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FAMILY MEDICINE POSTING

20 Common Symptoms
Class of 2008/2013
Academic Year 2010/2011
June 2010 Edition

Division of Family Medicine


University Medicine Cluster
Yong Loo Lin School of Medicine
NATIONAL UNIVERSITY OF SINGAPORE

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Contents
Preface 3
Contributors & Editors 4

Common Symptoms in Ambulatory Care

1 Fatigue 5
2 Weight Loss 9
3 Fever 13
4 Dyspepsia 18
5 Breathlessness 24
6 Cough 27
7 Sore Throat 33
8 Chest Pain 36
9 Diarrhoea 40
10 Constipation 44
11 Vomiting 48
12 Abdominal Pain 52
13 Skin Rash 56
14 Backache 61
15 Joint Pain 64
16 Giddiness 68
17 Headache 72
18 Insomnia 75
19 Persistently Crying Baby 79
20 Red Eye 81

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PREFACE
COMMON SYMPTOMS IN AMBULATORY CARE
Symptoms form the starting point in the investigation of the patient's dis-ease. It is
necessary that we are knowledgeable as to what these symptoms may mean.

The meaning of symptoms in the hospital revolves largely around serious organic causes
because patients who eventually reach the hospital have been screened either in the
general practitioners' clinic, the government polyclinic or the Accident & Emergency
department. The list of differential diagnosis corresponds to that in standard medical
textbooks, except for differences in local incidence of some diseases. For example,
ulcerative colitis or cystic fibrosis is less common in Singapore compared to that in the
United Kingdom. Primary hepatocellular carcinoma is more common in Singapore.

In the outpatient environment, the diagnostic possibilities are more numerous and minor
diseases are more common. The spectrum is broader: besides organic causes, the reasons
for encounter may be an admixture of psychological and social factors. The family physician
therefore needs a different diagnosis checklist to think about.

It is with this need in mind that the Family Medicine Teachers in the Department of
Community, Occupational and Family Medicine have included the study of the 20 common
symptoms as one of the learning tasks in the GP clinical posting. It is hoped that as you
encounter the common symptoms in the GP clinical posting you will read up the relevant
pages in this set of notes as a starting point and discuss with your GP tutor details on the
approach, workup, management and referral of a patient with such a symptom.

In this edition, clinical cases for reflection have been included. These are for self-study and
for discussion between students and tutor when there are lull periods. They form part of the
“rainy day pack” of things to do when there are no patients in the clinic.

Acknowledgments are due to many GP clinical teachers who contributed in one way or
another to this set of notes or in the correction and updating of the reading material.

We look forward to further inputs from both the student and the GP clinical tutor in the effort
to refine and improve on what we have today.

Assoc Prof Goh Lee Gan


Department of Medicine, Yong Loo Lin School of Medicine
National University of Singapore

Sept 2009, Singapore

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CONTRIBUTORS & EDITORS
Current Edition

A/ P Goh Lee Gan (Editor)


A/P Annelis Wilder-Smith
Adj A/P Cheong Pak Yean
Dr Gerald Koh Choon Huat
Dr Cheong Seng Kwing
Dr Wong Teck Yee
Dr Helen Leong Soh Sum
Dr Ruth Lim Mien Choo
Dr Victor Loh

Past Editions

Assoc Prof Goh Lee Gan (Editor)


Assoc Prof Annelis Wilder-Smith
Assoc Prof Lim Lean Huat
Dr Chang Ming Yu, James
Dr Chong Tong Mun
Dr Chiong Peck Koon, Gabriel
Dr Koh Choon Huat, Gerald
Dr Koh Tze Chung, Kevin
Dr Kee Chin Wah, Patrick
Dr Lee Suan Yew
Dr Lim Chun Choon
Dr Lim Khai Liang, John
Dr Lim Kim Leong
Dr Myint Myint Thein
Dr Wong Wee Nam
Dr Yeo Siam Yam
Dr Yin, Karen

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months and not resolving with bed
rest), and

1 Fatigue
 Chronic (present for six or more
months).

CAUSES
It is helpful to start by drawing up a
DEFINITION shortlist of possible causes so that
Fatigue may be defined as excessive realistic diagnostic probabilities can be
tiredness of body or mind. Patients may considered.
use different words to express it:
weariness, loss of energy, listlessness In those patients in whom a positive
and exhaustion (Murtagh, 2003). diagnosis can be made, being tired all the
time (TATT) is much more likely to arise
RELEVANCE TO from psychological or social causes than
GENERAL PRACTICE
 Everyone is occasionally tired but it is physical ones. About 75% of cases may
noteworthy to remember that fatigue have psychological or social causes, 10%
can be a symptom of many serious have physical causes, and the remaining
conditions including malignancy. 15% have unexplained fatigue (Ridsdale
 Also, most studies on chronic fatigue et al, 1993). (See Table 1)
syndrome (CFS) show that the vast
majority to have a psychological cause Table 1. Causes of feeling tired all the
but few patients initially report time
psychological symptoms. Also,
attempts by the doctor to address PSYCHOLOGICAL AND SOCIAL
psychological issues may be  Anxiety, depression or mixed (75%)
misinterpreted by the patient as not PHYSICAL
being taken seriously (Goroll, 1995).  Uncommon (less than 10%)
 The task of the primary care physician - anaemia
is to pick up the patient with an organic - diabetes
cause for definitive treatment and to - hypothyroidism
provide advice and reassurance to the - side-effects of medication
rest. - cardiovascular disease
 Anaemia is the commonest physical - chronic renal or hepatic disease
cause of fatigue. Other physical - chronic renal or hepatic disease
- malignancy (rare -- less than 1%)
causes include hypothyroidism,
- postviral fatigue syndrome
cardiovascular disease, diabetes,
carcinoma and post infectious UNEXPLAINED
mononucleosis infection. A full blood  Relatively uncommon (15%)
count is therefore the single most
useful test if investigation is Source. Ridsdale L, Evans A, Jerret W et al.
considered necessary Patients with fatigue in general practice: a
 Do not forget to review the patient‟s prospective study. BMJ 1993:307:103-6.
medication as it is a possible
contributing factor of tiredness. Psychological
Anxiety or depression, or a combination of
CLASSIFICATION the two, are overwhelmingly responsible
Fatigue can be classified (Dick & Sundin, for most cases of feeling tired all the time.
2003) as: Such anxiety or depression is often linked
 Physiological (i.e., fatigue which can to psychological stress and usually has a
normally be expected in a mentally clear underlying cause.
and physically healthy individual when
an imbalance in exercises, rest or diet
exists Anaemia
 Acute (not explainable by physiological For anaemia to be a cause, it has to be
fatigue, present for fewer than six severe, that is, 7-8gm/100ml. Lassitude

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prevails, at times in association with Post-viral fatigue syndromes are relatively
exertional dyspnoea or with postural uncommon. Fatigue due to infectious
hypotension when blood loss is acute. mononucleosis is well documented
(Goroll, 1995).
Endocrine
Diabetes mellitus is the most common Physiological tiredness
endocrine cause for fatigue. Other Tiredness following any form of exertion,
common ones are hypothyroidism, be it mental or physical, is normal. It is
hypogonadism, hyperparathyroidism unusual for patients to complain of this
Uncommon causes are hypoadrenalism, form of tiredness to the doctor, unless it is
and apathetic hyperthyroidism (Morton & used as a "ticket of entry" for another
King, 2003). problem.

Pharmacologic WORKUP
Drugs commonly causing tiredness
include antihistamines, antihypertensives History
and psychotropics. It is important to ensure that the patient
and the doctor are talking about the same
Cardiopulmonary & other vital organ thing. Patients should be questioned
dysfunction about what they mean by "tiredness".
Failure of any of the vital organs can Local muscle aches or shortness of breath
present as fatigue, e.g. congestive cardiac may be described as “tiredness”. A brief
failure, chronic renal failure, hepatocellular look of the patient‟s records should
failure and chronic obstructive lung disclose past and present medical history,
disease. In the diabetic patient and in the including current drug therapy, and may
elderly, acute myocardial infarction may give a clue to the present complaint.
present as tiredness.
The initial part of the consultation should
Chronic fatigue from disturbed sleep due concentrate on open questions, allowing
to sleep apnoea is an often overlooked the patient to elaborate on his or her
etiology. Daytime sleepiness, excessive complaints, before focusing on specific
snoring, irregular breathing, disturbed questions designed to confirm or refute
sleep, and haemoglobin desaturation are the diagnostic hypotheses forming in the
characteristics of this condition (Murtagh, doctor‟s mind.
2003).
If a psychological cause seems likely then
Malignancy it will be necessary to focus on the specific
Occult malignancy is a much feared features of anxiety and /or depression and
etiology. Fatigue and lassitude to seek evidence of underlying social
accompany most cancers, but pancreatic stress.
carcinoma is the typical example of a
tumour that may present initially as If a psychological disorder seems unlikely,
marked fatigue with few localising then systematic questioning is needed to
symptoms. Also, severe weight loss, elucidate the problem.
depression and apathy may also dominate
the clinical picture before other General questions
manifestations of the malignancy become Duration of complaint is important.
evident. Malignancies causing  days -- prodromal phase of infections,
hypercalcemia (e.g., breast cancer, recent infarct
myeloma) may present with fatigue,  weeks -- underlying malignancy,
although the hypercalcemia is usually a chronic infections
late development (Murtagh, 2003).  months, or life-long duration -
psychological cause.
Infections Periodicity
Occult infections like tuberculosis or  constant - organic problem
endocarditis, prodromal phase of hepatitis,  fluctuating - functional aetiology
and acute infections can all cause fatigue.

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Worst time of the day and thyroid function tests, to name a
 in the morning, especially after a good few.
night's sleep -- functional cause more
likely MANAGEMENT
 worsens as the day progresses --  Specific Problems
physical cause more likely If there is a specific problem,
Significant preceding event management is directed towards the
 acute - e.g. bereavement underlying cause.
 some time past - e.g. dental extraction  Functional Problems
resulting in subacute bacterial  It is important to separate clearly
endocarditis. patients who suffer from
depression or anxiety from patients
Systems review who are basically normal but are
If a psychological disorder seems unlikely not coping with excessive stress.
then systematic questioning, for example  Patient education and explanation
about change in weight, cough, dyspnoea, as to why the patient is feeling
polydipsia, polyuria, or a recent history of fatigued helps in the latter group.
viral illness, should help to confirm or Showing him or her the normal
refute possible physical causes. investigation results also help to
reinforce the message of
Exploration of possible psychological normality.
factors  Anxiolytics can be used in
A psychological cause, as for example, conjunction with advice and
over-burdened life situations, may cause counselling. Improvement can be
fatigue. A grandparent who suddenly has expected in 6 weeks.
to look after a grandchild may well be tired  Work situation and social
out by the responsibility. considerations may need
modification.
Physical Examination  Family support is important.
The general condition of the patient is Explanation and call for supportive
important. If the patient looks obviously attitude on the part of the family
well, then a functional cause is more members helps.
likely, though this does not preclude a
thorough physical examination. If the CHRONIC FATIGUE SYNDROME
patient looks unwell, then one should look A proportion of individuals with fatigue
very hard for physical signs that may be remains unexplained. Over the past 20
pointers to the underlying problem. years, there has been considerable
worldwide consensus on the criteria for
Investigations diagnosing this condition (Murdoch,
Investigations may not be required if a 2003). The Centres for Disease Control
psychological cause is clear-cut from the (CDC) in the US has defined the 2 criteria
history, and physical examination is for its diagnosis:
normal. For those without a clear cut
history, investigations are needed. 1. Type of fatigue – chronic fatigue
lasting more than 6 months which
 Basic Investigations is:
These include full blood count, ESR,
blood film, and blood for urea,  Clinically evaluated and
electrolytes, glucose and calcium. A unexplained
chest X-ray should be done in the local
 Persistent or relapsing
setting to exclude tuberculosis.
 With a definite onset
 Further Investigations
 Not the result of ongoing exertion
These depend on findings from the
history and clinical examination  Not substantially alleviated by rest
pointing to a particular cause. They  Results in a substantial reduction
include tests of liver function, in previous levels of occupational,
electrocardiogram, cardiac enzymes,

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educational, social or personal CASE FOR REFLECTION
activities
A 46-year-old woman has returned to you
2. Symptoms – Four or more of the for the results of blood tests. Two weeks
following should be present: earlier she had complained of increasing
tiredness, constipation, dry skin, and
 Substantial impairment in short- weight gain. Thyroid function tests at her
term memory or concentration previous consultation showed
 Sore throat concentrations of free thyroxine (T4) of 7
 Tender lymph nodes nmol/l and of thyroid stimulating hormone
(TSH) of 38 mU/L. (Rehman & Bajwa,
 Muscle pain and tenderness
2004).
 Multi-joint pain without swelling or
redness,
 Headaches of a new type, pattern References
or severity 1. Murtagh J. Fatigue – a general diagnostic
 Unrefreshing sleep and approach. Aust Fam Physician Nov 2003;
 Post-exertional malaise lasting 32:11:873-876.
more than 24 hours. 2. Goroll AH. Evaluation of chronic fatigue.
in: Goroll et al. Primary Care Medicine, 3rd
Symptoms must have persisted or ed. Philadelphia: Lippincott, 1995: 32-37.
recurred during six or more consecutive 3. Maire-Loise Dick & Josie Sundin.
months of illness and must not have Psyhcological and psychiatric causes of
predated the fatigue. fatigue. Aust Fam Physician Nov 2003;
32:11:877-881.
Minimal Clinical and laboratory 4. Ridsdale L, Evans A, Jerret W et al.
evaluation of CFS Patients with fatigue in general practice: a
 Full clinical examination prospective study. BMJ 1993:307:103-6.
5. Morton A, & King D. Fatigue and
 Urinalysis endocrine disorders. Aust Fam Physician
 FBC, ESR/CRP, autoantibodies 2003;32(11):895-899.
 Thyroid function tests 6. J Campbell Murdoch. Chronic fatigue
 Fasting morning cortisol syndrome. Aust Fam Physician Nov 2003;
 Epstein-Barr virology including nuclear 32:11:883-887.
antibody. 7. Rehman HU & Bajwa TA. Newly
diagnosed hypothyroidism. 10-minute
consultation. BMJ 2004 Nov;329:1271.
Management
Once organic causes are excluded,
management is symptomatic and
supportive.

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2 Weight Loss weight gain, it may also result in anorexia
and apathy resulting in weight loss,
especially in the elderly.
DEFINITION
An involuntary weight loss of greater than
5% within 6 months or greater or equal to
10% within a year should trigger concern Infection
(Reife, 1995). Hidden infection should be searched for in
many patients with unexplained weight
loss. Tuberculosis, fungal disease,
RELEVANCE TO
amoebic abscess and subacute bacterial
GENERAL PRACTICE endocarditis should be considered.
 An organic cause need to looked for,
although a substantial fraction of Gastrointestinal disease
patients eventually turn out to be free Patients who have had a partial
of any organic disease. gastrectomy for ulcer disease may have
 Patients with no significant history and malabsorption and loss of weight. Patients
found to be normal on physical with prior abdominal surgery may have
examination can be watched and partial intestinal obstruction with
followed up. The risk of serious discomfort, vomiting, and weight loss.
disease is small.

CAUSES Table 1. Involuntary Weight Loss


The differential diagnosis of involuntary
Medical causes
weight loss is extensive, but case studies
 Cancer
(Goroll, 1995) indicate that cancer,  Endocrine and metabolic causes
depression, and disorders of the  Infection
gastrointestinal tract to be the most  Gastrointestinal disease
common causes.  Cardiac disorders
 Respiratory disorders
In approximately 25% of cases, no cause  Renal disease
 Connective tissue diseases
of weight loss is found despite extensive  Oral disorders
evaluation and prolonged follow-up. The  Age-related factors
main causes are shown in Table 1.
Neurologic causes
Medical causes  Dementia
 Parkinson‟s disease
 Stroke
Malignancy
Malignancy is probably the most common Social causes
cause of weight loss, especially when  Isolation
major signs and symptoms are absent.  Economic hardship
Although any cancer may present with
Psychiatric and behavioural causes
weight loss, the gastrointestinal tract,  Depression
including the pancreas and liver, is the  Anxiety
most frequent site for occult tumours to be  Bereavement
found. Lymphoma and leukemia as well  Alcoholism
as cancer of the lung, ovaries or prostate  Sociopathy
should be searched for in such patients.
Source: Reife. Med Clin N Am 1995 March;
78:2:299-312
Endocrine and metabolic causes
Hyperthyroidism, hypothyroidism and
diabetes mellitus need to be considered. Cardiac, respiratory and renal disease
Weight loss has been described as the End-stage cardiac, respiratory and renal
most common presenting symptom of diseases have varying degrees of loss of
hyperthyroidism in the elderly1. Although appetite which result in weight loss.
hypothyroidism is often thought to cause

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Alcoholism
Oral disorders, age-related factors The diagnosis of alcoholism can be
Absence of teeth, ill-fitting dentures and difficult to make, and vague complaints
pain with eating may be a cause in the such as anorexia or weight loss may be
older patient. Also, functional disabilities the only signs of an underlying problem.
may make it difficult for elderly patients to
shop or prepare food; these factors Sociopathy
include arthritis, stroke, visual impairment, As patients age, they may lose a sense of
cardiac disease and dementia. control. Food refusal may be used as a
way to gain back some degree of control
Neurologic causes and increase interaction with others.

Dementia
Such patients may lose the ability to eat WORKUP
independently. The time required to feed A thorough history and physical
these patients may overwhelm family examination, in most cases, reveal
resources or institutional staffing, and possible causes of weight loss and yield a
patients may not be adequately fed. plan to begin an evaluation.
History
Parkinson’s disease  Documentation of weight loss
Such patients with late stage disease may  Assess the extent of weight loss:
develop swallowing difficulties. Check previous weight records
and change in clothing size
Stroke  Check that the patient is not
A stroke may result in dysphagia, dieting
weakness and depression, all of which  Determine the time course of
may cause patients to decrease food weight loss
intake.
 Identification of mechanisms for
Social causes weight loss
Isolation Ascertain whether the appetite is
People tend to eat more in social good, normal or decreased.
situations, and social isolation from any
reason may result in decreased food Weight loss in the presence of
intake. increased appetite is seen in
thyrotoxicosis, diabetes mellitus and
Economic hardship malabsorption.
Economic hardship as the result of life
events may result in difficult financial Weight loss in the presence of normal
choices and healthy food may not always or decreased appetite is seen in
be affordable. malignancy, infection, inflammatory
disease, malabsorption and
Psychiatric and behavioural causes depression.
Depression  Ask for symptoms accompanying
Depression may lead to apathy, anorexia the weight loss
and weight loss. Examples are: symptoms of diabetes
mellitus; bulky stools in malabsorption;
Anxiety symptoms of thyrotoxicosis; cough in
Patients may be preoccupied and forget to tuberculosis.
eat. They may not have appetite.
 Past history of relevance
Bereavement Examples are: gastrointestinal
Loss of a loved one may cause surgery, cancer surgery.
bereavement over an extended period of
time with loss of interest in eating entirely.

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 Family history of chronic diseases This may show a pertinent
Ask for diabetes mellitus, thyroid abnormality like a mass, infiltrate,
disease and malignancy. heart failure or lymphadenopathy
in up to 41% in one study
 Psychiatric history
Ask for symptoms suggestive of  Further investigations where
depression or anxiety. indicated
- Stools for inspection and tests for
 Social history malabsorption.
Changes in socio-economic status or - blood sugar
life events may be the underlying - thyroid function tests.
cause.
 Search for occult carcinoma
Physical Examination One of the most difficult diagnostic
 Assessment of degree of weight issues encountered in the workup of
loss weight loss concerns the possibility of
 Clinical signs to confirm weight occult malignancy (Goroll, 1995)
loss e.g. loose clothing, loose skin
folds. Investigations for occult malignancy
 Accurate weight determination. may need to be very extensive, and
should be considered in the light of the
 Systems check for signs of likelihood of finding a cause and the
diseases chance that it will be treatable.
 fever, tachycardia, pallor,
ecchymoses, jaundice, signs of Unfortunately, by the time that weight
hyperthyroidism, hepatocellular loss has occurred, most gastro-
failure intestinal malignancies are rather
 head and neck for glossitis, advanced. When weight loss is the
stomatitis, poor dentition, goitre, only symptom, pancreatic carcinoma
lymphadenopathy may still be resectable if no other
 lungs and heart for crepitations, symptoms have appeared.
consolidation, effusion,
cardiomegaly and murmurs If an initial assessment does not identify a
 abdomen for distension, course; careful follow-up rather than
tenderness, masses and ascites undirected diagnostic tests is the optimum
management of the patient.
 rectum for masses, tenderness
and appearance of the stool
 neurological examination
MANAGEMENT
 Examination of mental state for  A patient with weight loss should be
depression and dementia assessed clinically.

Laboratory Investigations  Patients with no significant history and


Laboratory investigations should be found to be normal on physical
selective, based on clues obtained from examination can be watched and
history and physical examination. followed up. The risk of serious
disease is small.
 Basic investigations
- complete blood count and PBF
- BSR INDICATIONS FOR REFERRAL
- selected blood chemistry (calcium,  Severe unexplained weight loss where
albumin, protein, transaminases an organic cause is suspected, such
and blood urea) as. malignancy.
- urinalysis and culture if indicated  Referral to a gastroenterologist for
- chest X - ray those with symptoms of malabsorption
such as bulky and foul stools.

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 Referral to a psychiatrist for those
suspected to have anorexia nervosa. References
 Continued unexplained weight loss. 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.
CASE FOR REFLECTION Philadelphia: Lippincott, 1995:38-42.
A 70 year old man complains of weight 3. Wise GR and Craig D. Evaluation of involuntary
weight loss. Postgraduate Medicine, 1995
loss of 5 kg in the last 3 months. His March; 95;4:143-150.
usual weight 6 months ago was 70 kg. 4. Alibhai SMH et al. An approach to the
What are the issues that you should management of unintentional weight loss in
cover? What should you do? (Alibhai SMH elderly people. CMAJ 2005;172(6):773-780.
et al, 2005).

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37.5 C (oral), or

3 Fever 37.2 C (axilla) (Pearce & Cutis, 2005;


Benincasa, 1991).

The Canadian Paediatric Society has


summarised the recommended
RELEVANCE TO temperature measurement techniques
GENERAL PRACTICE (See Table 1).
 Fever is a sign of an illness, the
significance of which needs to be We must also remember that individuals
assessed. can be sick with a serious infectious
 The risk of serious infections increases disease without an elevated temperature,
with the very young and the very old. and that an elevated temperature does not
 The child with undifferentiated fever is always mean infection or illness per se
a challenge – there is a higher risk of (Pearce & Curtis, 2005).
serious infections.
 Fever of unknown origin needs a A rising temperature may cause chills. In
careful history, careful examination some children between 6 months and 6
and relevant investigations for a years old, a rising temperature can result
solution. in febrile convulsions and not the level of
the fever per se. A meta analysis of
DEFINITIONS paracetamol in the prevention of febrile
Fever is any elevation of the core body convulsions concluded that: “there is no
temperature above the range expected for evidence that antipyretics reduce the risk
age and the individual. of subsequent febrile convulsions in at risk
children.” So while paracetamol may
Normal body temperature provide comfort and symptomatic relief, it
In adults, the normal oral temperature is should not be recommended for
around 37 C (98.6 F). The normal rectal prevention of febrile convulsions (Pearce
temperature is 0.5 C (1 F) higher than & Curtis, 2005; El-Radhi & Barry, 2003).
the oral temperature, and the normal
axillary temperature is correspondingly Table 1. Summary of recommended
lower. Rectal temperature is more reliable temperature measurement techniques
Age Recommended technique
than oral temperature in patients who are
mouth breathers or who are tachyneic. Birth to 2 years Rectal (definitive)
There is a variation of what is normal Axillary (screening low risk
amongst individuals. children)

Healthy young children have generally Over 2 years to 5 Rectal (definitive)


higher temperature than adults and the years Axillary, Tympanic (or
temperature does not stabilize to the adult Temporal Artery if in
average until adolescence. Between 12 hospital)(screening)
and 24 months of age, some children may
Older than 5
Oral (definitive)
have a temperature close to 38 C without years Axillary, Tympanic (or
evidence of illness. In general, fever is Temporal Artery if in
diagnosed when a child has a temperature hospital)(screening)
above 38 C to 38.4 C (100.4 F to 101 Source: Canadian Paediatric Society, March
F) (Woodhead, 2003). 2005

Fever, chills, and febrile convulsions


Fever means a body temperature at least
0.5C above normal on two recordings Definition of fever patterns
taken at least two hours apart. In children, General characteristics of fever that may
the following may be taken as fever if it is provide some discriminatory value include
more than: onset (abrupt vs gradual), height (very
38 C (rectal) high vs low), pattern (e.g. constant, every

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48 hours, biphasic, intermittent) and
duration. Fever can be defined by duration Diagnosis
(Long, 2005) into: Most acute fevers encountered in the
acute fever -- up to 10 days; ambulatory care setting are of obvious
prolonged fever – a single illness in which cause and due to upper respiratory or
duration of fever exceeds that expected urinary traction infection.
for clinical diagnosis (e.g. >10 days for
viral upper respiratory tract infections; >3 Undifferentiated fever as a challenge
weeks for mononucleosis) OR a single Many infections first manifest with fever
illness in which fever was an initial major and other signs or symptoms, or only
symptom and subsequently is low grade nonspecific associated symptoms such as
or only a perceived problem; headache and malaise. With time, focal
Fever of unknown origin – a single illness findings or other clues often emerge, but
of at least 3 weeks‟ duration in which fever early interventions may be necessary to
>38 C is present on most days, and prevent serious sequelae or death.
diagnosis is uncertain after 1 week of
intense evaluation; Bacteremia, urinary tract infection,
pneumonia, osteomyelitis, and meningitis
CAUSES all represent potentially serious causes of
The causes of fever can be grouped into fever without easy identification of the
the following 5: (1) infections (viral, source, especially in the infant and young
bacterial & other infections), (2) child. The risk of such infections is
autoimmune conditions, (3) malignancies, greatest when fever is higher than 40 C
(4) miscellaneous, and (5) no diagnosis (104 F).
found. The proportion of each of the
groups of causes differ in different In the examination, look for signs of
population groups: newborns, children, toxicity as these correlate with the
adults, or elderly. From the standpoint of presence of serious bacterial illness.
diagnosis, it is useful to divide fevers into Careful physical examination is warranted
acute fevers and prolonged fevers. to identify a source of infection or another
disease that can explain the findings.
WORKUP
History Signs of toxicity
A careful history is needed for every new Toxicity refers to the clinical appearance
case and the objective of this and the associated with the sepsis syndrome.
accompanying clinical examination are to Findings that suggest “toxicity” include the
look for diagnostic clues. In this way, following:
laboratory studies can be used selectively.  Reduced or absent social
responsiveness to the parent
Duration and progression of fever,  Reduced or absent awareness of
accompanying symptoms, chills and rigors environmental stimuli
if any, recent travel, similar cases at
 High-pitched or weak cry
home, drugs taken so far, and the number
of other doctors consulted should be  Irritability or inconsolability
asked.  Lethargy or difficulty arousing the
child
Accompanying symptoms. In an acute  Pallor, mottling, or cyanosis
fever, accompanying symptoms may  Evidence of severe dehydration
provide the cue to correct diagnosis.  Respiratory distress.
Travel history. A positive travel history is The physical examination must be
also a useful lead. Detailed questioning of thorough. Remember to test the range
the activities during travel, place of stay and motion of the major joints, and
must be done. palpate the long bones to look for early
signs of osteomyelitis. Do not attribute a
Drug history. Ask for intake of drugs as high fever to a minor illness such as upper
they can induce a fever. respiratory infection or otitis media.

14
practitioner. Certain safeguards, however,
PROLONGED FEVER AND FEVER OF are required.
UNKNOWN ORIGIN (FUO)
Prolonged fever. For most patients with a Clinical Examination
fever lasting one or two weeks, the A thorough examination is required in a
underlying cause is soon discovered or patient with PUO: General inspection of
the patient recovers spontaneously. In the the patient looking for anaemia, jaundice,
latter case, a protracted viral illness is skin and nail lesions; lymph nodes;
usually presumed to be the source of abdomen for liver and spleen
fever. Table 1 shows the causes of fever enlargement; heart for murmurs; CNS,
of unknown origin for adults. spine, and bones and joints for localizing
signs.
Table 1. causes of fever of unknown origin Repeated physical examination is very
Infection (40%)
important in FUO cases, because key
 Endocarditis findings can be missed on the initial
 Abscess examination and new signs often develop
 Zoonoses (Q fever, brucellosis, leptospirosis) over time. For example, Osler‟s nodes,
 Epstein-Barr virus, cytomegalovirus Janeway lesions, and conjunctival
Neoplasia (20%) petechiae may not be present initially in a
 Hodgkin‟s disease
patient with endocarditis (Amin &
 Other lymphomas
 Hypernephroma Kauffman, 2003).
 Leukemia
 Hepatoma MANAGEMENT
Immune-mediated (20%) Acute fever in children and adults
 Systemic lupus erythromatosus  Initial routine management
 Polymyalgia rheumatica
 Polyarteritis nodosa  symptomatic relief of fever
 Stills disease  antibiotics if bacterial infection is
 Idiopathic vasculitis thought likely
Miscellaneous (20%)  advice on fluid intake
 No diagnosis
 advise further action to report back
 Drug fever (gold, phenytoin, penicillin)
 Granulomatous disease (sarcoid, Crohn‟s) if fever does not settle in a day or
Source: Whitby M. The febrile patient. Aust Fam two or there are new
Physician 1993 Oct;22:10:1753-1761 developments e.g., rash, patient
becomes more ill.
Prolonged fever  ill patients are referred for
The evaluation of prolonged fever is more admission.
demanding. The initial office evaluation
should help determine the proper pace of  Prevention of complications
diagnostic testing and the need for The complications of fever likely to be
therapeutic intervention. seen in general practice are
dehydration and febrile convulsions in
If the patient is a compromised host, or if childhood, and confusional states in
he is acutely ill and toxic, several the elderly. Old people also become
immediate diagnostic studies are needed easily dehydrated when febrile and ill.
such as blood counts and blood cultures
to confirm an infective cause and Dehydration in children occurs more
treatment may even be required such as quickly than in adults and children may
antibiotics given empirically before all the fail to drink when ill. Their parents
results are available. Hospitalisation is need clear instructions about
usually necessary in such cases. maintaining an adequate fluid intake.

If the patient is not toxic and clinically In the elderly, fever, dehydration and
stable, the workup can be less rushed. confusion are interrelated problems.
The diagnostic use of time is an essential Confusion results in failure to drink
problem-solving method for the general and dehydration increases the
confusion. It is just not enough to

15
leave a jug of water beside the bed. At general practitioner, and an important
least 1 1/2 litres of urine should be one for the patient.
passed daily and this requires a fluid
intake of 2 to 3 litres. If doubt exists a INDICATIONS FOR REFERRAL
regular routine fluid intake should be  The ill patient
organised and the intake recorded.  Clinically diagnosed serious
conditions: meningitis, pneumonia,
Febrile convulsions deserve a special cholecystitis, to name a few.
word. They occur chiefly between the  The patient whose fever persists
ages of 1 and 3 years. There is often a beyond a week and the cause is still
family history. The most important uncertain.
principle in the management of febrile  Febrile neonates: Infants between 1
convulsions is control of the rising and 28 days old with a fever should be
temperature. The parents must be presumed to have a serious bacterial
taught to do this with confidence. infection. They should be admitted for
Sponging helps. a full “sepsis workup” (i.e., WBC count,
blood culture, urinalysis, urine culture,
For the patient having the first febrile lumbar puncture) (Baraff, 2003)
fit, admission for observation and
investigation will be needed. In a CASE FOR REFLECTON
patient with a known history of febrile A 9-month-old girl has had fever and
fits, a single febrile convulsion is not a diarrhea for 24 hours. Her temperature
reason for admission to hospital but, if has been as high as 38.7 C. Her mother
the fits continue or recur, or if there is says that the child‟s appetite is decreased
any clinical suspicion of meningitis, the and that she has been increasingly fussy.
child must be in hospital, since a When her fever is high, her breathing
lumbar puncture is the only certain seems “panting”. According to the mother,
way to exclude meningitis. this is the most ill that the child has ever
been.
 Subsequent management
The initial wait-and-see diagnostic What information from the history worries
period where the presumptive you as the attending physician?
diagnosis is a viral infection commonly  What conditions could cause this
lasts from two to five days. During that clinical picture?
time it is useful to have in mind the
 What additional information do you
expected times for the appearance of
need?
the rashes of specific fevers.
 How do you interpret the following
Chickenpox appears on the first day, vital signs in the light of the above
rubella on the second or third, and history? Temperature 38.7 C; pulse
measles on the fourth. If by the end of 160 beats/minute; respiratory rate 36
the fifth day no rash has appeared, breaths/minute, not laboured
measles can usually be excluded. (Woodhead JC, 2003).
Most viral illnesses will have run their
course by that time. References
1. Pearce C & Curtis N. Fever in children.
Aust Fam Physician sep 2005;34(9):769-
Beyond this period, both doctors and
771.
patients begin to feel that something 2. Canadian Paediatric Society. Temperature
more must be done. It is often not until measurement in paediatrics. CPS March
then that the doctor feels obliged to 2005
treat the situation more seriously and http://www.cps.ca/ENGLISH/statements/C
the diagnostic label tends to change P/cp00-01.htm
from a presumed viral illness to 3. Woodhead JC. Fever. In: Paediatric
pyrexia of uncertain origin. This is not Clerkship Guide:Mosby: Missouri,
in fact a common situation in general 2003:250-256.
practice but it is a worrying one for the

16
4. Benincasa RM. Temperature
measurement in children. Ann Emerg Med
1991;20:829-31.
5. El-Radhi AS, Barry W. Do antipyretics
prevent febrile convulsions? Arch Dis
Child 2003;88:641-2.
6. Whitby M. The febrile patient. Aust Fam
Physician 1993 Oct;22:10:1753-1761.
7. Kamal Amin & Carol A Kauffman. Fever of
unknown origin. Postgraduate Medicine
Sep 2003;114:3:69-75.
8. Long SS. Distinguishing Among
Prolonged, Recurrent and Periodic Fever
Syndromes: Approach of a Paediatric
Infectious Diseases Subspecialist.
Paediatr Clin N Am 2005;52:811-835.
9. Baraff LJ. Clinical Policy for Children
Younger Than Three Years Presenting to
the Emergency Department with Fever.
Ann Emerg Med 2003;42:4:546-549.

17
4 Dyspepsia
Table 1. Causes Of Dyspepsia
Common causes
- simple dietary indiscretion
- non-ulcer dyspepsia (NUD) (60%)
- gastric erosions due to drugs
Less common causes
DEFINITION - chronic peptic ulceration
- gastro-esophageal reflux oesophagitis
Dyspepsia may be defined as upper
abdominal discomfort which could
Important not to miss
have various combinations of nausea, - Carcinoma of stomach & esophagus
vomiting, heartburn and epigastric (<2%)
fullness. - Ischaemic heart disease.

RELEVANCE TO Simple dietary indiscretion


GENERAL PRACTICE These are acute episodes of epigastric
 Dyspepsia is a common presenting distress due to large or fatty meals;
complaint in general practice. eating before lying down or going to
 The majority of patients who bed; alcohol intake and smoking.
complain of dyspepsia do not have These respond to symptomatic
serious disease and will respond to treatment and advice.
symptomatic treatment.
 Vigilance is needed to pick out the Non-ulcer dyspepsia (NUD)
alarm features of serious disease Non-ulcer dyspepsia refers to patients
in the minority of patients who have symptoms which are
(gastrointestinal bleeding, difficulty thought to be related to the upper
swallowing, unintentional weight gastrointestinal tract but in whom
loss, abdominal swelling and endoscopic examination shows no
persistent vomiting (NICE,2005; evidence of macroscopic disease.
MOH, 2004)). They account for up to 60% of patients
 Dyspepsia presenting for the first presenting with dyspepsia (Talley et al,
time in those 45 years and older is 1998; Fisher & Parkman, 1998). It can
an alarm feature and the cause be divided into four groups based on
need to be investigated (NICE, the predominant symptom (Barter &
2005). The incidence of cancer of Dunne, 2004):
stomach in Singapore starts to rise  Ulcer-like dyspepsia -- well-
between 35 to 40 years (Chia et al, localised epigastric pain, nocturnal
1992; Chun Tao Wai et al, 2002) in nature and relieved by antacids.
and so the cut off point is set at 35  Gastro-esophageal reflux-like
years of age: Singaporeans with dyspepsia -- heartburn, burning
uninvestigated dyspepsia above epigastric pain or regurgitation.
35 years of age, or with alarm  Dysmotility-like dyspepsia -- this
features should be investigated overlaps with irritable bowel
with endoscopy. syndrome (IBS) and is associated
with flatulence, bloatedness,
CAUSES distension, nausea, early satiety.
The causes of dyspepsia are shown in  Nonspecific dyspepsia -- no
Table 1. specific features. Anxiety neurosis
with increase or decrease acid
secretions resulting in anorexia
and fullness of abdomen or
sensation of "bloated feeling".

18
There is overlap between the four regurgitation; attitudes towards
different groups of NUD as well as with meals; lying down; and response
irritable bowel syndrome (IBS). to antacids. Consider biliary or
cardiac pain. Predominant bloating
Gastric erosions due to drugs may indicate aerophasia or irritable
Drugs may cause dyspepsia: NSAIDs, bowel syndrome.
COX-2 selective NSAIDs, calcium  Diet and lifestyle factors which
channel blockers, and theophylline. Up could precipitate dyspepsia.
to 20% of individuals taking NSAIDs  Drug use.
experience dyspepsia. Although COX-  Be alert to “alarm symptoms”.
2 selective NSAIDs appear to reduce  Has the patient has been
the risk of serious gastro-intestinal investigated previously? Peptic
bleeding, the incidence of dyspepsia ulcer disease and esophagitis can
with these drugs is similar to that with recur. A previously normal
conventional NSAIDs. investigation may not exclude new
disease.
Chronic peptic ulceration
Approximately 20% of patients with Physical examination
dyspepsia presenting in general This should be done systematically
practice have a chronic peptic ulcer. looking for signs of physical disease.
The three major causes are  General: anaemia or recent weight
Helicobacter pylori gastritis, NSAIDs loss.
and the rare Zollinger-Ellison  Abdominal examination: mass,
syndrome. supraclavicular node.
 Other systems: cardiovascular
Gastro-esophageal reflux disease, lung disease.
Reflux of gastric contents into the
esophagus is very common in the Investigations
general population. A diagnosis can be Most cases of dyspeptic symptoms
made on the basis of typical symptom without red flags are relieved by
of heartburn. symptomatic treatment. A specific
history helps to determine if immediate
Gastric cancer testing is warranted.
Advanced cancer, which is not curable
by resection, causes dyspepsia as well
 Baseline investigations - This
as anorexia and weight loss. Early
depends on the diagnosis, e.g. an
gastric cancer may cause vague
ECG is needed if one suspects the
abdominal symptoms. Gastric cancer
dyspepsia to be of cardiac origin. A
should be considered in any patient
chest X-ray is also useful to
over the age of 45 years who are non
provide baseline information.
Singaporeans (or 35 years in
Singaporeans) who presents with a
 Barium studies (including swallow
history of dyspepsia for the first time.
and meal) or endoscopy - either
Ischaemic heart disease
can be used to exclude a gastric
Ischaemic heart disease can
cancer. The advantage of the latter
masquerade as a dyspepsia. A high
is the ability for a biopsy to be
index of suspicion in an elderly patient
taken.
is therefore required.
Should all dyspeptic patients be
WORKUP
investigated?
History  Definitely necessary (“high-risk”) –
consider endoscopy:
 Ask questions to decide if the
problem is really dyspepsia:
epigastric pain, heartburn and acid

19
 > 35 years with recent onset of dyspepsia is the same or only
dyspeptic complaints, history of slightly higher then normal
gastro-intestinal bleed population.
 anorexia,
 weight loss MANAGEMENT
 non-responders to treatment:
no improvement after 7-10 Low-risk group/ first presentation
days of symptomatic treatment Empirical treatment is the mainstay of
 no resolution of symptoms after management for such patients:
4-6 weeks of H2 blocker  Antacids for pain, metoclopamide
therapy for dysmotility - like symptoms and
 frequent relapses i.e. more mild tranquilisers if stress is a
than 3 attacks in a year factor.
 obviously unwell  Dietary advice - bland food,
 anaemia avoidance of alcohol and
cigarettes.
 Unnecessary to investigate at first  Counselling and advice on life's
consultation (“low risk”) stresses and family problems
 young < 35 years where indicated.
 supporting history of  Stop/reduce dose of ulcerogenic
overeating, alcoholic intake drugs e.g., NSAIDs.
 presence of family/social
problems High-risk group/recurrent episodes
 previous negative investigation (>3 times a year)
 long history with preservation  If patient has never investigated
of good health. before:
 refer for investigations
 “Test and treat” approach for the (endoscopy or barium meal)
rest  meanwhile give antacids only,
 Either serology antibody test do not give H2 blockers.
or fecal antigen test is  If a patient has been previously
recommended as the most investigated fully and a diagnosis
cost-effective initial test but made (Peptic ulcer disease and
because a positive test is esophagitis), then the patient
indicative of active infection, should be considered to have a
the fecal antigen assay may be relapse of the condition and
the preferred non-invasive treated appropriately.
screening test for Helicobacter
pylori. Chronic peptic ulceration
 Urea breath test also has  If Helicobacter pylori testing shows
excellent sensitivity and the presence of active infection,
specificity (90%), and a positive provide a 7-day twice daily course
test is indicative of active of full dose PPI, with amxocillin 1g
infection; the higher cost may and clarithromycin 500mg or with
make it less attractive metronidazole 400mg and
compared to either the serology clarithromycin 500mg (MOH,
antibody test or fecal antigen 2004).
test in most clinical settings.
 Follow-up of H pylori treated ulcers
is not routine to confirm cure of the
 Testing for H pylori in non-ulcer infection, unless the ulcer has
dyspepsia previously bled or perforated.
 Studies indicate that the
 Follow-up of infection status
prevalence of H. pylori in
requires either an endoscopic
patients with non-ulcer

20
biopsy or the non invasive urea  If symptoms of bloating or
breath test rather than serology. postprandial fullness are present,
The Urea Breath Test is probably the patient should eat six small
the best way to assess eradication. meals a day, which may help
It is important to wait at least 4 ameliorate symptoms.
weeks after completion of  Management of the predominant
eradication therapies as there may symptom with the appropriate
be a transient decrease in bacteria medications may be considered.
numbers without full clearance. Not all patients however, may want
or need to take medications
NSAID ulcers routinely.
 Ulceration due to NSAIDs should  Eradication of H. pylori? One in15
be treated with an anti-ulcer drug may have symptom improvement
e.g. cimetidine and if at all with H pylori eradication (Moayyedi
possible, the NSAIDs should be et al, 2003; MOH, 2004). Hence
stopped and the therapy given for there is a need to explain this to the
8-12 weeks. patient.
 Ulcers that are associated with
both NSAIDs and H pylori should
Gastro-esophageal reflux disease
be treated as for H pylori ulcers,
(GERD)
and the NSAIDs should be
Patients in whom the predominant
stopped.
symptom is heartburn or acid
Non-ulcer dyspepsia regurgitation can be diagnosed with
 Management of NUD is GERD and treated for it (Talley, 1998).
multifactorial and includes making a Over 50% of patients have no
diagnosis early and explaining the macroscopic evidence of oesophagitis
situation to the patient. and are classified as having
 It is important for the physician endoscopy-negative reflux disease.
neither to investigate excessively The goals of treatment are
nor to investigate the presenting  Provide symptom relief
symptoms alone.  Promote oesophagitis healing and
 New investigation in a patient who prevent disease progression.
has been previously diagnosed with
NUD should be done whenever Start treatment
alarm symptoms present or if there  If symptoms interfere with usual
is a new objective symptom. It is lifestyle
important for the physician to  There is demonstrated oesophagitis
determine why the patient with
chronic symptoms presented at this Two approaches to managing GERD
particular time. are either to step or step down (Dent
 Psychological factors can et al, 2001:
exacerbate symptoms, so it is  Step up (minimum initial therapy) –
important for physicians to address start with H2 antagonist and, if
these issues and offer counselling. symptoms are not controlled,
 A mainstay of management is post- change to a PPI.
evaluation reassurance of the  Step down (high initial therapy) –
patient concerning the diagnosis start with a PPI and subsequently
and the absence of alarm use an H2 antagonist once
symptoms. symptoms are controlled.
 Patients should avoid any food or
substance that tends to exacerbate Lifestyle modifications are diet,
symptoms (NSAIDS, alcohol, or alcohol, smoking and weight loss in
tobacco). obese patients.

21
Non-drug measure is raising the bed mist. magnesium trisilicate in salt-
head. restricted patients.

Initial treatment alternatives are: H2 blockers


 Lifestyle + non-drug measure +
 Has a place in ulcer therapy and in
intermittent use of antacids
the treatment of GERD.
 Lifestyle + non-drug measure + H2
 Impaired metabolism caused by
antagonists
cimetidine and ranitidine of
 Lifestyle + nondrug measure + warfarin, theophylline, phenytoin,
PPIs. carbamazepine, propranolol,
nifedipine, imipramine,
Reassess in four weeks metronidazole will result in raised
 for patients on H2 antagonists, serum levels of these drugs.
those unresponsive are unlikely to  Cimetidine decrease the absorption
respond with continued therapy. of ketoconazole due to elevation of
 for patients on PPIs, most will gastric pH.
have responded in 4 weeks,  Magnesium and aluminium
although a small number will hydroxide antacids reduce by 30-40
benefit from 8 weeks‟ therapy. percent the bioavailability of
cimetidine and ranitidine. Thus if an
Maintenance antacid is used concurrently with an
 Reflux esophagitis is a chronic H2 blocker, the antacid should
condition: 50% to 80% will relapse ideally be given at least two hours
if therapy is ceased, often within 6 either before or after the H2
months. blocker.
 Long term maintenance is often  The H2 blockers available are:
necessary: cimetidine, famtodine, and
o intermittently (2-4 week ranitidine.
courses at same dose
that initially controlled Indications for maintenance H2
symptoms) blocker therapy
o continuously – doses
that initially promoted This is indicated under the following
healing. circumstances
 Peptic ulcer
Drug therapy in dyspepsia - history of complications e.g.
bleeding, perforation, outlet
Antacids obstruction.
 Useful in both ulcer and non-ulcer - rapid relapse after previous
dyspepsia. treatment
 Give 10-30 mls, four or more times - frequent relapses (3 or more
per day, between meals and at times a year)
bedtime. - difficult to heal
 Liquids more effective than solid - elderly (> 65 years)
preparations. intercurrent illness (where risk of
 Compound proprietary preparations bleed can jeopardise life)
have no clear advantage over - continued NSAID use
simpler preparations.  Zollinger-Ellison syndrome.
 Antacids should not be taken at
same time as other drugs because Proton pump inhibitors
the absorption of the latter may be
 Omeprazole (Losec) is capable of
impaired.
almost completely eliminating
 Avoid high sodium preparations gastric acid secretion. It would be
e.g. sodium bicarbonate mixtures or useful for treatment of refractory

22
peptic ulcer disease at a dose of 6. Moayyedi P, Soo S, Deeks J, Delaney
20mg/day. B, Harris A, Innes M, et al. Systematic
 Other PPIs available are review and economic evaluation of
Helicobacter pylori eradication
lansoprazole, rabeprazole,
treatment for non-ulcer dyspepsia.
pantoprazole, and esomeprazole. BMJ 2003;321:659-64.
7. Delaney BC. Dyspepsia (10-minute
INDICATIONS FOR REFERRAL consultation). BMJ 2001;322:77
 Initially, if organic disease is
present or suspected:
- carcinoma stomach (based on
age, anaemia, weight loss and
anorexia)
- chronic peptic ulcer.
 Patient requiring confirmation of
non-ulcer dyspepsia by endoscopy
 Patient‟s request.

CASE FOR REFLECTION


A man complains of recurrent
epigastric pain, which he has had
periodically for many years. He has
been prescribed proton pump
inhibitors several times, and he buys
antacids over the counter at other
times. He is fed up with pills and wants
to know what is wrong.

What issues would you cover with


him? What should you do for him?
(Delaney, 2001)

References
1. NICE. Dyspepsia – management of
dyspepsia in adults in primary care.
NICE, 2005; Clinical Guideline 17.
2. MOH. Management of H pylori
infection. MOH CPG 9/2004; Sep
2004:11
3. Dickerson LM & King DE. Evaluation
and management of nonulcer
dyspepsia. Am Fam Physician 2004
Jul 1; 70(1):107-14.
4. Barter C & Dunne L. Nonulcer
dyspepsia. In: Jeanette E South-Paul
et al. Current diagnosis & Treatment in
Family Medicine. New York: McGraw-
Hill, 2004:355-356.
5. Chia KS, Lee HP, Seow A,
Shanmugaratnam K. Cancer
incidence in Singapore 1968-1992.
Singapore Cancer Registry, Report
No. 4 1992;74.

23
5 Breathlessness

DEFINITION
 Respiratory causes
Respiratory causes of chronic
dyspnoea are: chronic obstructive
Breathlessness (dyspnoea) may be pulmonary disease, pulmonary
defined as the sensation of being out of parenchymal disease, pulmonary
breath. It implies difficult or hypertension, severe kyphoscoliosis,
uncomfortable breathing. large pleural effusion, and chronic
asthma.
RELEVANCE TO
GENERAL PRACTICE  Severe chronic anaemia
 Shortness of breath may be This causes breathlessness from
physiological or pathological. tissue anoxia.
Accurate diagnosis depends on a  Psychological
carefully taken history and clinical The cue may be the way patients
examination. describe their shortness of breath.
 Acute shortness of breath requires Often there is an admitted fear of
prompt assessment and appropriate lung disease which may have
emergency treatment. originated from knowledge of a close
 Management of chronic acquaintance in whom a serious lung
breathlessness centres on disease has recently been diagnosed
management of the underlying or has caused death.
cause.
Table 1. Causes Of Breathlessness
CAUSES Sudden onset; patient previously not
An approach to the causes of short of breath
breathlessness is to classify them based  Cardiovascular
on the mode of onset. See Table 1.  acute heart failure e.g. AMI
 Severe respiratory infections
Sudden onset; patient previously not  pneumonia
short of breath  acute epiglottitis (children)
Acute and severe shortness of breath is  acute bronchiolitis (children)
 Respiratory disorders
a medical emergency and, although
 inhaled foreign body
treatment directed to its relief must be
 upper airways obstruction
given with the least possible delay, it is
 pneumothorax
still all-important to attempt to reach a
 atelectasis
diagnosis of its cause.  acute anaphylaxis
 Metabolic acidosis e.g. diabetic
Sudden onset; patient had similar ketosis
attacks  Psychogenic disorders
The only two conditions which commonly  anxiety with hyperventilation
give rise to recurrent attacks of sudden  panic attack
shortness of breath are left ventricular Sudden onset; patient had similar
failure and bronchial asthma. attacks
 acute left ventricular failure
Insidious onset; within few days or  bronchial asthma
weeks Insidious onset; within few days or
 Cardiac causes weeks
The causes under this group are  Cardiac causes
 Respiratory causes
congestive cardiac failure and other
 Severe chronic anaemia
cardiac causes of pulmonary venous
 Psychological
congestion (mitral stenosis and mitral
regurgitation).
24
a consequence of longstanding
pulmonary disease and therefore are
WORKUP not specific for a cardiac pathology.
 Abdomen -- Ascites and
History hepatojugular reflux.
 The most difficult task in the
evaluation of acute dyspnoea is MANAGEMENT
differentiating dyspnoea due to
cardiac disease from that resulting Acute Breathlessness
from pulmonary pathology. Both This should be managed as an
etiologies share a number of clinical emergency.
features. In general, a past history  Foreign body - acute onset with
dominated by chronic cough, sputum stridor should immediately suggest
production, recurrent respiratory its site and cause. A history of
functions, occupational exposure, or having swallowed a foreign body is
heavy smoking points more to a lung likely to be elicited. An attempt
rather than to a cardiac disease. should be made to dislodge it by the
 Dyspnoea that is a manifestation of finger or by tipping the patient upside
a chronic anxiety state may down and vigorously thumping his
superficially mimic cardiopulmonary back. If these measures fail, a
disease and cause some confusion. tracheotomy must be undertaken as
Onset at rest in conjunction with a a life-saving emergency.
sense of chest tightness, suffocation,  Acute left ventricular failure and
or inability to take in air are status asthmaticus - if the differential
characteristic features of the history. diagnosis is in doubt, intravenous
 It is helpful to define as precisely as aminophylline and a diuretic such as
possible the degree of activity that frusemide, are safe to give in either
precipitates the sensation of condition. The patient should be
dispense, in order to estimate the admitted after emergency treatment.
severity of disease, determine the  Croup - in a young child, the
extent of disability, and detect presence of cyanosis, restlessness
changes over time. One means of or exhaustion requires urgent
achieving these objectives is to relate hospitalisation.
symptoms to the patient's daily  Acute asthma - nebuliser treatment
activities and interpret the degree of with salbutamol has replaced the
restriction in terms of the expected need for subcutaneous adrenaline.
endurance of a patient of similar age. Re-examination for improvement is
 The occupational history is done after such treatment. If relieved,
particularly important, as the bronchodilator therapy, and
relationships between exposures and antibiotics with adequate explanation
lung disease are becoming evident. of the need for continuing treatment
and follow-up follows.
Physical examination
 General examination -- fever, Chronic breathlessness
anaemia, tachypnoea, tachycardia, Treatment depends on the underlying
respiratory efforts, pedal edema and cause which may be established after a
phlebitis. careful history examination and
 Respiratory system -- air flow appropriate investigations, including
obstruction, percussion note, and chest x-rays and lung function tests.
breath sounds.
 Cardiac examination -- raised JVP, Anxiety induced breathlessness
third heart sound, cardiac murmurs, The neurotic patient with anxiety-induced
and carotid pulse abnormalities. It dyspnoea often benefits from having a
should be recognised that many of chest film and simple pulmonary function
the signs of right sided failure may be tests; the confirmation of a well-
25
functioning respiratory system may
provide some reassurance and lessen CASE FOR REFLECTION
concern over bodily symptoms. At times, A 70 year old woman complains of
a walk with the patient up and down a increasing breathlessness over the last 4
few flights of stairs is just as convincing weeks. She has lost some weight but is
for both the physician and patient. One unable to quantify it. What are the
must however, remember that the issues to cover? What would you do?
patient with Guillain Barre syndrome with
respiratory muscle paralysis may be INDICATIONS FOR REFERRAL
misdiagnosed as anxiety induced  Bronchial asthma - cyanosis, patient
breathlessness. exhaustion, a quiet chest, marked
tachycardia, pulsus paradoxus,
obvious use of accessory muscles of
respiration, failure to respond to full
non-steroidal therapy, and subjective
report of severe difficulty in
breathing.

 Referral for further workup in the


patient with insidious onset of
breathlessness may be needed.

References
1. Goroll AH. Evaluation of Chronic
Dyspnoea. in:Goroll et al. Primary Care
Medicine, 3rd ed., Philadelphia:
Lippincott, 1995:227-231.
2. Murtagh J. Accident and emergency
medicine Unit 6. Acute dyspnoea. Aust
Fam Physician 1995 April; 24;4:663-669.

26
6 Cough
Table 1. Common etiologies of cough in
DEFINITIONS adults & elderly
Cough can be divided into three Acute Chronic
Allergic rhinitis Aspiration
categories:
Aspiration Benign endobronchial
 Acute – if it is less than 3 weeks; Asthma neoplasm
 Subacute – cough lasting 3 to 8 Bronchitis Bronchiectasis
weeks; and Congestive heart Bronchogenic
 Chronic cough – cough lasting more failure (CHF) carcinoma
Foreign body Chronic obstructive
than 8 weeks.
aspiration Influenza pulmonary disease
Inhalation of irritants (COPD)
RELEVANCE TO Laryngitis Fungal disease
GENERAL PRACTICE Pneumonia Gastroesophageal
 Cough is the commonest single Pulmonary edema reflux disease (GERD)
symptom presented to the family Pulmonary embolism Lung abscess
physician. Respiratory distress Medication side effect
 In the patient with acute cough, adult syndrome Tobacco use
or child, a large proportion will be viral Sinusitis Tubeculosis
Upper respiratory
infections; early serious disease needs
tract infection (URI)
to be excluded through the history and Source:Paulman et al, 2005
clinical examination.
 In the patient with cough that does not Table 2. Causes of chronic cough in
resolve within 3 weeks, a chest X-ray children
should be considered to rule out Infant Preschool School
treatable causes. age/
 In the adult patient with chronic cough adolescen
that is X-ray negative, postnasal drip t
syndrome, asthma, and Congenital Foreign Asthma
anomalies: body Postnasal
gastroesophageal reflux disease
tracheoesophage Infections: drip
(GERD) are the common causes and al fistula; airway viral, GERD
have been referred to as a “pathogenic malacia Mycoplasm Infections:
triad of chronic cough”. Infections: viral, a, pertussis, viral,
 In child with cough, the parents are Chlamydial, bacterial Mycoplasm
often concerned if it is asthma: there is pertussis Asthma a
a need to sort this out and Asthma Irritant Irritant
communicate effectively with them. (passive (smoking)
smoke) Habit
cough
CAUSES
Since all types of cough are acute at the Infection. Infections underlie most of the
cough and cold seen in general practice.
outset, it is the duration of the cough at
the time of presentation that determines The majority of these are viral. Most
the spectrum of causes. viruses are associated with short-lived
illnesses but a number are associated with
See Table 1 and 2. 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

27
illness in children, and in some adults too;
and the influenza A virus in both children, WORKUP
adults, and elderly patients. Occasionally, COUGH IN THE CHILD
the causal agent may be mycoplasma or The child with persistent or recurrent
fungal. Coliform and staphylococcal episodes of cough, worse at night, is a
infections are normally found in debilitated common cause of anxiety, especially to
patients or in patients or in patients with young parents. The child is often at the
bronchiectasis or recent hospital infection. stage of attending school or play-group for
the first time and may have a past history
Physical and chemical. The effect of of croup or eczema. A family history of
cold and of smoke (especially from allergic respiratory illness may coexist.
tobacco) in aggravating, prolonging or The common pattern is one of recurrent
causing cough is well known. bouts of acute wheezy respiratory
infections interspersed by periods of
Cardiac failure. This as a cause of comparative health often, however,
cough, particularly in the elderly, may be including nights interrupted by persisting
overlooked. A persistent dry cough may dry cough. The tendency for the child to
be found in the early stages of heart be well and free of abnormal signs when
failure. Although confirmatory physical seen by the doctor may create the unfair
signs may be absent, the response to impression of fussing parents. Careful
diuretics. The prompt relief from a short history taking will identify the syndrome,
course of diuretics confirms the diagnosis. and the possible additional precipitating
causes of animal or plant allergy may be
Allergic. Cough, in particular night cough, identified on specific questioning or a
may occur in patients with an allergic home visit.
tendency with or without asthma.
Physical Examination
Medications. Medications can cause A selective examination of the upper
cough. The angiotensin-converting respiratory tract, cervical lymph nodes and
enzyme (ACE) inhibitors cause a dry, the lungs, (not forgetting to note down the
hacking cough in more than 15% of temperature and the pulse), is usually
patients taking these medications, sufficient in cases of upper respiratory
possibly by stimulating C fibres in the tract infection causing cough.
airways and activating the cough reflex
arc. After discontinuation of the causative In cases where the history indicates that
drug, the cough usually resolves within 1 the cause may be more complex, a more
to 14 days. Beta blockers can cause thorough examination is warranted. Acute
cough as a result of drug induced serious illness is normally suggested by
bronchospasm. Inhaled medications, such breathlessness, complaint of chest pain or
as beta agonists, disodium cromoglycate the general condition of the patient. The
(Intal) and corticosteroids have also been presence of cyanosis or ashen pallor is
found to sometimes cause a dry hacking more worrying than the flushing caused by
cough, apparently by local irritation. fever. The absence of rhonchi with
decreased air entry in a breathless patient
Psychological. Psychological or social indicates a more severe form of airway
problems may present as a habit cough as obstruction than when rhonchi are heard.
a form of nervous tic.
MANAGEMENT
Neoplastic. Low in the order of frequency  Symptomatic treatment with or without
but high in the list of fatal causes of cough antibiotics as the case may be is
is bronchial carcinoma. usually sufficient in patients with acute
cough.
Other causes. Inhaled foreign body  Patient education and explanation are
should also be thought of, particularly in necessary in patients with recurrent
children. cough due to bronchial asthma.

28
 Management of chronic cough will pleural effusion or atelectasis. Finally,
depend on the cause. non-acute serious diseases may not have
much definitive physical signs.
COUGH IN THE ADULT
The starting point is the history and
physical examination. Acute cough
Based on the history and physical
History examination, the most important first step
Although the timing and characteristics of is to decide whether the acute cough is:
the cough are of little diagnostic value, the  potentially a reflection of a serious
medical history is important to determine illness (pulmonary embolism,
whether the patient is receiving an ACE congestive heart failure, and
inhibitor, is a smoker, or has evidence of a pneumonia) or
serious life-threatening or systemic 
non-life-threatening diagnosis such as
disease. Other details will depend on the an acute (upper) respiratory tract
duration of the cough. infection (e.g., the common cold), a
lower respiratory tract infection,
exacerbation of a preexisting
Physical Examination condition such as asthma,
A selective examination of the upper bronchiectasis, COPD, or upper
respiratory tract, cervical lymph nodes and airway cough syndrome (UACS),
the lungs, (not forgetting to note down the which was previously referred to as
temperature and the pulse), is usually postnasal drip syndrome (Pratter et
sufficient in cases of upper respiratory al, 2006).
tract infection causing cough.  Acute bronchitis from a viral lower
respiratory tract infection such as
In cases where the history indicates that influenza, acute asthma, acute
the cause may be more complex, a more exacerbation of chronic bronchitis, and
thorough examination is warranted. the common cold all can mimic acute
bronchitis.
Acute serious illness is normally
suggested by breathlessness, complaint Subacute cough
of chest pain or the general condition of From the history, the first step is to
the patient. The presence of cyanosis or determine if the cough has preceded by
ashen pallor is more worrying than the preceding respiratory episode:
flushing caused by fever. The absence of  No -- it should be evaluated and
rhonchi with decreased air entry in a managed as if it were a chronic cough.
breathless patient indicates a more severe 
Yes – this is a post-infective cough.
form of airway obstruction than when
rhonchi are heard.
The differential diagnoses of post-infective
cough are: (1) persistent postnasal drip,
Carious teeth, infected gums, tonsillar
(2) upper airway irritation, (3) mucous
disease or sinusitis are often associated
accumulation due to hypersecretion or
with bronchiectasis and lung abscess. An
decrease clearance, or (4) a manifestation
inspiratory stridor may be due to upper
of bronchial hyperresponsiveness that
airway obstruction from various causes.
may be transient or associated with
asthma that has been exacerbated, (5)
One should look out for scars of previous
ongoing allergen or irritant exposure or (6)
surgery e.g. tracheostomy, thoracotomy.
the lingering effects of an infection such
Localised inspiratory and expiratory
as that caused by B pertussis (7) acute
wheeze may indicate a major airway
exacerbation of chronic bronchitis, (8)
obstructive lesion.
Pneumonia that has not been diagnosed
e.g. tuberculosis.
Localised areas of dullness on percussion
of the chest may indicate consolidation,

29
Chronic cough  Acute irritant or allergic exposures --
This is a more complex problem because avoidance or elimination from the
the differential diagnosis is broader than environment is effective.
that for acute or subacute cough. It often is
due to more than one condition being Cough mixtures commonly prescribed for
simultaneously present, the history often symptomatic treatment contain
offers few clues as to the initiating event. antihistamines, decongestant, demulcent
The characteristics of a chronic cough (to counteract irritation of mucosa) and
have been shown to lack both diagnostic codeine or phocodeine.(to suppress
sensitivity and specificity (Pratter et al, cough reflex).
2006). Nevertheless, when approached in
a systematic fashion, an accurate Antibiotics used should be considered
diagnosis and therapeutic success can only in (site) specific URTI as non-specific
usually be achieved. The starting point is URTI and viral syndromes do not need
the history, physical examination, and antibiotics.
chest roentgenogram.
Subacute cough
History is important to determine (1) If the subacute cough is thought to be due
whether the cough is acute (i.e., < 3 to:
weeks), subacute (i.e., 3 to 8 weeks), or  Allergen or irritant exposure --
chronic (i.e., > 8 weeks); (2) whether the removing the patient from the
patient is receiving an angiotensin- environment or limiting contact is
converting enzyme (ACE) inhibitor, important.
particularly if the onset of the cough is  B pertussis during the initial phase,
temporally associated with starting to pneumonia, and acute exacerbation of
receive the medication within the past chronic bronchitis – if bacterial
year. infection is thought to be present,
treatment with appropriate antibiotics
Chest X-ray findings in chronic cough is indicated.
 If abnormal – Refer to a specialist
colleague for further investigation.
See Table 1. Chronic cough
 If essentially normal findings -- the  Patient is receiving an ACE inhibitor --
three most common causes of cough therapy should be stopped no matter
are: (1) UACS (postnasal drip) due to what the temporal relationship. For
a variety of rhinosinus conditions, (2) example, cough may have preceded
asthma, and (3) gastroesophageal the use of the ACE inhibitor.
reflux disease (GERD) in descending However, the original cause of cough
order of prevalence. The cough will may have resolved and the persisting
resolve only when each of this is cough could be due to the drug. The
resolved. resolution of cough usually will occur
within a few days to 2 weeks of
MANAGEMENT stopping use of the drug, but the
median time is 26 days (Irwin, 2000).
Acute cough
If acute cough is thought to be due to:  Current cigarette smoker -- Cigarette
 Common cold -- a first-generation smoking is commonly associated with
antihistamine plus a decongestant is cough that is usually productive in
effective (Curley et al, 1988 in:Pratter nature and typically meets the
et al, 2006). definition of chronic bronchitis.
 Bordetella pertussis or Chlamydia Smoking cessation is almost always
[e.g., TWAR] -- that will respond to effective (Buist et al, 1979 in: Pratter
antibiotic therapy if initiated early in et al, 2006). The majority of patients
the course of the disease. will have cough resolution within 4

30
weeks, but in some cases it may take asthma have been eliminated or treated
longer. However, in patients with without the elimination of cough, NAEB
severe COPD cough may persist and should be considered next with a properly
not completely resolve or may be performed induced sputum test for
perpetuated due to ever more eosinophils. If a properly performed
frequent exacerbations of chronic induced sputum test to determine whether
bronchitis. eosinophilic bronchitis is present cannot
be performed, an empiric trial of
 COPD – if this is present, a clinical corticosteroids should be the next step.
decision as to whether the cough is
part of an exacerbation, as opposed In the majority of patients with suspected
to a chronic cough associated with cough due to asthma, ideally, before
stable COPD, needs to be made. If starting an oral corticosteroid regimen, a
the former is the case, then therapy BPC should be performed and, if the result
with antibiotics or corticosteroids is positive, some combination therapy of
needs to be considered. ICSs, inhaled ß-agonists, or oral
leukotriene inhibitors should be
 Tuberculosis -- Determine whether administered. A limited trial of oral
there are any systemic signs of corticosteroids, however, should be
disease such as fever, sweats, or administered in some patients who are
weight loss if tuberculosis is endemic. suspected of having asthma-induced
cough before eliminating the diagnosis
 Others -- A history of cancer, from further consideration.
tuberculosis, or AIDS is also important
to ascertain. In patients whose cough responds only
partially or not at all to interventions for
In patients with chronic cough, UACS and asthma or NAEB, treatment for
systematically direct empirical treatment at GERD should be instituted next.
the most common causes of cough (i.e.,
UACS (postnasal drip, asthma, NAEB, and In patients with cough whose condition
GERD). remains undiagnosed after all of the above
has been done, referral to a cough
Initial empiric treatment should begin with specialist is indicated.
an oral first-generation
antihistamine/decongestant (A/D). The INDICATIONS FOR REFERRAL
typical time course of response to A/D  In acute severe cough associated with
therapy for UACS (postnasal drip) is at symptoms such as dyspnoea and
least some noticeable improvement in cyanosis, in-patient management may
cough within days to 1 to 2 weeks of be necessary.
initiating therapy. Marked improvement or  Referral may be needed to investigate
resolution of cough may take several a prolonged cough.
weeks and occasionally as long as a few
months.

If the chronic cough persists after


treatment for UACS (postnasal drip) with
an oral first-generation A/D, the possibility
that asthma is the cause of cough should
be worked up next. The medical history is
sometimes suggestive, but is not reliable
in either ruling in or ruling out asthma.

If the chronic cough, in whom the


diagnoses of UACS (postnasal drip) and

31
CASE FOR REFLECTION
A 15-year-old girl presents with chronic
nasal congestion. She has a one-year
history of recurrent stuff nose, yellow
nasal discharge, and itchy eyes. She is
not exposed to tobacco products. Vital
signs are blood pressure 110/50, pulse
80, respirations 14, temperature 37 C.
Conjunctiva is injected. Nares reveal pale,
boggy mucosa and a yellow discharge,
There is no sinus tenderness. Throat is
slightly erythematous. Lungs are clear.
What is the most likely diagnosis?
What additional evaluation could be
performed if the diagnosis is in doubt?
(Paulman, 2005).

References
1. Irwin RS, Madison JM. The diagnosis and
treatment of cough. New Engl J Med
2000;343:1715-21.
2. Pratter et al. An Empiric Integrative
Approach to the Management of Cough:
ACCP Evidence-Based Clinical Practice
Guidelines. Chest 2006;129;222S-231S.
3. Currie GP, Gray RD, McKay J. Chronic
cough (10-minute consultation). BMJ
2003;326:261.
4. Howie JGR, The Patient Complaining of
Cough, in: Practice - a Handbook of
Primary Medical Care. London: Kluwer,
1984.
5. Zervanos NJ. Acute disruptive cough.
Postgraduate Medicine 1994 March;
95:4:153-168.
6. Paulman PM et al. Cough. In: Family
Medicine Clerkship Guide.
Mosby:Missouri, 2005:95.

32
7 Sore Throat
Gonococci
RELEVANCE TO This is uncommon in the local setting.
GENERAL PRACTICE
 One of the most common presenting Viral causes
symptoms in general practice. A viral aetiology is found in 17-25% of
 The task of the primary care physician adults and children over 2 years of age.
is to exclude serious causes of sore The most common viral causes are the :-
throat, have a rational approach to the use
of antibiotics and provide symptomatic "Respiratory" viruses
and expectant management for those not Namely rhinovirus, influenza virus,
initially requiring antibiotics. parainfluenza virus, adenovirus and
others. Symptoms may include rhinitis,
CAUSES cough, fever, body aches and malaise.
It has been estimated that about a third of
the sorethroats are caused by bacterial Coxsackie and herpes simplex
infections, a third by viral and other May cause painful ulcers in the oral
microorganisms and the remaining one mucosa and oro-pharynx.
third by non-infective causes.
Epstein-Barr virus
Bacterial infections Causes the infectious mononucleosis
Group A beta hemolytic streptococcus syndrome. The sorethroat may be
This is isolated in 10-15% of throat prolonged and constitutional upset
cultures done in adults. It is important to prominent.
recognise, treat early and adequately such
infections with penicillin or erythromycin Other Microorganisms
because this prevents the occurrence of
acute rheumatic fever, a non-suppurative Chlamydia trachomatis and
complication. Unfortunately, only some Mycoplasma pneumoniae are found to
15% present with the triad of fever, be quite common, contrary to what is
pharyngeal exudate and tender anterior previously known.
cervical adenopathy1 so diagnosis may not
be so easy in the remaining 85% of cases. Candida
Especially in immunocompromised
individuals, and may be an early sign of
Non-group A streptococcus acquired immunodeficiency syndrome
This rarely produces non-suppurative (AIDS).
complications.
Non-infectious causes
Haemophilus influenzae There are a number of such causes:
Haemophilus influenzae causes a painful referred pain; drying of pharyngeal
sore throat and it may be complicated by epithelium from mouth breathing; chemical
acute otitis media. irritation from smoking or other toxic
inhalation; and cancer of pharynx or
Corynaebacterium diphtheriae tongue which may present as persistent
Almost never seen today because of early sore throat but this is uncommon.
immunisation. It must however be thought
of in a patient not immunised against WORKUP
diphtheria for some reason. The white History
adherent membrane over the tonsil is The presence of accompanying running
diagnostic. nose suggests a viral cause. Knowledge
of family members being similarly affected
and presence of an epidemic helps in the

33
diagnosis. Use of medications should be tonsils and pharyngeal wall are covered
asked e.g., carbimazole. by a gray membranous exudate that
bleeds easily on removal.
Physical Examination
A general examination, examination of the Systemic Examination
oro-pharyngitis, anterior cervical nodes  Anterior cervical lymph nodes are
and selectively other systems is required. usually found in patients with
streptococcal sore throat.
General examination  Posterior cervical lymph nodes are
This includes the temperature, presence enlarged in 90% of patients with infectious
of jaundice (jaundice is present in 5-10% mononucleosis in the first week.
of patients with infectious mononucleosis).  Generalised lymphadenopathy,
hepatic tenderness and splenomegaly
Examination of the oro-pharynx further indicate infectious mononucleosis.
Posterior mouth ulcers are typically Most children (up to 80%) with glandular
caused by Coxsackie viruses manifesting fever will have splenomegaly at some time
as herpangina with severe pain on during the illness, but this is found less
swallowing. Primary (first episode) herpes commonly in adults (Englund, 1988).
simplex infection produces ulcers only in
the anterior parts of the mouth and lips Laboratory Investigations
manifesting as acute gingivo-stomatitis; it
is important to recognize this and Throat culture
antinvirals e.g., acyclovir be given. This is not needed in every case. Patients
Candidiasis is characterised by white, with no clinical evidence of streptococcal
curdy exudates in the immuno- infection, and with typical signs and
compromised patients, and also in symptoms of viral upper respiratory tract
neonates who are yet to develop their infection, do not warrant a throat culture.
immuno-competence adequately.
Culture is indicated in patients with special
Acute epiglottitis should be suspected in risk factors for streptococcal disease.
patients with high fever, hoarseness of
voice and stridor in a child or adult. The Useful Investigations
enlarged and inflamed epiglottis may be TWDC. Atypical lymphocytes, if
visible on inspection. Do not attempt to constituting >20% of total white cells,
examine in detail lest a spasm of the oro- indicate infectious mononucleosis.
pharynx is provoked. Though rare, it is
important to pick up this condition as it is Specific Investigations
potentially life-threatening. The patient  Anti-streptolysin O Titre. Lack of a
should be admitted as an emergency. four fold rise in titre of convalescing
serum indicates carrier status,
Enlarged tonsils may be streptococcal or estimated to comprise 20-30% of
viral in origin. Drooling and pain on positive throat cultures.
opening mouth should lead the doctor to  Rapid office diagnosis. Latex
suspect the presence of peritonsillar or agglutination and ELISA techniques.
retropharyngeal abscess; unilateral  Tests to confirm EBV. Paul-Bunnel
erythema of the soft palate accompanied or Monospot test.
by deviation of the uvula confirms the
diagnosis. Investigations to identify specific
causative agents are done only if the
Palatine petechiae are sometimes found illness is prolonged
in patients with infectious mononucleosis.
MANAGEMENT
Exudates are seen in streptococcal sore Symptomatic Treatment
throat, infectious mononucleosis and
diphtheria. The latter is suspected if the

34
This is sufficient when a viral cause is CASE FOR REFLECTION
suspected. Antipyretics, antihistamines, A 4-year-old boy is brought to your clinic
decongestants and lozenges are with a sore throat and decreased appetite
prescribed where indicated. Rest and of four-day duration. On physical
sufficient fluid intake should be stressed. examination, he has a fever of 38 C. His
Symptomatic treatment is also indicated in posterior oropharynx is red with enlarged,
infectious mononucleosis, as no definite non exudative tonsils. He does not have
antiviral therapy is as yet available. cervical lymphadenopathy. He has a
cough.
Streptococcal pharyngitis
Recommended treatment regimens are as What causes are in your differential
follows:- diagnosis?
Penicillin G, benzathine (Bacillin) 1.2 Should you send this child home with
million units i/m in one single dose, or antibiotics?
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.
References
Other Infections 1. Kiselica D. Group A Beta-Hemolytic
Streptococcal Pharyngitis: Current Clinical
A trial of 10-day course of erythromycin or
Concepts. Am Fam Physician, 1994
tetracycline 250 mg q.i.d. is probably April;1147-1154.
justified in prolonged sore throat, to 2. Englund JA. The many faces of Epstein-
eradicate any mycoplasma present. Treat Barr virus. Postgrad Med 1988;83:167-78.
other rarer forms of pharyngitis according 3. Gorroll AH et al. Approach to the patient
to the specific treatment regimens for the with pharyngitis. in:Primary Care Medicine,
particular organism. 2nd ed. 1987; 885-889.

INDICATIONS FOR REFERRAL


 Suppurative e.g. peritonsillar or
retropharyngeal abscess
 Life-threatening conditions e.g. acute
epiglottis.

35
8 Chest Pain
cardiovascular risk factors. This must be
excluded if the patient:
RELEVANCE TO
GENERAL PRACTICE  is male
 is aged  40 years
 Chest pain is taken seriously by the  is of Indian ethnic group
patient.  has a history of ischaemic heart
disease, diabetes mellitus.
 In general practice, it is common to Severity of ischaemia ranges from angina
find that chest pain is of muscular to infarction.
origin or psychogenic origin.

 The important tasks of the primary Pain of infarction:


care physician are first to distinguish  is more severe
between cardiac and non-cardiac pain,  usually occurs at rest
and then to decide whether this is  lasts longer than 20 minutes
serious or not serious, whether urgent  is typically associated with sweating
or not urgent. and vomiting
 is not relieved by glyceryl trinitrate
CAUSES tablets.
Chest pain may be classified according to Gallstones and peptic ulcer
anatomical structures, e.g. chest wall pain,
visceral pain and referred pain. It is more Gallstones and peptic ulcer may present
useful in practice to classify the causes with chest pain and be mistaken for
into acute and chronic or intermittent chest myocardial infarction. Hypotension,
pain and within each of these categories, tachycardia and extrasystoles may also
serious and non-serious causes of chest occur if there is bleeding from the
pain. gastrointestinal tract. Melaena or
haemetemesis if present differentiates the
Acute chest pain diagnosis.

Serious causes of acute chest pain arise Less common


from (1) the heart, (2) the lungs and (3)
the aorta. As these are potentially life- Pericardial pain
threatening, and it is important that the Common causes of pericardial pain
diagnosis be made early. Once these  Viral – young person, presence of
causes are excluded, there is less systemic symptoms of viral illness.
urgency in diagnosis and management.  Myocardial infarction – within a few
hours, or after 1-2 weeks (Dressler‟s
Serious causes syndrome)

Common This should be suspected when pain is


worse on lying down, and patient prefers
Ischaemic cardiac pain to sit up and lean forward. Pericardial rub
There is increased likelihood of ischaemic is diagnostic.
cardiac pain in the presence of

36
Pneumothorax „secondary gain‟, e.g. malingering,
Most cases of pneumothorax are financial compensation, sympathy. Nature
idiopathic. Known causes of of pain variable. Usually described as
pneumothorax are asthma, bullous sharp, stabbing and intermittent.
emphysema and interstitial lung disease.
In hyperventilation syndrome, the patient
is usually a young female presenting with
Pleural pain
diaphoresis and acute respiratory distress.
Pleural pain can be a feature of bacterial Carpopedal spasm helps to confirm the
pneumonias, viral infections and diagnosis.
connective tissue diseases. There may be
associated with cough, haemoptysis and Less common
dyspnoea. If a pleural rub is present, this Oesophageal spasm
will be diagnostic.
A motility disorder that is sometimes seen
in diabetes mellitus. Patient complains of
Uncommon
severe chest pain on swallowing a large
Rare causes include pulmonary embolism
bolus of food or cold drinks. This may be
and dissecting aortic aneurysm. Patient is
relieved by nitroglycerin, and may hence
usually ill and needs immediate referral.
be further confused with angina.
Diagnosis by fluoroscopy during barium
meal.
Non serious causes
Common Table 1. Diagnosis of chest pain
Reflux oesophagitis Anginal pain Nonspecific pain
This is commonly described as Described as a Patient complains of
„indigestion‟. It is related to eating, „discomfort‟ or „ache‟ pain, rather than
exacerbated by bending down, relieved by discomfort, stabbing
antacids. Nocturnal pain may be in nature, lasting a
experienced. As its prevalence is 30-40 % few seconds.
of the population, it may coexist with other Occurs in the centre Pain radiates down
causes of chest pain. It may also be of chest. Radiation left arm, but not to
relieved by nitroglycerin, further confusing to jaw and neck neck or jaw.
it with angina. diagnostic.
Commonly also
radiates to the arms,
Musculoskeletal pain L > R, and to the
Musculoskeletal pain is common. It can be back.
result of strain involving muscles of the Pain induced by Apparent relationship
neck, shoulder, thorax; rib and sternal exercise, and after a with exercise, but
pain of various causes. Such chest wall meal. Pain induced pain usually comes
pain is usually superficial, localised, and by sexual on at the end of a
can be reproduced or aggravated by intercourse. busy day, and not
pressure applied to the affected area, or after exercise.
with movement. Pain improves with Pain not relieved by
rest. rest.
Viral illnesses can cause intercostal
Relieved by Patient often claims
myalgia. Tietze‟s syndrome – an idiopathic
sublingual nitrates that nitrates are
costochondritis is diagnosed by within seconds or helpful, but only after
tenderness at a particular costochondral within 2 minutes. 20-30 minutes.
junction.
Adapted from Hampton J, The patient with chest pain
and breathlessness. Medicine International 1989,
Psychogenic chest pain 3:2723.
Psychogenic causes may be due to
anxiety, depression, or the means to

37
Neurovascular The patient may be in shock or
Herpes zoster infection can cause chest hemiplegic.
wall pain (a radiculitis) before the onset of
the rash, which is diagnostic. Post- Past history, family history, a history of
herpetic neuralgia may persist for weeks social habits, life style and current
after the acute episode. Degenerative medications need to be asked for.
changes in the spine, metastatic tumours
to the spine, can impinge on the dorsal Physical Examination
nerve root and cause chest pain.
The physical examination further helps
distinguish the serious from the not
Chronic or intermittent chest pain serious causes of chest pain. It should be
Chronic or intermittent chest pain may be approached systematically.
due to repeated attacks of acute pain.,
e.g. angina, reflux oesophagitis, General
musculoskeletal problems. The term Is the patient distressed, pale, sweating,
„nonspecific chest pain‟ is used to dyspnoeic or tachypnoeic? Check the vital
describe chest pain when ischaemic heart signs. Abnormalities in any suggest an
disease is unlikely and no other cause can unstable, urgent condition. Palpate the
be found. A middle-aged man may also pulses. Unequal pulses may mean aortic
have non-specific chest pain. dissection.
Distinguishing features are listed in the
Table 1. Examination of the heart and lungs
Murmurs, abnormal heart sounds, rhythm
WORKUP abnormalities especially bradycardia,
crepitations in the lungs and poor air entry
History all indicate a pathological cause for the
chest pain. Raised jugular venous
History taking should be directed towards pressure, the presence of 3rd or 4th heart
confirming or disproving the serious sounds, pericardial rub are other abnormal
causes of chest pain. signs. Pnuemothorax result in increased
Cardiac pain is located in the front of the percussion resonance and diminished
chest, mid or upper sternum radiating to breath sounds on the affected side.
the left arm or both arms, round the chest
or into the jaw. The duration is rarely of Examination of the other systems
more than 30 minutes, unless a coronary Examination of the musculoskeletal
thrombosis has occurred. The words used system may point to the anatomical site of
to describe it are: tight, heavy, musculoskeletal chest pain. One should
constricting, crushing, numbing or remember to examine the breast and the
burning." abdomen. Examination of the patient's
mental state is also important if serious
Pneumothorax is a condition seen off and causes of chest pain are not suspected.
on in general practice. Pulmonary
embolism is uncommon. Pleurisy, Investigations
mediastinitis and pneumomediastinum are The extent of initial investigations is
rare but serious causes of chest pain. The guided by the urgency of the presenting
pain of pneumothorax is described as problem. If the patient is very ill, minimal
stabbing, sudden in onset, localised; investigations necessary are done in the
associated with dyspnoea, sometimes physician's office before urgent referral. If
giddiness and fainting. Pulmonary the patient's general condition is well, and
embolism is also associated with sudden especially if the cause is still unclear after
onset chest pain and dyspnoea. history and physical examination, then
further investigations should be done.
Dissecting aortic aneurysm usually causes
excruciating pain radiating down the back.

38
Electrocardiogram MANAGEMENT
In establishing a diagnosis of ischaemic
cardiac pain, a resting ECG should be A decision is made on the likelihood of an
done to detect presence of ischaemic acute, life-threatening conditions. If this is
changes. not likely, symptomatic and expectant
 If ECG shows evidence of ischaemic management is given; these are patients
heart disease / old infarction, the who diagnosis of musculoskeletal chest
patient requires referral for further pain is clear from history, examination with
evaluation of the ischaemic heart or without simple investigations.
disease.
 If ECG is normal, then a treadmill test Where a psychogenic cause is clear, the
is required. physician should delve further into the
family and social background and enlist
The ECG is useful to diagnose the type of help from these quarters in the
arrhythmia if one is suspected clinically. management of the patient if necessary.

An exercise ECG may be considered. A INDICATIONS FOR REFERRAL


normal stress ECG reduces considerably
the chance that ischaemic heart disease is In acute, life-threatening conditions,
a cause of chest pain. referral for hospital management should
be made urgently, after having stabilised
In pericarditis, the ECG is not very helpful the patient in whatever emergency
unless ST segments are present. measure available, e.g. setting up an
intravenous infusion.
Radiology/Echocardiography
 A chest X-ray is an useful Where diagnosis is in doubt, or where the
investigation in the diagnosis of investigative procedures required are
cardiac and pulmonary causes. Chest sophisticated, the patient should be
X-ray may be normal, or may show referred to the appropriate specialists for
abnormalities such as a pleural further management. The threshold for
effusion, a pneumothorax, or a referral is reduced in a patient with
widened cardiac silhouette due to a multiple cardiac risk factors.
pericardial effusion. Chest X-rays are
diagnostic in pneumothorax. Where the chest pain does not improve
 Radionuclide angiocardiography, with symptomatic and expectant
coronary arteriography, lung scans, treatment, or becomes more frequent, a
echocardiography may be helpful in review and referral should be made.
pulmonary embolism.
Echocardiography is helpful in Recurrent chest pain
diagnosis of pericardial effusion.  Repeated ECG evaluation may be
 Barium studies, X-ray cervical spine worthwhile.
may need to be done if the suspected  If chest pain is stress-related, exploring
cause of chest pain is outside the cause/s of stress may be helpful.
chest.
References
Laboratory Investigations 1. Rakel RE, Textbook of Family Practice,
Biochemical cardiac markers are now 4th Edition, Philadelphia: WB Saunders,
available for early diagnosis of ischaemic 1990; 874-882
heart disease causing chest pain. 2. Hampton J. The patient with chest pain
Troponins, CK-MB, and myoglobin and breathlessness. Medicine
elevation will be confirmatory. The patient International 1989;3:2720-5.
should be referred if there is a likelihood of
ischaemic chest pain.

39
9 Diarrhoea

DIARRHOEA IN ADULTS Foods taken: Although it is often


difficult to establish the source of the
RELEVANCE TO diarrhoea, a history of the types of
GENERAL PRACTICE food taken within the last 24 hours
may be helpful.
 Diarrhoea is an affliction familiar to
everyone. Most episodes are brief, Milk and diary products can cause
self-limited and well-tolerated loose stools in the susceptible adult.
without need for medical attention.1
If an epidemic of food poisoning
 Diarrhoea being a self-limiting occurs, information on the type of food
complaint, it is useful to find out eaten and the place where it was
why for this episode, the patient served will help the Ministry of
needs to see the doctor. Environment in its investigations.

 Symptomatic treatment is often all Associated symptoms: Vomiting,


that is necessary for acute nausea, dizziness, colicky abdominal
diarrhoea. However, one should pain, fever, thirst indicates that a
be alert for the occasional serious bacterial infective cause for the
cause. diarrhoea is likely.

Physical examination
WORKUP
Assessing dehydration
History One should look at the tongue and
mucous membranes as well as the
Onset: It is important to establish turgor of the patient's skin. A dry
whether the diarrhoea is an acute tongue and mucous membrane with or
problem of a few days duration or a without a rapid pulse rate indicate that
chronic one spanning some time. dehydration needs to be corrected.

Timing: One should ask when the Abdomen


diarrhoea usually occurs. Diarrhoea An examination of the abdomen for
occurring at night is always tenderness and bowel sounds is
pathological. warranted to reassure the patient that
there is nothing more serious. A rectal
Nature of stools: Watery stools examination is indicated if bloody
constitute diarrhoea whereas loosely diarrhoea is present.
formed stools do not and may indicate
a different pathology like irritable Other systems
bowel syndrome. It is also important to If a systemic cause for the diarrhoea is
ask whether the stools are mucoid, suspected, a full examination should
blood stained or foul smelling and be done.
floating.
Investigations
Travel: Recent travel overseas may
be etiologically important.  These are not necessary for the
majority of mild acute diarrhoeas.

40
Chronic cases will require a DIARRHOEA IN INFANTS AND
workup or hospital referral. CHILDREN

 Stool culture and smear for cysts RELEVANCE TO


and organisms are useful if GENERAL PRACTICE
giardiasis or amoebiasis is
suspected.  Diarrhoea in a child has to be
attended to promptly as the patient
 Endoscopy, barium enema or is more prone to suffer from
barium meal may be needed for dehydration and its consequences.
the evaluation of a chronic
diarrhoea.  Parents may have their incorrect
views of diarrhoea in their child;
 Other investigations: Thyroid thus teething does not cause
function tests, glucose tolerance diarrhoea, contrary to what is often
tests and other endocrine tests believed by mothers.
may be necessary.
 Fully breast-fed babies may have
MANAGEMENT loose stools. Their stools are
explosive, contain curd and may
The adult patient be bright green in colour. These
Most acute cases need only babies should not be treated for
symptomatic treatment. These are: diarrhoea.
 Bed rest if diarrhoea is severe or
frequent  Starvation stools should not be
 Adequate fluid and electrolyte confused with diarrhoea.
replacement. COMMON CAUSES
 Drugs like kaolin, charcoal which
have some absorptive properties Milk formula and improper feeding
may be prescribed. Infants vary widely in tolerance to
 Anti-cholinergics like Lomotil or quantity and quality of food. The
opiates like codeine phosphate contents of protein, fat and
may help to relieve the symptoms carbohydrate affect the volume of
if diarrhoea is severe. stools. Volume of water in stool varies
 Antibiotics and Flagyl are rarely directly with fat and sugar content of
indicated unless the responsible formula, e.g. babies on formula high in
organism is identified as being polyunsaturated fats have looser
bacterial or amoebic respectively. stools than those on formula
 Anti-emetics may be useful if containing greater percentage of
vomiting is severe. saturated fats.

INDICATIONS FOR REFERRAL Also if sugar content in formula is


greater than 7.2% weight per volume,
Referrals may be indicated for the stools tend to be soft and watery. With
following: age the gut matures and tolerance to
 Severe cases which may be food content improves.
infectious or warranting IV fluid
replacement. Breastfed babies may have frequent
 Chronic cases for diagnosis and loose stools. This is normal.
treatment.
 Cases where the diagnosis is not Infections
clear. Infection as a cause of diarrhoea is
common. It may be enteral or parental.
Rotavirus is the commonest cause. If

41
blood is associated with diarrhoea,  May need to continue on soy
Shigella or Salmonella should be formula for a longer duration before
suspected. Cholera produces profuse attempting to switch back to milk.
rice water stools. Stool culture should May consider „olac‟ (lactose free
be done if a bacterial cause is cow‟s milk).
suspected, such as dysentery, typhoid  Refer to hospital if no improvement
or cholera. and symptoms deteriorate.

MANAGEMENT Infants

Management begins with assessment Mild diarrhoea: not more than 1 stool
of the severity of the diarrhoea and every 2 hours, give 10-15 ml/ kg/hour
degree of dehydration (see Table 1). ORS until diarrhoea stops
(approximately 1 dissolved tablet of
Children above age of one year Servidrat for each liquid stool). If
breastfed, continue breastfeeding.
Mild diarrhoea (< 4 stools per day)
Moderate diarrhoea: > 1 liquid stool
 Continue breastfeeding if child is every 2 hours. Give 10-15 ml/ kg/hour
breastfed. ORS until diarrhoea becomes mild
 Establish cause of diarrhoea, e.g. (approximately 1 dissolved tablet
overfeeding, dietary indiscretion, every hour or as much as patient will
viral upper respiratory tract accept). If breastfed continue
infection, systemic infection and breastfeeding. Solutions should be
food allergy. given slowly, in sips at short intervals
 Treat the underlying cause. If mild to reduce vomiting and improve
dehydration and child is able to absorption.
retain fluids – treat as outpatient.
Severe diarrhoea: refer to the
Moderate diarrhoea (4-10 stools per hospital.
day)
 Off solid diet. References
 Half strength milk. 1. Richter JM. Evaluation and
 Oral rehydration fluids, e.g. rice- management of diarrhoea. in: Goroll et
al. Primary Care Medicine, 3rd ed.
water or dextrose saline solution.
Philadelphia: Lippincott, 1995:
Oral rehydration from tablet 357-368.
(Servidrat): 1 tablet in 4 ounces of 2. Goepp JG, Katz SA. Oral rehydration
water, or commercially available therapy. American Family Physician
solutions (e.g. Oralyte, Paedialyte). 1993;47:4: 843-848.
Give 50 to 100 mls after each stool. 3. Haffezee IE. Nutritional management
during acute infantile diarrhoea.
Severe diarrhoea (>10 stools per Maternal and Child Health. June
day) 1992:175-179.
4. WHO. Treatment and prevention of
 Off solids and off milk. Only Oral dehydration in diarrhoeal diseases - a
Rehydration Solution (ORS). guide at primary care level. WHO:
 Continue ORS till at least 3 Geneva, 1976.
consecutive stools of normal 5. Biloo AG. Infantile diarrhoea:
frequency and consistency. When management with oral rehydration.
reverting back to milk formula, Medical Progress Feb 1986:15-24.
advise graduated increase in 6. Barnes G. The Child with diarrhoea. In:
Robinson MJ, ed. Practical Paediatrics.
strength of milk.
Churchill Livingstone, 1990:505-513.
 If diarrhoea recurs on restarting
milk gradually, suspect lactose
intolerance (usually temporary).

42
TABLE 1. HOW SEVERE IS THE DEHYDRATION?
Mild Moderate Severe
1. ASK DIARRHOEA Less than 4 liquid stools per 4-10 liquid stools per day More than 10 liquid stools per day, with
day 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 quickly Pinch, goes back slowly Pinch, goes back very slowly
PULSE Normal Faster than normal Very fast, weak, or cannot be felt
FONTANELLE Normal Sunken Very sunken
(in infants)
4. WEIGH 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

43
10
DEFINITION
Constipation 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.
There is no uniform definition of
constipation. To some it means Drugs are an important cause of
movements that are too infrequent or constipation that may be overlooked,
stools that are too hard. Others complain e.g. cough mixtures containing opiates,
of incomplete or difficult evacuation. antacids containing calcium and
Among normal people, bowel habits aluminium, anti-cholinergics and
vary widely, and there are diverse anti-depressants.
perceptions of what is normal.
Population studies show that most Specific medical conditions may also
normal people have more than three result in constipation. Depression and
bowel movements per week. hypothyroidism are common examples.

CONSTIPATION IN THE ADULT


Table 1. Causes Of Constipation
RELEVANCE TO
GENERAL PRACTICE General
Poor fluid intake
Inadequate dietary fibre
 Constipation is a common symptom
Inconvenience toilet access
in general practice. It is among the Inactivity
most frequent reasons for self- Specific pathology
medication and is particularly Depression
troublesome in the elderly. Hypothyroidism
Abdominal tumour -- large bowel
 There is a need to clarify what the cancer, external compression
patient means by constipation and Spinal cord compression
what is the normal bowel habit for Drugs
Opiates
that patient.
Anticholinergics
Tricyclic antidepressants
 The primary care doctor must be Phenothiazines, haloperidol
able to uncover any underlying Antacids containing calcium or
pathology and to provide aluminium
symptomatic relief to those without a Iron
structural lesion.
WORKUP
CAUSES
History
The common causes of constipation in
the adult are shown in Table 1. The presence of associated symptoms is
sought to define any underlying cause,
Simple constipation due to inadequate which may be serious.
fluid intake, dietary intake and inactivity  Abdominal pain, recurring and
is the commonest cause seen in general colicky - suggests mechanical
practice. obstruction.
 Perianal pain - suggests anal fissure
In the sedentary adult, constipation is or abscess.
often compounded by a hectic schedule
- repeated failure to respond to nature's
call and lack of regular bowel timing.

44
 Alternating diarrhoea and lunch and dinner; include
constipation, with or without blood in fruits in the diet if not already
stools - suggest colonic carcinoma. done.
 Low mood, negative feelings and  Advice to increase physical activity.
fatigue – these are symptoms of  Laxatives or suppositories as a
depression. temporary measure. See Table 2.
 Observation of family members that
the patient shows a slowing of Faecal impaction in the bedridden
physical and mental activities, weight elderly
gain and cold intolerance – these are  Manual evacuation followed by
symptoms of hypothyroidism. regular enemas and laxatives may be
necessary.
Physical Examination  Advice to increase fibre and fluid
A selective physical examination intake but bearing in mind the
includes: problems of eating in the elderly.
 Observation of the general health of  Fruits like bananas, papaya are
the patient and mental state suitable and the making purees of
 Abdominal examination for faecal vegetables will be necessary.
masses and other masses,
abdominal distension and INDICATIONS FOR REFERRAL
tenderness.
 Rectal examination is useful to detect Further assessment is indicated where a
perianal conditions, faecal impaction, colonic carcinoma is suspected.
and also to obtain a sample of stools
for inspection and occult blood
testing. CONSTIPATION IN THE CHILD
 The hypothyroid patient has
characteristic facies and delayed RELEVANCE TO
relaxation of deep tendon reflexes. GENERAL PRACTICE
 Breast-fed infants tend to have
Investigations frequent loose stools, whereas
 Investigations are unnecessary bottle-fed infants tend to have less
where a cause of constipation can be frequent hard stools.
found.
 A barium enema may be considered  Some older Children may normally
if a large bowel carcinoma is have a bowel movement as seldom
suspected. as once or twice a week.

MANAGEMENT  Parents often worry about whether


their child‟s bowel movements are
The management of constipation normal.
extends well beyond the use of laxatives.
Attention to other issues – diet, fluid CAUSES
intake, mobility, physical activity, and
barriers to physical activity including pain The diet is the commonest cause:
– contributes to an effective outcome. inadequate fluid and fibre intake; and
excessively concentrated formula milk in
Simple constipation the younger child.
 Attend to patient's concerns about
constipation. The child fearful of defecation or crying
 Advice to increase after defecation, and blood in stools
-- fluid intake point to the presence of a perianal
-- fibre intake e.g. at least 1-2 fissure.
servings of vegetables for

45
Serious causes are rare: INDICATIONS FOR REFERRAL
 Hypothyroidism in a child may
present as persistent constipation in Referral is indicated for intestinal
the neonate obstruction, anal fissure.
 Acute intestinal obstruction would
present with associated abdominal References
pain or a persistently crying baby. 1. Goroll AH. Approach to the patient with
 Stubborn constipation (obstipation) constipation. in: Goroll et al. Primary
Care Medicine, 3rd ed. Philadelphia:
with failure to thrive is present in
Lippincott, 1995: 369-372.
Hirschsprung's disease (very rare). 2. Ebelt VJ. Constipation in childhood. Can
Fam Physician 1992 September
WORKUP 38;2167-2174.
History 3. Schaffer DC & Cheskin LJ. Constipation
A detailed history is important. It should in the Elderly. Am Fam Physician 1998;
cover age of onset; precipitating events 58(4):907-14.
such as diet changes, toilet-training
problems, pain and bleeding with
defeacation; abdominal pain; bowel
routine; behavioural problems; previous
treatment including punitive measures;
and medications for other reasons.

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. Perianal inspection may reveal
a fissure.

MANAGEMENT

For simple constipation


 Allay parental anxiety and concern
about constipation and advice on
bowel training where necessary.

 Advice about bottle feeding,


increasing fluid and fibre intake e.g.
water and fruit juices for the older
infant.
 A laxative may be prescribed: Liquid
paraffin (Agarol) or Microlax (sodium
citrate and sodium lauryl
sulfoacetate).

46
Table 2. Laxative Effects and Side Effects
Type of laxative Mechanism of action Onset of action Potential adverse
effects

Bulk laxative Increases fecal bulk as 12 to 24 hours or Increased gas;


 Psyllium seed well as the fluid retained more bloating; bowel
 Bran in the bowel lumen obstruction if
 Calcium polycarbophil strictures present;
choking if powder
forms are not taken
with enough liquid
Emollients and stool Lubricates and softens 24 to 48 hours Minor effects such
softeners fecal mass as bitter taste and
 Dioctyl sodium nausea
 Calcium sulfosuccinate
(docusate sodium)
Stimulants and irritants Bisacodyl 10 minutes (sodium Dermatitis;
Alters intestinal mucosal Senna bicarbonate plus electrolyte
permeability Cascara potassium bitartrate imbalance;
Stimulates muscle activity Sodium bicarbonate suppository [Ceo- melanosis coli
and fluid secretions plus potassium two]) to 12 hours
bitartrate
Osmotic laxative Salts lead to retained 2 to 48 hours Electrolyte
 Ricinoleic acid fluid in the bowel lumen, imbalance;
 Lactulose with a net increase of excessive gas;
 Magnesium salts fluid secretions in the hypermagnesemia,
 Sodium salts small intestines hypocalcemia and
 Sorbitol hyperphosphatemia
in patients with
renal failure;
dehydration
Enema Causes reflex Within 30 minutes Dehydration;
 Tap water evacuation hypocalcemia and
 Saline hyperphosphatemia
 Sodium phosphate in patients with
 Oil chronic renal failure

Source: Schaffer & Cheksin, 1998.

47
11 Vomiting
RELEVANCE TO Reactions to drugs (e.g., digoxin and
GENERAL PRACTICE aspirin), uraemia, diabetic
ketoacidosis, and rarities like
 Vomiting is a relatively Addison's disease.
common presenting symptom
in general practice and is twice WORKUP
as common in children as in
adults. History

 It is a non-specific symptom The history will give guidance to a


covering a wide range of likely diagnosis. Systematic enquiry
possible causes which will be should be made on how the symptoms
identified only by piecing began and how long they have been
together other clinical features present. Any nausea and/or vomiting
of the illness presented. that go on longer than three to four
days, in the absence of pregnancy,
must raise possibilities of an
CAUSES underlying cause.
The timing of the vomiting may be
There are many possible causes of noteworthy. Vomiting of relatively
nausea and vomiting and it requires unaltered food soon after a meal
time, observation, clinical experience suggests an oesophageal obstruction.
and awareness to decide on the cause Pyloric stenosis is associated with
of the problem and the correct large offensive vomitus but with no
management. Nausea and vomiting evidence of bile. A gastro-colic fistula
may result from local, central or characteristically produces faeculent
general causes. vomit.

Local causes The possibility of nausea and vomiting


"Acute gastritis" (a useful label for the being part of a psychiatric disturbance
syndrome of vomiting abdominal pain is unlikely. They are not features of an
and malaise). This may be caused by anxiety state or depression. In
an infective agent (e.g., viral) or some anorexia nervosa, although refusal of
other ingested gastric irritant (in and abstention from eating are the
particular, excessive alcohol main symptoms there may also be
consumption). induced vomiting.

Central causes Examination


Acute vertigo associated with nausea
and vomiting (as in Meniere's The many possible causes of vomiting
syndrome or acute labyrinthitis), make it necessary to carry out a full
motion sickness, migraine and rarer physical examination of patients
conditions like vestibular neuronitis presenting with this symptom.
and tumours. Associated symptoms, however, may
direct particular attention to certain
General causes areas.

48
The child patient
 Nausea and vomiting
 The pyrexial infant or child who associated with vertigo or
presents with vomiting will lead headache should lead to a
the practitioner to look careful neurological
particularly for neck stiffness, examination with particular
signs of inflammation in the examination of the optic fundi
ears and throat, and abdominal for signs of raised intracranial
tenderness. In the presence of pressure, eye movements for
respiratory distress or cough nystagmus, and for signs of
he will try to elicit signs of ataxia in the limbs. The ears
pulmonary infection. In the should also be examined.
absence of any abnormalities
in these systems he will  Nausea and vomiting of
examine a mid-stream gradual onset will draw special
specimen of urine attention to the gastro-intestinal
bacteriologically. tract. The practitioner should
look for signs of weight loss,
 Very often vomiting in infancy abdominal masses, visible
is caused by mild peristalsis and abdominal
gastroenteritis, when the distension and should carry out
practitioner's main concern will a rectal examination.
be with eliciting signs of
dehydration, in the absence of  In the young adult infective
which rapid recovery may be hepatitis often presents with
expected. A question about the nausea, and jaundice and liver
frequency with which the infant tenderness should be looked
is wetting his nappies is a for.
useful guide to impending
dehydration.  In a young woman pregnancy
is a common cause of nausea.
 In the apyrexial infant in the This may be confirmed by a
first few weeks of life pyloric urine pregnancy test.
stenosis may be suspected by
the presence of projectile Investigations
vomiting and the doctor will
then examine the infant during These will depend on the history and
a feed in order to identify a examination. In the vast majority of
pyloric tumour. patients presenting in general practice
with vomiting they will add nothing to
the diagnosis. In the second half of
life, patients presenting with nausea
The adult patient and vomiting of gradual onset will
require a full investigation to exclude
 The apyrexial adult presenting organic bowel disease.
with vomiting associated with
colicky abdominal pain and
possibly diarrhoea is almost MANAGEMENT
certainly suffering from an
acute dietary indiscretion or  In selecting the treatment for
gastro-intestinal infection. In patients presenting with
these cases it is always wise to nausea and vomiting, the first
examine the abdomen for priority is to make a correct
localized tenderness to exclude diagnosis.
appendicitis.

49
The adult patient
The child patient
 In the adult patient the most
 In the infant and child most common cause of vomiting is a
cases will be due to feeding dietary indiscretion or
problems, gastro-intestinal gastro-intestinal infection.
infections or infections of the Treatment consists of bed rest,
upper respiratory tract. Feeding withdrawal of all solid food and
problems are most commonly adequate simple fluids. Very
due to faulty technique rather commonly diarrhoea follows the
than faults in the content of the gastric symptoms and may be
feed. They require time for relieved by a kaolin mixture or
diagnosis and not only must a codeine phosphate, 30 mg four
careful history be taken, the hourly, Lomotil 2 tab tds or
mother must be observed Imodium 2 tab tds.
feeding her infant.
 Some of the specific causes of
 In treating acute nausea and vomiting may be
gastro-intestinal infections in treated with more specific
the child, (and adult), the most remedies. Thus, vestibular
important step is to stop all disorders, including motion
solid food and to ensure an sickness, vestibular neuronitis and
adequate intake of simple Meniere's disease, may be helped
fluids, of which water is the by the use of hyoscine
most appropriate. In the infant hydrobromide, 0.1 to 0.5 mg or
dehydration may occur rapidly. one of the anti-emetic
The mother should be antihistamines, e.g.
instructed to give 30 to 120 ml diphenhydramine 50 mg or
of water every two hours, the prochlorperazine maleate 5mg.
amount depending on the size Transdermal scopolamine is also
of the infant. In most cases this effective for prevention of motion
will maintain hydration and sickness. The major side-effects
vomiting will cease. are dry mouth and
lightheadedness. A single patch
 Probably more harm than good lasts up to 72 hours.
comes from administering  Vomiting in pregnancy will usually
electrolyte solutions to infants in resolve without specific treatment
general practice. As vomiting but with reassurance and advice
ceases, the child should be slowly about taking something by mouth
weaned back on to a normal diet. before rising in the morning, and
Should electrolyte replacement small frequent snacks, rather than
become necessary the child large meals, during the day. The
should be admitted to hospital. more resistant case may be
helped by use of meclozine
 Acute infections in childhood other hydrochloride, 25mg, or
than gastro-intestinal should be diphenhydramine 50 mg which
treated with an appropriate has stood the test of time and for
antibiotic. In the vomiting child this which there is no evidence of
should normally be administered teratogenicity.
by intramuscular injection. Parents
in this situation should be  Vomiting may be a troublesome
particularly warned not to use symptom in migraine. It may be
aspirin which may exacerbate the prevented by the administration of
gastro-intestinal upset. ergotamine tartrate, 2 mg, early in

50
an attack and in some proprietary References
preparations this drug is combined 1. Fry J. The patient complaining of
with an anti-emetic antihistamine. nausea and vomiting. in: Cormack J,
In the established attack, Marinker M and Morrell D. Practice: A
suppositories of prochlorperazine handbook of primary medical care.
London:Kluwer, 1982;436-441.
maleate may be useful.
2. Goroll AH. Evaluation of Nausea and
Vomiting. in:Goroll AH, May LA and
 In terminal illness, particularly that Mulley AG. Primary Care Medicine.
due to gastrointestinal neoplasms, 2nd ed. Philadelphia:Lippincott, 1987;
vomiting may be troublesome. 270-274.
The use of morphine for pain relief
may exacerbate this symptom. In
such cases dia-morphine should
be preferred and this may be
combined with chlorpromazine or
prochlorperazine.

INDICATIONS FOR REFERRAL

 The child with more than mild


dehydration.

 The patient with serious organic


gastrointestinal disease. Referral
for surgical treatment may be
required urgently.

 The patient with hyperemesis


gravidarum. Give nothing by mouth
for 48 hours, and maintain
hydration and electrolyte balance
by giving appropriate parenteral
fluids and vitamin supplements as
indicated.

51
Abdominal
12 Pain
RELEVANCE TO  diabetic ketoacidosis
 herpes zoster (pre-rash stage)
GENERAL PRACTICE  ruptured aortic aneurysm (rare)
 Munchausen syndrome.
 The causes of abdominal pain in general
practice cover a wide clinical spectrum.
Although most cases may not be “Less-acute” abdominal pain
dramatic, the GP must be vigilant for the  Organic – any intra-abdominal organic
occasional patient with serious physical disease can present as a less acute or
pathology. even have an insidious onset of
abdominal pain, e.g. appendicitis
 A careful history followed by appropriate  Functional – irritable bowel syndrome and
examination helps to clarify the cause. periodic syndrome are common
conditions in young adults and children
 The probability of various diseases respectively.
depends on the age group. A practical
classification of abdominal pain in Table 1 Causes Of Acute Abdominal
general practice is according to the Pain
mode of onset.
Group A
 The patient with acute abdominal pain Life-threatening conditions which
requires a careful early assessment. must be excluded
Non-acute abdominal pain allows the Appendicitis
doctor more time to think and act but a Acute obstruction
systematic approach is essential in the Perforated peptic ulcer
history, examination and investigation. Liver abscess
Acute pancreatitis
Ectopic pregnancy
CAUSES
Twisted ovarian cyst
Obstructed hernia
Abdominal pain may be divided
chronologically into acute and less acute Group B
pain. Less urgent but important conditions
Acute cholecystitis
Acute abdominal pain Biliary colic
A useful classification of acute onset of Hepatitis
abdominal pain is summarised in Table 1. Renal colic
 Group A causes are life-threatening Pelvic inflammatory
which require surgical intervention except Group C
for acute pancreatitis.
Common causes
 Group B causes are managed medically
initially. Gastritis / Dyspepsia
Mesenteric adenitis
 Group C causes are the commonest
Dietary indiscretion
causes which may upset the patient or
Gastro-enteritis
family tremendously, but are not life-
Alcohol abuse
threatening. Migraine
Constipation
Other causes to keep in mind are:
 acute myocardial infarction
The likely diagnoses vary with age:
 pneumonia
 Age related conditions are:

52
In infancy - intussusception suffer from serious abdominal diseases at
In children - periodic syndrome, any times.
febrile illness  Any relevant history of previous
Young adults - gastritis, peptic ulcer, abdominal diseases and operations
hepatitis, irritable bowel should be noted. A family history for
syndrome, major diseases e.g. carcinoma of colon,
dysmenorrhoea should also be recorded.
Middle age - peptic ulcer, gall bladder  Clarify the features of the abdominal pain:
disease, irritable bowel - duration
syndrome, carcinoma of - site and radiation
stomach, colon, pancreas, - character : colicky or dull ache
or liver - onset and progression: constant,
Elderly - gastric ulcers, gall bladder intermittent, increasingly severe,
disease, neoplasms, recurrent
obstructed hernia - severity : dull ache or agonising pain
- aggravating and relieving factors.
Acute appendicitis and acute intestinal
obstruction are important causes to  Look for associated features:
exclude in all age groups (although acute - nausea and vomiting
appendicitis is most common in young - loss of appetite
children and young adults). - change in bowel habits
- delayed or current menstruation
 Acute gastroenteritis is a common cause - frequency, dysuria or haematuria.
in all age groups.

WORKUP Examination

Three questions to answer General


 the patient‟s general demeanour
The questions facing the general practitioner
 appearance, pallor or jaundice
presented with a patient with abdominal pain
 temperature
are:
 pulse
 Is there a surgical or a medical cause of
pain?  character of respiration
- If not surgical, should the patient be  tongue and
admitted or managed at home?  skin turgor.
 Is this an „acute abdomen‟ ?
- If not clearly an „acute abdomen‟ should The abdomen
the patient be admitted for observation?  Observe any obvious distension,
 If managed at home, what should be movement with respiration, and any
done? obvious skin signs e.g. an occasional
case of herpes zoster.
Acute abdominal pain  Palpate all quadrants of the abdomen
carefully; note any masses and
History tenderness (any deep tenderness in area
A good history may reveal as much, if not of pain?). Search specifically for right iliac
more (about the likely cause), than the fossa pain of appendicitis, Murphy‟s sign
physical examination. of cholecystitis and renal angle
 It is helpful to assess and manage the tenderness of pyelonephritis.
patient and family in the context of past  Percuss for: air, fluid, or mass
knowledge of their demeanour, attitudes abnormalities.
and beliefs. Nevertheless, it is wise to  Auscultate for: a silent or a very noisy
remember that even the most neurotic, abdomen which may be highly significant
anxious and depressed patients may

53
in the context of suspected ileus or Cardinal features of some major causes of
intestinal obstruction. an acute abdomen are shown in Table 2.

Other examination Investigations


If the diagnosis is in doubt, the examination No investigations will be required in the
may be extended to include the chest, back majority of patients with abdominal pain,
and central nervous system. Frequently a who suffer from relatively minor conditions of
rectal and/or vaginal examination will be short duration.
necessary to clarify the diagnosis or exclude
disease in the pelvis.

Table 2. Cardinal features of major causes of acute abdomen

Cause Features
Colic Arise from viscera – exaggerated peristalsis (pain typically waxes and wanes)

Renal colic Site of pain – loin


Radiation - loin to groin
Associated features - vomiting, dysuria and haematuria
Biliary colic Site of pain - right hypochondral or epigastric region
Tenderness in right hypochondrium
Appendicitis Site of pain - early stages periumbilical region and later right iliac fossa pain;
Pain worse on coughing; Vomiting; Guarding if perforated; Mild fever, none in
early stages
Constipation or diarrhoea may be a presentation; Tenderness in right iliac fossa;
Rectal tenderness

Peritonitis Site of pain - generalised


Rebound tenderness and boardlike rigidity
Associated with perforated peptic ulcer, ruptured appendix or ruptured ectopic
pregnancy
Peptic ulcer Site of pain - epigastrium
History of drug intake - NSAIDs, steroids
Relation to meals - night pains in duodenal ulcer and postprandial pain in gastric
ulcer
Pancreatitis Site of pain - epigastrium and radiating to the back
Severity out of proportion to clinical findings
May be in hypovolaemic shock
Serum amylase is markedly elevated

Non-acute abdominal pain Relevant useful investigations available in the


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

54
MANAGEMENT References
Acute abdominal pain 1. Goroll AH. Evaluation of chronic fatigue. in:
Goroll et al. Primary Care Medicine, 3rd ed.
Where the cause is clear and minor, Philadelphia: Lippincott, 1995: 325-333.
symptomatic and definitive treatment may be
all that is necessary. Where the decision is 2. Scott BR. Recurrent abdominal pain during
to observe the patient, as for example, when childhood. Can Family Physician Mar
a diagnosis of the mesenteric adenitis is 1994;40:539-547.
made, the patient should be pain increase
over the next six hours. This asked to report
back or to go to hospital should be
emphasised to the patient. Hospital
admission is necessary for the obvious
acute abdomen or when an acute abdomen
cannot be excluded. It is better to err on the
side of caution than to take the risk of
leaving a patient at home with a possible
progressing abdominal emergency.

Non-acute abdominal pain


The management of the patient with a non-
acute abdominal pain depends on the
underlying pathology. Psychological causes
should be looked for if organic causes have
been excluded. Attention to reasons for
encounter may provide useful cues. Where
no organic cause is found, the patient should
be reassured and followed-up.

55
13 Skin Rash
RELEVANCE TO - accompanied by minimal
GENERAL PRACTICE constitutional upset or pruritis
Localised rash (at times can be
 A rash accounts for 5% of all widespread)
new symptoms presented in
general practice. Generalised rash of acute onset

 Extent of involvement and the Accompanied by malaise and fever


presence or absence of
accompaniments of itch or Most are due to specific infectious
constitutional upset are helpful diseases:-
in differential diagnosis.
 Measles - This is commonly
DEFINITIONS associated with cough, running
nose and conjunctivitis. The
It is important to define the terms child is usually miserable.
commonly used to describe skin Koplik spots may be found on
rashes. the oral mucosa before the
onset of the rash. The rash
Macule - A flat spot which differs itself consists of dusky red
in colour from the macules which coalesce to
surrounding skin form irregular blotches. The
Papule - A raised spot on the rash remains as a brownish
surface of the skin staining for 2-3 weeks after the
Nodule - A lump deeply set in the fever has subsided.
skin
Scale - A flake of horny cells  Rubella - The constitutional
loosened from the skin upset is mild compared to
surface measles. The rash consists of
Crust - Dried serum adherent pale pink macules, and first
to the skin appears on the face. It spreads
Vesicle - A skin bleb filled with rapidly over the trunk and limbs
clear fluid and fades in 2-4 days.
Bulla - A blister filled with clear Generalised lymphadenopathy
or blood-stained fluid is an accompanying feature.
Pustule - A skin bleb filled with Enlargement of the suboccipital
pus lymph nodes are typical.
Urticaria - An irregular white or
pink pruritic weal.  Chicken pox - The rash
CAUSES appears as macules which
rapidly progress to umbilicated
An approach to skin rashes is to group papules and vesicles. It
them into the following: appears in crops and are
commonly found to be in
Generalised rash of acute onset different stages of development
- accompanied by malaise and fever on the same patient. It first
- accompanied by acute pruritis as a appears on the trunk and has a
prominent feature centripetal distribution.

56
 Pityriasis rosea - seen mainly
 Non-specific viral infections - in young adults. The rash
These are usually consists of symmetrical oval-
accompanied by catarrhal shaped macules, spreading
symptoms. The rash is over the trunk and proximal
commonly macular or parts of the limbs. This may be
erythematous, clinically similar preceded by a `herald patch'
to rubella, and fades in 24-48 several days earlier.
hours without leaving any
serious sequelae. Localised rash
These are usually not associated with
 Infectious mononucleosis - The any constitutional symptoms, and may
rash, which occurs in 10% of have typical sites of occurrence. The
patients, consists of an cause may be may be endogenous or
erythematous eruption exogenous. Exogenous causes may
occurring on the trunk, buttocks be infective or non-infective.
and extensor surfaces of the
limbs. Accompanying features  Atopic eczema
include membranous tonsillitis, This is part of the eczema-asthma-
lymphadenopathy and hay fever syndrome. Onset is
splenomegaly. Patients given usually in the second year of life.
ampicillin will develop a The rash is typically located in the
widespread, maculo-papular flexures of the elbows and knees.
erythematous eruption. It can also be found on the face,
neck, wrists and buttocks. In the
Accompanied by acute pruritis as a infantile form, it may be
prominent feature generalised, but it usually persists
as a recurrent flexural eczema in
The cause may be drugs, insect bites older children.
or allergens. The morphology of the
rash ranges from erythematous  Irritant dermatitis
papules and macules to urticaria and These are produced by
purpura. Mucous membrane lesions substances that chemically
are sometimes present. The reaction damage the skin. Some are very
may be mild, lasting several days, or powerful, and produce eczematous
may be severe and life-threatening. skin changes even with very short
contact. Examples are alkalis and
Accompanied by minimal certain solvents. Other irritants are
constitutional upset or pruritis `low grade', and cause changes on
prolonged, repeated contact.
These are not so common. Two Detergents and soaps can be
conditions which are sometimes seen classified under this category. The
in general practice are:- skin changes are varied, but are
usually localised to the site of
 Erythema multiforme - The contact.
rash consists of slightly raised
macules up to 1 cm in diameter  Allergic dermatitis
which may coalesce and show This occurs when the skin is in
target lesions. Steven-Johnson contact with a substance to which
Syndrome is a more severe the patient is allergic. The reaction
form, with mucous membrane may be localised, or may spread to
involvement. other areas not in contact with the
allergen. Examples are allergy to
nickel and cement.

57
versicolor is caused by a yeast.
 Other eczemas The lesions may be hypo- or
These include seborrhoeic hyperpigmented. There is no
dermatitis, which is of exudative characteristic distribution.
nature, and can be found on the Candida albicans is an
hair margins, face, axillae, chest opportunistic yeast. The skin
and groin; pompholyx, which is a lesions are found mainly in the
blistering condition occurring on warm, moist parts of the body,
the palms and soles; lichen and consist of inflammatory
planus and others of uncertain reaction with satellite lesions.
aetiology classified under Mucous membrane
morphology and distribution. involvement consist of white
exudative plaques.
 Psoriasis
This presents most commonly in  Parasitic infestations/insect
early adult life. The characteristic bites
lesion is a raised red plaque with a Scabies is caused by the mite
well-defined margin, covered with Sarcoptes scabiei. The
silvery scales. The lesions occur characteristic lesion is a `burrow',
mainly on the extensor aspects of at the end of which the mite can
the knees and elbows, the sacrum sometimes be found. The
and the scalp. Psoriasis may also distribution is typically in the skin
present as guttate psoriasis fold areas, between the fingers
which appears as small lesions and toes, and in the groin.
0.5-1 cm in diameter scattered
over the skin surface, sometimes Papular urticaria represents an
after a streptococcal infection. urticarial and vesicular response to
Other forms of psoriasis include a variety of insect bites, including
pustular and erythrodermic fleas, bedbugs, mites and
forms, which are potentially mosquitoes. The lesions are seen
serious. Nail involvement is mainly on the exposed parts of the
common. Arthritis occurs in about body.
10% of patients.
WORKUP
 Skin infections History
These may be bacterial or fungal. One should establish the duration of
- Bacterial infections include illness, the site and distribution of the
impetigo, which is mainly rash.
localised, and has
characteristically golden yellow In patients presenting with skin rash of
crusts; folliculitis, involving the short duration, the presence of
hair follicles; boils and associated symptoms should be asked
carbuncles. for, namely, constitutional disturbance,
- Fungal infections run a more and itch. A history of prior
chronic course, and are spread unaccustomed food and drug
over a wider area. Those ingestion, immunisations, allergy
caused by dermatophytes are should be obtained. A working
classified according to the diagnosis can often be reached even
distribution, e.g. tinea capitis, before the patient is examined.
tinea cruris. The lesions are
typically annular, with the outer In patients presenting with a more
edge as the most active area, chronic rash, it is important to
and central clearing. Scales establish the site of onset and mode of
may be present. Tinea spread of the rash, any aggravating or
relieving factors, or allergy. Past,

58
family, social and occupational history  Rashes affecting the scalp -
are also important, as for example, in seborrhoeic dermatitis, tinea
atopic eczema, in contact dermatitis. capitis, psoriasis, impetigo
 Rashes affecting the trunk -
Physical Examination seborrhoeic dermatitis, guttate
psoriasis, tinea corporis, tinea
Examination of the skin should include versicolor, pityriasis rosea,
examination of the mucous rarely secondary syphilis
membranes and the nails. Some  Rashes affecting the buttocks -
conditions can be diagnosed by scabies, psoriasis, napkin rash
morphology and distribution e.g. and atopic dermatitis in infants
pompholyx. Some acute conditions  Mucous membrane lesions -
have characteristic non-cutaneous moniliasis, less commonly
physical signs, e.g. presence of Steven-Johnson syndrome,
suboccipital lymph nodes in rubella, syphilis, lichen planus, etc.
which help in narrowing down the
differentials. Laboratory Investigations

Look out also for signs confirming Laboratory investigations are limited in
certain symptoms, e.g. excoriation the office setting. One useful
marks in patients complaining of procedure is skin scraping for the
pruritis, lichenification in long-standing diagnosis of fungal infections using
rash. A magnifying glass is a useful potassium hydroxide. Other more
aid in studying the morphology of the involved investigative methods e.g.
rash. biopsy and patch testing can be done
if facilities are available.
The distribution of rashes provides a
useful guide as to the differential
diagnoses in rashes of insidious onset.
MANAGEMENT
 Rashes affecting the hands -
irritant eczema, pompholyx, Management depends on the
scabies diagnosis. Acute infections of viral
 Rashes affecting the flexor origin need only symptomatic
aspects of the arms and legs - treatment. Patient education and
atopic eczema most common reassurance are important.
 Rashes affecting the feet -
tinea pedis most common, Allergic and contact eczema are
contact dermatitis due to managed by identification and
leather or dye from shoes also avoidance of the offending agent,
common antihistamines, topical applications
 Rashes affecting the extensor and steroids for severe cases.
surfaces of the limbs - Psoriasis and skin infections are
characteristic in psoriasis, treated according to specific protocols.
uncommonly dermatitis
herpetiformis General guidelines regarding the
 Rashes affecting the groin area vehicle for therapeutic agents of all
- tinea cruris, seborrhoeic rashes are as follows :-
dermatitis - Lotions to be used for moist or
 Rashes affecting the axilla - weeping lesions.
Contact eczema e.g. due to - Creams for oedematous but not
deodorants, less commonly exudative lesions.
seborrhoeic dermatitis, - Ointments for dry lichenified
folliculitis and tinea. fissured lesions.

59
INDICATIONS FOR REFERRAL
 For consultation where diagnosis
is in doubt.
 For specialised investigative
procedures e.g. patch testing,
or management e.g. ultraviolet
light treatment in psoriasis
 In acute life threatening
conditions e.g. erythrodermic
psoriasis, exfoliative dermatitis,
severe allergic reactions.

References
1. Morell D. The patient complaining of a
rash. in: Cormack et al. Practice: A
handbook of primary health care.
London:Kluwer, 1982

60
14 Backache
WORKUP
RELEVANCE TO
GENERAL PRACTICE The cornerstone of the assessment of
the patient with acute low backache is
 Backache is a common a careful medical history and physical
accompaniment of common examination, which is critical in
conditions like viral fever, urinary determining the presence of more
tract infections and multiple serious conditions.
psychosomatic complaints.
History
 In over three-quarters of cases of
General
acute backache, symptoms
Age. This could indicate the likely
disappear within 4 weeks with
diagnosis as many causes of
simple general measures and
backache are age related, for
analgesia.
example, degenerative diseases,
Paget's disease and malignancy.
 The remaining likely serious
causes should be identified as
Occupation. This should be asked as
early as possible.
it may reveal the main reason for
consultation, i.e. compensation,
CAUSES
medical certification and therefore aid
Table 1 shows the main causes of
backache. in the patient's management.

Table 1. Causes of Backache Symptoms


Spondylogenic Duration. One should ask the
- Injury duration and onset of the backache
musculo-ligamentous strain and whether it has been recurrent.
disc prolapse
bony injuries Associations indicating serious
- Structural defect conditions (red flags)
scoliosis
 Cancer – history of cancer,
spondylolysis
spondylolisthesis unexplained weight loss, night
spinal stenosis pain/rest pain.
- Infection  Infection – fever,
tuberculosis immunocompromised states
pyogenic (steroid, diabetes), rest pain.
- Inflammatory arthritis  Cauda equine syndrome – urinary
ankylosing spondylitis retention of incontinence, bilateral
rheumatoid arthritis lower extremity
- Tumor
weakness/numbness or
malignancies-myeloma, secondaries
vascular malformations progressive neurological deficit
- Others  Fracture – use of steroids, recent
osteomalacia significant trauma, age more than
Viscerogenic 70 years or history of osteoporosis
- Pyelonephritis  Significant herniated nucleus
- Pancreatitis pulposus – major muscle
- Dysmenorrhoea. weakness
Psychogenic
 Acute abdominal aneurysm –
- Functional overlay
- Tension rest/night pain, age more than 60
- Hysterical conversion years, other atherosclerotic
- Depression vascular disease.

61
 Power
Psychogenic backache. Low back In particular movements of foot
pain can also be psychogenic or a and big toe.
symptom of depression; however,
other diagnosis must be excluded  Sensation
before hand. Especially the saddle area, as
saddle area anaesthesia may be a
Past History. A history of recurrent feature of central disc protrusion.
pain and what had been done for the
patient in the past, e.g. surgery, Investigations
traction, etc would be helpful.  Laboratory testing should be
reserved for patients who have red
Physical examination flags.
 Observation of the back
Acute disc prolapse: there may be  Diagnostic imaging is rarely
a forward tilt obliterating lumbar indicated in the acute setting of low
lordosis and a lateral tilt (sciatic backpain.
scoliosis). Plain films remain the most widely
available modality for imaging the
 Palpation of the back lumbar spine. Plain X-rays are
Local tenderness common in rarely useful in evaluating or
apophyseal joint, ligamentous guiding treatment of adults with
injury and often in acute disc acute low backpain in the absence
prolapse. Note that acutely tender of red flags.
areas due to strains may be
helped by local injection. The primary objective of X-ray is to
identify any bony and/or structural
 Movements (flexion, abnormality associated with back
extension, rotation, lateral pain. Plain lumbar X-rays are
flexion. Also test the sacroiliac helpful in detecting spinal factures
joints) and in evaluating tumour and/or
In ligamentous injuries the infection.
movements are likely to be full. In
apophyseal joint dysfunction there  Further investigations on imaging
may be locally reduced mobility. In will be in the domain of the
disc prolapse movements are referred specialist.
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.

62
Table 2. Nerve Roots And Associated Neurologocal Signs

Nerve Change in power Reflexes


root
L2 Hip flexion No change
L3 Weakness of the Reduced or absent knee jerk
quadriceps (knee
extension)
L4 Weakness of knee Reduced or absent knee jerk
extension and
dorsiflexion of the
foot (footdrop)
L5 Weakness of No change
dorsiflexion of the
foot and toes (foot-
drop)
S1 Weakness of Absent ankle jerk
plantar flexion
(unable to stand on
tip-toe)
Cauda Any or all of the Ankle jerk lost, and reflexes lost
equina above with bladder
lesion and rectum
paralysis

MANAGEMENT INDICATIONS FOR REFERRAL


Analgesia.. Consider muscle relaxants,
physiotherapy.  For diagnosis.

General back care:  Suspected serious disease i.e.


- Rest - medical leave, control physical neoplasia, TB, referred pain.
activities.  Emergency referral for surgery i.e.
- Rest - lying rests the back; ensure cauda equina lesion. Symptoms are:
there is a firm mattress. - saddle area anaesthesia
- Avoid lifting heavy weights. - retention of urine/urinary
- Avoid bending the back; when lifting symptoms
objects, bend at the knees keeping - atomic anal sphincter
back straight. - severe weakness of legs
- Posture: when sitting, do not hunch; a peripherally.
small cushion as lumbar support is useful;
try to get a well-designed chair. References
1. Boyd RJ: Evaluation of Back Pain in
Attend to psychogenic factors. Primary Care Medicine, Ed. Goroll, May &
Mulley, 2nd Ed. 651-659.
Follow-up:
When conservative treatment fails, 2. Quinet RJ and Serebro LH: Management
- Review compliance. of Regional Low Back Pain in Practical
Care of the Ambulatory Patient by Stults &
- Reassess home/work
Dere, WB Saunders 1989, 479-489.
environment.
- Reassess clinically, as thoroughly
as on the initial examination.
- Refer for specialist assessment.

63
15 Joint Pain If the involvement is mono-articular,
consider trauma, septic arthritis and
monoarticular stage of a polyarthritis. Of
RELEVANCE TO these, septic arthritis is the most important
GENERAL PRACTICE condition to be sorted out. If the
involvement is polyarticular, the
 Although osteoarthritis accounts for distribution of joints helps to define the
many of the more obvious cases of underlying disorder. In rheumatoid
joint pain (particularly in the elderly), arthritis, typically, the joints involved are
the differential diagnosis can the feet, metacarpophalangeal joints,
encompass a bewildering array of proximal interphalangeal joints and wrists.
conditions, both articular and non- In osteoarthritis, when the hands are
articular, inflammatory and non- involved, these joints are usually not
inflammatory. involved.

 Many patients with joint pains self


medicate and seek advice from friends
and alternative medicine practitioners Table 1. Causes Of Joint Pains Seen In
before they consult a doctor. General Practice
ACQUIRED CAUSES
 Careful attention to the history and  Inflammatory
- infective
physical examination helps chart a
- non infective
logical course to minimise diagnostic - rheumatoid arthritis
error and cost and maximise patient - ankylosing spondylitis
benefit. - psoriatic arthritis
- SLE, inflammatory bowel disease
CAUSES - metabolic
These are many ways that joint pains can - gout
be classified. One way is to classify - pyrophosphate arthropathy
aetiologically as in Table 1.  Degenerative
- Osteoarthritis, spondylosis,
WORKUP intervertebral disc prolapse
 Trauma/ overuse
- Shoulder capsulitis, tendinitis,
History tenosynovitis, bursitis, carpel tunnel
The history should address the following syndrome, ligament/muscle tear,
questions: chondromalacia patellae, trigger
 Is the problem articular or non- finger, metatarsalgia, and plantar
articular? fasciitis
 Is it inflammatory or non-  Miscellaneous
inflammatory? - Psychogenic rheumatism, neoplasm
 Is the involvement polyarticular (5 or
HEREDITARY (Uncommon)
more joints) or pauci-articular?
- Marfan's syndrome, Ehlers-Danlos,
 Are there any extra-articular Osteogenesis imperfecta
manifestations? Source: Grahame R. The Practitioner,
1986:316
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.

64
Table 2. Inflammatory And Non- changes clinch the
Inflammatory Joint Disorders diagnosis

Symptoms & Inflammat Non- Chronic Tophaceous deposits


signs ory inflammat tophaceous found under the skin
ory gout
Oligoarthropat
Morning > 1 hour < 1 hour
hy
stiffness
Fatigue Marked Occasional Ankylosing Iritis, aortic incompetence
With activity Better Worse spondylitis
With rest Worse Better
Soft tissue Yes Uncommon Reiter‟s Conjunctivitis,
swelling syndrome keratoderma
Bony swelling Uncommon Yes blenorraghica, balanitis
in males
Source: Catherine Alderice. Can Fam
Psoriatic skin rash, nail changes
Physician 1990; 36:553.
arthritis reveal the diagnosis
The presence of extra-articular
manifestations helps to clinch the Inflammatory Ulcerative colitis and
diagnosis. See Table 3. bowel regional ileitis
arthropathy
Table 3. Extra-Articular Manifestations Early subcutaneous nodules
In Joint Disorders rheumatoid
arthritis
Inflammatory Extra-articular
arthropathy manifestations Physical examination
Examination may be normal or there may
Polyarthropat be redness and swelling of affected joints,
hy deformities and extra-articular
Rheumatoid Extra-articular manifestations.
arthritis manifestations tend to
occur later in the course Every painful joint should be examined
of disease. with regard to the following:
Subcutaneous nodules,  joint swelling and tenderness
sicca symptoms (dry
eyes and dry mouth);  synovial and capsular thickening
hand deformities – volar  deformity
subluxation, swan neck,  range of movement
boutonniere deformity,  instability
ulnar deformity of the  gait
metacarpophalangeal  muscle power
joints are common
Systemic lupus Extra-articular Next consider the pattern of affliction and
erythematosus manifestations are symmetry of the disease:
usually prominent, often  peripheral Joints
preceding joint
 symmetrical pattern in RA
complaints: alopecia,
mouth ulcers,  asymmetrical pattern in gout
Raynaud‟s (usually single joint affected)
phenomenon, butterfly  axial Joints (sacroiliac, spine, lower
rash, photosensitivity limbs)
and serositis  AS, Reiter's syndrome
Psoriatic In 15% of patients with
arthritis psoriatic arthritis, the For polyarticular disease other systems
arthritis appears first need to be examined and these should
and the typical skin rash include:
develops months to  the eye e.g.conjunctiva, sclera, iris
years later. Typically and retina
the skin lesions and nail

65
 skin - pattern of rash, ulcers, Only if the patient‟s symptoms strongly
ischaemia and infarction, nodules, suggest SLE should a positive test for
nails, and hair. ANA be taken as confirmation of the
 mucous membranes - ulcers diagnosis. Like rheumatoid factor,
 abdomen and genito-urinary system. ANA tests are not useful to monitor
 cardiac murmurs disease activity.
 muscle wasting (disuse atrophy,  Synovial fluid analysis
dermotomyositis in SLE) In oligoarthopathy and
monoarthropathy, synovial fluid
Investigations analysis is helpful. It is almost
Not all joint pains require further diagnostic in septic arthritis and in
investigations. A negative result does not gouty or pseudogout arthritis. By
necessarily exclude the presence of the contrast, such analysis does not help
disease process. to differentiate the aetiology of
polyarthropathy.
In inflammatory polyarthropathy, initial
investigations need only be confined to
the following: Table 4. X-Ray Features In Joint Disorders
 Erythrocyte sedimentation rate
Rheumatoid arthritis
The erythrocyte sedimentation rate is
Periarticular osteoporosis, and periosteal
a very useful test of inflammatory reaction
activity, particularly in patients with Ankylosing spondylitis
rheumatoid arthritis or polymyalgia Typical diagnostic features: blurring of
rheumatica. In RA it is raised and very margins of sacro-iliac joints, erosions and
high in the acute stage. In the elderly squaring of lumbar vertebrae; “bamboo
with polymyalgia rheumatica (PMR) a spine”
markedly raised ESR is usually Gouty arthritis
present In late stages of disease, punched out juxta-
 Complete blood count articular erosions and degenerative joint
changes
 Hb - moderate anaemia is the Osteoarthritis
most common systemic Narrowed joint space, irregular joint space,
manifestation of inflammatory joint sclerosis of subchondral bone, subchondral
disease. Its severity reflects the cyst, osteophytes
activity of the disease. Radiological investigations
 TW - Total white is raised in X-rays of joints are useful as a baseline
infection, and in gout examination and for monitoring progress.
 Platelets - can be raised or low The following should be looked for:
 Rheumatoid factor  soft tissue changes
Rheumatoid factor is an important test  juxta-articular osteoporosis
in confirming the diagnosis, but only if  uniform narrowing of joint spaces
the positive results correspond to the  erosions at joint margins.
patient‟s symptoms and current
knowledge of rheumatoid arthritis. MANAGEMENT
Early in the disease, it may be This depends on the cause and stage of
negative in rheumatoid arthritis but will the joint disease and is based on a
normally turn positive within one year. combination of:
Rheumatoid factor is used mainly to  physiotherapy
confirm a diagnosis. It should never be  local injections
used to monitor disease activity.  drug therapy - a wide range of drugs is
available from the simplest analgesics,
 Anti-nuclear antibodies (ANA) NSAIDs, gold to cytotoxics.
Anti-nuclear antibodies (ANA) should
 surgery - to joints and deformities
be approached in the same way as a
 aids for walking and ADL
positive test for rheumatoid factor.

66
 patient education and counselling References
 social and community support/self- 1. Alderdice C. Approach to the patient with
help groups polyarthritis. Can Fam Physician
1990;36:549-551, 553-554.
2. Goroll AH, May LA and Mulley.
From the standpoint of management,
Management of rheumatoid arthritis.
patients can be divided into 3 groups: in:Primary Care Medicine, 3 ed.
 Inflammatory arthropathy and Philadelphia: Lippincott, 1995:790-794.
physical examination is positive 3. Dorbrand L et al. Chapter on Muscular
 Patients whose history indicates Skeletal problems. In: Manual of clinical
inflammatory polyarthropathy and problems in adult ambulatory care, 1992.
who have objective evidence of Toronto: Little Brown: 283-339.
joint involvement are usually fairly 4. Stuart RA & Macedo TF. Antirheumatic
drugs. Medical Progress. August 1993:11-
easy to manage. If gouty arthritis
17.
or septic arthritis is present, the 5. Soll AH, Weinstein WM, Durara J &
treatment is specific. In McCarthy D. Non-steroidal anti-
inflammatory polyarthritis, the initial inflammatory drugs and peptic ulcer
management is symptomatic. Self- disease. Ann Intern Med 1991; 114:307-
limiting conditions, particularly a 19.
viral illness (which can mimic
rheumatoid arthritis), will resolve
within six weeks.

 If symptoms persist beyond six


weeks, one must establish the most
likely diagnosis and then treat the
symptoms as they occur; the need
for second line drugs may need to
be sought.

 Inflammatory arthropathy but


physical examination is normal
These patients probably have early
arthritis like rheumatoid arthritis but
may not have yet developed
recognisable features. The patient
may develop new symptoms 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.

67
16 Giddiness
RELEVANCE TO
It is useful to try and categorise the
patient‟s symptoms into one of the
GENERAL PRACTICE following categories in Figure 11, 2:

 Dizziness is a common symptom and  Vertigo -- a sense of rotation, that is


its interpretation can be difficult, made either the patient or his surroundings
worse by its very subjective nature and are spinning around. In its severest
the many disorders that can cause it. form, it may be accompanied by
Few doctors will not feel a sense of nausea, vomiting, pallor and sweating.
despair when confronted with a patient  Unsteadiness -- characterised by a
whose main complaint is that of tendency to fall; dysequiIbrium.
dizziness.  Lightheadedness -- presyncopal
feeling. May be relieved by assuming
 A careful history including drug intake a supine position.
will help determine whether the  Giddiness (hing-hing) -- nonspecific;
Dizziness is a true vertigo or cannot be easily put into any
pseudovertigo and pinpoint the recognisable pattern. In the elderly,
diagnosis. consider a problem of multisensory
deficits. These sufferers may have
 Important serious causes to keep in cataracts, neuropathy, limited neck
mind are cerebral tumours and cardiac movements and aging of the vestibular
dysrhythmias. system.

MEANING OF DIZZINESS Differentiation into these categories must


be attempted despite the obvious difficulty
Dizziness is a sense of abnormal balance, in doing so, because this helps in
and results from disturbance of one or identifying the problem.
more of the organs maintaining balance.

When a patient complains of “dizziness”, CAUSES


he or she can be using this term to
describe many different phenomena, and The causes of dizziness are shown in
hence a careful history is required to Table 1.
unravel the problem.1
Table 1. Causes of Dizziness
Figure 1. Classification of Dizziness Peripheral disorders
Labyrinth labyrinthitis
Vertigo Meniere‟s disease
benign paroxysmal positional
Unsteadiness vertigo
(tendency to labyrinthine window fistula
fall; Eighth vestibular neuronitis
Dizziness dysequilibrium) nerve acoustic neuroma
Central causes
Brain stem vertebro-basilar insufficiency
Pseudo- infarction
vertigo Lightheadedness Cerebellum degeneration
(fainting or syncopal tumours
episodes) Others hypotensive drugs, alcohol,
tranquillisers, anticonvulsants
Giddiness (hing-hing) cardiac dysrhythmias
nonspecific sensation anaemia

Source: Aust Fam Physician 1991; 20:10: 1484


(adapted)

68
From the standpoint of diagnosis, it is postulated, though there is little direct
useful to classify dizziness as with or evidence for this.
without vertigo.  vertebro-basilar insufficiency. This
may be the result of , either
Dizziness without vertigo suggests one of arteriosclerotic narrowing of the blood
the following: vessels or narrowing of the
 Acute infection usually viral in intervertebral foramina secondary to
origin. This may be associated with osteoarthrosis. As expected, it is seen
other symptoms such as gastric or most commonly seen in the elderly.
bowel disturbance and aches and  Other causes. Temporal lobe epilepsy
pains in the limbs or body. and an acoustic neuroma. also causes
 Postural hypotension. This is seen dizziness with vertigo.
most often in young women who are
otherwise fit. This may be due to the
earlier stages of pregnancy. Postural WORKUP
hypotension in the known hypertensive
on treatment and the diabetic with History
autonomic neuropathy may also be a When the patient present with 'light-
cause of dizziness. headedness', not associated with rotation,
 Hypoglycaemia. This is associated the history and examination will be
with sweating and hunger, in a known directed towards identifying a non-
diabetic or in one who omits his vestibular complaint.
regular meals for whatever reason.
 Drugs. Drugs should not be forgotten Does the patient experience the symptom
as a cause of dizziness without after rising rapidly from the sitting
vertigo. Examples are hypotensive position? Is the patient receiving
drugs, tranquillisers and treatment for hypertension or diabetes
anticonvulsants. mellitus? Does the patient sweat or feel
 Other causes. Anaemia (often hungry during an attack, and is it relieved
implicated but not substantiated) and by eating food?
cardiac disease (e.g. aortic stenosis
and regurgitation; dysarrythmia) are In evaluating a patient with vertigo, there
other causes of dizziness without may be associated symptoms of tinnitus
vertigo. and impaired hearing. A patient
complaining of vertigo should be asked if
Dizziness with vertigo may be caused by: he has suffered any head injury in the
 Meniere's disease. The attacks of recent past, or about ingestion of drugs
vertigo may last for hours. Malaise or with known toxic effects on the inner ear
instability may persist for a day or two, (such as salicylates, quinine and
and there is always associated streptomycin). The addition of headache
deafness, which may be unilateral. to these symptoms suggests the
Long periods of freedom between possibility of acoustic neuroma causing
attacks are common. raised intracranial pressure.
 Vestibular neuronitis. This is
characterised by the acute onset of Physical Examination
rotatory vertigo, with systemic The patient who suffers from 'light-
disturbance. The vertigo may subside headedness' unaccompanied by rotation
spontaneously after a day or a few is not suffering from any disease of the
hours, and may recur on sudden head labyrinth. In such a patient, the clinical
movement or on postural change examination will be directed towards
during the following few weeks. This identifying a non-vestibular cause. It will
condition is usually self-limiting. A include recording of the pulse,
viral infection of the labyrinth has been temperature and blood pressure on lying
and standing. If an infective cause for the
symptom is suggested by raised pulse

69
and fever, then a general examination of The known diabetic requires
throat, sinuses, ears, chest and abdomen measurement of his blood sugar level to
will be conducted to identify the site of the identify hypoglycaemia as a cause of his
infection. symptoms.

Signs of early pregnancy should be looked In a patient with associated deafness,


out for in the young woman complaining of audiometry will determine whether the
dizziness, especially if her period is deafness is caused by a lesion of the
delayed. cochlear end organ (e.g. Meniere's
disease). This will show the characteristic
True vertigo requires detailed examination known as loudness recruitment: as the
of the ears and the function of the sound intensity is increased, the
labyrinth. Conductive deafness (bone subjective loudness in the affected ear
conduction better than air conduction in progressively approximates that of the
Rinne's test) will suggest a local middle good ear.
ear cause for vertiginous symptoms.
Perceptive deafness (air conduction More sophisticated tests for example
greater than bone conduction) will suggest computerised tomograms, cerebral
the possibilities of disease of the eight arteriograms are required only when a
nerve or cochlear end organ. posterior fossa tumour is suspected.

Nystagmus should be looked out for, as it MANAGEMENT


may be caused by disease of the labyrinth If the dizziness is due to a self-limiting
or its central connections (though bearing viral infection, symptomatic treatment and
in mind that it may occur in normal fluids are all that are needed. If the site of
subjects on extreme lateral gaze, or if the the infection is identified and the organism
test object is held too close). amenable to antibiotics then appropriate
antibiotics may also be required.
Benign positional vertigo is confirmed by a Vestibular neuronitis is also treated with
positive Dix-Hallpike manoeurve. This is symptomatic remedies, such as
done with the patient sitting on the couch cinnarizine or prochlorperazine.
and suddenly lowering the patient to a
position below horizontal and with the The hypertensive patient with postural
head turned 45 degrees to the side. The hypotension will require readjustment of
patient is left in this position for about 30 the dose or schedule of hypotensive
seconds before returning to the sitting agents. The hypoglycaemic attacks
position with the head looking at the same occurring in the known diabetic require
direction for another 30 seconds. The test similar reassessment of his regime of
is then repeated with the head turned to treatment.
the other side. Severe vertigo and
nystagmus occurring some seconds (that The elderly patient with dizzy attacks may
is, with latency) after lowering the patient benefit from the wearing of a cervical
indicates a vertigo of peripheral origin. If collar which will restrain the movement of
fatiguable (disappears after repeated the cervical spine. The advice to rise
testing) it is virtually diagnostic of benign slowly from the sitting position and to
positional vertigo. If there is no latency avoid movements which will provoke the
and there is no fatiguability, a posterior attack is also of help. Prochlorperazine
fossa tumour has to be excluded. tablets, 5 mg twice daily, will often reduce
the intensity of the attacks.
Investigations
A simple blood count, chest x-ray and The medical treatment of Meniere's
electrocardiogram may be needed to disease is at present symptomatic.
further evaluate suspected anaemia or Low-salt diet and diuretics may be
cardiac disease. employed with variable degrees of
success. Betahistine has had some

70
success in a dose of 8 mg thrice daily. References
Vestibular sedatives are helpful and of 1. Murtagh J. Dizziness (vertigo). Aust Fam
these cinnarizine has been recommended. Physician 1991 Oct; 20:10:1483-1489.
2. Chong PN. Office evaluation of the dizzy
Vertigo in the presence of middle ear patient. Sing Fam Physician 1990;
16:2:72-75.
infection requires an urgent opinion from
3. Morrell, D.C, Gage, H.G and Robinson,
an ear specialist. N.A (1971) Symptoms in General Practice,
Journal of the Royal College of General
If the dizziness is caused by psychiatric Practitioners, 21-32.
illness, this may require appropriate 4. Hodgkin, K. Towards Earlier Diagnosis.
management by psychotherapeutic 3rd ed. Edinburgh: Churchill Livingstone,
means, tranquillisers or antidepressants. 1987.

INDICATIONS FOR REFERRAL


 Central vertigo - characterized by
presence of neurological features.
Vertebro-basilar stroke is an
emergency.
 Suspected serious disease e.g. aortic
stenosis, psychosis, for expert
management.
 When the diagnosis is not clear.

71
17 Headache  Headache of extraordinary severity
RELEVANCE TO (“my worst headache ever”)
GENERAL PRACTICE suggests a serious intracranial
 Headaches are a very common cause, namely, subarachnoid
experience and about 90% of the haemorrhage, raised intracranial
population will have had this symptom pressure and meningitis.
within one year. Commonly, it is an  Diffuse headache in conjunction
accompaniment of acute febrile illness with a stiff neck and fever suggest
where the cause is clear. At other acute meningitis.
times, the causes are usually benign.  Subarachnoid haemorrhage
 The primary care physician's most typically produces a sudden
immediate task is to identify on clinical severe headache -- the
grounds the occasional patient who “thunderclap” headache.
requires aggressive work up. The  When acute headache and stiff
ever-present possibility of a serious neck occur in conjunction with
organic cause in the minority makes it ataxia of gait and profuse nausea
incumbent for the doctor to take a and vomiting, a midline cerebellar
careful history and conduct an haemorrhage needs to be
appropriate examination in a patient considered. Cerebellar
with headache. haemorrhage is uncommon, but
 The nature of the headache is of some early recognition is important
value in diagnosis. An occipital because prompt treatment can be
headache is more likely than a frontal life saving.
one to be due to an organic lesion. A  Acute fever with fronto-orbital
headache of recent onset, changing headache is suggestive of acute
character, increasing frequency or sinusitis.
severity, persistent, or accompanied  Eye pain and blurred vision raise
by vomiting or behaviour change the possibility of acute glaucoma.
suggests an organic cause.  New onset of headache in an
elderly patient requires
CAUSES consideration of temporal arteritis.
Headaches may be broadly classified as  Acute throbbing headaches are
primary or secondary. Primary headaches mostly vascular in aetiology: the
are those without underlying structural patient needs to be asked about
pathology. Secondary headaches are fever, vasodilator use, drug
caused by underlying disease. See Table withdrawal, and hypoglycaemia.
1.  Migraine (common migraine and
classic migraine) produces a
A diagnosis of primary headache requires recurrent acute headache.
the prior exclusion of a secondary  Common migraine - occurs in
headache. A previously diagnosed 80% of patients with migraine,
primary headache does not preclude a the headache is bilateral or
secondary headache developing. shifts sides, nausea,
photophobia and related
WORKUP symptoms usually accompany
ACUTE HEADACHE the headache.
History
 Classic migraine accounts for 10 to
This should include inquiry into onset,
15 per cent of cases. It is
severity, location, associated symptoms
characterized by prodrome of
especially neurological deficits and fever.
transient visual, motor or sensory
A previous history of headaches and head
disturbances followed by onset of
trauma should also be noted.

72
a hemicranial throbbing headache,  Examination of the scalp for cranial
nausea, photophobia and artery tenderness; the sinuses for
sensitivity to noise. tenderness to percussion.
 Hypertensive encephalopathy may be  Examination of eye:- pupils are noted
heralded by diffuse headache, nausea, for loss of reactivity and the cornea for
vomiting and altered mental status. haziness due acute glaucoma; the disc
margins for blurring from raised
Table 1. Causes Of Headache (2004) intracranial pressure.
 Examination of neck - neck rigidity on
PRIMARY HEADACHES -- anterior flexion suggests meningitis or
STRUCTURAL LESION ABSENT a vascular leak from an AV
malformation or an aneursym.
Migraine
- common  Neurological examination for ataxia in
- classical (with aura) patient with severe, profuse vomiting
- migraine variants suggesting cerebellar haemorrhage;
Tension-type headache (TTH) early recognition is important because
Cluster headache and other trigeminal prompt treatment can be life saving.
autonomic cephalalgias
Other primary headaches e.g. cough Investigations
headache  If the causes are obvious and benign,
investigations are not needed.
SECONDARY HEADACHES --
UNDERLYING
LESION PRESENT  Where organic neurologic cause is
suspected patient should be referred
Headache attributed to: to hospital for further investigations
Head and/or neck trauma such as lumbar puncture, CT scan etc.
Cranial or cervical vascular disorder
Non-vascular intracranial disorder CHRONIC AND RECURRENT
Substance or its withdrawal HEADACHES
Infection History
Disorder of homeostasis
It is important to keep in mind that more
Disorder of cranium, neck, eyes, ears,
nose, sinuses, teeth, mouth, or other than one kind of headache may be
cranial structures present; a full description of each type of
Psychiatric disorder head pain must be elicited.
Cranial neuralgias and central causes of  A dull, steady, recurrent, unilateral
facial pain headache that occurs in the same
Other headache, cranial neuralgia, central area each time and progressively
or primary facial pain not elsewhere worsens in frequency and severity is
classified suggestive of an intracranial lesion
(tumour, brain abscess.
Source: International Headache Society
Headache Classification & Diagnostic  Recent head trauma and a symptom-
Criteria (2004), Second edition interval between injury and onset of
headache are characteristic of
Physical examination subdural hematomas; patients may
In a patient where headache is an show only subtle personality changes
accompaniment of fever or an acute and be mistakenly thought to have a
respiratory infection, confirmation of the psychogenic problem.
fever and selective examination of the  Most throbbing, recurrent headaches
affected part will be all that is necessary. are of vascular origin; migraine
accounts for the vast majority.
Where the cause is not immediately clear,  Headache that are variable in quality
physical examination to rule out a serious and location, or constant over weeks
cause is necessary. to months but not relentlessly
 The blood pressure and temperature progressive in severity are likely to
should be checked for any elevations. have a muscle contraction or
psychogenic aetiology.

73
Physical examination situations with quite different implications
A complete examination is necessary. The for management.
finding of a fixed focal deficit is important
evidence of intracranial pathology,
especially in a patient with a headache INDICATIONS FOR REFERRAL
that is progressively worsening.
Urgent situations
 Any patient with evidence suggesting
Laboratory studies meningeal irritation, increased
The patient with a chronic or recurrent intracranial pressure, an A-V
headache that is getting worse with time malformation or malignant
deserves consideration for CT scan. hypertension obviously requires
prompt hospital admission.
MANAGEMENT  Presence of symptoms suggestive of
The effort taken to perform a careful an intracranial mass lesion requires
history and physical examination are well hospital referral.
worth the time, for these methods remain  The ophthalmologist needs to be
the best means available for the accurate consulted at once if acute glaucoma is
diagnosis of headache. felt to be the cause of an acute orbital
headache.
For benign causes, symptomatic
management like analgesics should be Non urgent situations
given. Treatment of specific causes e.g.  Referral to neurologist for the rare
sinusitis, upper respiratory tract infections case of migraine refractory to
and migraine. treatment, the patient with muscle
contraction or psychogenic headache
For the patient in whom headache is a that requires reassurance.
manifestation of a deep-seated conflict,  Dental consultation is indicated if
psychotherapy is often necessary. temporomandibular joint problems
appear refractory to conservative
Recurrent headaches in children therapy.
Headache in childhood that is not typical  Referral for a vision check and
of migraine and not due to structural assessment of the need for refraction.
intracranial pathology is common. In
some cases there is strong clinical Recurrent headaches
evidence that acute or chronic May require referral for a more thorough
psychological stress is important in the assessment to exclude space occupying
genesis of the headache and in a small lesion.
number of children frank psychiatric illness
such as depression is present. However, References
in a not insignificant number of cases, the 1. Lane RJM. Is it migraine? The differential
basis of the headache remains uncertain. diagnosis. Update 1991 Nov;760-72.
2. Pruitt AA. Approach to the patient with
It is of vital importance to remember that a headache. in: Primary Care Medicine, 3rd
stressful family or school situation does ed; Philadelphia: Lippincott, 1995:821-829.
not protect the child from having 3. ISH. Classification of Headache &
significant intracranial pathology as the Diagnostic Criteria (2004). Second edition.
basis of headaches. Headaches due to
psychological stress and psychiatric
illness occurs in several different

74
indicate that psychological variables
strongly influence an insomniac's

18
perceptions of the time spent in bed and
Insomnia its influence on satisfaction during the day.

RELEVANCE TO
GENERAL PRACTICE
DEFINITION  The complaint of disordered sleep is
common and it is estimated that as
Insomnia is defined as the complaint of much as a quarter of the adult
long-standing (more than 2 weeks) trouble population has sleep problems.
falling or staying asleep that is associated  The elderly and those with psychiatric
with compromised daytime functioning. In problems are more likely to complain
this framework insomnia is the end point of sleep problems.
of disorders in the initiation and  The primary care doctor needs to be
maintenance of sleep (DIMS). skilled in the assessment and therapy
of insomnia, not because the problem
Normal Sleep is extremely common and a cause of
By using the polysomnogram (a considerable misery but also because
continuous, all-night recording of a it is an important precipitant of
patient's respirations, eye movements, excessive drug use and habituation.
electroencephalogram (EEG), muscle
tone, blood oxygen saturation and CAUSES
electrocardiogram), normal sleep can be These are shown in Table 1.
divided into two basic phases: REM, or
rapid eye movement sleep, and nonREM WORKUP
(NREM). REM is a state of mental and History
physical activation. Pulse and respiration A careful clinical history, which
are increased but muscle tone is systematically addresses the host of
diminished, so little body movement possible etiologies of DIMS, is the key to
occurs. The brain is active, and the EEG the workup of insomnia.
shows a pattern similar to that seen during  Close attention must be given to
waking. Most dreaming occurs during medication, drug, and food intake,
REM. current mental and physical status,
past and family medical and
In contrast, NREM is a time of deep rest. psychiatric history, as well as
Pulse, respiration, and EEG all slow, and occupational and travel patterns.
the patient goes from light sleep, called  Whenever possible, interviewing the
stages I and 2, to deep or delta sleep, spouse, bed partner, or family member
called stages 3 and 4. REM and NREM is of great value.
normally cycle in a reciprocal pattern,  The use of a sleep log, or diary, which
giving a typical "architecture" to the includes time in bed, estimate of time
polysomnogram. The entire cycle lasts asleep, any awakenings, time of
about 90 minutes, and is repeated morning arousal, estimate of sleep
smoothly four or five times during the quality, and comments on unusual
night. events, recorded by the patient directly
upon getting up each morning, should
There is no polysomnographic pattern be standard procedure in every
pathognomonic of insomnia. Some insomnia workup.
insomniacs have slightly shorter than  Thhose who are natural "short
normal sleep times, some have less sleepers" (regularly have less than 7
stages 3 and 4 sleep, but most have hours of well-maintained sleep and
normal-appearing polysomnograms. have no problems other than too much
Recent data suggest that slight disruptions time on their hands at night) likewise
of the normal smooth cycling caused by do not have insomnia.
frequent brief arousals may be related to
subjectively unsatisfying sleep. Other data

75
 Those who have a brief, time-limited psychotic illness appear along with
disturbance or sleep related to the insomnia, facilitating
stressful events in their lives also do recognition of this problem.
not have "insomnia." The same  The remaining 50% of DIMS are
pertains to the normal elderly patients nonpsychiatrically based. Drug and
who experience the decline in total alcohol abuse are responsible for
sleep time, depth, and continuity which about 10 to 15% of this group. Alcohol
are a natural part or the aging process. induces sedation, but the resulting
 Psychiatric disorders are believed by sleep is often shallow, fragmented,
most experts to be the underlying and not restorative. Alcoholics can
cause of DlMS in about half of all have prematurely "aged" sleep (i.e.,
insomnia cases. shallow and short) during and for
 Among the psychiatric aetiologies, months after cessation of drinking.
the affective disorders -- major Sedatives, such as most
depression and dysthymic disorder benzodiazepines and especially
(mild depression, or the old barbiturates, when used on a regular,
"neurotic" depression) -- account long-term basis lead to shallow,
for approximately 50% of the fragmented sleep. Rebound insomnia
cases. Patients suffering from and rebound anxiety prompt reuse,
dysthymic disorder typically and tolerance leads to dose
complain of feeling tired. They escalation, so patients get caught in a
often feel irritable, have difficulty vicious cycle. Sedatives and alcohol
falling asleep, and report that they depress respiratory function, which
cannot get enough sleep to feel can lead to very poor quality sleep in
rested. Sometimes they deny patients with sleep apnoea. Stimulant
feeling sad or depressed and focus drugs such as amphetamine or
only on their physical complaints. methylphenidate, activating
Indeed, insomnia may be the antidepressants such as phenelzine or
major presenting complaint in protriptyline, and the
many of these patients. Patients phenylpropanolamine found in many
with major depression complain of over-the counter decongestant, cold,
either difficulty falling asleep or of and diet remedies can induce
waking in the early morning and significant difficulty falling asleep.
being unable to return to sleep. Terbutaline, aminophylline, and other
Diurnal variation of mood is often anti-asthmatics can produce insomnia.
noted. The caffeine and stimulant xanthines
 Character disorders make up found in tea, coffee, cola drinks, and
about 40% of the other chocolate may produce difficulty falling
psychiatrically based DIMS. asleep in most people if used in large
Patients with anxiety and enough quantities, and if used at all in
obsessive disorders frequently some who are sensitive. Finally, the
have great difficulty falling asleep nicotine and other substances found in
because they lie in bed and cigarette smoke have been shown to
ruminate. They have difficulty disrupt sleep induction and continuity.
falling asleep because they focus  Medical problems of all types can
on their lack of sleep as the source cause insomnia, and make up
of all their troubles. They lie in bed, approximately 10% of all the DIMS.
furiously trying to make Pain, of whatever source, is a frequent
themselves sleep. Such patients cause of insomnia in the elderly.
may use their insomnia as a Delirium is another frequent cause of
justification for their inability to insomnia in the elderly. Dementia,
function or to improve their lives. unrecognized infection, and even
 Active psychosis of any type e.g. medication toxicity (sometimes
schizophrenia produces disturbed secondary to the anticholinergic
sleep and accounts for the other agents used to induce drowsiness in
10% of psychiatric insomnia. The over-the-counter sleep remedies) are
other signs and symptoms of common sources of delirium.

76
Cardiovascular dysfunction leading to Therapeutic Recommendations
orthopnea, paroxysmal nocturnal  If the DIMS is related to affective
dyspnoea, or nocturnal angina; chronic disorder, begin a sedating tricylic
obstructive pulmonary disease; antidepressant, such as amitriptyline
hyperthyroidism, and urinary 25 mg, to be taken an hour before
frequency also can produce insomnia. bedtime every night for at least a
 Primary sleep disorders make up month. Increase the dose as needed.
approximately 10% to 20% of DIMS.
Ask the patient's bed partner for  If the DIMS is related to anxiety or
observations of cessation of other personality disorder, offer
respiration (sleep apnoea) or twitching psychiatric consultation and treatment,
of legs (nocturnal myoclonus or require close adherence to good sleep
restless legs syndrome). These hygiene. If the insomnia persists and
produce poor quality sleep and lead to daytime anxiety is also a problem,
the complaint of "insomnia". begin therapy with a before-bed dose
of flurazepam (15 mg).
Physical Examination  If the DIMS is related to drug, alcohol,
 A full examination should be or other substance use, clearly inform
conducted to exclude medical causes the patient that improvement is based
of insomnia. on proper substance withdrawal and
the maintenance of abstinence.
 The effects of alcoholism and addictive Supervise withdrawal; support the
drugs if any, should be noted. patient's efforts at maintaining
abstinence. Try to avoid treating "dry"
Investigations alcoholics with sedatives, as this may
These will depend on the nature of rekindle their drinking.
medical problems detected.
 Treat any underlying medical DIMS; a
MANAGEMENT brief course of benzodiazepine therapy
Patient Education after treatment can re-establish the
 The overall promotion of good "sleep sleep pattern and boost patient
hygiene" is useful for many patients. confidence.
- Establishing a regular bed and
wake time,  Use reduced dose and caution when
- Avoiding any and all naps, prescribing sedatives for the elderly.
- Having regular exercise (although
not at night),  Withdraw benzodiazepine therapy
- Avoid using the bed for reading or slowly in tapering fashion over 1 to 2
watching TV, and getting in bed weeks to avoid
only when ready for sleep
(leaving bed if sleep is not forth-  rebound insomnia if drug therapy has
coming) been used daily for more than 6 to 8
- Avoiding caffeinated foods, weeks.
stimulants, cigarettes, and alcohol,
- avoid trying too hard to fall asleep.  Refer patients with primary sleep
disorders, or those who are refractory
 Disabusing patients of the myth that to all efforts, for evaluation by a sleep
everyone must have 8 hours of sleep laboratory.
every night makes many people feel
relieved. Also, informing patients that INDICATIONS FOR REFERRAL
much of the time they spend in bed  Referral to a sleep laboratory if
believing they are "only drowsy" is primary sleep disorder (sleep apnea or
time spent actually, in the lighter nocturnal myoclonus) is suspected, or
stages of sleep can ameliorate some if careful workup fails to reveal the
patients' frustration. source of the DIMS.

77
 Psychiatric consultation is indicated
only when character problems
interfere with diagnosis or Table 1: Disorders In Initiation And
management, or if the nature of a Maintenance Of Sleep (DIMS)
suspected mental or emotional
problem is obscure. Psychiatric Disorders--50%
 Affective disorders: major
depression, dysthymic disorder,
References
manic depressive disorder
1. Weilburg JB. Approach to the patient with
insomnia. in: Goroll et al: Primary Care  Character disorders: Anxiety,
Medicine, 3rd ed, 1985; 1062-1066. obsessive-compulsive, borderline,
2. Fleming J A E & Warneboldt R B. Multiple narcissistic character disorders
Sleep Pathologies Presenting as  Psychosis: schizophrenia
Depression. Drug and Alcohol Abuse--10% to 15%
3. Can Fam Physician 1990, 36:1185-9.  Sedatives: alcohol, benzodiazepines,
barbiturates, narcotics
 Stimulants: caffeine and stimulant
xanthines in coffee, tea, cola, and
chocolate
 Anti-asthmatics, decongestants:
terbutaline, aminophylline,
phenylpropanolamine
 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 apnoea
 Nocturnal myoclonus
 Phase shift (night shift, jet lag)
Other--10%
 Idiopathic insomnia
 Psychophysiological, or conditioned,
insomnia
 Persistent complaint without
objective evidence
 Unusual polysomnographical
patterns: alpha-delta sleep

Source: Weilburg JB. in: Goroll et al. Primary


Care Medicine, 3rd ed. Philadelphia:
Lippincott, 1995: 1063.

78
 separation from parents
Persistently
19
 pain
 infection
Crying Baby WORKUP
The parents are likely to be harassed and
RELEVANCE TO GENERAL PRACTICE anxious. A sympathetic approach helps to
 A persistently crying baby requires the diffuse the tense situation.
doctor„s full attention to sort out what
is the underlying problem and the History
consequences of the crying. Evaluation of the history should include
 Some mothers feel that the baby is the following:
abnormal because he cries so much;  Clarify whether the baby normally cries
they may be right, particularly if the a lot. If the baby does not normally cry
baby does not normally behave like like this it is important to look for a
this. physical cause. History of outbursts of
 Most of the cases seen are of benign crying, drawing their knees and legs
cause but the important point is not to up may suggest the possibility of colic,
miss a serious cause. wind or intussuception. Enquire for
 A persistently crying child may cause symptoms of constipation, diarrhoea,
strained relationships at home. Not vomiting, passing blood in stools and
many parents can stand a baby crying poor feeding.
intermittently throughout the night.  Once serious causes have been
Their tolerance therefore is often excluded from the history, look for
exceeded. benign causes. Ask systematically
about feeding patterns and difficulties
CAUSES if any; frequency of changing of wet
Infant and younger child nappies; and the sleeping
 Crying without disease environment. Often parents have
This may be due to changed types of feed, used infant
 hunger, thirst colic mixtures and made changes in
 discomfort - cold, heat, the sleeping environment -- all in vain.
 wet nappies - urine or soiled  Finally, attention should turn to the
 pain -- e.g., from local reactions to parents if a serious cause is not likely.
immunisation Allowing the parents opportunity to
 wants to be picked up - need for vent their difficulties help in the
physical contact management of the problem.
 colic Questions like 'You must be feeling
 feeding problem -- e.g., hole in teat pretty desperate" or "you must find it
too small or too big. difficult to cope" are useful in getting
them to speak up. Explore how do
 Crying with disease they feel about each other and the
The following needs to be considered: baby? Are they staying alone? How do
household members react to the
 infection -- e.g., upper respiratory
crying? Are they helpful, complaining
tract infection, meningitis, acute
or interfering? These questions will
otitis media, urinary tract infection
help to uncover any social and
 intussusception, strangulated
emotional problems.
hernia, torsion of the testes.

The older child


The older child may also cry from:
 fatigue
 hunger
 frustration
 scared of being left alone

79
Physical examination  infant above 3 months -- 2.5 ml
A thorough physical examination is before meals four times a day.
necessary.  Discussion of parental concerns and
 Is there a fever? coping skills should be part of
 Look for signs of serious illness like management. The natural history of
poor peripheral perfusion, dehydration, persistent crying in infancy is
respiratory embarrassment or improvement over time. Reassurance
petechial rash, or neck stiffness to and supportive management may be
suggest meningitis. all that is necessary.
 The abdomen should be examined to  A variety of behavioural techniques
exclude strangulated hernia or torsion have been described to help soothe
of the testes. Are there faecal the crying baby:
masses?  rocking the baby
 Examine the anus for anal fissures.  walking while holding the baby
 soothing sounds like singing or
Observe the baby feeding. Too small a playing music
teat or wrong positioning of the feeding  taking the baby for a ride in the car
bottle resulting in air swallowing and wind or stroller.
colic is often the cause of discomfort and None is superior over another. Each
persistent crying. could be tried to see which works.
 Where the child is unwell or where
MANAGEMENT serious organic disease cannot be
 Once serious illness can be excluded excluded, referral to hospital should be
and a benign cause is present, done.
attention to this will be all that is
necessary: INDICATIONS FOR REFERRAL
Hunger: Feeding advice for babies  The ill child is suggested by the history
who cry because of hunger. Some of altered consciousness, respiratory
need to be fed more than three-hourly. distress, bile stained vomiting,
Feed times may need to be adjusted. abdominal distension, bloody stools
Thirst: A drink of water instead of an and excessive pallor. Physical
extra bottle may pacify the baby. examination may provide supporting
Wet nappies: Changing wet nappies information of poor peripheral
more frequently may be needed. perfusion, obvious respiratory
Feeding problems: Hole in the teat embarrassment, petechial rash or
may be too big or too small; wrong hypotonia in acute infections.
positioning of the bottle so that the  A child that is fretful also warrants
baby sucks in too much air is admission for observation if serious
commonly overlooked. disease cannot be excluded.
Emotional need: Babies like to be
with their mothers and like the warmth References
of contact; picking them up may stop 1. Field D, Harris A and Stewart A. How I treat a
the crying. Sleeping in the same room crying baby. The practitioner 1990; 234:317-
as the mother may have a quietening 320.
2. Parkin PC, Schwartz CJ, Manuel BA.
effect. Randomised controlled trial of three
Wind, colic: Parents should be interventions in the management of persistent
taught how to burp the child after crying in infancy. Paediatrics 1993 Aug
every food, sometime they may need 92(2):197-201.
3. Treem WR. Infant colic. A paediatric
to burp the child more than once. gastroenterologist‟s perspective. Paediatric
Clinic North Am 1994 Oct; 41(5):1121-38.
In severe cases of infantile colic, 4. St James-Roberts I. Managing infants who
dicyclomine hydrochloride (Infacol) cry persistently. BMJ.
may be of help. Dosage: 1992;304(6833):997-8
 infant under 3 months -- 1 ml
diluted with an equal volume of
water given before meals three to
four times a day

80
20 Red Eye
RELEVANCE TO
Red eye of gradual onset

Conjunctivitis
Conjunctivitis is the most common cause of
GENERAL PRACTICE a red eye.

 The red eye is the most common eye


problem encountered by the primary Viral conjunctivitis
care physician. Viral conjunctivitis is characterized by
watery, sometimes mucoid discharge, often
 Patients present with a wide range of beginning in one eye but spreading to the
conditions that are characterised by a other eye several days later. It may be
red eye. Most are fortunately self-limiting associated with fever and pharyngitis
or easily treatable conditions. particularly in children. Periauricular
adenopathy is common.
 There is a need to be alert for the
occasional serious red eye. Bacterial conjunctivitis
Bacterial conjunctivitis is characterized by a
CAUSES mucopurulent discharge and usually occurs
unilaterally without pre-auricular
These can be classified into lid or eye adenopathy. The eyelids have a thick crust
conditions and of gradual or sudden onset on them after a night's sleep.
(See Table 1)1. Pneumococcus, streptococcus,
staphylococcus and haemophilus are
Table 1. Causes Of The Red Eye common causal agents.

Allergic conjunctivitis
RED EYE OF GRADUAL ONSET Allergic or atopic conjunctivitis is
Conjunctivitis characterized by itching, tearing and
 viral, bacterial or chlamydial redness of both eyes and may be associated
conjunctivitis with atopic dermatitis or vasomotor rhinitis.
 allergic conjunctivitis
 prolonged wearing of contact lens
Contact lens conjunctivitis
Problems of the eye lid
 blepharitis
This is common as the number of contact
 stye
lens users are increasing. It is usually a
 Meibomian cyst, chalazion bacterial conjunctivitis.
 entropion and ectropion
 dacryocystitis or dacryoadenitis Chemical keratoconjunctivitis
 orbital cellulitis Chemical keratoconjunctivitis is a common
Keratitis industrial injury due to a splash of an irritant
 viral or bacterial keratitis solution. The conjunctiva is uniformly red,
 marginal keratitis the pupil constricted, vision decreased, the
 Iritis and anterior uveitis cornea may be hazy and the eye painful
 Episcleritis because of spasm of the iris. Alkaline
solutions are more dangerous than acidic
RED EYE OF SUDDEN ONSET ones.
Spontaneous subconjunctival haemorrhage
Foreign body Malingering
Arc eye
Occasionally the doctor may come across
Acute glaucoma
Blunt trauma one who fakes a diseased red eye by
Chemical burns rubbing his eyes with irritant substances
Source: Khunti K. Update Jun 1, 1995:751 such as tobacco. The eye is red and may
(Arranged in order of frequency as seen in have chemosis. The cue is that there is
general practice) much tearing that is clear and not mucoid or

81
purulent; however, allergic conjunctivitis can Episcleritis and scleritis
also appear like this. Episcleritis is usually a benign inflammation
of superficial episcleral vessels. Sometimes
Eye lid conditions seen in association with collagen diseases,
Included are blepharitis, stye, meibomian gout, allergic conditions and psoriasis. The
abscess, chalazion, ectropion and entropion patient complains of tender irritated eyes,
and orbital cellulitis. the conjunctiva shows local raised areas of
redness. Scleritis is inflammation of deeper
Blepharitis layers of the sclera. In most cases no
Blepharitis is inflammation of the lid margin. specific cause is found but it may occur as a
In the mild squamous variety, skin scales feature of systemic lupus erythematosus,
and grease line the lid margin which is rheumatoid arthritis or polyarteritis nodosa.
slightly inflamed. In the ulcerative variety,
the lash follicles are inflamed and the lid Red eye of sudden onset
margin is ulcerated.
Subconjunctival haemorrhage
Stye The cause is a rupture of subconjunctival
A stye is an inflamed lash follicle. vessels either spontaneously, or as the
result of straining at stools or from coughing,
Meibomian abscess often in an elderly person. In patients
A meibomian abscess may form in a receiving anticoagulant medications,
meibomian gland forming a visible swelling spontaneous subconjunctival haemorrhage
on the eyelid. may be a sign of overdose.

Chalazion Foreign body


After the acute inflammation in a Meibomian Foreign body on the bulbar conjunctiva or
gland has subsided, a Meibomian cyst may under either the upper or lower lid may result
form. This is called a chalazion. Some may in copious tearing and conjunctival injection.
resolve spontaneously so some period of
observation is in order. Acute glaucoma
Acute glaucoma is an ocular emergency that
Entropion and ectropion presents as a painful, red eye with
An ectropion or entropion can cause a red prominent ciliary flush. The patient reports
eye. Entropion may do so because of the cloudy vision, coloured rings around lights,
conjunctival and corneal irritation by in- unilateral headache, nausea and vomiting.
turned lashes and ectropion because the
everted conjunctiva and stagnant pool of WORKUP
tears become secondarily infected.
History
Keratitis and corneal ulcers The patient should e asked specifically
Some conjunctivitis are associated with about the onset and progression of the red
corneal involvement. There are many eye. Key symptoms to ask are the presence
causes of keratitis and corneal ulcers: if any, of visual impairment, discharge, pain,
bacterial ulcers secondary to foreign body, photophobia, grittiness and itch. A past
blunt injury or contact lens wear, exposure history of eye problems and any recent
secondary to facial palsy, thyrotoxic eye injury or foreign body entry should be
disease and herpes simplex infection. sought. The patient should be asked if any
of the family are affected.
Iritis and Uveitis
This may be secondary to systemic disease Physical Examination
or more likely, of unknown cause. One or If the diagnosis is not obviously a lid
both eyes may be affected. Photophobia and problem, bilateral conjunctivitis or a
impaired vision are prominent complaints. subconjunctival haemorrhage, then a
There is ciliary injection, altered iris color, complete examination of the eye using a
smaller pupillary size with sluggish light bright light is important. The distribution of
response in the affected eye. the red eye should be noted.

82
 The lid margins should be inspected for
crusting, ulceration, ectropion or  Contact lens conjunctivitis -- advice on
entropion and infection as well as proper care of the lenses and avoid lens
localised lesions such as stye, wear until conjunctivitis subside.
dacryocystitis or dacryoadenitis. Bilateral  Stye, cellulitis, meibomian inflammation -
eyelid edema may be caused by an - systemic antibiotics with or without
allergy. incision and drainage may be necessary.

 The upper and lower eyelids should be  Superficial foreign body - dislodging and
retracted to and the eye carefully removing this with a moistened cotton
examined to exclude any foreign bodies. bud may be tried initially for a very
superficial foreign
 The conjunctiva should be inspected for body.
redness, ciliary flush and foreign body.
The palpebral conjunctiva should not be Removal of a lightly embedded foreign
overlooked. body may be attempted by the use of a
syringe needle tip under good lighting if
 Corneal ulcers, hypopion and corneal one is sufficiently experienced; if that
opacity should be looked for. fails the patient should be referred.

 The pupil size should be checked. INDICATIONS FOR REFERRAL


Abnormality is seen in iritis or glaucoma.  Red eye associated with eye pain, visual
disturbance, signs of acute glaucoma or
 If there is any suggestion of visual iritis should be referred immediately.
impairment or if there is any diagnostic
doubt, it is essential to measure the  Corneal ulcer -- particularly, the dendritic
visual acuity. ulcer should be regarded as an
emergency.
 Fundoscopy should be done if there is
history of injury by a flying foreign body.  Gonococcal infection of the newborn is a
serious potentially blinding condition
Table 2 summarises the chief features in which requires intensive treatment. It is
differentiating conjunctivitis from iritis, characterised by profuse mucopurulent
keratitis and acute glaucoma. discharge.

Investigations  Foreign bodies and more than superficial


For purulent discharges, culture and eye injuries should also be immediately
sensitivity should be done. referred.

MANAGEMENT  A conjunctivitis that is not recovering


The management of the patient general after initial treatment of 2-3 days or even
practitioner can provide symptomatic relief earlier; if in doubt, one should not
or specific treatment for the following: hesitate to refer.

 Viral conjunctivitis -- hydrocortisone or References


betamethasone eyedrops. Steroid 1. Wirbelauer C. Management of the red eye
eyedrops are contraindicated if a corneal for the primary care physician. Am J Med.
ulcer is present; consider referring such 2006;119(4):302-6.
patients to the ophthalmologist for further 2. Bal SK, Hollingworth GR. Red eye. BMJ.
2005;331(7514):438.
management.
3. Vafidis G. When is red eye not just
conjunctivitis? Practitioner.
 Bacterial conjunctivitis -- antibiotic 2002;246(1636):469-71, 474-5, 478-81.
eyedrops. 4. Manolopoulos J. Emergency primary eye
care. Tips for diagnosis and acute
 Allergic conjunctivitis -- antihistamine management. Aust Fam Physician.
eyedrops or mild steroid eyedrops. 2002;31(3):233-7.

83
Table 2. The Red Eye

Clinical feature Conjunctivitis Iritis Keratitis (corneal Acute glaucoma


inflammation or
foreign body)

Vision Normal or Slightly blurred Slightly blurred Marked blurring


intermittent blurring
that clears on
blinking

Pain None or minor and Moderately Sharp, severe, Very severe;


superficial severe and foreign body frequently
aching sensation nausea and
vomiting

Photophobia Nil ++ + Nil

Discharge Usually significant None None to mild None


with crusting of eye
lashes

Pupil size Normal Constricted Normal or Semi-dilated and


constricted fixed

Conjunctival Diffuse Circumcorneal Circumcorneal Diffuse with


injection predominant
circumcorneal

Cornea Clear Clear or slightly Opacification Hazy; altered


hazy present; altered light reflex
light reflex; positive
flourescein staining

Pupillary Normal Minimal further Normal Minimal or no


response constriction reaction of dilated
to light pupil

Anterior Normal Normal Normal Shallow


chamber depth

84