up
In the patient’s history, look for occurrences in relation to menstruation, mid-cycle
ovulation and sexual excitement when the cause is likely to be physiological. Pathological
vaginal discharge is often associated with blood, pruritus, foul odour, vulvitis, ulcers
and soreness.
History.
• Features of the discharge - Nature - mucoid, serous, purulent, bloody; Colour - clear,
white, yellow, yellow-green, bloodstained; Consistency - watery , viscid, curd like;
Duration - continuous, intermittent; Amount - does it require added protection, e.g.
pads?
• Associated symptoms - irritation, itching, burning
• Frequency of attacks
• Relationship to menstrual cycle, sexual intercourse, pregnancy
• Hygiene practices - douching, use of tampons
• Risk factors and likelihood of sexually transmitted diseases
• Associated urinary tract infection
• Associated medical conditions, e.g. diabetes mellitus
• History of allergy to rubber/spermicides
• Drug history, especially antibiotics
• Last cervical smear
402
• Gram stain of vaginal discharge
• Specimen for culture - discharge from posterior fornix and endocervical swabs
• Colposcopy (if indicated)
Treatment of Infections:
• Candidiasis - clotrimazole 500mg X1 stat dose; or isoconazole 300mg X2 stat dose;
Nystatin 100000 units vaginal tablet X 7days.
• Trichomonas - oral metronidazole 2g as a stat dose (preferable) or 400mg bd for 7
days (if relapse); or tinidazole 2g as a stat dose
• Bacterial vaginosis - metronidazole 400mg orally for 5 days
Screening for cervical cancer by regular Pap tests should be performed in all women who
are or have been sexually active, and should be instituted after a woman first engages in
sexual intercourse. If the sexual history is unknown or considered unreliable, screening
should begin at age 18.
At least two initial screening tests should be performed one year apart. For women who
have had at least two normal annual smears, the screening interval may then be
lengthened at the discretion of the patient and physician after considering the presence
of risk factors, but should not exceed three years.
Screening may be discontinued at age 65 if the following criteria are met: the woman has
been regularly screened, has had two satisfactory smears, and has had no abnormal
smears within the previous nine years. For all women over age 65 who have not been
previously screened, three normal annual smears should be documented prior to
discontinuation of screening.
Clinicians should use proper techniques in collecting specimens, should submit them to
qualified cytopathologic laboratories for analysis, and should provide appropriate follow
up on test results.
The Pap smear should sample cells from the transformation zone, and specially designed
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spatulas are available. One of the most commonly used is the Ayre’s spatula, which is
shaped such that cells from the transformation zone can be obtained even if the zone is
slightly recessed. It should be air dried and fixed immediately in 95% alcohol, and read by
a pathologist specializing in cytology.
Management
An Inflammatory smear should be treated first and the Pap smear repeated 3-4 weeks
later. Inflammatory cells are quite common in menopausal women if they have a
significant degree of atrophic vaginitis. They can be treated with a topical oestrogen
preparation for three weeks, and the smear should be repeated after that. An infective
vaginitis, whether bacterial, fungal or otherwise, should also be treated appropriately
before the smear is repeated. Very exceptionally, cervical cancer can present with just an
inflammatory smear, without other changes suggestive of an invasive lesion.
All smears showing dysplasia, persistent Inflammatory changes, atypical cells and
obviously those suggestive of an invasive cancer should be investigated further. The
patient should be referred for colposcopy, which is essentially a microscopic examination
of the cervix.
Outline
Focus on men’s health
Approach to urinary symptoms in men
Disorders of the prostate
Erectile dysfunction
Endocrinology of the ageing male
Scrotal pain; disorders of the penis; haematospermia
Concerns over men’s health covers three broad areas: physical disorders; lifestyle issues as
a means to reduce the physical disorders; and genito-urinary disorders. Men have higher
incidence of physical disorders such as cardiovascular disease, accidental death, suicide,
obesity, alchoholism, HIV and hypertension compared to women.
Physical disorders
404
• Cardiovascular issues (hypertension, raised cholesterol levels)
• Cancer (especially prostate and bowel cancer)
• Injuries sustained in sport, work, traffic accidents and the home
Lifestyle issues
The primary care doctor can play a part to help in dealing with lifestyle issues, physical
disorders and positively reduce morbidity and mortality. This can be achieved through
public health education strategies; encouraging men patients to adopt healthy lifestyles
and coping strategies; and opportunistic intervention to reduce risk factors like smoking,
lack of exercise, hypertension, obesity and diabetes mellitus. The details are covered
elsewhere in this Primer.
Symptoms
Obstructive symptoms
• slow / weak stream - decrease force
• hesitancy in voiding - prolonged interval necessary to initiate voiding
• straining - need to increase intra abdominal pressure to initiate voiding
• decreased calibre - narrowing of stream
• split stream - bifurcation or splaying of stream, implies possible urethral stricture
• terminal dribbling - prolonged dribbling of urine after completion of micturition
• sense of residual urine - sensation of incomplete emptying of bladder
• intermittency - interrupted stream
Causes: benign prostatic hyperplasia (BPH), urethral stricture, cancer of prostate, acute
prostatitis, bladder neck contracture, meatal stenosis, detrusor sphincter dyssynergia,
stone, and foreign body.
Irritative symptoms
• Frequency - There is a need to urinate more often than usual. Causes: Polydipsia (due
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to high fluid intake); Polyuria (due to uncontrolled diabetes mellitus (DM), diabetes
insipidus, diuretic therapy); Small bladder capacity (due to past infection, tumour,
stone, bladder outlet obstruction (BOO), neurogenic bladder, foreign body). Frequency
is recorded as the number of many hours between voiding.
• Nocturia - There is a need to wake up at night to urinate. The causes are the as in
frequency. Waking up 1 - 2 times per night is inconsequential if patients drink a few
cups of coffee before bed.
• Urgency - There is a sensation to urinate immediately if an accident is to be avoided.
Often accompanies infection, BOO or neurogenic bladder
• Dysuria - There is a burning or painful sensation on urination, felt in the urethra. Eg in
urinary tract infection (UTI).
• Strangury - This is a subtype of dysuria in which intense discomfort accompanies
frequent voiding of small amount of urine
Incontinence
• Urge incontinence - This is the result of an involuntary rise in intravesical pressure
secondary to detrusor contraction which overcomes outlet resistance, i.e bladder
instability. Local causes: UTI, bladder stone, tumour (carcinoma in situ / CIS), interstitial
cystitis, foreign body. Neurological causes: loss of cortical inhibition of voiding reflex in
strokes, dementia or Parkinsonism.
• Overflow incontinence - This is due to failure to empty bladder rather than inability to
store urine. Causes: BOO (BPH, strictures), detrusor weakness (DM, anticholinergic
medications) or combination of both.
• Stress incontinence - This is due to the sudden increase in intra abdominal pressure
(laughing, straining etc) resulting in elevated bladder pressure causing urine leakage. It
is frequently after radical prostatectomy for carcinoma of prostate or rarely after
transurethral resection of prostate (TURP).
• Enuresis - Involuntary urination and bed wetting occurs during sleep. It usually implies
overflow incontinence in adult male.
Workup
History
• Determine onset and duration of symptoms.
• Quantify symptoms e.g., how many times do you wake up at night to urine? What is
the interval between successive urination during daytime?
• Associated symptoms e.g., frequency, urgency, dysuria implies UTI (cystitis, urethritis,
prostatitis)
• History of perineal or pelvic trauma (stricture), prior instrumentation (stricture, bladder
neck contracture), venereal diseases (stricture)
• History of spinal injury
• History of stone disease
• Other medical conditions e.g., DM, MS, stroke, Parkinson’s disease, psychiatric
disorders
• Medications eg alpha agonists, anticholinergics, anti psychotics etc
Physical examination
• Abdominal examination especially to exclude any palpable bladder, ballotable renal
mass or inguinal hernia.
406
• Examine the penis for any phimosis, paraphimosis or meatal stenosis.
• Rectal examination to assess the prostate size and consistency as well as anal tone.
• If neurological cause suspected, proceed to do full neurological assessment.
Assessment
• IPSS (international prostate symptoms score) - Classified as mild (0 - 7), moderate (8 -
19) or severe (20 - 35)
• Urinalysis +/- urine cultures - Pyuria - infection, stone, foreign body; Sugar - need to
exclude DM; Hamaturia - malignancy, stone
• Voiding charts - Patient will chart down amount of fluid intake and amount of
urination every time per day for at least 3 days
• Serum electrolytes and creatinine - Indicator of renal function
• Fasting blood sugar - To exclude DM
• Prostate specific antigen - Prostate organ specific but not cancer specific
• Uroflowmetry and postvoid residual urine - Peak urine flow rate - objective documen-
tation of severity of obstruction. Useful indicator of response to treatment; Postvoid
residual urine is single most useful information - categorised patients into failure to
store or failure to empty
• Urodynamics - Include uroflowmetry, cystometry, urethral pressure profilometry and
electromyography
• Imaging - An intravenous urogram is indicated in patients with haematuria, persistent
infections or suspected bladder tumour; an ultrasound scan of the bladder can detect
any significant intravesical prostatic protrusion that suggests BPH.
• Cystoscopy - Indicated if there is associated haematuria, persistent infection or
suspected tumour
Three common but often misunderstood conditions affect thousands of men everyday:
benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer.
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patients with histological evidence of BPH require treatment. Symptoms of BPH rarely
presents before 60 years of age.
Clinical Presentations
• The most common clinical presentation of patients requiring surgical treatment is
acute retention of urine.
• Other symptoms of bladder outlet obstruction are hesitancy, poor stream and
intermittency. Irritative symptoms of nocturia, frequency and urgency may supervene.
• Less common symptoms are painless gross haematuria, recurrent urinary infection,
and chronic retention of urine resulting in uraemia and overflow incontinence.
• The important differential diagnoses are carcinoma of the prostate, and the various
types of neurogenic bladders especially diabetes mellitus and Parkinson’s disease. In
the elderly bed-ridden patients, it is important to exclude chronic constipation with
impacted stool as a cause of acute retention of urine.
Physical examination
• A non-tender palpable bladder after micturition indicates chronic retention of urine.
• Digital rectal examination demonstrating a smooth, globular and firm prostate
indicates BPH; an irregular and hard prostate suggests malignancy.
Investigations
Initial screening - urine dipstix is helpful in detecting haematuria, pyuria and glycosuria,
and a serum PSA level allows screening for prostate cancer.
408
Treatment
BPH may be treated by watchful waiting, pharmacotherapy or surgery.
• Plant extracts are a mixed bag of compounds comprising different ingredients from
various plant sources. Short-term randomized trials suggest some efficacy for certain
preparations but proper studies with long term follow-up is lacking.
Surgery - Indications are: acute retention of urine and failed trial-of-catheter; obstruc-
tion complicated by chronic retention, bladder stone, recurrent urinary tract infections or
recurrent gross haematuria. The procedure of choice is transurethral resection of prostate
(TURP). Open prostatectomy is seldom indicated. For the elderly patient, as long as he is
ambulant, he would benefit from a TURP.
Post-operatively, the patient is kept on continuous bladder washout for 24 hours and sent
home a day after the removal of catheter on the 3rd post-operative day. Post-operative
pain is minimum and they can resume their meals the same evening. They can return to
normal activity two weeks after discharge from hospital. After discharge from hospital,
most patients would still complain of irritative urinary symptoms which should improve
within a few weeks.
Prostatitis
Classification
The classification based on Meares-Stamey’s four-glass test has been largely abandoned.
To improve the diagnosis and management of prostatitis, the National Institutes of Health
(NIH) established an International Prostatitis Collaborative Network. The 1998 consensus
conference from this network classified prostatitis syndromes into 4 categories
(see Table 1).
410
penetrate the prostatic lipid membrane (trimethoprim-sulfamethoxazole or
fluoroquinolones) are used and are curative after 4-6 weeks in 33-50% of patients.
Treatment may even be extended up to 12 weeks in selected patients.
Prostate Cancer
Prostate cancer is rare below the age of 50 and is most common between the ages of 70
to 80 years. It is often diagnosed late because it arises from the posterior aspect of the
gland and by the time it involves the urethra anteriorly to give rise to symptoms of urinary
obstruction it has already spread outside the prostate gland, often to the bone.
Diagnosis
With the widespread use of prostate specific antigen (PSA) and routine digital rectal
examination (DRE), prostate cancer is now being diagnosed much earlier, before it spreads.
The normal value of PSA is 0-4.0ng/ml; above 20ng/ml there is 70% chance of cancer,
while with a value between 4-20ng/ml, the risk is roughly 20-30%, many patients (about
70%) have benign prostatic hyperplasia or prostatitis. Transrectal ultrasound and biopsy
need to be done to differentiate the various types of prostatic diseases.
Prostate cancer is staged by the extent of involvement of adjacent structures and its
histological grading. Organ-confined cancer (T1-2) does not extend beyond the prostatic
capsule whereas extra-capsular disease (T3-4) can include the seminal vesicles, lateral
pelvic wall or rectum. Lymph node involvement is determined by histological evidence of
cancer cells and metastasis is confirmed by hot spots on T99 Technetium bone scan or x-
ray evidence of metastatic lesions. Histological grade is classified by a Gleason score
where a higher score denotes poorer cellular differentiation.
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Treatment
For early localised disease (T1-2), the current accepted treatment is radical prostatectomy
for those who are medically fit and have a life expectancy of 10 years or more. Radical
radiotherapy is also an acceptable alternative. There may be a place for watchful waiting
for those with incidental well-differentiated cancer.
For patients with extracapsular (T3-4) and metastatic disease, many of them also have
significant degree of bladder outlet obstruction. The treatment of choice then would be
transurethral resection of the prostate and bilateral orchidectomy (as hormonal treat-
ment). For those with no obstruction or not keen for orchidectomy, hormonal treatment
with stilbesterol, anti-androgens such as cyproterone acetate (Androcur), Flutamide or
LHRH analogues (Goserelin, Lucrin) could be given to control the disease.
For patients with metastatic disease, the focus is on minimizing morbidity from skeletal
events such as pathological fractures and vertebral compression fractures. Radiotherapy
and operative management of the fractures may help to reduce immobility and control
bone pain. Physicians managing these patients also need to look out for metabolic
abnormalities such as hypercalcaemia which may be treated with intravenous saline
hydration and concomittant diuretics. Hormonal therapy by orchidectomy or medical
treatment can prolong symptom-free survival and delay onset of hormone-refractory
prostate cancer.
Prognosis
For early disease with treatment, the 10 year survival rate is about 70%; while for
patients with distant spread, the outlook is not immediately hopeless, the mean survival is
still about 30 months and a number of them died with and not of their disease.
ERECTILE DYSFUNCTION
Incidence. With the increased aging population, there is an increase in patients present
with erectile dysfunction. In the Massachusetts Male Aging study, 52% of the general
male population aged between 40 and 70 years reported some degree of ED.
Causes
ED may have psychogenic or organic causes, in many patients the disorder is of mixed
aetiology, with both factors present. The causes of ED can be classified into the following
causes and their approximate distribution shown:
• Vascular - Greater than 50% of men older than 50 have vascular disease as the cause
of ED. Smoking, hyperlipidemia, obesity and diabetics are risk factors that would
contribute to the development of ED.
• Neurogenic - In any lesions that would affect the parasympathetic sacral spinal cord or
the peripheral efferent autonomic fibers to the penis (post-surgery) cause partial or
complete ED. Any lesion in the spinal cord, supraspinal lesion like strokes would also
412
contribute to ED. This neurogenic cause represent about 15-20% of cases.
• Hormonal - This only contributes 5-10% of the causes of ED. Any lesion that would
affect the androgen whether by castration, aging, tumour (hyperprolactinemia), hypo
or hyperthyroidism will cause ED.
• Medication - The medication background of ED is important. Many medications affect
erectile function. The commonest are - the anti-hypertensives; cimetidine; and
antipsychotics that affect the central and peripheral noradrenergic and dopaminergic
pathways will also affect erectile function to some extent.
• Anatomical -- Anatomical abnormalities of the penis like pyronie disease will also
cause ED
• Psychogenic - Any form of psychiatric illness will affect the erectile function. The younger
the patient, the more important is the psychogenic origin of the ED in the aetiology.
Workup
The diagnosis of ED should include an evaluation of the patient’s medical and
psychosexual history, a physical examination and selective investigations.
Medical and psychosexual history - This is probably the most important aspect of the
diagnostic process and allows the identification and differentiation of common risk
factors for both organic and psychogenic ED. The medical history should focus on
identifying risk factors for organic ED. This usually involves determining patients’ lifestyle
habits, including smoking, alcohol consumption and drug use or abuse. ED may be
symptomatic of several conditions or chronic diseases which must be excluded, e.g.
cardio-vascular disease, diabetes, neurological disorders or psychological illness. Prescrip-
tion drugs are also an important consideration.
Past and present sexual relationships - These should also be investigated, as well as any
other emotional stressors such as employment history.
known significant risks, in a form that the patient (and partner) can assimilate and
from which it is sufficient for them to evaluate the options.
• The final choice of treatment is tailored to the needs and preferences of the patient;
• Agreed treatment goals are established at the start of treatment.
• Appropriate information is given on management of the chosen treatment, including
advice on what to do and who to contact in case of problems and complications.
Treatment Options
Oral Therapy . This is the most convenient form of treatment. Patient instruction is brief
and simple. The variety of oral therapy for erectile dysfunction has proliferated in recent
years. Prior to sildenafil, oral therapy consisted of Yohimbine and traditional medicines
and aphrodisiacs. Since then, the newer classes of drugs namely the phosphodiesterase 5
(PDE5) inhibitors, as typified by sildenafil, has become the popular choice.
• Sildenafil acetate (Viagra) - Sildenafil is the first PDE5 inhibitor in the market. It is an
effective oral treatment for ED with an efficacy rate of up to 80%. This is lowered in
patients with severe medical conditions such as DM and after radical prostatectomy.
It’s absorption is affected by food, especially oils and fat. Time to action is 20 mins to
an hour. It is important to remind users that PDE5 inhibitors do not cause a
spontaneous erection. Sexual stimulation is required to initiate the erection. It remains
effective for up to 24 hours. Side effects are minimal. Blue vision occurs in about 3%
of patients, usually in those on higher dosages and this is transient. Priapism is a rare
occurrence. Contraindications include concurrent use of nitric oxide donors (e.g.
nitrates), presence of retinitis pigmentosa, severe aortic stenosis, severe/uncontrolled
cardiac failure or hypertension, unstable angina, severe ventricular arrhythmias,
obstructive cardiomyopathy and recent myocardial infarct. Recommended doses are
25, 50 and 100-mg when necessary.
• Vardenafil (Levitra) - This drug is similar to sildenafil in efficacy and half-life except that
it’s absorption is not affected by food. However, a high fat meal may delay onset of
action. The contraindications are common to all PDE5 inhibitors, namely no concurrent
use with nitric oxide donors. The most commonly reported side effect in trials is
headache. Tablets are available in 10 and 20 mg doses.
• Tadalafil (Cialis) - The main difference of Cialis from the other PDE5 inhibitors is the
long half-life of 18 hours with possible duration of action of 36 hours. It is also
reported to have minimal activity against PDE6 receptors on the retina. Absorption is
not impaired by food in any way. Clinical experience with the drug is still in early
stages. Potential side effects include myalgia and backache. A 20-mg dose gives an
efficacy of 80%.
414
Apomorphine (Uprima) - This acts centrally upon the dopamine D2 receptor in the
paraventricular nucleus of the hypothalamus. It is administered sublingually. The efficacy
rate is 47 to 60%. Main concerns are nausea and possible vaso-vagal syncope in trial
users. Preferred dosages are 2 and 3mg.
Injectables. Vasodilators can be injected directly into the corpora to induce an erection.
Common injectable agents include PGE1, papaverine, phentolamine and vasointestinal
peptide (VIP). These remain a valuable part of the treatment armamentarium because of
the direct delivery of the drug to the corpora without the problems of digestive
absorption and first pass effect. It gives a spontaneous and rigid erection with an efficacy
rate of 75 - 80 %. Drawbacks include pain and possible fibrosis at the injection sites. The
incidence of fibrosis is low. Priapism is more likely with injectables than the other
treatments. The most popular agent is PGE1. Usual doses used are 10, 20 or 40µg. It may
be used alone or in combination, usually with papaverine and phentolamine. The latter is
commonly known as Triple Therapy.
Vacuum Device. This consists of a cylinder placed over the penis. Vacuum is then created
in the cylinder by a pump. The vacuum forms a negative pressure around the penis and
draws blood into the penis for an erection. A constriction band placed around the base of
the penis maintains the erection. Users should be reminded to remove the band after 30
minutes as it may lead to ischemia. Being a mechanical device, it avoids the use of drugs
and chemicals and appeals to those concerned about drug side effects.
Surgery. The options are a penile prosthesis and penile revascularisation surgery.
Penile prosthesis — Penile prosthesis remains the most popular surgical option for ED at
present. It has a long history of durable good results with follow-up exceeding 10 years.
The preferred implant is the 3-piece inflatable prosthesis. Success rate is 80%. Failure is
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Decline of function
Among many other organ systems, there is a gradual decline in the function of a number
of endocrine glands with aging.
Treatment mandatory - Of these, the decline in pancreatic and thyroid function leads to
clinically defined disease states that need proper diagnosis and treatment.
Treatment not recommended in normal healthy elderly males -- The causative role of the
decline in the serum levels of testosterone, DHEA, DHEAS, GH and IGF-1 in the changes
seen in body composition with aging is far from clear. It is indeed unknown whether the
decline in these hormones with aging is a cause or effect of aging. Hormone replacement
strategies have been recommended by some for the aging male but remain highly
controversial. Increasing serum hormone levels in aging men to those seen in young
adults has not been uniformly proven to be of benefit or safe.
SCROTAL PAIN
Scrotal pain in males can occur in all age groups. Causes are: Torsion of the testis and
torsion of a testicular appendage (paradidymis; hydatids of Morgagni); Strangulated
416
inguinoscrotal hernia; Haematoma/haematocele; Neoplasm; Epididymo-orchitis; Mumps
orchitis; Acute hydrocele; Referred pain; Scrotal skin conditions ; and Varicocele. Of these,
the first four require early surgical intervention.
Workup
History
Key questions are:
• Have you had any injury to your scrotal region? Consider haematoma into the scrotum
and acute haematocele.
• Have you had an illness lately and have you noticed any swelling near your ear?
Consider mumps orchitis.
• Have you noticed any burning of urine or penile discharge? Any recent sexual
intercourse? Consider epididymo-orchitis caused by STI
• In older men, any instrumentation of the lower urinary tract? Any obstructive
symptoms - poor stream, incomplete emptying on passing urine? Consider epididymo-
orchitis from instrumentation and urinary tract obstruction respectively
• Do you have back pain or have you injured your back? Consider referred pain.
Clinical examination
• The scrotum should be examined with the patient supine and then standing.
• Examine and compare both sides of the scrotum. The left testis usually hangs lower
than the right.
• On inspection, note any sebaceous cyst, nodules (scabies), any ulcer, sinuses, scrotal
edema which causes taut pitting skin, and erythema.
• Gently palpate each testis and epididymis between the thumb and the first two fingers
- the spermatic cord is palpable as it enters the scrotum after passing through the
superficial ring and the testis and epididymis are normally readily palpable.
• Pain may limit the palpation that can be done. A painful testis should be elevated
gently to determine if the pain improves.
• After palpation, test for translucency of any swelling in a darkened room by shining
the beam of a strong torch from behind the scrotum through the swelling.
Transilluminable swellings that light up with a red glow are hydroceles and cysts of the
epididymis. Swelling that contain blood or other tissue, such as testicular tumours and
most hernias, do not transilluminate.
• Check on both sides the inguinal and femoral hernial orifices
Clinical features
Torsion of the testis - Table 2 compares the clinical characteristics of the two conditions.
With torsion of the testicle there is pain of sudden onset, described as a severe, aching,
sickening pain in the groin that may be accompanied by nausea and vomiting. With
epididymo-orchitis the attack usually begins with malaise and fever. The testicle soon
becomes swollen and acutely tender; however, elevation of the scrotum usually relieves
pain in this condition while tending to increase it with a torsion.
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Orchitis - Acute orchitis is invariably due to mumps and occurs during late adolescence. It
is usually unilateral but may be bilateral. Chronic orchitis may be due to syphilis,
tuberculosis, leprosy or various helminthic infections such as filariasis. The majority are
tuberculous in origin.
Testicular neoplasm - Testicular tumours can occur at all ages but are more common in
young men aged 20-30 years (teratoma) and 30-40 years (seminoma). Associated
presentations may mask the tumour - hydrocele, varicocele, epididymo-orchitis, swollen
testis with trivial injury, and gynaecomastia (teratoma). Those at high risk of testicular
neoplasm are those with a family history and a history of crypto-orchidism, orchidopexy,
testicular atrophy, previous testicular cancer. The golden rules to remember are - all solid
scrotal lumps are malignant until proved otherwise and must be surgically explored;
beware of hydroceles in young adults; tumours can mimic acute epididymo-orchitis, the
so-called inflammatory, or flash fire presentation.
Trauma and haematoceles - A diffuse haematoma into the scrotum which causes no
significant problems can follow surgery to the inguinal area, a blow to this area or a
fracture of the pelvis. These conditions cause extravasation of blood distally. However, a
haematocele of the tunica vaginalis can be either acute or an ‘old clotted haematocele’
following injury, such as a blow to the testis, or the drainage of a hydrocele (Murtagh,
2003). Sometimes it can arise spontaneously. All types of haematoceles require surgical
exploration to exclude testicular rupture or a tumour. Trauma to the scrotum may
produce urethral injury and extravasation of urine into the scrotum. This problem requires
urgent surgery.
418
Problems of scrotal skin - Sebaceous cysts are common and may be infected and require
drainage. Fournier’s gangrene (idiopathic gangrene of the scrotum) is an acute fulminat-
ing cellulitis affecting the scrotal skin. It usually develops suddenly and without any
apparent cause. Gangrene of the scrotal skin appears early if the infection is not quickly
checked with broad spectrum antibiotics. The end result is sloughing of the scrotal
coverings, leaving the testes exposed.
Referred pain - Pain can be referred to the scrotal region from ureteric colic and quite
commonly from disorders of the thoracolumbar spine, notably a disc disruption at the
T12-L1 level involving the L1 nerve root. The pain therefore may be referred or radicular.
Management
When to refer
Referral of a patient with scrotal pain should be most urgent, using the critical 4 hour
guideline for the following:
• Any suspicion of torsion of the testis
• Sudden onset of acute scrotal pain at any age
• A history of recurrent transient testicular pain in a young man
• Presence of a tender testicular lump
• Presence of a haematocele surrounding the testis
The most common penile disorders are those of psychosexual dysfunction and STIs, but
there are also problems related to the foreskin (phimosis, paraphimosis), the urethral
meatus (meatal stenosis, hypospadias, epispadias), carcinoma, and Peyronie’s disorder
(characterised by painful ‘crooked’ eruptions).
Further reading
Murtagh J. Disorders of the penis. In: General Practice, 3rd ed. Australia:MacGrawHill, 2003:1079-1084.
HEMATOSPERMIA
Haematospermia is blood in the semen. It is an alarming symptom that brings the patient
quickly to the doctor. It is sometimes encountered in young adults and middle-aged men.
The initial step is to determine that the blood is actually in the semen and not arising from
warts inside the urethral meatus or from the partner. True haematospermai usually occurs
as an isolated event. It can also be secondary to urethral warts, prostatitis,
prostatomegaly or prostatic tumour (especially in elderly patients). If a micro-urine shows
no accompanying haematuria, and prostatic specific antigen and blood pressure are
normal, reassurance and a 6 week review is appropriate as spontaneous cessation of
haematospermia is the rule (Murtagh, 2003).
Further reading
Murtagh J. Disorders of the penis. In: General Practice, 3rd ed. Australia:MacGrawHill, 2003:1079-1084.
Outline
Travel medicine
Sexually transmitted infections
TRAVEL MEDICINE
Conditions that may be adversely affected by air travel and therefore requiring medical
clearance are shown in Table 1. Medical clearance and special arrangements need to be
made at the time of booking the flight.
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Table 1. Conditions That May Be Adversely Affected By Air Travel
Cardiovascular Diseases
• Conditions likely to give trouble are congestive heart failure, myocardial ischaemia,
pulmonary hypertension, severe systemic hypertension with complications.
• Recent myocardial ischaemic patients will only be accepted for air travel 3 weeks after
onset, provided, the prognosis is uncomplicated, and the patient is fully mobilised, and
allowed to walk and climb stairs.
Respiratory Diseases
• Those with chronic bronchitis, emphysema, bronchiectasis and corpulmonale are at risk to
the effect of hypoxia.
• Pneumothorax is contraindicated for air travel.
• Pneumonia is contraindicated for air travel
Blood Disorders
• Severe anaemia: haemoglobin 7.5g/dI is the lowest acceptable value for air travel.
Gastro-IntestinaI Diseases
• Recent gastro-intestinal surgery: minimum post-operative period of 10 days before flying.
• Recent gastric or duodenal haemorrhage is a contraindication to air travel.
Neurological Diseases
• Cerebral infarction from thrombosis or haemorrhage
• Epilepsy.
Ear, Sinuses and Jaws
• Common cold, sinus and middle ear infections
• Recent facio-maxillary surgery, middle ear surgery - contraindicated for air travel.
Psychiatric Conditions
• Mentally ill travellers, especially the dangerous patients, need medical escorts (doctors)
for air-travel.
Pre-Travel Advice
Travellers should seek medical and travel health advice six weeks before departure. This
gives sufficient time to not only receive the relevant vaccinations but also to have any
underlying medical problems stabilised.
Checklist
A checklist of areas to be covered in the pre-travel consultation is shown in Table 2. The
use of simple and easy to read information leaflets covering the topics appropriate to the
needs of the traveller are often helpful.
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Source: Pugh C & Fante PD. Aust Fam Physician, 1994;23:9:1689-1693 (adapted)
Source: Pugh C & Fante PD. Aust Fam Physician, 1994;23:9:1689-1693 (adapted)
422
Illness In The Returned Traveller
In general, one should consider the differential diagnosis had the patient not travelled,
and then add possibilities related to travel. Especially for older returned travellers, many
illnesses presenting after travel may be quite unrelated to the travel and assuming that
the illness is travel related may lead to errors just as serious as those due to failure to
consider travel-related conditions; for example, mistaking choIangitis for hepatitis A.
Irrespective of whether they are travel-related or not, the focus of attention should be on
conditions that are potentially lethal, treatable or transmissible. The threshold for seeking
specialist advice or referral or both for diagnostic or management problems in returned
travellers should be low and for a sick patient the need may be urgent.
Table 4. Selected Causes of Fever In Returned Travellers
Treatable infections
• Malaria, Typhoid (and other enteric fevers), Bacterial sepsis (eg staphylococcal, streptococcal,
meningococcal), Amoebic liver abscess, Typhus, other rickettsiae, Legionellosis, Leptospiorsis,
Brucellosis, Viral haemorrhagic fevers (African and Crimean Congo).
Not specifically treatable causes
• Dengue and other arboviruses, Influenza, Hepatitis A , Acute HIV infection
Non infective causes
• Drug
Less common but treatable causes
• Meloidosis, Schistosomiasis, Lymphatic filariasis, Leishmaniasis, Trypanosomiasis,
• Plague, Trichinosis, Relapsing fever
Source: Tilman Ruff. Aust Fam Physician, Sep 1994:1715
Fever
Returned travellers presenting with fever and no clear localising features on history or
examination often pose an urgent diagnostic problem. Selected causes are shown in Table
4. Management decisions are often necessary before a specific diagnosis can be
identified. Four useful questions in working up such patients are:
• What non travel related conditions are possible?
• What additional diseases are possible given this patient’s exposures?
• What is possible given these clinical findings and the incubation periods of conditions
identified above?
• What conditions require urgent intervention?
Again, it should be reminded that non-travel related causes are more likely in older than
in younger individuals. If the patient is sick or immunocompromised (including extremes
of age, diabetes mellitus, splenectomised, on immunosuppressive drugs, and known HIV
infection), hospital admission should be arranged straightaway.
If the patient is not sick, is co-operative, and does not live alone or in a remote area, initial
tests may establish a diagnosis quickly and outpatient management may be appropriate.
Specific initial investigations include:
• full blood examination (including manual examination of the film)
• thick and thin smears for parasites
• liver function tests
• cultures of blood, urine and faeces.
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Diarrhoea
Diarrhoea is the commonest travel-related illness. It can be acute or chronic.
Acute diarrhoea
Factors influencing the approach to acute traveller diarrhoea are the severity of the
illness, whether features of dysentery (fever >38ºC or bloody stools) are present, and
whether the patient is at increased risk of severe or complicated diarrhoea.
Effective, simple and safe empiric therapy is available for managing traveller’s diarrhoea. As
most episodes occur while travelling the patient should be instructed in self-management.
This includes advice for all patients on appropriate fluid and electrolyte replacement.
Empiric antimicrobial therapy should be commenced for diarrhoea that have the
following features:
• is dysenteric,
• that fails to improve after 48 hours or
• after the third loose stool for diarrhoea that is moderate to severe.
Therapy should commence with a single double dose then continued at the usual doses
for three days (see Table 5).
Chronic diarrhoea
Diarrhoea persisting for three or more weeks warrants more thorough investigation. The
range or causes is considerably broader than for acute diarrhoea. Non E coli bacteria are
common with other causes including protozoa (Giardia lamblia, Entameba histolytica and
Cryptosporidia). Helminths, tropical sprue and non-infective causes such as inflammatory
bowel disease which may be precipitated or exacerbated by an infective enteric insult.
The possibility of malignancy in older individuals should never be forgotten.
Appropriate investigations include three fresh faecal samples on different days for
microscopy and culture full blood examination, ESR, liver function tests and electrolytes.
Amoebic, strongyloides and where relevant schistosomal serology may be useful as
important late complications are associated with these agents. Further tests. such as a
424
string test for upper small bowel pathogens, tests for malabsorption, mucosal sampling
and colonoscopy may be indicated. If no pathogens or features of concern are identified,
sequential empirical treatment with tinidazole (2g as a single oral dose) and mebendazole
(100mg 12 hourly for three days) is often useful diagnostically and therapeutically.
Jaundice
The possibilities are many. Viral hepatitis, malaria, ascending cholangitis, leptospirosis,
drug jaundice are the commoner causes. Unless the clinical picture and laboratory
findings are typical (transaminase levels 10 or more times the upper limit of the reference
range and a normal or near normal alkaline phosphatase), blood smears for parasites,
blood cultures and ultrasound examination should be performed promptly. Cholangitis
with eosinophilia, particularly in travellers from Asia, should prompt a search for liver
flukes (Clonorchis, Opisthorchis and Fasciola species) as well as ascariasis.
Presentation
STIs may present with
• urethral or vaginal discharge (with or without vulval irritation)
• genital ulceration
• other genito-urinary manifestations (e.g. rash, dysuria, painful regional lymph nodes)
• general manifestations (e.g. fever, abdominal pain, arthralgia, or jaundice).
Work-Up
Sexual history. A relevant clinical and sexual history is a basic essential in the proper
management of STI. This should include details of the types of sexual activity, sites of
sexual contact, sexual orientation, use of condoms and contraceptives, previous STI
symptoms in the patient and partners.
Examination. Examine the genitalia for discharge, ulcers or warts (including the vagina
and cervix in females), the mouth for ulcers, and perform proctoscopy if there are anal
symptoms or a history of anal intercourse.
Use of the laboratory. The right collection of and handling of specimens and accurate
interpretation of the laboratory results in relation to the patient’s clinical problem.
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Gonorrhoea
CF: Mucopurulent urethritis; Mucopurulent cervicitis; Proctitis; Pharyngitis.
PD: Gram stain of discharge - intracellular gram negative diplococci.
DD Culture on modified Thayer Martin media and confirm by Gram stain of colonies,
Oxidase test, Sugar Fermentation test
Syphilis
CF: Primary - chancre; Secondary - mucocutaneous lesions (generalised symmetrical.
non-itchy rash, painless erosions of mucous membranes) and systemic signs
(malaise, fever, anorexia, generalised lymphadenopathy); Latent - no symptoms and
no signs; Tertiary - CVS, CNS and soft tissue lesions
PD: VDRL or RPR as screening test; TPHA and/or FTA-ABS as specific test; TPI in special cases
DD: Demonstration of Treponema pallidum by dark field microscopy OR Fluorescent
antibody technique in tissue histology sections
Chancroid
CF: Painful purulent genital ulcers
PD: Gram stained cocobacilli formation in school of fish or tramline
DD: Isolation by special chocolate culture media of Haemophilus ducreyi; Identification
by colony morphology and Gram stain
426
Herpes Genitalis
CF: Grouped vesicles; Grouped erosions/ ulcers; Genital ulcers
PD: Herpes Antigen detection by Elisa OR immunofluorescence (DIF) ;Tzanck’s test -
multinucleated giant cells
DD: Isolation of HS Virus on cell culture media showing CPE; Identification by
Immunofluorescent method for virus type
Genital Warts
CF: Papillary or filiform painless growths; Flat warts; Hyperkeratotic pigmented warts
PD: Biopsy - histology; Pap smear - koilocytes
DD: DNA Hybridisation technique for identification of HP V
Lymphogranuloma Venereum
Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3.
CF: Tender inguinal and/or femoral lymphadenopathy that is most commonly unilateral.
Women and homosexually active men may have proctocolitis or inflammatory
involvement of perirectal or perianal lymphatic tissues resulting in fistulas and
strictures. A self-limited genital ulcer sometimes occurs at the site of inoculation.
However, by the time patients seek care, the ulcer usually has disappeared.
PD: Serologically and by exclusion of other causes of inguinal lymphadenopathy or
genital ulcers. Complement fixation titers >1:64 are consistent with the diagnosis
of LGV.
DD: The diagnostic utility of serologic methods other than complement fixation is unknown.
Trichomoniasis
CF: Purulent frothy malodorous yellow-green vaginal discharge; Dysuria; Vulval, vaginal itch
PD: Microscopy identification of ovoid protozoan with jerky motility on saline wet mount
DD: Culture for trichomonads using Feinburg media; Microscopy identification of ovoid
protozoan with jerky motility on saline wet mount
Candidiasis
CF: Intense vulval and vaginal pruritis with or without vaginal discharge; Vulvovaginitis
(erythema and fissures)
PD: Identification of budding yeast cells and pseudohyphae on KOH wet mount or
Gram stain
DD: Culture on Sabourauds’ medium; Identification by microscopy
Bacterial Vaginosis
CF: maldorous watery vaginal discharge
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SECTION 08 APPLIED MEDICINE IN THE VARIOUS AGE GROUPS
PD: Identification of clue cells on saline wet mount or Gram stain; Amine test
DD: Culture for G vaginalis on blood agar and identification by colony and Gram stain
Pediculosis Pubis
CF: Itch in pubic area
DD: Identification on microscopy of adult louse (pthirus pubis) and/or nits from genital hair
Treatment Principles
Early treatment. Early treatment of STI is essential to render the patient non-infectious
and prevent complications. Treatment should be administered based on the clinical
syndromes and results of microscopy while waiting for laboratory confirmation.
Effective therapy. Recommended treatment regimens for STI must be highly effective,
safe and simple to administer, easy to comply with and cost-effective. Recommended
treatment regimens should be based on local microbial sensitivities. Clinic based
supervised treatment is to be preferred.
Follow-up and test of cure. Patients with STI should be counselled on the importance
of returning for a test of cure before resuming sexual activity. This test of cure could be in
the form of a serological or bacteriological or even a clinical assessment depending on
the type of infection treated. All patients should refrain from sexual activity (or
unprotected sex) until the tests of cure are completed.
Screening for other STIs. Screening for other STI is cost effective in patients with one
STI. As many of the STI are asymptomatic, a patient treated for one STI should be
examined and screened for other sexually transmitted diseases. Serological testing for
gonococcal antibodies, herpes antibodies and chlamydial antibodies are of no value for
screening and clinical management of patients.
Management of sexual contacts. The importance of tracing all sexual contacts at risk of
infection for investigation and treatment must be emphasised to all patients with STI. Patient
initiated referral is preferred, failing which health care worker assistance would be needed. If
the patient is diagnosed with non-specific urethritis (NSU), chlamydia, Trichomonas vaginalis
or gonorrhoea, the partner should be treated even if tests are negative.
Sexual abuse. Children with STI must be carefully examined and investigated for possible
child sexual abuse. Appropriate microbiologic and laboratory test must be carried out.
Hospitalisation would be indicated until the medical and social circumstances can be clarified.
428
prevention of STI is based primarily on changing the sexual behaviours that put patients at
risk for infection.
Notification of STI. STIs are notifiable infectious diseases. Data collected from
notifications are extremely important in understanding trends and in planning prevention
programmes. Identification data of patients are essential for these purposes.
Treatment Guidelines For STI — Based on CDC 1998 and updated CDC
2002 Guidelines for the treatment of STI
Key
• Recommended Therapies (RT)
• Alternative Therapies (AT)
Gonococcal Infections
Uncomplicated urethritis, endocervicitis, rectal gonorrhoea
RT: 1. Cefixime 400mg orally as a single dose OR
2. Ceftriaxione (Rocephin) 250mg IM single dose plus Azithromycin 1gm oral
single dose OR Doxycycline 100mg bid for 7 days
AT: 1. Spectinomycin 2g IM single dose
2. Ciprofloxacin 500mg oral single dose
3. Ofloxacin 400mg oral single dose
Pharyngeal gonorrhoea
RT: Ceftriaxione 250mg IM single dose plus Azithromycin 1gm oral single dose or
Doxycycline 100mg bid for 7 days
AT: —
Granuloma inguinale
RT: 1. Trimethoprim-sulphamethoxazole double strength (800mg/160mg) bid for 21 days
2. Doxycycline 100mg bid for 21 days
AT: 1. Ciproflixacin 750mg daily for 21 days
2. Erythromycin base 500mg qid for 21 days plus (during pregnancy) Gentamicin
1mg per kg IV tid for 21 days
If only erythromycin can be used and the patient cannot tolerate high dose erythromycin
schedules, one of the following can be used: Erythromycin base 250mg qid for 14 days or
Erythromycin ethylsuccinate 400mg qid for 14 days
Recurrent/persistent urethritis
RT: 1. Metronidazole 2gm oral single dose plus either
2. Erythromycin base 500mg qid for 7 days or
3. Erythromycin ethylsuccinate 800mg qid for 7 days
Syphilis
Early - primary, secondary or latent infection less than 1 year
RT: Benzathine Penicillin 2.4 million units IM in a single dose
AT: 1. Procaine Penicillin 1.2 million units IM single dose for 10 days
2. Penicillin allergic pregnant patients — Erythromycin base 500mg qid for 14 days
to 21 days
3. Penicillin allergic non-pregnant patient — Doxycycline 100mg bd x 14-21 days
Late - indeterminate or more than 1 year’s duration; cardiovascular late benign syphilis
RT: Benzathine Penicillin 2.4 million units IM 3 doses at 1 week’s intervals
AT: Doxycycline l00mg bd for 30 days
430
Chancroid
RT: 1. Azithromycin 1gm oral single dose
2. Ceftriaxone 250mg IM single dose
3. Ciprofloxacin 500mg bid for 3 days
4. Erythromycin base 500mg tds for 7 days
Note: Ciprofloxacin is contraindicated for pregnant and lactating wormen
Severe disease
RT: Acyclovir 5-10mg/kg body weight IV every 8 hours for 5-7 days or until clinical
resolution is attained.
Genital Warts
External genital area
RT: 1. Cryotherapy with liquid nitrogen or cryoprobe repeat every 1-2 weeks
2. Podophyllin 10-25% weekIy
3. Trichloroacetic acid (TCA) 80-90% weekly
4. Podophylotoxin 0.5% solution bid for 3 days, wait 4 days, then repeat as
necessary for 4 cycles (patient applied)
5. lmiquimod 5% cream daily at bedtime tid weekly for up to 16 weeks
(patient applied)
Vaginal
RT: 1. Cryotherapy with liquid nitrogen or cryoprobe repeat every 1-2 weeks
2. Trichloroacetic acid (TCA) 80-90% weekly
3. Podophyllin 10-25% weekIy
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SECTION 08 APPLIED MEDICINE IN THE VARIOUS AGE GROUPS
Urethral meatus
RT: 1. Cryotherapy with liquid nitrogen or cryoprobe repeat every 1-2 weeks
2. Podophyllin 10-25% weekIy
Anal area
RT: 1. Cryotherapy with liquid nitrogen or cryoprobe repeat every 1-2 weeks
2. Podophyllin 10-25% weekIy
3. Surgical removal
Oral
RT: 1. Cryotherapy with liquid nitrogen or cryoprobe repeat every 1-2 weeks
2. Surgical removal
Trichomoniasis
RT: Metronidazole 2gm oral single dose
AT: Metronidazole 400mg twice daily for 7 days
Bacterial Vaginosis
RT: 1. Metronidazole 500mg oral twice daily for 7 days
2. Metronidazole gel 0.75%, one full applicator (5g) intravaginally, once a day for
5 days
3. Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days
AT: 1. Metronidazole 2g orally in a single dose
2. Clindamycin 300mg oral twice daily for 7 days
3. Clindamycin ovules 100mg intravaginally once at bedtime for 3 days
Vulvovaginal Candidiasis
RT: Intravaginal agent
1. Butoconazole 2% cream 5g intravaginally for 3 days
2. Clotrimazole 1% cream 5g intravaginally for 7-14 days or Clotrimazole tablet
intravaginally 500mg single dose or Clotrimazole tablet intravaginally 100mg for
7 days or Clotrimazole tablet intravaginally 100mg, 2 tablets for 3 days
3. Miconazole cream 5g intravaginally for 7 days or Miconazole 200mg
suppository intravaginally for 3 days or Miconazole 100mg suppository
intravaginally for 7 days
4. Nystatin 10000 unit vaginal tablet for 14 days
5. Terconazole 0.4% cream 5g intravaginally for 7 days or Terconazole 0.8% cream
5g intravaginally for 3 days or Terconazole 80mg suppository intravaginally for
3 days
Oral agent
Fluconazole 150mg oral tablet, one tablet single dose
Ectoparasitic Infections
Pediculosis Pubis
RT: 1. Permethrin 1% cream apply to affected area and wash off after 10 minutes
2. Gammabenzene hexachloride 1% shampoo apply for 4 minutes, then wash off.
This is not recommended for pregnant or lactating women
432
3. Pyrethrins with piperonyl butoxide applied to affected area and wash off after
10 minutes.
Scabies
RT: Permethrin cream (5%) applied to all areas of the body from the neck down and
washed off after 8-14 hours
AT: 1. Lindane (1%) 1oz lotion or 30g cream applied in a thin layer to all areas of the
body from the neck down and thoroughly washed off after 8 hours
2. Ivermectin 200ug/kg orally, repeated in 2 weeks.
Screening tests
Screen all “at risk” individuals with VDRL, TPHA, ± HIV (with patient’s consent).
Screening of asymptomatic persons with the VDRL test, followed by treponemal test
confirmation on positive sera, is recommended for all pregnant women, contacts of
persons with infectious syphilis, and other high-risk groups. Quantitative VDRL
assessment at 3, 6, and 12 months after treatment should be used to assess the adequacy
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of treatment for both late latent and early syphilis. Cerebrospinal fluid VDRL assessment
and cell count should be restricted to seropositive persons with a high risk
of neurosyphilis.
434
CHAPTER 5 ELDERS’ HEALTH
Outline
Ageing and a new paradigm of medical care
Assessment of the older patient
Preventive care in the older patient
Falls management and prevention
Delirium, dementia and depression
Reducing polypharmacy
The age related changes and their consequences are shown in Table 1. Also shown in the
table are the consequences of disease and not age.
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SECTION 08 APPLIED MEDICINE IN THE VARIOUS AGE GROUPS
Footnote: Inc = increased; Dec = decreased. Source: Resnick, 1994 (in: Harrison’s Principles of Internal
Medicine, 13th ed Isselbacher K et al (editors), McGraw-Hill, 1994
436
Table 1. Selected Age-related Changes And Their Consequences (2) – Cont’d
ORGAN AGE-RELATED CONSEQUENCES OF CONSEQUENCES
OR PHYSIOLOGIC AGE-RELATED OF DISEASE,
SYSTEM CHANGE PHYSIOLOGIC CHANGE NOT AGE
Hermatolgic Inc False-positive rheumatoid
and immune Autoanti bodies factor, antinuclear antibody
systems
Renal Dec GFR Impaired excretion of some drugs Inc Serum creatinine,
renal failure
Renal Dec Urine Delayed response to salt or fluid Dec or Inc serum Na
concentration- restriction or overload; nocturia
dilution (see also
Endocrine, above)
Source: Resnick, 1994 (in: Harrison’s Principles of Internal Medicine, 13th ed. Isselbacher K et al
(editors), McGraw-Hill, 1994
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For example, whereas a 45-year-old may seek care for productive cough, fever, and
dyspnoea as manifestations of pneumonia, the same disease may cause an 80-year-old to
present with a new problem with falls and difficulty following a conversation. Indeed,
regardless of the presenting symptom in older people, the differential diagnosis is often
pretty much the same.
For example:
• a mild anticholinergic agent (e.g., diphenhydramine) may cause confusion;
• diuretics may precipitate urinary incontinence;
• digoxin may induce anorexia even with normal serum levels; and
• over-the-counter sympathomimetics may result in urinary retention in older men with
mild prostatic obstruction.
For example, cognitive impairment in patients with Alzheimer’s disease may respond
much better to interventions that address co-morbidity than to prescription of donepezil,
as co-morbid conditions may interfere with the ability to compensate for cognitive loss.
Similar approaches apply to most other common geriatric syndromes, including falls,
incontinence, depression, and syncope. Small improvements in the underlying causes can
have a dramatic improvement in the reduction of the geriatric syndromes.
On the other hand, some abnormalities must not be dismissed as due to old age. There is
no anemia, depression, or confusion of old age. They are symptoms of important
underlying disease requiring investigation.
438
Law of parsimony often does not apply. Symptoms in older people are often due to
multiple causes, and the diagnostic “law of parsimony” often does not apply. Fever,
anaemia, retinal embolus, and a heart murmur are almost diagnostic of endocarditis in a
younger patient but are more apt to reflect aspirin-induced blood loss, a cholesterol
embolus, insignificant aortic sclerosis, and a viral illness in an older patient.
Greater benefits of treatment and prevention. The older patient is more likely than a
younger one to suffer the adverse consequences of disease and treatment. Prevention
may be equally or even more effective. The benefits to survival of exercise, beta-blocker
therapy after myocardial infarction, appear to be at least as impressive in older patients as
in younger ones; the relative benefits of immunization against influenza are even greater.
Prevention in older patients must be viewed in a broader context. Although interventions
to increase bone density may decrease fracture risk, this risk may be reduced further by
strategies that improve balance, strengthen legs, ameliorate contributing medical
conditions, replete nutritional deficits, and eliminate environmental hazards.
Therapeutic goals may shift from cure to care. In contrast to the care of younger
patients, for whom cure of disease and prolongation of life are usually of paramount
concern, the goals of care for older patients may well differ. Although some may seek a
focus on life extension, others clearly want emphasis on improved function, comfort, and
quality of life.
Patient’s Preferences, Goals & Priorities. An effective therapeutic encounter calls for a
clear understanding of the patient’s preferences and goals. The patient’s goals for care,
life expectancy, the prevalence of specific diseases, the performance of screening or
diagnostic tests, and the effectiveness of therapeutic interventions will shape the priorities
of care for a particular elderly patient. Thus, the priorities for the elderly are likely to differ
from those of younger people.
Examples are:
Tight glucose control in an elderly diabetic might be sacrificed if it would call for initiation
of insulin therapy with placement in a nursing facility. Colon cancer screening in 75-year-
old men requires investigating about 300 men over their remaining lifetimes to prevent
one death. But for men over 85 years of age, with average life expectancy of 5 years,
colon cancer screening is unlikely to increase life expectancy by finding screening-
detectable cancers. In this same advanced age group, however, screening for falls
requires questioning only two or three individuals to detect one at risk.
Some interventions produce almost immediate benefit, and those are useful at any age.
Evidence supports the conclusion that even the oldest old can benefit from beginning an
exercise program. Counselling patients on the benefits of physical activity is likely to be a
good use of physician time at any age.
Caregiver Issues. Providing primary care for a frail elderly person requires attention to the
caregiver as well as the patient, since the health and well-being of the two are closely linked.
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SECTION 08 APPLIED MEDICINE IN THE VARIOUS AGE GROUPS
Direct questions to the caregiver about stress, burnout, anger, and guilt are often
productive. For the stressed caregiver, a social worker may help identify programs such as
caregiver support groups, respite programs, adult day care, or hired home health aids.
The elderly patient who is also a caregiver is at risk for depression and should be screened
for it.
Using Time Efficiently. Certain strategies can guide a physician in using time wisely
with an elderly patient:
• Identify the patient’s goals and values for medical care early in your therapeutic
relationship.
• Use brief assessment instruments when appropriate, and train non-physician
personnel in their performance.
• Employ portable amplifiers, large print information, and magnifying lenses.
• Involve other professionals (nurses, social workers, dietitians, physical and
occupational therapists, psychologists) in complex cases.
Apart from formal assessments, much can also be gleaned from observations in the
doctor-patient encounter. Such observations complement the information obtained from
formal assessments and often times give a rapid insight into the functional status of the
patient. (Johnston et al, 2003). For example, Greeting the patient in the waiting room
allows the physician to note affective and cognitive response, the strength of the
handshake, the ease of rising from a chair without using the arms, the length and
steadiness of the stride, and the ability to follow directions to the examining room and to
sit down safely in the examining room chair. Observing the patient dress or undress can
also enhance detection of impaired cognition, fine motor skills, balance, and judgment.
History Taking
History taking should not be omitted. Most older patients are able to provide a reliable
medical history. Also, if the patient is unable to comprehend or communicate, data
should be sought from family, friends, and caregivers. Ask about visual impairment,
hearing loss, falls, and incontinence as many will not volunteer such information. The
history should also include drug ingestion; dietary patterns; falling, incontinence, sexual
dysfunction, depression and anxiety.
440
Physical Examination
Certain areas should receive special attention, depending in part on clues from the
history. The following is a checklist:
• General examination. Measure weight and postural blood pressure at most visits.
• Special senses. Check vision and hearing; if hearing is impaired, excess cerumen could
be the cause. Direct visual testing with a Snellen chart or Jaeger card is the most
sensitive and specific approach to visual screening. The whispered voice test is easy to
perform and has sensitivities and specificities ranging from 70% to 100%.
• Mouth and denture. Assess denture fit, and inspect the oral cavity with the dentures removed.
• Neck. Physical examination can rarely corroborate or exclude thyroid dysfunction in
older patients.
• Breasts. Do not overlook. Older women are more likely to have breast cancer and are
less likely to do breast self-examination.
• Cardiovascular system. The systolic murmur of aortic sclerosis is common and may be
difficult to differentiate from aortic stenosis, especially since the presence of a fourth
heart sound in an elderly person does not imply significant cardiac disease, and the
carotid upstroke normally increases owing to age-related arterial stiffening.
• Abdomen. Check for faecal impaction in inactive patients and those with faecal or
urinary incontinence. Since it may be the only finding in urinary retention; test perineal
sensation and the bulbocavernosus reflex.
• Gait and balance. The “get up and go” test and test for static (standing) balance to
confirm the fall prone patient and to predict fall risk.
• Neurological system. “Frontal release signs” (e.g., “snout,” “glabellar,” or
palmomental reflexes) absent ankle jerks and vibratory sense in the feet may be
normal in the elderly.
Cognitive testing. People with mild degrees of dementia usually retain their social graces
and may mask intellectual impairment by a cheerful and cooperative manner; the
examiner should therefore always conversational probing. Also, an examination that tests
only orientation as to person, place, and time is insufficient to detect mild or moderate
intellectual impairment.
• Conversational probing. For patients who follow the news, one can ask what stories
they are particularly interested in and why; the same applies to reading, social events-
even the soap operas on television. If there is any suspicion of a cognitive deficit after
this kind of conversational probing, further questioning is indicated.
• Draw a clock test. As a quick screen, ask the patient to draw a clock with the hands at
a set time (e.g., 10 min before 2:00). This test can be very informative regarding
cognitive status, visuospatial deficits, ability to comprehend and execute instructions in
logical sequence, and presence or absence of perseveration.
• Folstein’s MMSE. For slightly more detailed examinations, many practical mental status
tests are available. The most widely used is the Mini-Mental Status Examination of
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SECTION 08 APPLIED MEDICINE IN THE VARIOUS AGE GROUPS
Folstein, which provides a numerical score that can be obtained in 5 to 10 min. (Figure
1). A similar test is the EQAC score (Figure 2).
• Assessment of Decision-Making Capacity. It is common for a cognitively impaired elder
to face a serious medical decision and for the clinicians involved in his care to ascertain
whether the capacity exists to make the choice. There are four components of a
thorough assessment: (1) Ability to express a choice. (2) Ability to understand relevant
information about the risks and benefits of planned therapy and the alternatives,
including no treatment. (3) Ability to understand the situation and its possible
consequences. (4) Ability to reason. A patient’s choice should follow rationally from an
understanding of the consequences (Johnston et al, 2003). Decision-making capacity
varies over time: a delirious patient may regain his capacity after the infection is
treated, and so reassessments are often appropriate. Furthermore, the capacity to
make a decision is a function of the decision in question. A mildly demented woman
may lack the capacity to consent to coronary artery bypass grafting yet retain the
capacity to allow removal of a suspicious nevus.
• Screening the High-Functioning Elder. Standard functional screening measures may
not be useful in capturing subtle impairments in highly functional independent elders.
One technique for these patients is to identify and regularly ask about a target activity,
such as playing bridge, bowling, or practicing law. If the patient begins to have trouble
with or drop such an “advanced activity of daily living,” it may indicate early
impairment, such as dementia, or worsening hearing loss, which additional gentle
questioning or assessment may uncover (Johnston et al, 2003).
442
Figure 1. Folstein’s Mini-Mental State Examination (MMSE). — Cont’d
Write in the points for each correct response. Score Points
A total of 30 points is possible. Recall
5. Ask for the names of the three objects
learned in question 3. (Give one point for
each correct answer.) _____ 3
Language
6. Point to a pencil and a watch. Have
the patient name them as you point. _____ 2
7. Have the patient repeat “No ifs, ands
or buts.” _____ 1
8. Have the patient follow a three-stage
command: “Take a paper in your hand.
Fold the paper in half. Put the paper on
the floor.” _____ 3
9. Have the patient read and obey the
following: “CLOSE YOUR EYES.” (Write
the words in large letters.) _____ 1
10. Have the patient write a sentence of
his or her choice. (The sentence should
contain a subject and an object, and it
should make sense. Ignore spelling errors
when scoring.) _____ 1
11. Have the patient copy the following
design. (Give one point if all sides and
angles are preserved and if the intersecting
sides form a quadrangle.) _____ 1
Total _____
Total score 10
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SECTION 08 APPLIED MEDICINE IN THE VARIOUS AGE GROUPS
Interpretation: Correct answers > 7 = normal, 5-6 = borderline case of cognitive impairment, 0-4 = probable case
of cognitive impairment
Functional Assessment
Information about function can be used in a number of ways: (1) as baseline information;
(2) as a measure of the patient’s need for support services or placement; (3) as an
indicator of possible caregiver stress; (4) as a potential marker of specific disease activity;
and (5) to determine the need for therapeutic interventions. Functional assessment
gauges a patient’s ability to manage tasks of self-care, household management, and
mobility. This can be assessed by the ADL and IADL scores.
ADL - The Katz index. This gives an idea of dependency of the elderly person. While
many persons who need help with ADLs may require a nursing home level of care, most
live at home with caregivers. The activities of daily living (ADLs) are: bathing, dressing,
eating, transferring from bed to chair, continence, toileting). See Figure 3. Fully one-half
of those over 85 have ADL impairments.
When measuring ADL, one needs to be aware that patients sometimes report falsely that
they can perform an activity because they fear the repercussions of failure or simply
cannot remember. Thus, combination of all three methods is ideal: ask the patient, ask
the family, and observe what the patient can and cannot do.
Interpretation: Unable to perform 1-2 activities = mild to moderate dependence; 3 or more activities =
severe dependence.
Instrumental activities of daily living (IADL). Persons who need help only with IADL may be
aided by a chore worker, a day program, or placement in a board-and-care home or
assisted living situation. See Figure 4. About one-fourth of patients over 65 have
impairments in their instrumental activities of daily living (IADLs): transportation,
shopping, cooking, using the telephone, managing money, taking medications,
housecleaning, laundry). Persons who are unable to perform IADLs independently are 12
times more likely to have dementia than their independent counterparts.
Interpretation: Inability to perform activities pinpoint the intervention needed for independent living
444
Social And Economic Assessment
The social assessment evaluates the patient’s perception of his own health status, his
environment, his family situation, financial status, and leisure activities. Is the housing
affordable and accessible? What community supports does the patient have? Are there any
indications of substance abuse? Who pays the bills? How does the patient spend a typical
day? Social assessments are particularly important when the patient requires acute care and
also becomes temporarily or permanently less able to function independently at home.
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SECTION 08 APPLIED MEDICINE IN THE VARIOUS AGE GROUPS
Preventive care in the elderly can be grouped into primary prevention and secondary
prevention (health screening). The goals of preventive care are different for older adults,
especially in the old-old (75 plus) and the very-old (85 plus). In younger patients,
prevention of premature death drives the public health agenda, while prevention of
disability and maintenance of function becomes paramount for older adults.
Areas to focus
Educating and counselling seniors is one of the most efficacious and cost-effective
preventive efforts. Education programs should address the following topics:
• Smoking cessation to prevent vascular disease, chronic lung disease, lung cancer,
and osteoporosis.
• Nutrition to promote maintenance of optimal weight, good dental health, and
appropriate use of supplements.
• Exercise and mobility, to prevent heart attacks and strokes, diabetes, falls, and hip fractures.
• Safety programs, to prevent motor vehicle accidents, falls, and burn injuries.
446
Table 7. Suggested Screening And Interventions For People Over 70
Years of Age
SCREENING COMPONENT FREQUENCY
History
Physical activity/exercise Yearly
Mobility decline/history of falls Yearly
Medication review (including OTCs) Yearly (five or more medications: quarterly)
Nutrition ( for dec appetite, weight) Yearly
Mood Yearly
Tobacco/alcohol use (CAGE questions) Initially, then discretionary
Bowel/bladder dysfunction Yearly
Driving (safety assessment) Yearly
Relationships/sexuality Yearly
Functional assessment — ADL & IADL Yearly
Social supports Yearly
Advance directives Initially, then yearly updates
Physical examination
Weight, BP (postural, if on relevant drugs) Yearly (discretionary at each visit)
Skin assessment Yearly (immobile patients quarterly)
Eye (Snellen Chart) Yearly
Hearing (observe, whisper test) Yearly (check for cerumen if impaired)
Breast examination Yearly
Rectal examination (prostate cancer, note size) Yearly
Pelvic examination (women), Discretionary
bladder distention (men)
Gait: “Get up and go” test Discretionary (if dec mobility or falls)
Folstein Mini-Mental Status Initially, then discretionary
Examination (yearly average 80)
Screening laboratory and diagnostics
Urinalysis Probably Initially, then discretionary
Cholesterol Conflicting data; discretionary
Glucose (random) Initially, then discretionary
TSH Initially, then every 3 years unless
clinically stable
CBC Initially, then every 3 years
Vitamin B,2 Probably Initially, then discretionary
Electrolytes, liver function tests Probably Initially, then discretionary
TB testing (two-step, Mantoux) Initially, then discretionary in
nonhospitalized patients
ECG Initially, then discretionary
Chest x-ray Discretionary
Bone densitometry Initially, then every 2-3 years in
women not taking estrogen and
willing to take alendrolate
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Referrals
Ophthalmologist or optometrist Yearly, or discretionary
Dental evaluation Yearly
Home safety evaluation (Visiting Discretionary
Nurse Association)
Immunizations
Influenza Yearly
Pneumovax Initial, repeat every 6 years
Tetanus-diphtheria Initial immunizations if not
received; booster discretionary
Hepatitis B Not specifically indicated
In the elderly, a fall may be a warning symptom of an underlying medical problem and
falls are often a marker of frailty that could improve with intervention. Up to 50% of
those who have fallen admit to avoiding activities because of fear of further falls or injury
(Nevitt et al 1989). Falls in the elderly are not inevitable and the cause of each fall must
be investigated and intervention instituted to prevent future falls.
Workup
Causes
Falls can be divided into 3 categories from the standpoint of assessment
• Falls with loss of consciousness - Fits, epilepsy; vasovagal syncope; hypoglycemia;
cardiac syncope; TIA; postural hypotension.
• Hot falls (falls due to acute medical illness) - acute Myocardial Infarct; stroke; sepsis;
electrolyte abnormalities; bleeding GIT.
• Cold falls - chronic intrinsic causes; medications.
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For a patient who presented with an acute fall, it is always important to exclude an acute
medical illness. See Table 8.
History
Details of the fall. A thorough history of falls is important to determine the mechanism of
fall, the associated symptoms with falls, ability to get up after a fall and the consequences
of the falls. They should be asked about the activities they were engaged in before the
fall. Usually, activities which displace the centre of gravity e.g. changing positions,
walking, climbing stairs are the most common activities associated with falls. The location
of falls may be associated with hazards in that particular area. The symptoms if present
before the fall may help the physician decide on the appropriate diagnostic tests.
Medication review. A review of the patient’s medication may reveal potential causes
(Table 9).
Physical examination
The physical examination should include vision assessment, postural blood pressure, a
cardiovascular examination, a neurological examination and examination of the musculoskletal
system. Included in the physical examination should be a gait and balance assessment.
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Timed “up and go” test. This is a simple and useful test. The patient is required to get up
from a chair, walk 3 metres, turn and walk back to the chair and sit down. Previous
studies have shown that patients who make it in more than 20 seconds have mobility
problems and are at risk for falls. Those who take less than 10 seconds are independent
and those who take 10 to 20 seconds are borderline (Podsiadio & Richardson, 1991).
Testing for static (standing) balance. This can also predict fall risk. After the clinician
demonstrates each one, the patient is asked to assume three stances, keeping the eyes
open for each: side-by- side stance (feet parallel); semi-tandem stance (feet parallel, but
one of them ahead of the other by one-half of a foot length), and tandem stance (one
foot directly in front of the other). Patients unable to hold these stances for more than 10
seconds (without marked swaying) are at increased risk for falls (Sheman, 2000).
Management
Medical intervention will depend on the risk factors found during assessment and
physical examination.
Prevention Of Falls
Prevention of falls requires the attention to removal of the extrinsic factors, correction of
the intrinsic factors as far as possible, and attention to medications (See Table 8 and Table
9). An elderly person taking more than four prescribed drugs has an increased risk for
falls. It will be a good preventive measure to ask every new elderly if he or she has had a
recent fall and to report a fall, if any when he or she attends subsequently. A person who
reports a fall should undergo a balance and gait assessment to confirm or rule out poor
balance and gait as risk factors for further falls.
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References and further reading
Hadfizah N. The falling elderly. Sing Fam Physician 2002; 28(4):82-86
Steinweg KK. The changing approach to falls in the elderly. Am Fam Physician 1997 Nov 1;56(7):1815-23
Podsiadlo D, Richardson S. The Timed “Up & Go” a test of basic functional mobility for frail elderly. J Am Geriatr
Soc.1991; 39:142-8.
Delirium, dementia, and depression share in common, cognitive impairment. More than
one of these can co-exist in the same person. In an older adult, a good rule of thumb is
to consider any change in mental status to be a delirium till proven otherwise. This is
particularly true if the episode occurs when a patient is in the emergency department, the
hospital, a nursing home, or an assisted living setting (Sherman, 2000).
Delirium
Workup
Assessment
The Confusion Assessment Method (Inouye et al, 1990) can be used to identify the
presence of a delirium in a patient who meets the first two criteria and either of the other
two:
• An acute onset and fluctuating course (Is there evidence of an acute change in mental
status, and does the behaviour come and go?)
• inattention (Does the patient have difficulty focusing attention? Is the patient easily
distracted or having difficulty following what is being said?)
• disorganized thinking (Is the patient’s speech rambling or irrelevant, or switching from
one subject to the next?)
• an altered level of consciousness. (A normal patient should be alert; any other
assessment of the patient’s level of consciousness [e.g. lethargic, stupor, or hyper-alert]
is abnormal.)
Review medications that the patient is on, the addition of a new agent or the
discontinuation of a medication.
Physical examination
Look for abnormalities in the vital signs, evidence of organic disease in the cardiovascular,
respiratory, gastro-intestinal, neurological systems.
Investigations
Laboratory evaluation of most patients should include a complete blood count,
electrolytes, blood urea serum creatinine, glucose, calcium, albumin, liver function
studies, urinalysis, and electrocardiography. In selected cases, serum drug levels, arterial
blood gas measurements, blood cultures, and chest radiography may indicate the
underlying cause (Sherman, 2000).
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Management
Treat underlying cause. Correction of the underlying cause is important. Younger persons
with a delirium, including those experiencing alcohol withdrawal syndrome, typically
exhibit a hyperkinetic, hyperalert delirium. In older persons, however, a delirium tends to
be “quiet.” It is marked by lethargy and difficulty responding to stimuli, and patients are
hypokinetic and hypoalert.
However, if a cause is not found and behaviour does not respond to environmental
manipulation (e.g., ignoring the behaviour, distracting the patient, addressing situational
“triggers,” and providing a calm environment), low doses of an antipsychotic medication
may be helpful (e.g., haloperidol 0.25 to 2mg/d orally).
Lingering effects. Most clinicians presume that an episode of delirium is reversible, but
the data suggest otherwise. One important study looked at the outcomes of 325
hospitalised older patients with delirium who were admitted from either the community
or a long-term care facility (Levkoff et al, 1992). Using DSM-III criteria, the researchers
found complete resolution of delirium symptoms in 4% of patients at hospital discharge,
in 20% after 3 months, and in 17% after 6 months. Average length of hospitalisation
was 19 days for patients with a delirium, compared with 7 days for those without one.
Finally, older patients with a delirium had a seven-fold increased risk for nursing home
placement.
Thus, when counselling the family of a patient with delirium, it is important for physicians
to discuss potential outcomes frankly and realistically. Complete resolution of delirium is
often a slow process; in some cases, it can take months to years.
Dementia
Workup
Causes
The most common causes are: Alzheimer’s disease, vascular dementia, dementia with Lewy
Bodies and fronto-temporal dementia. Potentially reversible causes are drug effect,
depression, thyroid disease, vitamin B12 deficiency, hypercalcemia, subdural hematoma, and
452
normal pressure hydrocephalus. Unfortunately, the prevalence of fully reversible dementias is
well under 5%. Correction of these suspected causes leads only to partial improvement.
History
Demented patients have memory impairment, plus at least one or more of the following:
• language impairment (initially just word finding; later, difficulty following a
conversation; finally, mutism);
• apraxia (inability to perform previously learned tasks, such as cutting a loaf of bread,
despite intact sensory and motor function);
• agnosia (inability to recognize objects); and
• impaired executive function (poor abstraction, mental flexibility, planning, and judgment).
False dementia. Occasional difficulty retrieving items from memory (usually manifested as
word-finding complaints) and experience a slowing in their rate of information
processing. Is not dementia.
Animal-naming test. This screen is used to gauge impairment of verbal fluency and access
to semantic memory. Ask the patient to name as many animals as he or she can in a 1-
minute span. The typical response of a patient with Alzheimer’s disease would be: “dog,
cat, cow, [long pause] dog. . . .”Then the patient’s attention will drift off, and he or she
will lose focus. Older persons without dementia can usually name 18 different animals
within the 1-minute span. Anything less than 12 is abnormal and correlates well with an
MMSE score of less than 23.Animal-naming test scores can vary depending on the
patient’s age and level of education, but 18 and 12 are generally good cut-off points for
normal and abnormal results, respectively (Morris et al, 1989).
Physical examination
A neurological examination is essential besides mental status testing. Examine for focal
neurological deficits. The remainder of the physical examination should focus on
uncovering comorbid conditions that may aggravate the individual’s disability.
Investigations
Laboratory studies for most patients are intended to uncover treatable causes of cognitive
impairment and include a complete blood count, electrolytes, calcium, creatinine,
glucose, thyroid-stimulating hormone (TSH), and vitamin B12 levels. HIV testing, rapid
plasma reagin (RPR), and liver function tests may be informative in selected patients.
Although consensus is lacking with respect to which patients benefit from head
computed tomography (CT) or magnetic resonance imaging (MRI), those who have focal
neurologic signs or symptoms, seizures, gait abnormalities, and an acute or subacute
onset are most likely to yield positive findings.
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Management
Explanation and carer support. Upon the diagnosis of dementia, patients and families
should be made aware of the expected progression of the disease, the social support
available and what they can do for the elderly as well as how to cope with carer stress.
Treat co-morbid diseases. Because demented patients have greatly diminished cognitive
reserve, they are at high risk of experiencing acute cognitive or functional decline in the
setting of new medical illness. Co-morbid diseases such as congestive heart failure and
infections should be diagnosed and treated. The carers should be alerted to bring the
patient for medical attention early when he becomes unwell.
Medications. Donepezil has been shown to produce statistically significant but clinically
modest improvements in cognitive function when used to treat mildly to moderately
demented patients. Roughly one-third of patients show improvement. The drug is started
at 5 mg orally each day; if tolerated and the effect plateaus, the dose may be increased to
10 mg daily after 4-6 weeks. The drug should be discontinued if there is no demonstrable
benefit (as reported by caregiver) after 3-6 months. Other cholinesterase inhibitors such
as rivastigmine appear to have efficacy similar to that of donepezil.
Behavioural problems. Behavioural problems in demented patients are often best managed
with a nonpharmacologic approach. Initially, it should be established that the problem is
indeed a behavioural manifestation of dementia and not unrecognised delirium, pain,
urinary obstruction, or faecal impaction. Next, it helps to inquire whether the caregiver can
tolerate the behaviour, as it is often easier to find ways to accommodate the behaviour than
to modify it. If not, the caregiver is asked to keep a brief, informal journal in which the
behaviour is described along with antecedent events and consequences.Teach carers to use
simple language when communicating with the patient, to break down activities into
simple component tasks, and to employ a “distract, not confront” approach when the
patient seems disturbed by a troublesome issue. Additional steps to address behavioural
problems include the discontinuation of all medications except those considered absolutely
necessary and correction of sensory deficits.
454
typical drugs (such as haloperidol) are less so but have a higher incidence of associated
parkinsonism. The newer, atypical agents (risperidone, olanzapine, quetiapine) have
fewer motor side effects, at least at lower doses, but are considerably more expensive.
Drug reduction efforts must be made at least every 6 months. Haloperidol, trazodone,
behavioral management techniques, and placebo all resulted in comparable modest
reductions in agitation in patients with dementia (Lyons et al, 2003).
Prognosis
Life expectancy after a diagnosis of Alzheimer’s disease is typically 3-15 years. Other
neurodegenerative dementias, such as dementia with Lewy bodies, tend to show more
rapid declines.
Depression
Workup
The diagnosis requires the presence of a depressed mood for at least two consecutive
weeks plus at least four of the following eight symptoms: sleep disturbance, lack of
interest, feelings of guilt, decreased energy, decreased concentration, decreased appetite,
psychomotor agitation/retardation, and suicidal ideation.
The screening test for depression is a single question: “Do you often feel sad or
depressed?” Sensitivity and specificity for this question are 85 and 65%, respectively, so it
is a relatively sensitive but non-specific question. It is, however, a start. If the patient
answers affirmatively, further screening can be performed using the five-item version of
the Geriatric Depression Scale (Hoyl et al, 1999).
Score: Positive answers for depression screening are “yes” to questions 2, 3, 4, and 5 and “no”
to question 1. A score of 0 to 1 positive answer suggests the patient is not depressed; a score of
2 or higher indicates possible depression. Sensitivity: 97%; specificity: 85%; positive predictive
value: 85%; negative predictive value: 97%
Source: Reprinted with permission from Hoyl MT, Alessi CA, Harker JO, et al. Development and testing of a five-
item version of the Geriatric Depression Scale. J Am Geriatr Soc 1999; 47(7):873-8.
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If results of either test are positive, the primary care physician should perform a thorough
interview that evaluates neuro-vegetative signs, including sleep and appetite disturbances.
Management
Referral and joint management. Referral to a psychiatrist is necessary for the patient with
suicidal thoughts. Joint management with the psychiatrist could be instituted for the less
severe depressed patients.
Electroconvulsive therapy. This is successful and is well tolerated by elderly patients who
remain severely depressed despite drug treatment, particularly if they also have delusions.
REDUCING POLYPHARMACY
Reducing polypharmacy reduces the risks to the elderly from falls and other iatrogenic
disorders. Table 10 shows the steps to reduce it.
Table 10. Ten Steps To Reduce Polypharmacy
1. Keep an accurate record of all medications the patient is on, including over the counter medications.
2. Get into the habit of identifying all drugs by generic name and drug class.
3. Make certain that each drug being prescribed has a clinical indication.
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Table 10. Ten Steps To Reduce Polypharmacy – Cont’d
4. Know the side-effect profile of the drugs being prescribed.
5. Understand how pharmacokinetics and pharmacodynamics of aging increase the risk of
adverse drug events.
6. Keep an accurate record of all medications the patient is on, including over the counter medications.
7. Get into the habit of identifying all drugs by generic name and drug class.
8. Make certain that each drug being prescribed has a clinical indication.
9. Know the side-effect profile of the drugs being prescribed.
10. Understand how pharmacokinetics and pharmacodynamics of aging increase the risk of
adverse drug events.
Source: Carlson, 1996
Outline
The primary care doctor and public health
Control of non-communicable diseases
Control of communicable diseases
Principles of immunisation
Immunisations for adults
Integrated management of childhood illnesses
Developing countries of the world are in the epidemiological transition of having both the
communicable diseases of public health importance and also the non-communicable
countries. The primary care doctor is well placed to participate in the control of diseases
of public health importance.
Descriptive Epidemiology
Descriptive epidemiology is the measurement of prevalence rates by variables of time,
place, and person. The family physician uses this knowledge of disease prevalence in his
practice population to establish the relative likelihood of a particular disease in the
differential diagnosis of diseases in the individual patient.
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control, and these may be divided into three components: descriptive, analytical,
and experimental.
Descriptive Epidemiology
Descriptive epidemiology is the measurement of prevalence rates by variables of time,
place, and person. The family physician uses this knowledge of disease prevalence in his
practice population to establish the relative likelihood of a particular disease in the
differential diagnosis of diseases in the individual patient.
There are four important ways of transmission of disease agents to man: (1) by contact;
(2) by food, milk or water; (3) by the airborne route; and (4) by vectors. A single disease
may be spread by different ways, depending on the epidemiological circumstances. There
are four important types of reservoirs of human disease agents: (1) man, (2) other
animals, (3) soil, and (4) water.
Each time a family physician encounters a patient with an infectious disease, the source
and means of acquisition of the infection by his patient should be considered. In a
common source outbreak such a line of thinking may lead to timely action to prevent
further spread of the disease to someone else.
There are three types of disease outbreaks or epidemics: (1) common source, single
exposure epidemics, (2) common source, continuous exposure or multiple exposure
epidemics, and (3) person to person, non-common source epidemics. The necessary
epidemiological information to make the differentiation can only be obtained by having a
reasonably complete case count and examining the epidemic histogram, that is, a plot of
the time of onset of those who were ill.
If the epidemic peaks rapidly and there is little or no secondary wave, it is most likely a
common source, single exposure epidemic. If the epidemic continues over more than one
incubation period, there is either person-to-person spread or repeated or continuous
exposure to a common source.
Whilst it is recognised that the practising family physician does not always have the time
available to collect all data for a careful epidemiological study of a disease outbreak, he is
458
in an important position to alert the health department to the possibility of an outbreak in
the community if he notices a larger than usual number of cases in his consultations.
Analytical Epidemiology
Analytical epidemiology is the evaluation of the various etiological hypotheses, which
have been formulated from the descriptive data. There are basically two types of
analytical studies, case control and cohort.
A case control study is usually done after the fact or retrospectively. The important
defining feature of a case control study is that the two comparison groups are selected
on the basis that one has the disease and the other has not. The comparison then is
made to determine whether the two groups differ significantly in their exposure to the
suspected causative agent or risk factors. This type of study is used in an investigation
of a disease outbreak.
In a cohort study, two comparison groups are chosen from a population of persons who
do not yet have the disease. The advantages and disadvantages of this type of study over
the case control study are shown in Table 1.
• Direct estimates of the degree of risk or • Unless a disease is quite common or occurs
relative risk associated with an etiologic quickly after the exposure to the etiological
factor can be obtained factor(s), a cohort study may not be feasible.
• Dose response ratios can be calculated Thus, low incidence in the population and long
and interactions with other variables incubation period between the host-agent
directly examined. interaction and the appear ance of disease has
prohibited many cohort studies of cancer from
being undertaken. Nevertheless, some cancers
have been studied using cohort studies e.g.,
lung cancer and occupational cancers.
• Unless a risk factor has a strong and consistent
association with a given disease, it might not
be detected even in a large study.
Two important terms in analytical epidemiology are relative risk and attributable risk.
• Relative risk. This is the ratio of the incidence of the disease in those exposed to that of
those unexposed to the risk factor. If the relative risk is high, an etiological association
with the disease is very likely.
• Attributable risk. This is the absolute incidence of the disease that can be attributed to
the risk factor. The attributable risk is a predictor of what the effect of removing the
risk factor is likely to be. The concept of attributable risk, therefore, is useful in
planning analytical epidemiological studies and control programmes.
Experimental Epidemiology
Experimental epidemiology is used in clinical trials. A population is divided into two
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groups, one receiving a given treatment or vaccine and the other serving as a control. The
two groups are then observed for the subsequent rate of occurrence of disease. The
efficacy of the new treatment or otherwise compared to the control can be determined.
Important examples are: cardiovascular disease, cancer, chronic lung disease, diabetes
mellitus and other metabolic diseases, liver disease, musculoskeletal disease and
neurological disorders.
With globalisation, the risk of spread of a communicable disease from one community to
another is increased. For good communicable disease control, a mechanism for noting
and reporting numbers of communicable diseases need to be in place. Every medical
practitioner - hospital specialist, family physician or public health specialist — each has a
duty to report unusual increases of symptoms suggestive of disease outbreaks among the
patients seen and to assist in the investigation of such instances.
Disease outbreaks come to the attention of the public health authorities either by an
unusual increase of cases noted from epidemiological surveillance systems, or by
notifications from individuals directly or indirectly affected by the outbreak (e.g.
caregivers, cases, relatives) notify the authorities directly.
Epidemiological surveillance systems are structures set in place for the express purpose of
collecting, analysing, and interpreting information relating to disease outbreaks. The
timeliness of data availability is important if it were to be an effective early warning
system. An awareness of an unusually large number of cases by medical practitioners or
caregivers is a more common way of awareness of an outbreak.
460
The investigation of disease outbreaks uses descriptive and analytical epidemio-
logical principles.
Outbreak Investigation
Once the initial signal of an outbreak is verified, establish a reliable case definition.
Briefly, the case definition is the set of standardized criteria used to decide whether an
individual should be classified as having the disease in question. Once a reliable case
definition is established, the investigator submits each prospective case to these
standard criteria for inclusion or exclusion in the study.
The investigation team also searches for previously unidentified cases. In searching for
additional cases, the investigator checks local hospitals, clinics, and clinical laboratories
that are likely to participate in the diagnosis or treatment of cases. It often proves
useful to question directly those individuals who might treat or encounter the disease.
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Once data are collected, the investigator describes the outbreak according to the
epidemiologic variables of time, place, and person. Descriptive epidemiology has the
following objectives: (a) To assess data quality for completeness and accuracy; (b) To
learn about the range and extent of the outbreak (c) To assess the possible source of
exposure, mode of transmission, incubation period, environmental contributors, host
risk factors, and agent characteristics; (d) To generate hypotheses about the outbreak.
Time: determine dates and times of onset; draw epidemic curve; determine attack
rates over time.
Epidemic curves provide pictorial insights into: (a) The past and future course of the
epidemic; (b) The incubation period of the disease; (c) Whether the epidemic pattern is
common exposure or propagating. The y axis of an epidemic curve represents the
number (or percentage) of incident cases at a given time. The x axis represents a unit
of time (hours, hour groupings, days, day groupings, weeks, months, years) appropri-
ate to the incubation period of the disease. When drawing the curve, the x axis should
begin before the epidemic period (to show the endemic level of disease prior to the
outbreak’s onset) and extend to the period after the epidemic is over (to demonstrate
whether disease levels have returned to normal).
The shape of the epidemic curve is useful in determining the epidemic pattern of the
disease. Point source epidemics are caused by exposure to the agent from a single
source over a brief time. When this is the case, Does the epidemic exhibits a sudden
rise followed by a rapid fall off (a common source epidemic) or does it exhibit a
plateau or continual rise in the number of cases (a propagating epidemic)?
Place: draw spot map of cases; consider environments of home, work, recreational,
and special meeting places (e.g. weddings, restaurants).
Describing the occurrence of cases by place can provide powerful evidence about the
cause and transmission of the agent. Epidemic maps may take the form of simple dot
maps or more complex maps of area-specific rates. Dot maps may serve to document
the geographic extent of the problem and provide evidence of clustering. The problem
with dot maps, however, is that they fail to account for the number of people at risk in
462
a given area. If populations in areas being compared are unequal in size, dot maps can
be misleading. To compensate for this inherent weakness of dot maps, the investigator
might choose to map area-specific rates. (e.g. cases per 100 inhabitants in the
epidemic zone).
Person: calculate attack rates by age. sex, occupation, ethnic group, and other
personal factors; consider rates of infection, disease and death; note possible means
of transmission.
Description of disease rates by person variables is useful in identifying high risk groups.
Risk, in turn, is presumptively related to the opportunity for exposure or susceptibility
to disease. Examples of person factors relevant to outbreak investigation include
demographic characteristics (age, sex, ethnicity), personal activities and practices
(occupation, customs, leisure activities, religious activities, knowledge, attitudes, and
beliefs), genetic predispositions, physiologic states (pregnancy, parity, distress, nutri-
tional status), concurrent diseases, immune status, and marital status.
A hypothesis is a tentative explanation that accounts for a set of facts and can be
tested by further investigation. In the investigation of outbreaks, hypotheses should
address the most likely source of exposure to the etiologic agent, the means of
transmission, the next steps in the investigation, and future control measures.
Keep in mind, however, that hypothesis generation and development is more art than
science. It begins when the first clues that an epidemic might exist come to light and
continues until the investigation is complete. Hypothesis development requires an
understanding of the disease process and population at risk. It is supported by
discussions with patients, health-care providers, local public health officials, commu-
nity activists, and other interested parties and should include the review of all relevant
clinical, epidemiological, and laboratory information.
In generating and developing hypotheses one should consider: (a) What is generally
known about the disease itself; (b) All relevant clinical and laboratory findings; (c)
What patients say about the disease; (d) Descriptive epidemiological findings; and (e)
Other intuitive insights.
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clues, however, may also come from investigating why certain people exposed to the
putative agent did not become ill and why apparently unexposed people developed
the illness. Exceptions to the observed pattern, or outliers as they are occasionally
called, can provide important clues about the source of infection and mode of
transmission.
The investigation is not complete until the results are disseminated to the appropriate
parties. Study findings should be reported to initial informants, those involved in the
investigation, local, state, and federal public health agencies, and the community
of people affected by the outbreak. This is done in the form of oral briefings and
written reports.
464
Table 2. Elements Of Infection Control
ACTION EXAMPLE
Control the source of the pathogen Remove the source of contamination
Remove persons from exposure
Inactivate or neutralIze the
pathogen at its source
Isolate and treat the infected person
Interrupt the transmission Sterilize or interrupt animate
(environmental control) (vertebrate host) and inanimate
(water, food, soil, air) environmental transmission
Control insect vectors
Improve sanitation
Control or modify the host Immunlze susceptlbles
response to exposure Use prophylactic chemotherapy
Source: Methods In Observatlonal Epidemiology, Second Edition by JennIfer L KeIsey, OUP, 1996
PRINCIPLES OF IMMUNIZATION
No food or drinks must be in the refrigerator. There must be no vaccines kept in the door
of the refrigerator. The vaccines must be in the main compartment of the refrigerator.
Live vaccines can be stored in the freezer compartment but toxoids like DPT and Tetanus
cannot be put in the freezer. To avoid confusion all vaccines should be stored in the main
compartment of the refrigerator at the same temperature between +4°C to +8°C.
Good Storekeeping
When stocks of new vaccines arrive, they should be put behind the old vaccines in the
refrigerator so that, the old vaccines can be used first before their expiry date. This is the
“first in, first out principle of storekeeping and is another very important rule for good
vaccine storage.
WHO Recommendations
No immunization schedule is ideal The World Health Organization (WHO) Expanded
Programme of Immunization recommends that each country determine its own schedule
to best fit its own needs. A guiding strategic principle of any immunization programme is
that protection must be achieved prior to the time infants are at high risk from a disease.
For example, form one quarter to one half of all new poliomyelitis cases occur in infants
from 12 months of age with some cases occurring in those as young as 3 months. Infants
are susceptible to pertussis soon after birth.
Contraindications To Immunization
Contraindications to immunization can be divided into general contraindications to
immunization and specific contraindications.
466
Anaphylaxis. An anaphylactic reaction to previous dose of vaccine, is an absolute
contraindication to further doses of that vaccine. This is rare, but as with the injection of
all foreign proteins is a real and significant risk. Anyone administering vaccines should be
able to recognise anaphylaxis and if they cannot deal with it themselves, should have
someone on site who can. These reactions may be delayed by a few minutes so it is
advisable that children stay in the clinic for 20 to 30 minutes after immunisation. This is
particularly important with measles immunisation.
Specific Contraindications
Hepatitis B
There are no specific contraindications.
Special Considerations
Special considerations for Pertussis Immunization
• Children who have had cerebral damage in the neonatal period.
• Children with a history of convulsions.
• Children whose parents or siblings have a history of idiopathic epilepsy.
For these children, the risk from the vaccine may be higher than normal but the effects
from whooping cough disease itself could be more severe. Neurological complications are
considerably more common after whooping cough than after vaccination.
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HIV-positive children with or without symptoms should receive all vaccines except BCG
vaccine. No harmful effects have been reported following immunization with live
attenuated vaccines for measles, mumps rubella and poliomyelitis in HIV - positive
children, who may be at increased risk from these diseases.
Immunization Procedure
History-Taking
A good history must be taken for suitability for immunization. Before each immunization
the health of the child should be assessed by the nurse or the doctor and also by asking
the parent if the child is well. Minor coughs or colds should not postpone immunization
but a feverish acutely unwell child should not be immunized that day. There is no
evidence that immunizing an acutely unwell child is harmful; it just makes it difficult to
differentiate between a possible reaction to the vaccine and the signs of the acute illness.
Informed Consent
Parents should be informed about the benefits and risks of immunization. Either a written
consent or a verbal consent should be obtained before each immunization.
468
• Check the dose and name of the vaccine against the child’s clinic card.
• The skin should be clean and dry before giving the immunization.
Route of Administration
The routes of administration for different vaccines and their dosages are shown in Table 3.
Interrupted Immunizations
Interrupted immunization need not be restarted. The remaining dose or doses should be
given as if the prolonged interval had not occurred. If the child has missed the primary
doses for triple vaccine and poliomyelitis and is now over 7 years old, only DT and
poliomyelitis immunization will be given.
Unimmunized Children
Children not immunized in the first year of life may be started on a course of primary
immunization any time before the age of 7 years. The schedule should be modified for
these children so that they are properly protected against as many of the communicable
diseases as possible. Thus it is recommended that they receive MMR, DPT end’ oral
poliomyelitis initially at different sites and routes and that they receive subsequent DPT
and OPV at 8 week intervals. This should be continued until the child has received three
doses each of DPT and OPV. For children starting or continuing vaccinations after age 7
years, pertussis vaccine should be omitted.
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Recording
It is very important that all immunizations ale recorded and dated both on clinic records
and in child’s health booklet.
Notification
Notification of immunization is also very important. In Singapore, notify to the Central
Immunization Registry, Maternal and Child Health Department, Ministry of Health, No.
26 Dunearn Road, Singapore. After every immunization (each one) it should be notified,
not after all have been completed. The Central Immunization Registry staff will update it.
Reactions To Immunization
Reactions are rare but it is important to be aware of the possibility.
Immediate reactions
Very occasionally (approximately 1 in 300,000 administered vaccine doses) a child will
collapse within seconds or minutes after being given an immunization. The exact cause
of the collapse is frequently hard to ascertain, as there are difficulties in differentiating
between it and breath-holding. vaso-vagal attacks, and anaphylactic reactions. The
usual signs are pallor, limpness or apnoea. If the child collapses and then rapidly
recovers, this is probably a vaso-vagal or breath-holding attack However, with
anaphylaxis in which the child may loose consciousness or develop urticarial skin lesions
or wheezing rapid action is required.
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A child resuscitation pack should be available in immunization clinics or be carried by
doctors and nurses doing mobile clinics. It should include a box containing 2 x I ml
ampoules of adrenaline 1:1000 (I mg/ml). 4 x I ml syringes. 4 x 23G needles. Also included
should be an airway/mask; suitable for children and specific instructions concerning the
treatment of anaphylactic shock in children.
Non-Specific Reactions
Mild reactions
About 15% of babies have a mild reaction to immunization in the first 48 hours following
injection with either redness and soreness around the injection site or a slight fever and
irritability. These mild reactions are not a contraindication for further immunization.
Severe Reaction
Very rarely, within 72 hours following immunization. a baby may be extremely lethargic,
or have a convulsion or have a very red. swollen injection site around more than half the
circumference of the limb. This reaction must be reported and if this is after the triple
vaccination (Diphtheria, Pertussis and Tetanus), then further immunization should not
contain pertussis.
Specific Reactions
Mild Reaction to MMR Immunization
This is occurs in approximately 30% of children. 7-10 days after injection. and is like a
very mild attack of measles with fever, malaise and sometimes a rash. This reaction
usually-lasts 24-48 hours and the vaccine virus is not transmitted to contacts.
Immunisation for adults can be described under the headings of specific occupational
groups; travel; catch-up immunisations and boosters; elderly and those with chronic
diseases; HIV and immuno-compromised individuals and other high risk groups like
haemophiliacs, renal dialysis patients and infants of Hepatitis B carrier mothers.
Health workers. Health workers dealing with blood products, and surgeons, should be
immunised with Hepatitis B vaccine. Many medical institutions give Hepatitis B vaccine to
all health care workers, medical, dental, nursing staff and also laboratory technicians.
Transmission of rubella in medical facilities to and from health care workers particularly in
paediatrics occurs as well. Health care workers who might transmit rubella to pregnant
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patients should therefore be immune to rubella and it is prudent to screen them for
antibodies to rubella and immunise all susceptibles. Health care workers caring for
patients with chronic diseases can transmit influenza to them; such workers should be
vaccinated yearly with influenza vaccine.
Sex workers. Those occupations in the sex industry, or those who have sex with multiple
partners, should be vaccinated against Hepatitis B.
Police, emergency services personnel and morticians. Police, emergency services person-
nel and morticians are also at risk of Hepatitis B infection.
Travel
Information on immunisation requirements can be obtained from the websites of CDC
(http://www.cdc.gov/travel/destinat.htm). A check on the website should be done to
determine up-to-date travel requirements. Information on disease outbreaks can also be
found on the WHO website (http://www.who.int/en/).
Diphtheria and tetanus vaccines. Having had routine childhood immunisation programmes
for the last twenty five to thirty years, many adults should be immune to diphtheria and
tetanus. If adults are not previously immunised, they require a primary immunising course
of 3 doses of DT with the second dose 4 to 6 weeks after the first dose and the third dose
at 12 months, and boosters administered every 10 years thereafter. Many individuals
remain immune to tetanus into adulthood because they have received tetanus toxoid when
they had injuries, but they are commonly at risk for diphtheria.
Rubella. Rubella vaccine should be given to all women of childbearing age as the
infection is primarily a threat to the foetus. The infection in young infants and children is
quite mild. Rubella vaccine is given in most countries to girls at age 10-12 years and now
as part of the universal childhood immunization programme at 12 to 15 months age
together with measles and mumps. The goal is to ensure immunity before females enter
the reproductive age group.
Hepatitis B. The degree of endemicity of hepatitis B varies widely from country to country.
Hepatitis B is endemic in South East Asia. In areas of high endemicity, infection is
commonly acquired at birth (from a carrier mother) or in early childhood. The indications
for hepatitis B vaccination in adults are in the high risk groups. See Table 5.
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Table 5. Adults Who Should Be Given Hepatitis B Vaccine
Susceptible household or sexual contacts of HBs Ag positive individuals
Promiscuous homosexuals or heterosexuals
Those handling human blood products
Drug users
Those in epidemiologically defined high risk geographical areas
High risk groups -Haemophiliacs, renal dialysis patients.
Source: Lang S & Singh KP. Complete Guide to Immunisation. Part III: Adults, Elderly and Immuno-compromised.
Medical Progress, Sep 1990:27.
Influenza vaccine. Influenza viruses A and B are a frequent seasonal cause of morbidity
and mortality in the elderly, chronically ill and the immunocompromised. Vaccination with
purified components confers protection against vaccine-related type A and type B strains.
The immunity obtained from immunisation is short-lived compared with that following
natural infection. Influenza vaccine is typically 60 to 80% effective in healthy young
adults. Protection against infection in the elderly is much reduced because vaccine
responses may be diminished because of the natural waning of the immune system.
Hence larger amounts of an antigen may be required to produce the desired response.
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vaccine (IPV), diphtheria, tetanus, pertussis (DPT), influenza and pneunmococcal vaccines
are recommended for both symptomatic as well as asymptomatic HIV-infected persons.
Only BCG vaccine and oral polio should be avoided in HIV-infected persons.
Reference
MM Thein & LG Goh. Immunisation For Adults. The Singapore Family Physician 1995, Vol XXI No2
Preventable factors. The preventable factors in this high mortality are: many sick children
are not properly assessed and treated by health care providers; their parents are poorly
advised; diagnostic supports such as radiology and laboratory services are inadequate;
and drugs and equipment are often scarce. These factors make providing quality care to
sick children a serious challenge. WHO and UNICEF have addressed this challenge by
developing a strategy called Integrated Management of Childhood Illness (IMCI).
What is IMCI?
IMCI is an integrated approach to child health that focuses on the well-being of the
whole child and aimed to reduce death, illness and disability, and to promote improved
growth and development among children under 5 years of age. IMCI includes both
preventive and curative elements that are implemented by (1) first level healthcare
providers, (2) the local health care delivery system, and (3) families and communities, all
three components working in unison.
474
What does the IMCI Programme strive to do?
As a strategy, the IMCI Programme has 3 components:
(1) In the health care providers, the IMCI strategy promotes the accurate identification of
childhood illnesses in outpatient settings, ensures appropriate combined treatment of
all major illnesses, strengthens the counselling of caretakers, and speeds up the
referral of severely ill.
(2) In the healthcare delivery system, the IMCI stratergy’s attention to manpower training,
materials, budget.
(3) In the home setting, the IMCI Programme promotes appropriate care seeking
behaviours, improved nutrition and preventative care, and the correct implementation
of prescribed care.
The IMCI planning guide: Gaining experience with the IMCI strategy in a country
describes a phased approach to planning and implementing the IMCI strategy in
countries recommended by WHO and UNICEF. It is available on the WHO website at
http://www.who.int/child-adolescent-health/publications/IMCI WHO_CHS_CAH_99.1.htm.
Other MOH strategies substitute to the success of IMCI. These are:
• Roll Back Malaria (RBM) programme
• Nutrition (NUT) programme
• Expanded Program on Immunization (EPI) programme
• Integrated Management of Pregnancy and Childbirth (IMPAC) programme
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476
CHAPTER 6
PUBLIC HEALTH
SECTION 09
TEACHING FAMILY MEDICINE
1 Tasks Of Teaching
2 Curriculum Planning
3 Organising The Workshop
4 Giving A Lecture
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CHAPTER 1
SECTION 09 TEACHING FAMILY MEDICINE
SECTION 09
ROLE OF A TRAINER
Role Model
A trainer is a role model to his or her trainees. The trainees learn the professional values
and standards of a family physician by observing their trainer at work. Therefore, it is
necessary for a trainer to have good professional values and good professional standards
for the trainees to model upon.
The professional values of a family physician are the commitment to patient-centred care,
attention to the family, and being community-minded. In addition, having a community
perspective that encompasses social, cultural and economic values widens a physician’s
horizon in providing quality medical care. The professional values of continuity of care for
patients, attention to record keeping of patient information, the availability and
accessibility of physician in family medicine need to go beyond rhetoric by taking pains to
demonstrate them in the course of his work. It is important for a trainer to recognise that
he or she needs to practise what he or she preaches for him or her to gain credibility in
the eyes of his or her trainees as a role model of professional values.
To be a good role model, a trainer also needs to possess the desired traits of positive self-
esteem, honesty, good ethics, objectivity, non-judgemental and willingness to help.
Besides, a trainer must be able to show how, explain why and reflect on an action that
has been taken by himself or herself and the trainees.
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Motivator
A trainer is a motivator to his or her trainees. He or she inspires by leading by example, excites
by bringing challenges as well as encourages by enabling and empowering the trainees.
• exude enthusiasm to capture the attention of the trainees at all times and
facilitate learning;
• focus attention to subject areas that could be important and/or difficult for the
trainees to understand;
• try to make learning meaningful and memorable;
• facilitate the storing and retrieval of information by the trainees; and
• indicate the relevance of subject learned to the real world.
To be effective in this role, a trainer uses suitable teaching methods to facilitate the
learning process of the trainees.
One useful teaching method is the use of mnemonics. The idea behind mnemonics is to
inject sense into apparently senseless material. For example, the mnemonic “Ten zebras
beat my cow” makes remembering the branches of the facial nerve easier.
Another way of helping the trainees learn is to get them to look at a subject and think
beyond “what” but ask themselves “how” and “why”; to relate the new information to
existing knowledge; and to use the new information as often as possible.
Explicit categorisation of the subject also helps the trainees to store information. One
example of such method is that during learning, the trainees can categorise a medical
condition as presenting symptoms, differential diagnosis, important physical signs, relevant
investigations and management. These can then be further categorised into specific
treatment, symptomatic treatment, supportive treatment as well as indications for referral
and follow-up care. This categorisation method can also be used in patient education.
Assessor
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Researcher
A trainer is a researcher. He or she needs to be kept abreast of advances in his or her field
and find answers to unanswered questions. A trainer will encourage the trainees to do
likewise. In this context, research becomes “organised curiosity”.
After understanding the role of a trainer, the next topic to discuss in this chapter is ways
to be an effective trainer.
- An adult learner has varying motivations and expectations and very often, these are
pressures that can potentially conflict with the ability to learn.
- An adult learner has to know that relearning a subject is often the situation instead
of new learning and this is encouraged.
- An adult learner is keen to acquire problem solving knowledge and skills that can
be used immediately as opposed to theoretical knowledge.
- An adult learner is interested to share his experiences with others, thus co-teaching
is welcome.
- An adult learner values feedback.
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• The trainer-trainee relationship
The trainer-trainee relationship needs to be built on trust and mutual respect in another
teaching principle that is important to know. With trust and mutual respect, effective
learning can take place. With a scornful trainer, the trainee will be spending all his or her
time in trying not to make a fool of himself or herself or be the butt of ridicule. There will
be no energy left for learning.
In order to train others, a trainer needs to be equipped with the skills of teaching. These
skills can be categorised into four main areas: training needs analysis, curriculum
planning, knowledge and skills dissemination and learning facilitation.
Curriculum planning
A curriculum consists of a syllabus and teaching methods. Curriculum planning helps a
trainer to put the syllabus into operation. Details of curriculum planning will be discussed
in the next chapter.
Learning facilitation
A trainer can facilitate the learning process of the trainees by having them assess
themselves formatively by asking questions and fostering self-critique.
Through fostering self-critique, a trainer can encourage the trainees to be open and
clarify facts. In order to make self-critique a useful tool for self-evaluation, it is necessary
to take note of the following points:
• Put learner’s perspective before your own perspective
• Put forward his or her good points first
• Give recommendations and not destructive criticisms
• Give constructive, timely and specific feedback
• Make direct observation
• Explore underlying difficulties
An example will help to clarify the principles. A trainee shows you a video clip of himself
conducting a consultation and it did not go on very well, because the trainee had
monopolised the conversation leaving the patient not much opportunity to give his ideas
and concerns about his illness and the consultation ended with the trainee writing a
prescription. The patient looked dissatisfied and said that he did not come for a
prescription but whether he could leave the pain in his foot alone. Instead of condemning
the trainee and go into a list of what should be done, you can encourage the trainee to
assess his own performance. You may start with the question “What is the assessment of
your performance in this consultation?” He may well have the insight that he has not
explored the patient’s ideas and consultations about the foot pain. The trainer can
encourage him to go on and express how he would have done things differently. Also,
the trainer may ask, “What did you do well in this consultation?” Having listened to the
trainee’s self critique, the trainer is in a better position to reinforce learning by
highlighting that the trainee has made the self diagnosis of what to do and what not to
do. The trainee will go away having learnt how to improve his consultation skills without
his self-esteem being damaged. Fostering self-critique is therefore an important
teaching technique.
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Have a Positive Attitude Towards Teaching
To make training enjoyable and beneficial to both the trainees and self, a trainer needs to
have a positive attitude towards teaching. A positive trainer-trainee relationship will help a
trainer develops a positive attitude towards the learners under his or her charge. In
addition, keeping abreast of the subject matter and being enthusiastic will enable a
trainer to better enjoy the teaching process. Self-confidence and self-respect will also
boost the morale of a trainer and enable he or she to teach more effectively.
Reference
1 Fabb W. The Family Medicine Clinical Teacher. WONCA Asia Pacific Workshop, June 1995
CURRICULUM
The training sandwich is a useful model for planning a curriculum. The three components
in the sandwich are:
• Learning Objectives. These are the intentions of the teaching activities. From the
objectives a list of topics is developed. Together the topics form the syllabus.
• Learning/Teaching Methods. These are the teaching and learning activities.
• Assessment. These are the evaluation activities to ascertain if learning has
taken place.
There are three domains of learning objectives. They are namely knowledge-based
objective, skills-based objective and attitude-based objective. They cover
respectively the cognitive, psychomotor, and affective dimensions of learning.
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Knowledge-based Objective
Skills-based Objective
The skills-based objective can be stated as the ability to perform, the ability to interpret
and observations made. It can be further defined in terms of the standard of performance
required such as the competency level as well as the familiarity with and awareness of the
subject matter.
In clinical learning, students are taught to look at a case from a problem-solving point of
view. An example of skills-based objective is: Be able to establish why the patient came.
This in turn is part of the set of learning objectives in learning clinical consultation skills.
See Figure 1.
Attitude-based Objective
An attitude-based objective is the behaviour or effect that we are trying to develop in the
trainee. It has been said that attitudes are caught not taught. The trainer is the role model
from which the trainee catches this dimension of learning. Hence, trainers need to review
themselves and ask if their behaviour is exemplary. One example of an attitude-based
objective is: Be able to demonstrate willingness to accept constructive criticism.
The scope of learning and teaching activities is wide. They are shown in Figure 2.
Elaboration of the key teaching methods is found in the subsequent chapters.
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Figure 2. Scope of Learning and Teaching Activities - Cont’d
Small group Case discussion
(10-15 members) Topic discussion
Problem solving
Portfolio learning
Gaming
Defining Assessment
Sequencing
In the context of medical education, sequencing is the order that the learning objectives
are organised. The following are to be observed in sequencing:
This is an important part of curriculum planning. The activities of various teachers need to
be co-ordinated such that there is minimal overlap of the topic. In addition, the trainers
need to be briefed on the teaching objectives as well as areas to emphasise within the topic.
Allocation of Time
Timetabling is another integral part of curriculum planning. A good timetable will have
sufficient time allocated to carry out the activities required during the course. For
example, twenty minutes is a good time allocation unit for a presentation of a topic
whereas one hour or an hour and a half may be needed for a workshop with a report-
back activity.
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Teaching requirements such as rooms, clinics for the trainees to see cases, laboratories
and equipment need to be considered in curriculum planning. If there are workshops,
additional rooms for small group discussion will be required. For clinical teaching in a
consultation room, the ideal allocation ratio will be one or two students to a room.
Where audio-visual equipment is needed, technical staff must be considered unless the
teacher is able to operate it. Clerical staff may be needed to register learners at the
beginning of a course.
A quiet environment is necessary to provide a good and conducive teaching and learning
environment for both the teachers and students.
A workshop is a meeting where people with some experience come together with
resource persons to find solutions to problems as a group. The essential features are
active and full-time participation of everybody in small groups to discuss the problems
and find the solutions. The output of the small group discussions is reported back to the
whole meeting. The value of the workshop over individual problem solving is the breadth
of experience that could be brought together to focus on the problem.
486
WHAT TOPICS ARE USEFUL FOR A WORKSHOP?
In the clinical context, useful workshop topics are medical conditions or clinical situations
where there are many dimensions and solutions to a problem. The lessons to learn are
how is the choice made in such a setting. For example, the workshop can be a patient
with diabetes and complications. The discussion could be on what measures we can
consider to prevent such complications in a diabetic patient. Another area of discussion
could be on early intervention for the same patient.
The success of a workshop depends largely on the way it is planned and on the
arrangements made before the opening session. There are two main areas for
consideration when planning a workshop – administrative aspect and
scientific activities.
Administrative Aspects
The administrative aspect is the backbone that supports the activities of a workshop. The
tasks mainly focus on the logistical and financial components of the workshop. Some
useful tips in accomplishing the tasks are:
• Open a project file for documentation purposes and to ease the retrieval of
information. The file can be arranged according to categories such as budget,
workshop site, selection of participants and organisers, equipment check list, publicity
and evaluation.
• Define the aim of workshop. This will help to determine the topics and deliverables of
the workshop.
• Determine the funding estimation (FE) and sources of funding. A formula for
calculating funding estimation is:
FE = A + (S + T) x N
• Find a suitable venue for the workshop. Some areas of consideration when finding a
venue would be the space available to hold plenary and small group discussions and
tea breaks, accessibility of the location, parking availability and affordability of the place.
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Scientific Activities
The scientific activities together form the programme and content of the workshop.
These include:
• background reading materials and activities for the participants
• number of resource persons as speakers
• time allocation and coverage for each speaker
• invitation of speakers
• topic for the participants’ group discussion
• the reporting-back activity for example, a presentation to the entire audience on the
proceedings of the small group discussions
• workshop evaluation
• workshop summary
• workshop proceedings
Programme
1.15 – 3.00 pm Plenary session:
Introduction – size of the problem and what can be done?
Specialist perspective
Rehab perspective
General Practitioners perspective
In a workshop, participants would be broken up into small groups for discussion before
they convene to share with other groups their thoughts.
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• Elect a discussion leader and two reporters
• Have ice-breaker within the group
• Encourage active participation as small group leader, reporter or discussant
• Discuss plan and timetabling
• Sum up by workshop leader
• Write the discussion
• Have a 10-minute presentation
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The research in this area generally supports the view that notetaking should be encouraged.
The process of encoding information into the notes is one which aids its transfer into long
term memory, particularly if the students can be persuaded to read the notes made soon
after the lecture. It also encourages the students to attend the lecture.
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COMPARISON OF THE OVERHEAD TRANSPARENCY AGAINST THE 35-
MM SLIDE OR POWERPOINT
The comparison between overhead transparency against the 35-mm slide or PowerPoint
is shown in Table 2.
Tips • Don’t have more than six lines • Aim for one idea per slide
of writing on a transparency or • Keep wording to a minimum
more than six words per line • Have more than 10 slides for
• Keep the lettering at least a 20-minute talk
6mm high • Face the audience, not the slide
• Have more than 10 slides for when speaking
a 20-minute talk
• Use Winword to create
transparencies with font type
Arial bold and size 20 or 22 if
you are in a rush
• Face the audience, not the slide
when speaking
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Small group teaching is a teaching session for 5-7 participants. It is not a lecture to a small
audience and has the following three characteristics:
• Active participation from everyone
• Face-to-face arrangement – sit in a circle, not in rows
• A purposeful activity
The small group is a crucible of knowledge and wisdom. It provides an environment to develop:
• Interactive skills and interpersonal skills, e.g. listening, speaking, debating and
group leadership
• Higher-level intellectual skills such as reasoning and problem-solving
• Attitudes and group norms.
There are several types of small group teaching suitable for family medicine. For eaxmple:
• Case discussion – the most effective if based on real life situations
• Topic discussion
• Portfolio learning
• Role play – based on real life situations
To increase the usefulness of the small group teaching, one can introduce problem solving
into the discussion.
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Forming – initial stage – group members test the water
Questions asked – what is acceptable behaviour, what is the nature of the group’s task,
how to do the task? You need to have answers to these questions.
• Pairing. Discussion limited to a minority of the group. The leader needs to involve the
others by saying that he wants to hear from the others.
• Domination by a few members. Discussion is limited to only a few members of the
group. This is a bit better than pairing but does not involve the whole group. The
leader can thank the dominant group member and say he/she would like to hear the
views of the rest.
• Fight. Member(s) trying to score intellectual superiority. Group norms need to be set
that the culture is sharing and mutual respect. The trainer needs to make sure he does
not fall into the same trap.
• Flight. The group leaves problems unsolved. The trainer should attempt to achieve a
learning closure by providing a framework that will take care of all the conflicting
answers. He or she may also ask for further reflection or information gathering for the
next learning session.
• Dependency. The group depends on the brightest member or the trainer who does
work because he feels flattered. Should try to dissuade that by reminding that the
participation needs to come from all.
There are several ways that one can try to improve the clinical tutorial. Here are
some examples:
• Move from a disease oriented approach to a problem solving oriented approach.
• Plan the teaching. Do you have fixed topics to cover or do you have a free hand? Be
sure what you intend to cover.
• Involve the student. Make it clear that all are to participate and come prepared with
cases for presentation and read up aspects of the literature.
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Some thoughts and preparation as well as a procedure are needed for a problem-
solving tutorial.
Procedure
• A week before the tutorial, designate one or two students to prepare a case for
presentation. Tell them they are to be prepared on all clinical and theoretical and
theoretical aspects of the case.
• At the start of the tutorial, outline the aims of the exercise.
• Get the prepared students to give the presenting complaint or allow the patient to tell
the story.
• Stop, and ask the other students what they think the problem or diagnosis could be.
Ask them to justify their suggestions. Encourage the other students to react to
these suggestions.
• Allow the presentation of more data.
• Stop again, and ask the group whether they have changed their views and why.
• Continue the process.
One-to-one teaching is the teaching, supervising, feedback and assessment task of the
trainer in the context of the individual trainee. The focus is on that individual trainee’s
needs, strengths and weaknesses.
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WHAT IS ITS USEFULNESS?
It can be a:
• Consultation-based teaching.
• Case or topic discussion.
• Formative assessment.
• Needs assessment.
A Triadic Relationship
Role modelling is important for the trainee. In the clinical teaching setting, the trainer
shows the following:
• Exhibit enthusiasm in teaching.
• Prepares the trainee for observation, suggesting what he looks for in the consultation.
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It is important to decide on the type of cases or topics to focus on during the discussion.
The focus on cases or topics will be on those where the trainee finds it difficult to
comprehend and learn. Some tips on conducting case or topic discussions are:
• To use common cases and bread-and-butter topics
• To take the trainee step-wise in levels of consultation skills starting from basic skills
before moving on to advanced ones
Tobe effective, the following need to be noted about feedback. The feedback given:
• Is descriptive and not evaluative.
• Is specific and not general.
• Focuses on behaviour and not on personality.
• Shares information and not giving advice – this encourages the learner to decide for
himself how to handle the problem.
• Is given in the context of the trainee’s perception of how he/she performed – if the
trainee thinks he/she has done a poor job, a positive feedback can be confusing. The
trainee should first be asked to evaluate his/her performance.
• Is not misleading – do not say, “Oh, you are doing fine.” when he is not. It would be
more useful to say, “Well, now that you asked me, I observe that…”.
Effective supervision requires planning and effort. The trainer needs to:
• Plan with the learner what role the trainer will play at different stages.
• Select the level of difficulty that he wishes the trainee to experience.
• Assist the learner to focus on specific learning objectives in an encounter with a patient.
• Be accessible when needed.
• Recognises that no two learners are the same — some require more supervision,
some less.
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It is important that the single most important variable affecting the outcome of learning is
the relationship between the trainer and the trainee. The commitment of the trainer is to
the learner and not just to the subject matter. A trusting relationship must be present
before intense personal learning and growth can occur.
There is a need for initial and continuing needs assessment of the trainee. Four questions
are asked:
• Where are you going? Determine the educational objectives. What do you want
him to learn?
• Where are you now? What are the knowledge, skills and attitude levels of the trainee?
• How will you get there? This depends on his needs. Thus:
• If he lacks information ➠ reading assignment and follow-up on these are needed
• If he lacks clinical judgement ➠ practice in problem solving
• If he lacks psychomotor skills ➠ practice on patients and feedback is required on
his performance
• If attitude is interfering with clinical performance ➠ interaction with a respected
role model may be needed
• How do you know you have arrived? The formative assessment will provide the answer.
CHAPTER 7 ASSESSMENTS
WHY ASSESSMENTS?
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Examination drives learning. If the level aimed at is only recall, then the candidate will not
go beyond that level of learning.
Examples
• Confidence checklist
• MCQ, MEQ, Essays, Picture Quizzes
• Random case analysis
• Problem case analysis (Case study)
• Reading assignments
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WHAT DO SUMMATIVE ASSESSMENT INSTRUMENTS TEST?
Theory
Some examples are MCQ, essays (long and short answer essays), slide interpretation.
These can test:
• Recall of knowledge
• Interpretation
• Application of knowledge
• Analysis of problems
Oral Examination
Some examples are practice profile and case commentary. These can test:
• Interpretation of knowledge
• Application of knowledge
• Analysis of problems
Clinical Examination
Further reading
Neil Spike. Assessing Clinical Performance in Family Medicine. WONCA Asia Pacific Workshop, June 1995
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CHAPTER 7
ASSESSMENTS
SECTION 10
ROADMAP OF FAMILY
MEDICINE RESEARCH
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SECTION 10
SECTION 10 ROADMAP OF FAMILY MEDICINE RESEARCHH
Outline
Research & the discipline
Classifying research domain in Family Medicine
SWOT Analysis of Family Medicine research
The 7 Strategies Roadmap
Where do we go from here?
Gaps to effective Family Medicine research are found in the structure, processes and
outcome of the system.
Structure
• to explain phenomenon needs we need a tutored mind on “organised curiosity” and
we need the protected time to pursue things
• to meet our practice needs - we need to consider pilot and mainstream studies; Large
studies have better statistical power; Cross country studies show diversity; Multi-
country collaboration to provide mutual support and better statistical power because
of larger studies possible, the bigger studies can be organised.
Processes
• A cascade training and learning system to build capacity - User (101) - Researcher
(201) - Developer (301) levels for learning, teaching and doing research
Effective outcomes
• Collating & disseminating research findings – presently research is a situation of pearls
separated by oyster shells. There is a need for a system to collate the findings and
disseminate them in a user friendly way. One of the ways is to develop collaborating
family medicine centres to do the collating work. There are some centres in the West.
There is a place to develop such centres in the Asia Pacific countries.
• Publish work on the Internet and hard copy. The Internet is now an effective
worldwide portal that allows information to be shared, stored and printed. The family
medicine collaborating centres could work on using such a common channel
of information.
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• Develop and contribute to Practitioners’ Databases where all the user needs to do is to
click and find answers in the middle of a consultation. The TRIP database by UK
Practitioners is a good example of how family medicine research could find its way to
meet practitioners’ day-to-day information needs
Stange et al has described a new way of classifying the knowledge base of family
medicine into 4 quadrants of knowledge. This knowledge base provides a practical way
of classifying the research domain in family medicine.
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Strategy 1
Set up a country nodal system to span the various stakeholders for nodal development
and national collaboration:
• Universities can contribute the tools, research power, language and culture, and lead
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in the best practice of research
• College of Family Medicine provides the research hub where the various stakeholders
can be linked together for collaborative work and national capacity building;
it provides the channel to link to Wonca and small international groups for
research collaboration
• GP groups provide the real world, clinical questions, and are collaborators for showing
and sharing best practices.
Strategy 2
Establish a country research forum to discuss activities, build ideas, motivate research
• Promote discussion of research activities,
• Provide the platform to build up research ideas,
• Motivate research – awards, conferences, workshops e.g., the activities of NAPCRG
Strategy 3
Set up a country research resources archive to store research tools and outputs
• Tools. These are questionnaires, scales, methodologies useful to family medicine
research in a location that can be easily accessed
• Outputs. These are papers, proceedings, workshop programmes
We can work towards setting up an electronic library of research tools and outputs across
countries more effectively by working towards a common archival system. The member
countries of Wonca for example can contribute towards a Wonca network housed on the
Global Family Doctor website.
Strategy 4
Implement a cascade training system of learning and teaching, doing, and
developing research
• The cascade concept of learning & teaching, doing research through working with
trainers who are one/two levels up in the knowledge/skills ladder provides an effective
way to build capacity for research. Thus at the user level (101 level), novices and users
of research are taught by those who are able to show the way namely, practitioners
and researchers at the researcher level (201 level)/research programme developer level
(301 level); and those at the researcher level (201 level) hone their knowledge and
skills through their interaction with fellow researchers (201 level) and research
programme directors and developers (301 level).
• User level (101 level) – target all GPs and the course objectives will be to able to:
- Understand research as a pathway to evidence-based care;
- Ask relevant clinical questions;
- Search answers to clinical questions in databases;
- Read literature critically such as look for methodology flaws and interpretation
errors.
• Researcher level (201 level) – target 1% GPs for a start and the course objectives will
be to able to
- Ask answerable research questions
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SECTION 10 ROADMAP OF FAMILY MEDICINE RESEARCHH
• Research developer level (301 level) – self selected group with experience and research
interests and the course objectives will be:
- Research analysis and interpretation techniques
- Research programme organisation & funding
- Promotion of research culture, ethics and standards
- Participative and collaborative projects
Strategy 5
Set up a local research network for collaborative research and the activities of the
network will be to:
• Organise participatory research
• Promote ideas
• Pay attention to structure, processes and outcomes
• Building capacity
• Secure funding eg. seed money
• Link up with other networks across the world – collaborative projects on common
research ideas and projects
Strategy 6
Organise presentations for research endeavours — local, national, region, and world
• Local, national, region, world family research units can learn from one another and
build capacity this way
• Research is effective only when the results are disseminated and the new knowledge
and understanding result in outcomes of care — Conferences, workshops, meetings,
writings, and databases keep the meaning of research alive
Strategy 7
Initiate collaborations across countries and regions
• Cross countries & regions can link themselves up for capacity building activities as
well as build the network for research collaboration and dissemination
• The areas of collaboration can be in new topics in Primary care research like
genomics, meta-analysis of existing information; and contributions to physicians’
database contributions from primary care research centres
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WHERE DO WE GO FROM HERE?
For each country – the three initial tasks are suggested are:
• Get the ideas across – AP research network development workshop in July 2004
• Set up the AP country nodes – through AP country representatives by end 2004
• Provide answers to clinical questions for family physicians – a physicians’ clinical Q & A
database in GFD by 2007
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