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This section includes low (lumbosacral) back pain and thoracic back pain.

Low back pain (LBP)

The most common cause of LBP presenting to the doctor is dysfunction of the spinal intervertebral joints (mechanical back pain or back strain/‘sprain’) due to injury. This problem accounts for ∼72% of cases of LBP, while lumbar spondylosis (degenerative osteoarthritis) is responsible for ∼10% of cases of painful backs presenting to the GP. Musculoligamentous strain is common but usually settles in days. The management of back pain depends on the cause.

Key examination

Follow the LOOK, FEEL, MOVE, MEASURE clinical approach with an emphasis on palpation—central and lateral.

The movements of the lumbosacral spine with normal ranges are:

• extension 20°–30°

• forward flexion 75°–90°

• lateral flexion (left and right) 30°

Perform a neurological and vascular examination of the lower limb/s if pain.

Key investigation

This should be conservative, especially in the absence of red flags. Basic screening is:

• FBE

• ESR/CRP

• urinalysis

• serum alkaline phosphatase

• PSA in males 50–75 years

• plain X-ray if chronic pain and red flags

Reserve CT scan, MRI or radionuclide scan for suspected serious disease (malignancy and infection).

Summary of diagnostic guidelines for spinal pain

• Continuous pain (day and night) = neoplasia, esp. malignancy or infection.

• The big primary malignancy is multiple myeloma.

• The big 3 metastases are from lung, breast and prostate.

• The other 3 metastases are from thyroid, kidney/adrenal and melanoma.

• Pain with standing/walking (relief with sitting) = spondylolisthesis.

• Pain (and stiffness) at rest, relief with activity = inflammation.

• In a young person with inflammation think of ankylosing spondylitis, Reiter syndrome or reactive arthritis. Stiffness at rest, pain with or after activity, relief with rest = osteoarthritis.

• Pain provoked by activity, relief with rest = mechanical dysfunction.

• Pain in bed at early morning = inflammation, depression or malignancy/infection.

• Pain in periphery of limb = discogenic → radicular

  or vascular → claudication

  or spinal canal stenosis → claudication.

• Pain in calf (ascending) with walking = vascular claudication.

• Pain in buttock (descending) with walking = neurogenic claudication.

• One disc lesion = one nerve root (exception is L5–S1 disc). One nerve root = one disc (usu.).

• Two or more nerve roots—consider neoplasm.

• The rule of thumb for the lumbar nerve root lesions is L3 from L2–3 disc, L4 from L3–4, L5 from L4–5 and S1 from L5–S1.

• A large disc protrusion can cause bladder symptoms, either incontinence or retention.

• A retroperitoneal bleed from anticoagulation therapy can give intense nerve root symptoms and signs.

Vertebral dysfunction with non-radicular pain (non-specific LBP)

Typical features

• The common cause of LBP

• Usu. due to dysfunction (injury) of the pain-sensitive facet joint ± a minor disc disruption

• Pain usu. unilateral; can be central or bilateral

• No investigations needed for acute pain <2 wks if no red flags

Management—acute LBP (only) without spasm

• No bed rest—normal daily activities; keep active, return to work if possible

• Back education

• Regular simple analgesics (e.g. paracetamol, ibuprofen or aspirin)

• Exercise program (when exercises do not aggravate)

• Swimming (if feasible)

• NSAIDs: 14 d (only if evidence of inflammation)

• Spinal stretching, mobilisation or manipulation if needed after review in 4–5 d

Most of these patients can expect to be relatively pain free and able to return to work within 14 d.

Chronic LBP (pain >3 mths)

Investigations

Consider: plain X-ray, ESR, urine analysis, PSA (♂ >50 yrs)

Management

• Back education

• Normal activities

• Analgesics or paracetamol

• NSAIDs: 14 d (if inflammation)

• Exercise program

• Trial of mobilisation/manipulation (if untried) × 3, if no contraindications

• Referral for physiotherapy

• Consider amitriptyline 10–25 mg (o) nocte increasing to max 75–100 mg

Vertebral dysfunction with radiculopathy (sciatica)

Management

If abnormal neurological signs (e.g. foot drop) investigate with plain X-ray, CT scan ± MRI.

Sciatica is a more complex and protracted problem to treat, but most cases will gradually settle within 12 wks if the following approach is used:

• Relative rest for up to 3 d at onset (keep the spine straight—avoid sitting in soft chairs and for long periods)

• Resume activity ASAP

• Regular non-opioid analgesics with review as the patient mobilises

• NSAIDs: 14 d

• If severe unrelieved pain add tramadol 50–100 mg (o) 2–4 times daily (max. 400 mg/day) as necessary, for short-term use

• Consider steroids for acute severe pain, e.g. prednisolone 50 mg for 5 d → 25 mg → taper to 0 (3 wks total)

• Back education

• Exercises—straight-leg raising exercises to pain tolerance

• Swimming

• Traction (with care)

• Epidural anaesthesia (if slow response)

Guidelines for possible surgical intervention

The most common disc prolapses are L4–5, L5–S1.

• Bladder/bowel disturbances

• Progressive motor disturbance (e.g. increased foot drop, quadriceps weakness)

• Intense prolonged pain with no reponse to 6 weeks treatment and imaging shows a lesion corresponding to symptoms

Lumbar spondylosis

Typical profile

• >50 yrs: ↑ with age

• Dull nagging LBP

• Stiffness, esp. in mornings (main feature)

• Aggravated by heavy activity, bending (e.g. gardening)

• Relief by gentle exercise, hydrotherapy

• All movements restricted

Note: Tends to cause spinal canal stenosis with neurogenic claudication, which responds well to surgical decompression.

Management

• Basic analgesics (depending on patient response and tolerance)

• NSAIDs (judicious intermittent use)

• Appropriate balance between light activity and rest

• Exercise program and hydrotherapy (if available)

• Regular mobilisation therapy may help

• Consider trials of electrotherapy, such as TENS and acupuncture

Spondylolisthesis

About 5% of the population have spondylolisthesis but not all are symptomatic. The pain is caused by extreme stretching of the interspinous ligaments or of the nerve roots, or a disc lesion.

Diagnosis is confirmed by lateral X-ray (Fig. B2).

Management

• Strict flexion exercise program for at least 3 mths (avoid hyperextension)

• Passive spinal mobilisation may help some

• Lumbar corsets help but avoid if possible

• Surgery is last recourse

The spondyloarthropathies

The seronegative spondyloarthropathies are a group of disorders characterised by involvement of the sacroiliac joints with an ascending spondylitis and extraspinal manifestations such as oligoarthritis and enthesopathies ( See the spondyloarthropathies).

Typical features

• Young men 15–30

• Aching throbbing pain of inflammation

• LBP radiating to buttocks

• Back stiffness, esp. in mornings

• Absent lumbar lordosis

• Positive sacroiliac stress tests

Treatment

The earlier the treatment the better the outlook for the patient; the prognosis is usu. good.

• Advice on good back care and posture

• Exercise programs to improve the range of movement

• Drug therapy, esp. tolerated NSAIDs (e.g. indomethacin)

• Sulfasalazine—a useful second-line agent if the disease progresses despite NSAIDs. Consider methotrexate and other DMARDs.

Thoracic back pain

Thoracic (dorsal) back pain which is common in people of all ages is mainly due to dysfunction of the joints of the thoracic spine, with its unique costovertebral joints.

Muscular and ligamentous strains may be common, but rarely come to light in practice because they are self-limiting and not severe.

This dysfunction can cause referred pain to various parts of the chest wall and can mimic the symptoms of various visceral diseases, such as angina, biliary colic and oesophageal spasm.

Intervertebral disc prolapse is very uncommon in the thoracic spine and then occurs below T9, usu. T11–12, but it is a target for bony metastases (see red flags) and ‘not to be missed’ disorders for LBP.

Scheuermann disorder

Typical features

• Age 11–17

• Males > females

• Lower thoracic spine T9–12

• Thoracic pain or asymptomatic

• Increasing thoracic kyphosis over 1–2 mths

• Cannot touch toes

• Diagnosis confirmed by X-ray (Schmorl's nodes etc.)

Treatment

• Explanation and support

• Extension exercises, avoid forward flexion

• Postural correction

• Avoidance of sports involving lifting and bending

• Consider bracing or surgery if serious deformity

Idiopathic adolescent scoliosis

The vast majority of curves, occurring equally in boys and girls, are mild and of no consequence. 85% of significant curves in adolescent scoliosis occur in girls. Such curves appear during the peripubertal period, usu. coinciding with the growth spurt. The screening test (usu. in 11–13 yo) is to note the contour of the back on forward flexion. 10% of normal adolescents have a curve of >5% but only 1–2% >10%.

Investigation

A single erect PA spinal X-ray is sufficient; the Cobb angle is the usual measurement yardstick.

Management aims

• Preserve good appearance—level shoulders and no trunk shift

• Prevent increasing curve in adult life: <40°

• Not to produce a straight spine on X-ray

• Refer for expert opinion

General rules for Cobb angle

• <20° observe

• 20–40° brace

• >40° surgery

Kyphosis

Kyphosis is the normal curve of the thoracic spine when viewed from the side. The normal range is 20–45° with the angle measured between the uppermost and lowermost inclined vertebrae on the lateral X-ray. An excessive angle (>45–50°) occurs with a kyphotic deformity which usually presents in childhood and is congenital. Consider referral if >50°.

Dysfunction of the thoracic spine

Also called thoracic hypomobility syndrome, this is the outstanding cause of pain (often interscapular) presenting to the practitioner, is relatively easy to diagnose and usu. responds dramatically to a simple spinal manipulation treatment (beware of spinal disease, esp. osteoporosis).

Association: chronic poor posture

Diagnosis confirmation: examination of spine, X-ray (mainly to exclude disease)

Management

• Continued activity if pain permits

• Explanation and reassurance

• Back education program

• Spinal manipulation (very effective)

• Spinal mobilisation (if manipulation contraindicated)

• Simple analgesics as required

• Exercise program, esp. extension exercises

• Posture education

A. For unexpected death, e.g. motor accident

DOs

• Personal contact of relative/s, preferably by doctor.

• Be well-prepared: check facts, plan approach.

• Use suitable quiet private room (not to be disturbed).

• Provide empathy, support, understanding, sensitivity.

• Be honest, direct.

• Allow time, opportunities to react and question.

• Allow silence, touching and free expression of emotions.

• Allow viewing of a dead or injured body.

• Provide appropriate follow-up and ongoing support.

DON'Ts

• Delay contact.

• Rush the interview.

• Avoid fudging.

• Be blunt.

• Withhold the truth or get facts wrong.

• Give platitudes and euphemisms.

• Give false reassurance.

B. For sharing bad personal news (Table B2)

• Plan the consultation, check facts, set aside ample time.

• Meet in an appropriate room with privacy and no interruption.

• Ask the patient if they would like company (e.g. a relative or friend).

• Make good eye contact and be alert for non-verbal responses.

• Use simple, understandable language.

• Be honest and diplomatically to the point (don't cover up the issue).

• Allow time, silence, tears or anger.

• Avoid inappropriate methods (refer to ‘Dont's’ above) and don't give precise predictions about life expectancy.

Bereavement and coping with loss

Bereavement or grief is the emotional response to loss, with a complex amalgam of anger, sadness, helplessness, guilt, yearning and despair.

Stages

The usual normal stages are:

1. Shock or disbelief: hrs to days

2. Grief and yearning: 6 wks +

3. Despair—social withdrawal, sadness, hopelessness: ∼6 mths 2–3 include anger, guilt & self-blame

4. Adaptation and acceptance, includes: apathy, depression, physical ailments: 1 or more yrs

Role of GP

• Provide basic counselling and ongoing support.

• Provide patient handouts.

• Refer to grief counsellor, religious groups, support groups, e.g. SIDS.

• Watch for morbid or pathological grief.

Rules

The bereaved may:

• feel very guilty

• be angry towards you or others

• need a clear, gentle explanation about cause and manner of death

• need to sense you are genuinely interested

• need to work through stages of grief

Balanitis is inflammation of the foreskin, which usu. affects the glans penis and tissues behind the foreskin (balanoposthitis).

Causative factors

• Phimosis

• Poor hygiene

• Candida albicans infection

• Diabetes

• Reiter syndrome (esp. if asymptomatic)

Treatment

• Mild cases may be treated with gentle saline bathing, a barrier cream or hydrocortisone 1% to tip of penis, and then application of an antibacterial ointment, e.g. fucidin, if more severe

• Take swabs for culture

• Careful washing behind foreskin

If yeasts present—topical nystatin or imidazole cream (e.g. clotrimazole 1% for 5 days)

If trichomonads present—metronidazole or tinidazole (oral treatment)

If bacteria present (usu. cellulitis)—appropriate topical antibiotic (e.g. chloramphenicol); if severe, di(flu)cloxacillin (o) or IV

Thickening of the foreskin with skin pallor suggests balanitis xerotica obliterans, which may respond to corticosteroid cream if it is mild. Can result in phimosis, usu. 10–12 yrs. Circumcision is indicated for recurrent problems.

Mild cases with phimosis in children

Apply 0.05% betamethasone cream tds for 10 days.

Management

Prevention

• Identifying patient at risk, e.g. Norton scale assessment

• Good nursing care, inc. turning patient every 2 h (90% of pressure ulcers are preventable)

• Special care of pressure areas, inc. gentle handling

• Special beds, mattresses (e.g. air-filled ripple) and sheepskin to relieve pressure areas

• Good nutrition and hygiene

• Avoid smoking

• Control of urinary and faecal incontinence

• Avoid the donut cushion

Treatment of ulcer

The most important principle is early intervention, including relief of pressure, friction and shear.

Use above measures, plus:

• Clean base with warm water or saline solution (applied gently via a syringe) or Intra Site Gel (most antiseptics damage cells—use 0.5–1% Betadine)

• General guidelines for dressings:

  • deep ulcers: alginates (e.g. Algisite M Tegagel, Kaltostat)

  • shallow ulcers: hydrocolloids (e.g. Duoderm, Cutinova Hydro)

  • dry or necrotic ulcers: hydrogels (e.g. Intra Site)

  • heavy exudative ulcers: foams (e.g. Lyofoam, Lyofoam extra)

• Give vitamin C, 500 mg bd

• Give antibiotics for spreading cellulitis (otherwise of little use)

• Remove dressings with care, if nec. under shower

• Healing is usu. satisfactory but, if not, surgical intervention with debridement of necrotic tissue and skin grafting may be necessary

(Patient swallows air without admitting it)

• Make patient aware of excessive swallowing and belching.

• Advise patient to:

  • avoid fizzy (carbonated) soft drinks

  • avoid chewing gum

  • avoid drink with meals

  • avoid mixing proteins and starches

  • eat slowly and chew food thoroughly before swallowing

  • eat and chew with the mouth closed

If persistent: Simethicone preparation (e.g. Mylanta II, Phazyme).

If desperate: Place a small cork between the back teeth after meals for 30 mins.

Prednisolone 1 mg/kg (o) daily in the morning for 5 days, then taper to zero over next 7 d (start within 48 hours of onset). Evidence unconvincing for this and also aciclovir but considered applicable for more severe cases. Use aciclovir for Ramsay–Hunt syndrome (See Herpes zoster (shingles)).

• Patient education and reassurance

• Adhesive tape or patch at night over eye if corneal exposure

• Artificial tears if eye dry, esp. at night

• Massage and facial exercises during recovery

• About 80% spontaneous recovery

Long-term use should be avoided and care should be taken with ‘new patients’ requesting a prescription. Have a firm prescribing policy, e.g. reserving for:

• situational anxiety affecting lifestyle (e.g. plane travel—intermittent short use only)

• self-perpetuating anxiety following a precipitating event, not responding to counselling etc. (give short course 2–4 wks)

• emergency short-term use for agoraphobia and panic attacks

Benzodiazepine withdrawal syndrome

This syndrome is usu. relatively delayed in its onset and may continue for weeks or mths. Withdrawal features include:

• anxiety (rebound)

• depression

• insomnia

• nausea

• loss of appetite

• tremor

• confusion

An effective management method is to withdraw the drug very slowly while providing counselling and support, including referral to a self-help group. Antidepressants can be substituted if there is evidence of depression, while beta-blockers may help the withdrawal syndrome if other measures have failed.

Bites and stings from animals, spiders, marine stingers and insects in Australia are commonplace but fatal bites are uncommon.

Bite wounds

Snake bites

Most bites do not result in envenomation, which tends to occur in snake handlers or in circumstances where the snake has a clear bite of the skin.

First aid

• Keep the patient as still as possible.

• Do not wash, cut or manipulate the wound, or apply ice or use a tourniquet.

• Immediately bandage the bite site firmly (not too tightly). A wide crepe bandage is ideal: it should extend above the bite site for as high as possible, at least 15 cm (e.g. if bitten around the ankle, the bandage should cover the leg to above the knee).

• Splint the limb to immobilise it: a firm stick or slab of wood would be ideal.

• Transport to a medical facility for definite treatment. Do not give alcoholic beverages or stimulants.

Note: A venom detection kit can be used to examine a swab of the bitten area or a fresh urine specimen (the best) or blood.

The bandage can be removed when the patient is safely under medical observation. Observe for symptoms and signs of envenomation.

Envenomation

Important early symptoms of snake bite envenomation include:

• nausea and vomiting (a reliable early symptom)

• abdominal pain

• excessive perspiration

• severe headache

• blurred vision

• difficulty speaking or swallowing

• coagulation defects (e.g. haematuria)

• tender lymphadenopathy

Note: Do not give antivenom unless clinical signs of envenomation or biochemical signs (e.g. positive urine, or abnormal clotting profile).

Treatment of envenomation

• Set up a slow IV infusion of N saline.

• Have adrenaline on standby.

• Dilute the specific antivenom (1 in 10 in N saline) and infuse slowly over 30 mins via the tubing of the saline solution (may need 2 or more ampoules of antivenom).

• Have adrenaline, oxygen and steroids on standby.

• Monitor vital signs.

• Provide basic life support as necessary.

Note: A test dose of antivenom is not recommended.

Be careful of prophylactic adrenaline in some situations (e.g. avoid with brown snakes and with coagulopathy).

Spider bites

The toxin of most species of spider causes only localised pain, redness and swelling, but the toxin of some, notably the deadly Sydney funnel-web spider (Atrax robustus), can be rapidly fatal.

First aid

• Sydney funnel-web: as for snake bites

• Other spiders: apply an ice pack, do not bandage

Treatment of envenomation

• Sydney funnel-web: admit to a hospital critical care facility

  • specific antivenom (need at least 4–6 vials)

  • resuscitation and other supportive measures

• Redback spider: admit to hospital or emergency facility for observation

  • antivenom IM (IV if severe)

Human bites and clenched fist injuries

Human bites, including clenched fist injuries, often become infected by organisms such as Staphylococcus aureus.

Principles of treatment

• Clean and debride the wound carefully (e.g. aqueous antiseptic solution or hydrogen peroxide).

• Give prophylactic penicillin if a severe or deep bite.

• Avoid suturing if possible.

• Tetanus toxoid.

• Consider possibility of HIV, Hepatitis B or C infections.

For wound infection

• Take swab.

• Procaine penicillin 1.5 g IM, + amoxycillin/clavulanate 875 mg (children: 15 mg/kg up to 875 mg) (o), bd for 5 d

For severe penetrating injuries (e.g. joints, tendons)

• Metronidazole 400 mg (o) bd + cefotaxime or ceftriazone 1 g IV daily for 5–10 d. Treat for 14 days if established infection.

Dog bites (non-rabid)

Animal bites are also prone to infection by the same organisms as for humans, plus Pasteurella multocida.

Principles of treatment

• Clean and debride the wound with aqueous antiseptic, allowing it to soak for 10–20 mins.

• Aim for open healing avoid suturing if possible.

• Apply non-adherent, absorbent dressings (paraffin gauze and Melolin) to absorb the discharge from the wound.

• Tetanus prophylaxis: immunoglobulin or tetanus toxoid.

• Give prophylactic penicillin for a severe or deep bite: 1.5 mill. units of procaine penicillin IM statim, then oral penicillin or amoxycillin/clavulanate (dose as above) for 5–7 d.

• Inform the patient that slow healing and scarring are likely.

Cat bites

Cat bites have the most potential for suppurative infection. The same principles apply as for management of human or dog bites but use amoxycillin/clavulanate for 5 d. It is important to clean a deep and penetrating wound. If infected use metronidazole + doxycycline. Another problem is catscratch disorder, presumably caused by a Gram-negative bacterium. Treat with roxithromycin for 10 d if infected.

Bed bug bites

Now a common problem, usu. in children and teenagers: the ‘backpacker itch’.

Presents as a linear group of ≥3 bites commonly on neck, shoulders, arms, torso and legs corresponding to the superficial blood vessels. Appears as extremely itchy maculopapular red lesions ± weals.

Treatment

• Clean the lesions.

• Apply corticosteroid ointment qid or a simple antipruritic ointment.

• Call in a licensed pest controller.

Sandfly bites

Use soothing anti-itch cream or 5% lignocaine ointment if painful. For some reason, possibly the nature of body odour, the use of oral thiamine may prevent sandfly bites.

Dose: Thiamine 100 mg orally, daily.

Mollusc bite (blue-ringed octopus, cone shell)

Mollusc venoms usually cause numbness and paraesthesia but can be rapidly fatal because of prolonged muscular weakness leading to respiratory paralysis.

Treatment

• Apply compression bandage to bite site (usu. hand/arm).

• Immobilise the limb.

• Arrange transport (preferably by ambulance) to a medical facility.

• Observe (and manage) for respiratory paralysis. Ensure adequate ABC.

Stings

Bee stings

First aid

• Scrape sting off sideways with a fingernail or knife blade. Do not squeeze it with fingertips.

• Apply 20% aluminium sulphate solution (Stingose) or methylated spirits.

• Apply ice to the site.

• Rest and elevate the limb that has been stung.

If anaphylaxis, treat as appropriate.

Centipede and scorpion bites/stings

Usually causes minor systemic symptoms. The main symptom is pain, which can be very severe and prolonged.

First aid

• Apply local heat (e.g. hot water with ammonia/household bleach).

• Clean site.

• Local anaesthetic (e.g. 1–2 mL 1% lignocaine) infiltrated around the site (if still painful). Consider parenteral morphine or fentanyl for pain.

• Check tetanus immunisation status.

Box jellyfish or sea wasp (Chironex fleckeri)

Treatment

• The victim should be removed from the water to prevent drowning.

• Immediately remove any tentacles with a glove.

• Inactivate the tentacles by pouring vinegar over the sting site and surrounding area for 30 secs (do not use alcohol)—use up to 2 L of vinegar at a time.

• Check respiration and the pulse.

• Start immediate cardiopulmonary resuscitation (if nec.).

• Gain IV access and use colloid; give oxygen and ionotropes.

• Immobilisation for major stings.

• Give box jellyfish antivenom by IM or IV injection.

• Provide pain relief if required (ice, lignocaine and analgesics) and/or parenteral fentanyl or morphine.

Irukandji (carukia barnesi) syndrome

Tiny jellyfish can cause this severe, potentially fatal delayed (∼30 mins) syndrome. Be prepared for CPR. Give morphine IV or fentanyl IV every 5 mins as required. Consider IV magnesium. No antivenom to date.

‘Blue bottle’ and other stinging jellyfish

• Wash sting site with sea water.

• Remove any tentacles.

• Immerse site in hot water (about 45°C) for 20 min.

Stinging fish

The sharp spines of the stinging fish have venom glands that can produce severe pain if they spike or even graze the skin. The best known of these is the stonefish. The toxin is usu. heat sensitive.

Envenomation

• intense pain

• localised swelling

• bluish discolouration

Treatment

• Bathe or immerse the affected part in very warm to hot water (not scalding—about 45°C) for 20 minutes—may give instant relief.

• If pain persists, give a local injection/infiltration of lignocaine 1% or even a regional block. If still persisting, morphine IV or fentanyl IV.

• A specific antivenom is available for the sting of the stonefish.

Other bites and stings

This includes bites from ants, wasps, mosquitos and some jellyfish.

First aid

• Wash the site with large quantities of cool water.

• Apply vinegar (liberal amount) or Stingose to the wound for ∼30 secs.

• Apply ice for several mins.

• Use soothing anti-itch cream or 5% lignocaine cream or ointment if very painful.

Medication is not usually necessary, although for a jellyfish sting the direct application of Antistine-Privine drops onto the sting (after washing the site) is effective.

The 7th most common malignancy—transitional cell cancer.

• Haematuria esp. microhaematuria

• Irritative LUT symptoms—frequency, dysuria

Diagnosis is urine cytology (×3) & cystoscopy.

Treatment is according to staging and grading, e.g.

• intravesical BCG immunotherapy for Ca in situ

• other intravesical agents, e.g. mitomycin

• surgical resection

• radio-chemotherapy

Women with urethral syndrome constantly wake at night with the urge to micturate but produce only a small dribble of urine.

• Instruct patient to perform a pelvic lift exercise by balancing on upper back, lifting her pelvis with knees flexed and holding position for 30 secs.

• Squeeze pelvic floor inwards (as though holding back urine or faeces).

• Repeat a few times.

This is classified into three types:

• Seborrhoeic blepharitis

• Rosacea blepharitis

• Staphylococcus blepharitis

Treatment

• Eyelid hygiene for seborrhoea—clean with a cotton bud dipped in 1:10 dilution of baby shampoo or sodium bicarbonate solution or clean warm water, once or twice daily

• Artificial tears (e.g. hypromellose 1%) for dry eyes

• Control scalp seborrhoea with medicated shampoos (e.g. ketaconazole)

• If chronic: short-term use of hydrocortisone 0.5% ointment

• If facial rosacea: doxycycline 100 mg (o) bd for 4–8 wks

• If infected (e.g. S. aureus): tetracycline 1% or chloramphenicol 1% ointment to lid margins twice daily

• If lid abscesses: di(flu)cloxacillin

Body odour is caused by poor hygiene, excessive perspiration and active skin bacteria. Axilla and groin are the main focus.

Precautions

Consider uraemia, vaginitis.

Treatment

• Scrub body, esp. groins and axillae, with deodorant soap at least morning and night.

• Try an antibacterial surgical scrub.

• Keep clothes clean, regular laundry.

• Choose suitable clothes—natural fibres (e.g. cotton) not synthetics.

• Use an antiperspirant deodorant.

• Alternative soap—pine soap.

• Diet: avoid garlic, fish, curry, onions, asparagus.

• Reduce caffeine (coffee, tea and cola drinks), which stimulates sweat activity.

• Consider a sugar-free diet.

• Shave axillary hair.

• Axillary wedge resection for excessive perspiration ( See Perspiration: excessive (hyperhidrosis)).

• Obtain swabs

• 3% hexachlorophane body wash daily

• Mupirocin to the lesions and nares

• Antibiotics (according to swabs), e.g. difloxacillin 500 mg (o) qid for 7 d or erythromycin 500 mg bd for 10 d (may require up to 3 mths)

Key facts and checkpoints

• The commonest lumps are those associated with benign mammary dysplasia (fibrocystic breast disease).

• Benign mammary dysplasia is also a common cause of cysts, esp. in the premenopausal phase.

• Over 75% of isolated breast lumps prove to be benign but clinical identification of a malignant tumour can only definitely be made following aspiration biopsy or histological examination of the tumour.

• Breast cancer is the most common cancer in females (after skin cancer), affecting 1 in 8 Australian women before the age of 85.

• About 25% of all new cancers in women are breast neoplasms.

• A ‘dominant’ breast lump in an older woman should be regarded as malignant.

Breast lumps (women): diagnostic strategy model

Probability diagnosis

• Mammary dysplasia (32%)

• Fibroadenoma (23%)

• Cancer (22%)

• Cysts (10%)

• Breast abscess/periareolar inflammation

• Lactation cyst (galactocele)

Serious disorders not to be missed

• Vascular:

  • thrombophlebitis (Mondor disease)

• Infection:

  • mastitis/breast abscess

  • tuberculosis

• Cancer:

  • carcinoma

  • ductal carcinoma in situ

  • Paget disease of the nipple

  • sarcoma

  • lymphoma

  • mastitis carcinomatosa

• Other:

  • Phyllodes tumour

Pitfalls (often missed)

• Duct papilloma

• Lipoma

• Mammary duct ectasia

• Fat necrosis/fibrosis

The clinical approach

Breast cancer symptoms

• lump 76%

• tenderness or pain 10%

• nipple changes 8%

• nipple discharge 2%

• breast asymmetry/dimpling 4%

• periareolar inflammation—usu. due to nipple retraction or mammary duct ectasia

• Paget disease of nipple = underlying malignancy

Nipple discharge

This may be intermittent from one or both nipples. A common reason is physiological, is usu. part of a normal hormonal process. Discharge can be induced by quadrant compression.

• bloodstained

  • intraduct papilloma (commonest)

  • intraduct carcinoma

  • mammary dysplasia

• green-grey

  • mammary dysplasia

  • mammary duct ectasia

• yellow

  • mammary dysplasia (serous)

  • breast abscess (pus)

• milky white (galactorrhoea)

  • lactation cysts

  • lactation

  • hyperprolactinaemia

  • drugs (e.g. chlorpromazine)

Diagnosis—the triple test

1. clinical breast examination

2. fine needle aspiration cytology ± core biopsy

3. imaging: <35 yrs US; 35–50 yrs US ± mammogram; >50 yrs mammogram ± US

Investigations

X-ray mammography

Mammography can be used as a screening procedure and as a diagnostic procedure. It is currently the only effective screening tool for breast cancer. Screening:

• established benefit for women over 50

• possible benefit for women in their 40s

• follow-up in those with breast cancer, as 6% develop in the opposite breast

• localisation of the lesion for fine needle aspiration

Breast ultrasound

This is mainly used to elucidate an area of breast density and is the best method of defining benign breast disease, esp. with cystic changes. It is generally most useful in women less than 30 yrs.

Needle aspiration techniques

• cyst aspiration

• fine needle aspiration or core needle biopsy: very useful diagnostic test in solid lumps with an accuracy of 90–95% (better than mammography)

Carcinoma of the breast

Breast carcinoma is uncommon <30 yrs but steadily increases to a max. at ∼60 yrs. About ⅓ of women are premenopausal and ⅔ postmenopausal.

Clinical features

• Painless lump (10% associated pain)

• Hard and irregular lump

• Other symptoms include breast pain, nipple discharge (bloody or serous), nipple retraction or distortion, skin dimpling and skin oedema (peau d'orange).

• Rarely cancer can present with Paget sign (red scaly rash around nipple).

• Rarely it can present with bony secondaries (e.g. back pain, dyspnoea, weight loss, headache).

Management

Immediate referral to an expert surgeon on suspicion or proof of breast cancer is essential. Any doubtful breast lump should be removed.

Fibrocystic disease

Synonyms: fibroadenosis, chronic mastitis, mammary dysplasia, cystic hyperplasia. Most common in women between 30 and 50 years.

Management

• Consider mammography if diffuse lumpiness is present in patient >40.

• Perform needle biopsy if discrete lump is present and aspirate palpable cysts.

• Reassure patient that there is no cancer.

• Give medication to alleviate any mastalgia.

• Use analgesics as nec.

• Surgically remove undiagnosed mass lesions.

Breast cyst

A discrete asymptomatic mass that is firm and relatively mobile, rarely fluctuant.

Diagnosis

• mammography

• US (X-ray of choice)

• cytology of aspirate

Treat by draining with a fine needle. Surgery rarely required.

Lactation cysts (galactoceles)

• These milk-containing cysts arise during pregnancy and present postpartum with similar signs to perimenopausal cysts.

• They vary from 1–5 cm in diameter.

• Treat by aspiration: fluid may be clear or milky.

• Consider possibility of malignancy.

Fibroadenoma

Clinical features

• A discrete asymptomatic lump

• Usu. in 20s (range: 2nd–6th decade)

• Firm, smooth and mobile (the ‘breast mouse’)

• Usu. rounded

• Usu. in upper outer quadrant

Management

US and fine needle aspiration or core biopsy with cytology is recommended. If negative, the patient can be reassured and the lump left, unless there is some concern by both patient and surgeon about size or subsequent change.

Fat necrosis

Usu. the end result of a large bruise or trauma which may be subtle, such as protracted breastfeeding. The mass that results is often accompanied by skin or nipple retraction and thus closely resembles carcinoma.

Mammary duct ectasia

Synonyms: plasma cell mastitis, periductal mastitis.

In this benign condition a whole breast quadrant may be indurated and tender. The lump is usu. located near the margin of the areola and is a firm or hard, tender, poorly defined swelling. There may be a toothpaste-like nipple discharge. Sometimes surgery is needed to establish diagnosis.

Phyllodes tumour

Giant fibroadenoma-like tumour, usu. benign, but 25% are malignant.

Key facts and checkpoints

• Typical age span for mastalgia is 30–50 yrs.

• Peak incidence is 35–45 yrs.

• There are four common clinical presentations:

  1. diffuse, bilateral cyclical mastalgia (commonest)

  2. diffuse, bilateral non-cyclical mastalgia

  3. unilateral diffuse non-cyclical mastalgia

  4. localised breast pain

Cyclical mastalgia

Features

• Typical age is ∼35

• Discomfort and sometimes pain are present

• Usu. bilateral but one breast can dominate

• Mainly premenstrual; associated PMT

• Breasts diffusely nodular or lumpy

• Variable relationship to the pill

• Rare after the menopause

Management

After excluding a diagnosis of carcinoma and aspirating palpable cysts, various treatments are possible and can be given according to severity (see Table B3). Regular follow-up screening is advisable.

Non-cyclical mastalgia

Pain, which is continuous or intermittent, does not vary within the menstrual cycle. Typical age is early 40s.

Management

Non-cyclical mastalgia is very difficult to treat, being less responsive than cyclical mastalgia. It is worth a therapeutic trial.

Costochondritis (Tietze syndrome)

Features

• Palpable swelling ∼4 cm from sternal edge due to enlargement of costochondral cartilage

• Aggravated by deep breathing and coughing

• Self-limiting, but may take several mths to subside

Treatment

• Infiltration with LA and corticosteroid (with care).

Mastitis

Clinical features

• a lump and then soreness (at first)

• a red tender area

• (possibly) fever, tiredness, muscle aches and pains

Treatment (systemic symptoms)

• Antibiotics: resolution without progression to an abscess will usu. be prevented by antibiotics

  di(flu)cloxacillin 500 mg (o) qid for 10 d (IV if severe) or if hypersensitive to penicillin cephalexin 500 mg (o) qid for 10 d

• Therapeutic US (2 W/cm² for 6 mins) daily for 2–3 d

• Ibuprofen or paracetamol for pain

Instructions to patients

• Keep the affected breast well drained.

• Continue breastfeeding: do frequently and start with the sore side.

• Heat the sore breast before feeding (e.g. with hot shower or hot face washer).

• Cool the breast after feeding: use a cold face washer from the freezer.

• Empty the breast well: hand express if nec.

Inflammatory breast cancer (mastitis carcinomatosa)

This rare condition develops quickly with florid redness, swelling, dimpling and breast heaviness. Not as painful as it appears—confused with mastitis but unresponsive to antibiotics. Refer immediately.

Breast abscess

If tenderness and redness persist beyond 48 h and an area of tense induration develops, then a breast abscess has formed. The preferred treatment is aspiration with a large bore needle (with US guidance) under LA every second day until resolution, antibiotics (e.g. dicloxacillin 500 mg (o) qid for 10 days), rest and complete emptying of the breast. Continue breastfeeding from the affected side or express milk if this is not possible. Avoid surgery if possible because fistula formation is common.

This is a dramatic emergency. There are two types: one related to a tantrum (description follows) and the other a simple faint. They can manifest as ‘blue attacks’ (breath holding with closed glottic) or ‘white attacks’ known as reflex anoxic seizures, usu. with pain.

Clinical features

• Age group—usu. 6 mths to 6 yrs (peak 2–3 yrs)

• Precipitating event (minor emotional or physical)

• Children emit a long loud cry, then hold their breath

• They become pale and then blue

• If severe, may result in unconsciousness or even a brief tonic-clonic fit

• Lasts 10–60 secs

Management

• Place child in coma position.

• Reassure the parents that attacks are self-limiting, not harmful and are not associated with epilepsy or mental retardation (usu. resolve by 3 yrs).

• Advise parents to maintain discipline and to resist spoiling the child.

• Try to avoid incidents known to frustrate the child or to precipitate a tantrum: try distraction techniques.

• An acute viral illness due to RSV

• The most common acute LRTI in infants

• Usual age 2 wks to 9 mths (up to 12 mths)

• Coryza then irritating cough

• Wheezy breathing often distressed

• Tachypnoea

• Hyperinflated (barrel-shaped) chest

Auscultation:

• Widespread fine inspiratory crackles (not with asthma)

• Frequent expiratory wheezes

X-ray: hyperinflation of lungs with depression of diaphragm

Virus identified by PCR on nasopharyngeal aspirate. Rapid RSV viral test now available.

Management

Admission to hospital is usual, esp. with increasing respiratory distress (rate >50) reflected by difficulty in feeding.

• Minimal handling/good nursing care

• Observe colour, pulse, respiration, O₂ saturation (pulse oximetry)

• O₂ preferably warm and humidifed via nasal prongs: to maintain P_aO₂ > 90% (pref. 95%)

• Fluids IV or by nasogastric tube if unable to feed orally

• Antibiotics not indicated except if secondary bacterial infection

Acute bronchitis

• Cough and sputum (main symptoms)

• Wheeze and dyspnoea

• Usu. viral infection

• Can complicate chronic bronchitis usu. due to Haemophilus influenzae and Streptococcus pneumoniae

• Scattered wheezes on auscultation ± fever or haemoptysis (uncommon)

Outcome

Improves spontaneously in 4–8 d in healthy patients.

Treatment

• Symptomatic treatment

• Inhaled bronchodilators for airflow limitation

• Antibiotics usu. not needed

• Use antibiotics if evidence of acute bacterial infection with fever (e.g. amoxycillin 500 mg tds for 5 d; use doxycycline 200 mg stat, then 100 mg/d for 5 d if mycoplasma suspected)

Chronic bronchitis

Definition: chronic productive cough for at least 3 successive mths in 2 successive years:

• Wheeze, progressive dyspnoea

• Recurrent exacerbations with acute bronchitis

• Occurs mainly in smokers

COPD ( See Chronic obstructive pulmonary disease)

Many patients present with the complaint that they bruise easily but only a minority turn out to have an underlying blood disorder.

Key facts and checkpoints

• Purpura = petechiae ± ecchymoses.

• Abnormal bleeding is basically the result of disorders of (1) the platelet, (2) the coagulation mechanism, or (3) the blood vessel.

• There is no substitute for a good history in the assessment of patients with bleeding disorders.

• An assessment of the personal and family histories is the first step in the identification of a bleeding disorder.

• When a patient complains of ‘bruising easily’ it is important to exclude thrombocytopenia due to bone marrow disease and clotting factor deficiencies such as haemophilia.

• Differential diagnosis: ‘Palpable purpura’ due to an underlying systemic vasculitis is an important differential problem. The petechiae are raised so finger palpation is important. The cause is an underlying vasculitis affecting small vessels (e.g. polyarteritis nodosa).

• In general, bleeding secondary to platelet defects is spontaneous, associated with a petechial rash and occurs immediately after trauma or a cut wound.

• Laboratory assessment should be guided by the clinical impression.

• Bleeding caused by coagulation factor deficiency is usu. traumatic and delayed (e.g. haemorrhage occurring 24 h after a dental extraction in a haemophiliac).

• The routine screening tests for the investigation of patients with bleeding disorders can be normal despite the presence of a severe haemorrhagic state.

Purpura: diagnostic strategy model

Probability diagnosis

• Simple purpura (easy bruising syndrome)

• Senile purpura

• Corticosteroid-induced purpura

• Immune thrombocytopenic purpura

• Henoch-Schönlein purpura

• Liver disease, e.g. alcoholic cirrhosis

Serious disorders not to be missed

• Malignant disease:

  • leukaemia

  • myeloma

• Aplastic anaemia

• Myelofibrosis

• Infection:

  • septicaemia

  • meningococcal infection

  • infective endocarditis

  • measles

  • typhoid

  • viral haemorrhagic fevers

• Disseminated intravascular coagulation

• Thromobotic thrombocytopenic purpura

Pitfalls (often missed)

• Haemophilia A, B

• von Willebrand disease (vWD)

• Post-transfusion purpura

• Trauma (e.g. domestic violence, child abuse)

• Scurvy

• Masquerades

  • drugs—several (take drug history)

  • aplastic anaemia

Investigations

The initial choice of investigations depends upon the bleeding pattern.

If coagulation defect suspected:

• prothrombin time (PT), i.e. INR

• activated partial thromboplastin time (APTT)

• fibrinogen level

• thrombin time (TT)

If platelet pathology suspected:

• platelet count

• platelet function analyser (PFA-100)

If inherited disorders suspected:

• factor VIII (haemophilia A)

• von Willebrand factor activity

• von Willebrand factor antigen

The FBE and blood film is useful in pinpointing the aetiology. Other special tests such as von Willebrand screen and PFA-100 can be advised by the consultant. The bone marrow examination is useful to exclude the secondary causes of thrombocytopenia, such as leukaemia, other marrow infiltrations and aplastic anaemia.

Vascular disorders

Features

• easy bruising and bleeding into skin

• ± mucous membrane bleeding

• investigations normal

Simple purpura (easy bruising syndrome)

This is a benign disorder occurring in otherwise healthy women usu. in their twenties or thirties. The feature is bruising on the arms, leg and trunk with minor trauma. The patient may complain of heavy periods. Major challenges to the haemostatic mechanism such as dental extraction, childbirth and surgery have not been complicated by excessive blood loss.

Henoch–Schönlein (anaphylactoid) purpura

This is a palpable purpura due to small vessel vasculitis.

Clinical features

• All ages, mainly in children

• Usu. follows URTI inc. strep throat

• Rash mainly on buttocks and legs

• Can occur on hands, arms and trunk

• Arthritis: mainly ankles and knees

• Colicky abdominal pain (vasculitis of GIT)

• Haematuria (reflects nephritis and requires follow-up kidney function)

Prognosis is generally excellent. No specific therapy is available but corticosteroids may be helpful for abdominal pain.

Platelet disorders

Features

• petechiae ± ecchymoses

• bleeding from mucous membranes

• platelet counts <50 000/mm³ (50 × 10⁹/L), N: 150–400 × 10⁹/L

Immune thrombocytopenic purpura (ITP)

Two different types caused by immune destruction of platelets:

• acute ITP of children, often postviral; admit to hospital esp. if platelet count <30 × 10⁹/L or if active bleeding. Good prognosis—most self-limiting. Treat bleeding with immunoglobulin or steroids.

• chronic (adult type) ITP: autoimmune disorder; requires referral as may require steroids or a monoclonal antibody, even splenectomy

Coagulation disorders

Features

• ecchymoses

• haemarthrosis and muscle haematomas

• usu. traumatic and delayed

Von Willebrand disease is the most common haemostatic disorder— 1% pop. There is easy bruising, menorrhagia (♀) and ↑ bleeding with incisions, dental work and mucosal trauma. There is no specific treatment, but various preparations such as recombinant factor concentrates can be used. The inherited disorders such as haemophilia A and B are uncommon and involve deficiency of one factor only. The acquired disorders such as disseminated intravascular coagulation (DIC) occur more commonly and invariably affect several anticoagulation factors.

• Encourage patient to recognise and understand problem and work at overcoming it.

• Practise keeping teeth apart.

• Slowly munch an apple before retiring.

• Practise relaxation techniques, inc. meditation, before retiring (bruxism is related to stress).

• Place a hot face towel against the sides of the face before retiring to achieve relaxation.

• If this fails and bruxism is socially unacceptable during the night, use a mouthguard.

Anterior burning pain in forefoot—consider tarsal tunnel syndrome (usu. in menopausal women and worse at night), peripheral neuropathy (e.g. from diabetes), vascular insufficiency, Morton's neuroma or psychogenic causes.

Management depends on extent and depth (burns are classified as superficial or deep). Always consider pain relief.

Small burns should be immersed in cold water immediately (e.g. tap water) for 20 mins.

Chemical burns should be liberally irrigated with water. Apply 1 in 10 diluted vinegar to alkali burns and sodium bicarbonate solution to acid burns.

Refer the following burns to hospital:

• >10% surface area, esp. in a child

• all deep burns

• burns of difficult or vital areas (e.g. face, hands, perineum/genitalia, feet)

• burns with potential problems (e.g. electrical, chemical, circumferential)

Replacement fluids essential for severe burns (e.g. IV Hartmann's solution 2–4 mL/kg/%burn in first 24 h).

Treatment of superficial burns

Most scalds cause partial thickness (superficial) burns. If skin intact leave and apply mild antiseptic, e.g. use a fine mist water spray such as aqueous chlorhexidine. If blistering, apply hydrocolloid sheets or Fixomull, covered by an absorbent dressing. Then cleanse serous ooze from the adhesive material once or twice daily.

Exposure (open method)

• Keep open without dressings (good for face, perineum or single surface buns)

• Renew coating of antiseptic cream every 24 h

Dressings (closed method)

• Suitable for circumferential wounds

• Cover area with non-adherent tulle (e.g. paraffin gauze)

• Dress with an absorbent bulky layer of gauze and wool

• Use a plaster splint if nec.

Burns to hands

A first-aid method for superficial blistered burns to hands is to apply strips of retention adhesive dressings as described above. They conform well to digits.

Then apply a crepe bandage around the hand, leaving the fingers and thumb free so that the fingers can move freely in the bag. Consider placing the arm in a sling. At 7 days, soak the dressings in oil for 2 h before coming into the clinic for change of dressing.