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Dandruff (pityriasis capitis) is mainly a physiological process, the result of normal desquamation of scale from the scalp. It is most prevalent in adolescence and worst around the age of 20.

Treatment (if necessary)

Shampoos: zinc pyrithione (e.g. Dan-Gard, Head and Shoulders) or selenium sulfide (e.g. Selsun)

Method: massage into scalp, leave for 5 mins, rinse thoroughly twice wkly

Persistent dandruff

Persistent dandruff with severe flaking and itching indicates seborrhoeic dermatitis or psoriasis in which the scalp skin feels lumpy.

Treatment

Shampoos: coal tar + salicylic acid compound (Sebitar) shampoo or Ionil T plus shampoo

Method: as above, followed by Sebi Rinse or ketoconazole (Nizoral) shampoo

If persistent, esp. itching, and Nizoral shampoo ineffective, use a corticosteroid (e.g. betamethasone scalp lotion).

Deafness is defined as impairment of hearing, regardless of its severity. It is a major community health problem requiring a high index of suspicion for diagnosis, esp. in children. Deafness may be conductive, sensorineural (SND) or a combination of both (mixed).

• Deafness occurs at all ages but more common in the elderly—50% >80 yrs could be helped by a hearing aid.

• The threshold of normal hearing is from 0 to 20 dB, about the loudness of a soft whisper.

• Degrees of hearing impairment:

  • mild = loss of 20–40 dB (soft spoken voice is 20 dB)

  • moderate = loss of 40–60 dB (normal spoken voice is 40 dB)

  • severe = loss of 70–90 dB (loud spoken voice)

  • profound = loss of over 90 dB (shout)

• People who have worked in high noise levels (>85 dB) are more than twice as likely to be deaf.

• There is a related incidence of tinnitus with deafness.

Deafness in children

Deafness in childhood is relatively common and often goes unrecognised. A mother who believes that her child may be deaf is rarely wrong in this suspicion.

Screening

The aim of screening should be to recognise every deaf child by the age of 8–10 mths—before the vital time for learning speech is wasted.

Optimal screening times:

• 8–9 mths (or earlier)

• school entry

No child is too young for audiological assessment. Informal office tests are inadequate to exclude hearing loss.

Otosclerosis

Features

• A progressive disease

• Develops in the 20s and 30s

• Family history (autosomal dominant)

• Female preponderance

• Affects the footplate of the stapes

• Conductive hearing loss

• SND may be present

• Impedance audiometry shows characteristic features of conductive loss with a mild sensorineural loss

Management

• Stapedectomy (approx. 90% effective)

• Hearing aid (less effective alternative)

Noise-induced hearing loss

Features

• Onset of tinnitus after work in excessive noise

• Speech seems muffled soon after work

• Temporary loss initially but becomes permanent if noise exposure continues

• High-frequency loss on audiogram

Sounds exceeding 85 dB are potentially injurious to the cochlea, esp. with prolonged exposures. Common sources of injurious noise are industrial machinery, weapons and loud music.

Presbyacusis

• High frequency hearing loss of ↑ age

• A bilateral progressive SND

• Usually associated with tinnitus

• Intolerance to very loud sounds

• Difficulty picking up high frequency consonants (e.g. ‘f’ and ‘s’)

• Begin to speak loudly and may withdraw socially

Management

Referral for evaluation for an amplified hearing aid.

Hearing aids

Hearing aids are most useful in conductive deafness. This is due to the relative lack of distortion, making amplification simple. In SND the dual problem of recruitment and the hearing loss for higher frequencies may make hearing aids less satisfactory.

Wax impaction

• Occurs in at least 5% of normal population

• Common in nursing homes and institutions

• Often follows cotton-bud self-cleaning

• Mostly clears spontaneously

Methods of removal

• Direct removal with microforceps

• Gentle syringing with warm (body temperature) water or saline by a trained practitioner

• Consider ceruminolytic drops prior to syringing:

  • carbamide peroxide (Ear Clear)

  • docusate sodium (Waxsol)

  • hydrogen peroxide

  • sodium bicarbonate

Also oil based—olive oil, almond oil

Depressive illness, which is probably the greatest masquerade of general practice, is one of the commonest illnesses in medicine and is often confused with other illnesses.

Many episodes of depression are transient and should be regarded as normal but 10% of the population have significant depressive illness.

Major depression

DSM-5 diagnostic criteria for major depression

At least five of the following symptoms for 2 wks nearly every day (criterion 1 or 2 essential):

1. Depressed mood, subjective or objective (the essential feature)

2. Loss of interest or pleasure

3. Significant change in weight (5% over 1 mth) or change in appetite

4. Insomnia or hypersomnia (usually early-morning waking)

5. Psychomotor agitation or retardation

6. Fatigue or loss of energy

7. Feelings of worthlessness or excessive guilt

8. Impaired thinking or concentration; indecisiveness

9. Suicidal thoughts/thoughts of death or suicide

Minor depression

Minor depression is basically a condition where fluctuations of symptoms occur with some vague somatic symptoms and a transient lowering of mood that can respond to environmental influences. The diagnosis is based on a total of 2–4 symptoms from the above list, inc. 1 & 2. These patients usually respond in time to simple psychotherapy, reassurance and support.

Depression in the elderly

Depression can have bizarre features in the elderly and may be misdiagnosed as dementia or psychosis. Agitated depression is the most frequent type of depression in the aged. Features may include histrionic behaviour, delusions and disordered thinking.

Depression in children

Sadness is common in children but depression also occurs and is characterised by feelings of helplessness, worthlessness and despair. Parents and doctors both tend to be unaware of depression in children.

Major depression in children and adolescents may be diagnosed using the same criteria as for adults, namely loss of interest in usual activities and the presence of a sad or irritable mood, persisting for 2 wks or more.

Perinatal depression

Depression occurring in the antenatal period or in the 12 mths after delivery. See Postnatal depression

Management (adults)

Important considerations from the outset are:

• Is the patient a suicide risk?

• Does the patient require inpatient assessment?

• Is referral to a specialist psychiatrist indicated?

If the symptoms are major and the patient appears in poor health or is a suicide risk, referral is appropriate.

The basic treatments are:

• Psychotherapy, inc. education, reassurance and support. All patients require minor psychotherapy. More sophisticated techniques, such as cognitive behavioural therapy, can be used for selected patients. Cognitive therapy involves teaching patients new ways of positive thinking, which have to be relevant and achievable for the patient.

• Pharmacological agents (monotherapy is preferable)

• Electroconvulsive treatment

Note: Reassurance and support are needed for all depressed patients.

Useful guidelines

• Mild depression: psychotherapy alone may suffice but keep medication in mind

• Moderate to severe depression: psychotherapy plus antidepressants

• Severe to morbid depression: cease drugs, ECT then antidepressants

Recommended reading for patients

Rowe D. Depression: the Way out of Prison. Routledge and Kegan Paul, London, 1995.

Gordon Parker. Dealing with Depression. Allen & Unwin, Sydney, 2002.

Antidepressant medication

The initial choice of an antidepressant depends on the age and sex of the patient and the side-effect profile.

First-line therapy

The following are all first-line drugs, with the SSRIs and other newer agents being preferred.

1. Fluoxetine 20 mg (o) mane

   • This dose is usually sufficient for most patients.

   • If no response after 2–3 wks, ↑ by 20 mg at 2–3 wk intervals to 40–80 mg (o)/d in divided doses.

2. Sertraline or fluvoxamine, 50 mg (o)/d, starting dose: can increase up to 200 mg /d

3. Paroxetine or citalopram: 20 mg (o) mane; can increase by 10 mg/d every 2–3 wks to 60 mg/d

4. Escitalopram: 10 mg/d, up to 20 mg

All SSRIs can be increased every 14 days if necessary.

These new drugs have a similar efficacy profile to the tricyclics. There are definite differences between these SSRIs. They should not be used with MAOIs or the tricyclics.

Venlafaxine, desvenlafaxine, duloxetine. Recommended for major depression where other therapy is inappropriate.

Duloxetine is also recommended for diabetic peripheral neuropathic pain.

Mirtazapine: starting dosage 15 mg (o) nocte; average dose 30–45 mg to maximum 60 mg/d

Second-line therapy

Moclobemide 150 mg (o) bd

If no response after 2–3 wks, increase by 50 mg/d to max. 300 mg (o) bd.

• This is a reversible MAOI, which is less toxic than the irreversible MAOIs.

• It has minimal interaction with tyramine-containing foodstuffs, so that no dietary restrictions are necessary.

Reboxetine: adult dose 4 mg (o) bd, ↑ if required to 10 mg/d

1. Amitriptyline and imipramine

   • the first generation tricyclics

   • the most sedating: valuable if marked anxiety and insomnia

   • strongest anticholinergic side-effects (e.g. constipation, blurred vision, prostatism)

2. Nortriptyline, doxepin, dothiepin, clomipramine, trimipramine

   • less sedating and anticholinergic activity

   • nortriptyline is the least hypotensive of the tricyclics

Dosage: 50–75 mg (o) nocte, increasing every 2–3 d to 150 mg (o) nocte by day 7

If no response after 2–3 wks, increase by 25–50 mg/d at 2–3 wk intervals (depending on adverse effects) to 200–250 mg (o) nocte. Trial for 6 wks.

Mianserin 30–60 mg (o) nocte↑ to 60–120 mg (o) nocte by day 7

Notes about antidepressants

• There is no one ideal antidepressant.

• The SSRIs are now the first-line drugs of choice. Other first-line antidepressants are the SNRIs and mirtazapine.

• Tricyclics can be given once daily (usu. in the evening).

• There is a delay in onset of action 1–2 wks after a therapeutic dose (= 150 mg imipramine at least) is reached.

• Each drug should have a clinical trial at an adequate dose for at least 4–6 wks before treatment is changed.

• Swapping from one agent to another, inc. between SSRIs in those not responding, can be beneficial.

• Do not mix antidepressants.

• Consider referral if there is a failed (adequate) trial.

• Full recovery may take up to 6 wks or longer (in those who respond).

• Continue treatment at maintenance levels for at least 6–9 mths. There is a high risk of relapse. Lifelong treatment may be necessary.

• MAOIs are often the drugs of choice for neurotic depression or atypical depression.

Beware of the dangerous serotonin syndrome (agitation, nausea, headache, tremor, tachycardia, etc.) due to a toxic hyperserotonergic state when switching between antidepressants, esp. with SSRI use. In the treatment of depression, it is mainly due to an inadequate ‘washout period’—2 wks for most and 6 wks for fluoxetine.

It is usually caused by the combined use of two or more drugs that increase serotonin levels. These include the antidepressants, e.g. SSRIs and MAOIs, TCAs; selegiline, opioids and anti-emetics.

Electroconvulsive therapy (ECT)

ECT is safe, effective and rapidly acting. It is anticipated that the new generation treatment units will improve the management of major depression.

The usual course is 6–8 treatments over 3 wks. Tricyclic antidepressants can be used in combination with ECT and after ECT to prevent relapse.

Transcranial magnetic stimulation is an experimental procedure being evaluated as a less invasive alternative.

The terms ‘dermatitis’ and ‘eczema’ are synonymous and denote an inflammatory epidermal rash, acute or chronic, characterised by vesicles (acute stage), redness, weeping, oozing, crusting, scaling and itch.

Atopic dermatitis (eczema)

Criteria for diagnosis

• Itch

• Typical morphology and distribution

• Dry skin

• History of atopy

• Chronic relapsing dermatitis

Distribution

The typical distribution of atopic dermatitis changes as the patient grows older. In infants the rash appears typically on the cheeks of the face, the folds of the neck and scalp. It may then spread to the limbs and groin. The change from infancy to older children is presented in figures D2 and D3.

Treatment

Advice to parents of affected children:

• Avoid soap. Use a bland bath oil in the bath and a cleansing bar, e.g. Cetaphil, DermaVeen as a soap substitute.

• Older children should have short, tepid showers.

• Avoid rubbing and scratching—use gauze bandages with hand splints for infants.

• Avoid sudden changes of temperature.

• Wear light, soft, loose clothes, preferably made of cotton. Cotton clothing should be worn next to the skin.

• Avoid wool next to the skin.

• Avoid dusty conditions and sand, esp. sandpits.

• Avoid contact with people with ‘sores’, esp. herpes.

• Consider dust mite reduction strategies: premium grade dust mite covers for bedding, wash linen in hot water >55°C and consider replacing carpets and fabrics on furniture.

Medication

Mild atopic dermatitis

• Soap substitutes, such as a cleansing bar, e.g. Cetaphil, DermaVeen

• Emollients: apply twice daily to dry skin, choose from:

  • Ego skin cream

  • sorbolene alone or with 10% glycerol

  • QV cream (esp. winter) or lotion (summer only)

  • paraffin creams (e.g. Dermeze), esp. infants

  • bath oils (e.g. Alpha Keri, QV)

• 1% hydrocortisone (if not responding to above), once daily, increasing to twice daily if an inadequate response short term for flares of facial dermatitis

Moderate atopic dermatitis

• As for mild

• Topical corticosteroids (twice daily)

  • vital for active areas

  • moderate strength (e.g. fluorinated, to trunk and limbs) once or twice daily

  • weaker strength (e.g. 1% hydrocortisone, to face and flexures)

• Non-steroidal alternative is pimecrolimus cream, bd, use for flares of facial dermatitis then cease

• Oral antihistamines at night for itch

Severe dermatitis

• As for mild and moderate eczema

• Potent topical corticosteroids to worse areas (consider occlusive dressings)

• Consider hospitalisation

• Systemic corticosteroids (rarely used)

• Immunosuppressants may be used for severe recalcitrant disease

Weeping dermatitis (an acute phase)

This often has crusts due to exudate. Burow's solution diluted to 1:20 or 1:10 can be used to soak affected areas.

General points of dermatitis management

Acute weeping → wet dressings (saline or Burow's)

Acute, non-weeping → creams

Dry, scaly lesions → ointments, with or without occlusion

Lichenified → ointments under occlusion

Infection → antibiotics: topical, e.g. mupirocin 2%; if poor response → oral ABs

Moisturising → use lotions not creams

Other types of atopic dermatitis

Nummular (discoid) eczema

• Chronic, red, coin-shaped plaques

• Crusted, scaling and itchy

• Mainly on the legs, also buttocks and trunk

Treatment as for classic atopic dermatitis

Pityriasis alba

• These are white patches on the face of children and adolescents.

• Can occur on the neck and upper limbs, occasionally on trunk.

• Full repigmentation occurs eventually.

Treatment

• Reassurance

• Simple emollients

• Restrict use of soap and washing

• May prescribe hydrocortisone ointment (rarely necessary)

Lichen simplex chronicus

• Circumscribed thick plaques of lichenification

• Caused by repeated rubbing and scratching of previously normal skin

• Due to chronic itch of unknown cause

Treatment

• Explanation

• Refrain from scratching

• Potent fluorinated corticosteroid ointment with plastic occlusion or tar paste (e.g. liquor picis carbonis 4%, Lassar's paste to 100%)

Dyshydrotic dermatitis (pompholyx)

• Itching vesicles on fingers

• May be larger vesicles on palms and soles

• Commonly affects sides of digits and palms

• Often triggered by high humidity

Treatment

• Wet dressings/soaks if severe

• As for atopic dermatitis

• Potent fluorinated corticosteroids topically use under occlusion (e.g. damp cotton glove)

• Oral corticosteroids for 3 weeks may be necessary

Asteatotic dermatitis (‘winter itch’)

This is the common, often unrecognised, very itchy dermatitis that occurs in the elderly, with a dry ‘crazy paving’ pattern, esp. on the legs. It is a form of eczema that occurs in the elderly subjected to considerable scrubbing and bathing. Other predisposing factors include low humidity (winter, central heating) and diuretics.

Treatment

• Avoid scrubbing with soaps.

• Use aqueous cream and a soap substitute.

• Apply topical steroid diluted in white soft paraffin.

Dermatitis of hands

‘Cracked’ hands

The classic symptoms of uncontrolled diabetes are:

• polyuria (every hr or so)

• polydipsia

• loss of weight (type 1)

• tiredness and fatigue

• characteristic breath

• propensity for infections, esp. of the skin and genitals

Note: For every diagnosed diabetic there is at least one undiagnosed diabetic.

Diagnosis

• Fasting venous plasma glucose ≥7.0 mmol/L on two occasions

• Random venous plasma glucose ≥11.1 mmol/L on two occasions

• In asymptomatic or mildly symptomatic patients, the diagnosis is made on two separate elevated readings, either a fasting test or 2 or more hrs postprandial (or the 2 values from an oral glucose tolerance test).

If random or fasting VPG lies in uncertain range (6.0–11.0 mmol/L) in either a symptomatic patient or one with risk factors, perform an OGTT.

Management

The three key tasks:

1. Achieve strict glycaemic control (HbA1c ≤7%)

2. Achieve BP ≤130/80 mmHg (≤125/75 if proteinuria)

3. Achieve control of blood cholesterol: <4.0 mmol/L

Both type 1 (IDDM) and type 2 (NIDDM):

• patient education, reassurance and support

• consider diabetic educator, dietitian

• dietary control vital

• exercise also very important

• referral to ophthalmologist

• Goals of management (Table D2)

Diet

• Type 1 patients often require three meals and regular snacks each day.

• Type 2 patients usually require less food intake and restriction of total intake.

Principles of dietary management

• Keep to a regular nutritious diet (follow GI index foods)

• Achieve ideal body weight

• Reduce calories (kilojoules), i.e. added sugar, dietary fat

• Increase proportions of vegetables, fresh fruit, cereal foods

Type 1 diabetes mellitus

Preferred insulin regimens. (Fig. D4)

1. 4 injections per day (basal-bolus): short-acting or neutral (regular) insulin before each meal (breakfast, lunch and dinner) i.e. bolus with an intermediate or long-acting insulin at bedtime (basal)

2. 2 pre-mixed injections (biphasic) per day: ‘split and mix’ of short-acting and long-acting insulin (e.g. Mixtard or Humulin 30/70), twice daily before breakfast and before the evening meal (the most common)

3. 3 injections per day: short-acting insulin before breakfast and lunch and long-acting before evening meal (Fig. D5).

Shared care with an endocrinologist is recommended.

Type 2 diabetes mellitus

• First-line treatment (esp. if obese):

  • diet therapy

  • exercise program (aim for 20–30 mins/d)

Most symptoms improve dramatically within 1–4 wks on diet and exercise alone.

If unsatisfactory control persists after 3–6 mths, consider adding one of the oral hypoglycaemic agents usually starting with metformin (Table D3). These agents include insulin secretogagues such as sulfonylureas and glitinides, which increase insulin production, and insulin sensiters such as metformin and the glitazones, which reduce insulin resistance. If glycaemic targets are not achieved on monotherapy, common practice is to combine one from each class according to the step-up approach, e.g. metformin plus a sulfonylurea. (Figure D6.)

Step-up approach to management of type 2 diabetes

When oral hypoglycaemics fail (secondary failure), an injectable agent (insulin or GLP-1 agonist) can be added. Insulin may eventually be required in many.

Hypoglycaemia

Treatment of severe cases or patient unconscious

Treatment of choice: 20–50 mL, 50% dextrose IV (instil rectally using the nozzle of the syringe if IV access difficult) or

• Alternative: 1 mL, glucagon IM then oral glucose

• Admit to hospital if concerned (rarely necessary).

Diabetic ketoacidosis

This life-threatening emergency requires intensive management. It usually occurs during an illness (e.g. gastroenteritis) when insulin is omitted.

Management

• Arrange urgent hospital admission.

• Give 10 units rapid-acting neutral insulin IV.

• Commence IV infusion of normal saline.

Diarrhoea is defined as the frequent passage of loose or watery stools.

Essential features are:

• an increase in frequency of bowel action

• an increase in softness, fluidity or volume of stools

Probability diagnosis

Acute diarrhoea

Common causes are:

• gastroenteritis

  • bacterial

    • Salmonella sp.

    • Campylobacter jejuni

    • S. aureus (food poisoning)

    • Clostridium perfringens

    • enteropathic Escherichia coli

  • viral

    • rotavirus (50% of children hospital admissions)

    • norovirus

    • dietary indiscretions (e.g. binge eating)

    • antibiotic reactions

Chronic diarrhoea:

Irritable bowel syndrome was the commonest cause of chronic diarrhoea in a UK study.

Drug reactions, coeliac disease and chronic infections such as giardiasis and cryptosporidium are also important causes.

Diarrhoea: diagnostic strategy model

Probability diagnosis

• Acute:

  • gastroenteritis/infective enteritis

  • dietary indiscretion

  • antibiotic reaction

• Chronic:

  • irritable bowel syndrome (IBS)

  • drug reactions (e.g. laxatives)

  • chronic infections

Serious disorders not to be missed

• Neoplasia/cancer:

  • colorectal cancer

  • ovarian cancer

  • peritoneal cancer

• Infection:

  • cholera

  • typhoid/paratyphoid

  • amoebiasis

  • malaria

  • enterohaemorrhagic E. coli enteritis

  • HIV infection (AIDS)

Others:

• Inflammatory bowel disease:

  • Crohn/ulcerative colitis

  • pseudomembranous colitis

• Intussusception

• Pelvic appendicitis/pelvic abscess

Pitfalls (often missed)

• Coeliac disease

• Faecal impaction with spurious diarrhoea

• Lactase deficiency

• Giardia lamblia infection

• Cryptosporidium infection

• Malabsorption states (e.g. coeliac disease)

• Vitamin C and other oral drugs

• Nematode infections:

  • strongyloides (threadworm)

  • whipworm

  • hookworm

• Radiotherapy

• Diverticulitis

• Post-GIT surgery

• Ischaemic colitis (elderly)

Masquerades

• Drugs and hyperthyroidism

Key investigations

In some instances, such as acute self-limiting diarrhoea, nil is required. Consider:

• microscopy and culture of stool

• FBE

• ESR/CRP

• C. difficile tissue culture assay

• U&E

• specific tests for organisms

• endoscopy

• selective radiology (e.g. small bowel enema)

Diagnostic triads for diarrhoea

• Acute dia + colicky abdominal pain ± vomiting

  → gastroenteritis

• (Young adult) dia ± blood & mucus + abdominal cramps

  → inflammatory bowel disease (UC/Crohn)

• As above + constitutional symptoms ± eyes/joints

  → Crohn disease

• Pale bulky offensive stools, difficult to flush, weight loss

  → malabsorption

• Fatigue + weight loss + iron deficiency

  → coeliac disease

• Failure to thrive (child) + recurrent chest infections

  → cystic fibrosis

• Altered bowel habit –diarrhoea ± constipation ± rectal bleeding

  ± abdo discomfort → colorectal carcinoma

• Diarrhoea (fluid/incontinent) + constipation ++ + abdo discom + anorexia/nausea

  → faecal impaction

• Profuse watery dia. + abdo cramps (on antibiotics)

  → pseudomembranous colitis

• Variable dia/constipation + abdo discomfort + mucus PR

  + flatulence ++ → irritable bowel syndrome

Specific conditions

Pseudomembranous colitis (antibiotic-associated diarrhoea)

This colitis can be caused by the use of any antibiotic, esp. clindamycin, lincomydn, ampicillin, the cephalosporins (an exception is vancomycin) and even metronidazole. It is usually due to an overgrowth of Clostridium difficile, which produces a toxin that causes specific inflammatory lesions, sometimes with a pseudomembrane and is becoming resistant to antibiotics. It may occur, uncommonly, without antibiotic usage.

Features

• Profuse watery diarrhoea

• Abdominal cramping and tenesmus, maybe fever

• Within 2 d of taking antibiotic (can start up to 4–6 wks after usage)

• Persists 2 wks (up to 6) after ceasing antibiotic

Diagnosed by characteristic lesions on sigmoidoscopy and a tissue culture assay for C. difficile toxin.

Treatment

• Cease antibiotic

• Choice 1: metronidazole 400 mg (o) tds for 7–10 d or

• Choice 2: vancomycin 125 mg (o) qid for 10 d

Ischaemic colitis in the elderly

Due to atheromatous occlusion of mesenteric vessels. Clinical features include:

• sharp abdominal pain in an elderly patient with bloody diarrhoea or

• periumbilical pain and diarrhoea about 15–30 mins after eating

Diarrhoea in children

The two commonest causes are infective gastroenteritis and antibiotic-induced diarrhoea.

Acute gastroenteritis

Toddlers diarrhoea (‘cradle crap’)

• Infants with loose, bulky, non-smelly stool with fragments of undigested food in a well-thriving child, solid in morning, ‘runny’ in afternoon

• Onset usually between 8 and 20 mths

• Associated with high fructose intake (fruit juice diarrhoea)

• Diagnosis by exclusion

• Treatment is by dietary manipulation

Chronic diarrhoea in children

Sugar intolerance

Synonyms: carbohydrate intolerance, lactose intolerance.

The commonest offending sugar is lactose. Diarrhoea often follows acute gastroenteritis when milk is reintroduced into the diet. Stools may be watery, frothy, smell like vinegar and tend to excoriate the buttocks. They contain sugar. Investigation: lactose breath hydrogen testing.

Treatment

• Remove the offending sugar from the diet.

• Use milk preparations in which the lactose has been split to glucose and galactose by enzymes, or use soya protein.

Cow's milk protein intolerance

Not as common as lactose intolerance. Diarrhoea is related to taking a cow's milk formula and relieved when it is withdrawn. Replace with either soy, a hydrolysed or an elemental formula.

Inflammatory bowel disorder

These disorders, which include Crohn disease and ulcerative colitis, can occur in childhood.

Chronic enteric infection

Responsible organisms include Salmonella sp., Campylobacter, Yersinia, Giardia lamblia and Entamoeba histolytica. With persistent diarrhoea it is important to obtain microscopy of faeces and aerobic and anaerobic stool cultures. G. lamblia infestation is not an uncommon finding and can mimic coeliac disease.

Coeliac disease

Clinical features in childhood:

• usually presents at 9–18 mths, but any age

• previously thriving infant

• anorexia, lethargy, irritability

• failure to thrive

• malabsorption: abdominal distension

• offensive frequent stools

Diagnosis:

• characteristic duodenal biopsy—villous atrophy (gold standard test)

• IgA markers

• serum antigliadin (limited value), anti-endomysial and transglutaminase Abs—90% sensitivity and specificity

Treatment: remove gluten from diet

Note: Coeliac disease can occur at any age.

Classic triad: diarrhoea, weight loss, iron deficiency.

Cystic fibrosis

Cystic fibrosis is the commonest of all inherited disorders (1 per 2500 live births). Clinical features include:

• family history

• presents in infancy

• meconium ileus in the neonate

• recurrent chest infections (cough and wheeze)

• failure to thrive

• malabsorption

Diagnosis: can be diagnosed antenatally (in utero) neonatal screening—CFTR protein

Treatment: oral pancreatic enzyme replacement for malabsorption attention to respiratory problems

Acute gastroenteritis in adults

Features

• Invariably a self-limiting problem (1–3 d)

• Other meal sharers affected → food poisoning

• Consider dehydration, esp. in the elderly

• Consider possibility of enteric fever

Traveller's diarrhoea

Symptoms are usually as above but very severe diarrhoea, esp. if associated with blood or mucus, may be a feature of a more serious bowel infection such as amoebiasis. Most is caused by an E. coli, which produces a watery diarrhoea within 14 days of arrival in a foreign country ( See Traveller's diarrhoea).

It will respond to norfloxacin 400 mg (o) bd for 3 days.

Persistent traveller's diarrhoea

If there is a fever and blood or mucus in the stools, suspect amoebiasis. Giardiasis is characterised by abdominal cramps, flatulence and bubbly foul-smelling diarrhoea.

Principles of treatment (adults)

Acute diarrhoea

• Maintenance of hydration

• Antiemetic injection (for severe vomiting): prochlorperazine IM, statim or metoclopramide IV, statim

• Antidiarrhoeal preparations (avoid if possible: loperamide preferred)—loperamide (Imodium) 2 mg caps, 2 caps statim then 1 after each unformed stool (max. 8 caps/d)

Dietary advice to patient

Keep to a modest normal diet and drink good amounts of clear fluids such as water, tea, lemonade and yeast extract (e.g. Marmite) until the diarrhoea settles. Then eat low-fat foods, such as stewed apples, rice (boiled in water), soups, poultry, boiled potatoes, mashed vegetables, dry toast or bread, biscuits, most canned fruits, jam, honey, jelly, dried skim milk or condensed milk (reconstituted with water).

Avoid fatty foods, fried foods, spicy foods, raw vegetables, raw fruit (esp. with hard skins), Chinese food, wholegrain cereals and cigarette smoking.

Antimicrobial drugs

It is advisable not to use these except where the following specific organisms are identified. Use appropriate reduced doses for children.

Pseudomembranous colitis

Shigella dysentery (moderate to severe)

• Cotrimoxazole (DS) 1 tab (o) 12 hrly for 5 d or

• Norfloxacin 400 mg (o) 12 hrly for 5 d or ciprofloxacin

Campylobacter jejuni (if prolonged)

• Norfloxacin 400 mg (o) 12 hrly for 5 d or

• Azithromycin 500 mg (o) daily for 3 d

Salmonella enteritis

Antibiotics are not generally advisable but if severe or prolonged use ciprofloxacin 500 mg (o) bd or azithromycin for 2 wks. It is a notifiable disease.

Giardiasis

• Tinidazole 2 g (o), single dose (may need to be repeated) or

• Metronidazole 2 g (o) daily for 3 d

Amoebiasis (intestinal)

• Metronidazole 600 mg (o) tds for 7–10 d or tinidazole plus

• Paromomycin 500 mg (o) tds for 7 d (to prevent relapse)

Specialist advice should be sought.

Special enteric infections (treatment regimens)

Typhoid/paratyphoid fever

• Azithromycin 1 g (o) or IV until oral can be tolerated per d for 7 d or (if not acquired in Indian subcontinent)

• Ciprofloxacin 500 mg (o) 12 hrly for 7–10 d

Cholera

Antibiotic therapy reduces the volume and duration of diarrhoea but rehydration is the key factor.

• Azithromycin 1 g (child 20 mg/kg) (o) as single dose or

• Ciprofloxacin 1 g (child 25 mg/kg up to 1 g) (o) as single dose

Inflammatory bowel disease

Inflammatory bowel disease should be considered when a young person presents with:

• bloody diarrhoea and mucus

• colonic pain and fever

• extra-abdominal manifestations such as arthralgia, low back pain (spondyloarthropathy), eye problems (iridocyclitis)

Two important diseases are ulcerative colitis and Crohn disease, which have equal sex incidence and can occur at any age, but onset peaks at 20–40 yrs.

The main symptom of ulcerative colitis is bloody diarrhoea and of Crohn disease is colicky abdominal pain.

Management principles for both diseases

• Treat under consultant supervision.

• Treatment of acute attacks depends on severity of the attack and the extent of the disease:

  • mild attacks: manage out of hospital

  • severe attacks: hospital, to attend to fluid and electrolyte balance

• Pharmaceutical agents (the following can be considered):

  • 5-aminosalicylic acid derivatives (mainly UC)

    • sulfasalazine (mainstay) 1–2 g (o) 2–4 times/d

    • olsalazine; mesalazine

  • corticosteroids

    • oral

    • parenteral

    • topical (rectal foam, suppositories or enemas)

  • immunosuppressive drugs (e.g. azathioprine, cyclosporin (acute UC), methotrexate and infliximab (Crohn)

• Surgical treatment: reserve for complications only.

‘It is the patients who have the problems while doctors have the difficulties.’ Four of the more common types of difficult ‘heartsink’ patients are: dependent clingers, entitled demanders, manipulative help rejectors and self-destructive deniers.

Adhere to the principles of good communication and consulting skills, esp. the art of listening, rapport building, diplomatic confrontation, facilitation and searching. Seek the reason for the behaviour and become familiar with the characteristics of personality disorders, esp. the antisocial (sociopathic) group (e.g. impulsive ‘mad dog’, borderline ‘hell raiser’, narcissistic ‘prima-donna’).

Guidelines for handling the angry patient

The onset of double vision in adults can be uniocular (confined to one eye) or binocular, usually due to extraocular muscular imbalance or weakness.

Examples of:

• uniocular diplopia: early cataract, dislocated lens, psychogenic (rare)

• binocular diplopia: ocular nerve palsies (3, 4 or 6) (e.g. CVA, TIA, diabetes, trauma, multiple sclerosis) (Fig. D7)

Test for diplopia with each eye occluded—if it persists it is uniocular, if it disappears it is binocular. Refer urgently if binocular, if recent onset and persistent.

Cranial nerves in general (with function)

1. Olfactory nerve—sensory for smell

2. Optic nerve—sensory for vision

3. Oculomotor—3 eye movements, eyelid closure, pupil constriction

4. Trochlear—down and in eye movement

5. Trigeminal—mastication, facial sensation

6. Abducens—abduction of eye

7. Facial nerve—motor for eye closure and facial muscles, taste anterior ⅔ tongue

8. Acoustic nerve—sensory for hearing and balance

9. Glossopharyngeal—motor to palate and pharynx, sensory to pharynx and taste posterior ⅓ tongue

10. Vagus—motor to palate, pharynx, larynx, sensory to pharynx and larynx (gag reflex)

11. Accessory—motor to trapezius and sternomastoid muscles

12. Hypoglossal—motor for tongue movement

Key facts

• Depression affects 15% of people >65 and can mimic or complicate any other illness, inc. delirium and dementia.

• Elderly patients with depression are at a high risk of suicide.

• Always consider the 4Ds:

  • dementia

  • delirium (look for cause)

  • depression (maybe ‘pseudodementia’ in elderly)

  • drugs

    • toxicity

    • withdrawal

Dementia (chronic organic brain syndrome)

There is no known cure for dementia—tender loving care is important. Assess with the mental state examination (Appendix 2).

Drugs available for Alzheimer disease

Cholinesterase inhibitors:

• donepezil 5 mg (o) nocte 4 wks, ↑ 10 mg nocte or

• galantamine 4 mg (o) bd 4 wks, ↑ 8 mg bd or

• rivastigmine 1.5 mg (o) bd 2 wks, ↑ 6 mg bd

Asparate (NMDA antagonist):

• memantine 5 mg (o) mane 1 wk, ↑ 5 mg bd wk 2, ↑ 10 mg bd

Psychotropic medication is often not required.

To control psychotic symptoms or disturbed behaviour:

• risperidone 0.5–2 mg (o)/d or olanzapine 5–10 mg (o)/d

To control symptoms of anxiety and agitation:

• oxazepam 15 mg (o) 1–4 times/d (short-term use)

Antidepressants for depression.

The acutely disturbed patient

Approach to management

• React calmly.

• Try to control the disturbed patient gently.

• Ensure the safety of all staff.

• An adequate number of staff to accompany the doctor is essential—six is ideal (one for immobilisation of each limb, one for the head and one to assist with drugs).

• Benzodiazepines usually the drug of first choice for tranquillisation. Oral preferred if possible but parenteral most practical.

Treatment options

Oral: diazepam 5–20 mg (o), rpt 2–6 hrly or lorazepam 1–2 mg (o), rpt 2–6 hrly; add olanzapine 5–10 mg or risperidone 0.5–1 mg if nec.

Parenteral: diazepam or midazolam 2.5–5 mg increments IV, repeated every 3–4 mins until required level of sedation reached (max 20–30 mg) or if IM route best

• droperidol (Droleptan) 5–10 mg IM (probably best) or

• olanzapine 5–10 mg (o) up to 30 mg/d (watch for possible laryngeal dystonia and treat with benztropine 2 mg IM) or

• midazolam (Hypnovel) 2.5–10 mg IM as single dose

• then search for the cause and/or refer accordingly

Delirium (acute organic brain syndrome)

DSM-5 criteria for diagnosis of delirium

1. Disturbance of consciousness and awareness

2. Clinical features appearing over a short period

3. A change in cognition:

   • perceptual disturbance

   • incoherent speech

   • disorientation

   • memory impairment

4. A & C not explained by another disorder

5. Evidence of a cause

Treatment principles

• Acute delirium is a medical emergency.

• Establish normal hydration, electrolyte balance and nutrition.

Medication

Medication may not be needed but will be in the presence of anxiety, aggression or psychotic symptoms. (Doses for a fit adult.)

For anxiety and agitation:

• midazolam 1.25–5 mg IM

For psychotic behaviour (delusions or hallucinations):

• haloperidol 0.5 mg (o) as a single dose or

• olanzapine 2.5–10 mg (o) daily in 1 or 2 doses

For severe symptoms, when parenteral medication required:

• haloperidol 0.5 mg (IM) as single dose or

• olanzapine 2.5 mg (IM) as single dose (more sedating)

Oxygen if hypoxic

For anticholinergic delirium:

• tacrine hydrochloride 15–30 mg with caution by slow IV injection (an antidote)

The acute psychotic patient

Schizophrenia: DSM-5 key diagnostic criteria

1. 2 or more of the following—each present for a significant portion of time during a 1 month period:

   1. delusions

   2. hallucinations

   3. disorganised speech (at least one of these first three)

   4. grossly disorganised or catatonic behaviour

   5. negative symptoms, e.g. flat effect

2. social, learning or occupational dysfunction

3. continuous sign of disturbance at least 6 mths

4. no evidence of other psychoses, e.g. bipolar

5. not attributable to other disorders

Remember explanation and support to family and patient.

Treatment of acute phase of psychosis

(schizophrenia and related psychoses)

• Hospitalisation usually necessary

• Drug treatment for the psychosis

1. When oral medication possible, first-line treatment is one of the second generation (atypical) antipsychotics:

   • olanzapine 5–10 mg (o) nocte or

   • risperidone 1 mg (o) nocte titrated gradually to 2–4 mg (o) bd (beware hypotension) or

   • quetiapine 50 mg (o) bd ↑ as tolerated to 200 mg bd (by day 5) or other

   Note: First generation (typical) antipsychotics include haloperidol and chlorpromazine.

2. When parenteral medication required:

   • haloperidol 2.5–10 mg IV or IM, initially, ↑ 20 mg in 24 h, depending on response or

   • zuclopenthixol acetate 50–150 mg IM as a single dose add

   • benztropine 1–2 mg (o) bd (to avoid dystonic reaction)

If dystonic reaction:

• benztropine 1–2 mg IV or IM

If very agitated:

• diazepam 5–20 mg (o) or 5–10 mg IV

Chronic phase of schizophrenia

Long-term antipsychotic medication recommended to prevent relapse.

Examples of oral medication regimens:

• olanzapine 10–20 mg (o) nocte or

• quetiapine 150 mg (o) bd or

• risperidone 0.5–1 mg (o) bd, up to 2–4 mg (o) bd

Use depot preparations if compliance is a problem (use test dose first):

• fluphenazine decanoate 12.5–50 mg IM, every 2–4 wks or

• haloperidol decanoate 50–200 mg IM, every 4 wks or

• flupenthixol decanoate 20–40 mg IM, every 2–4 wks or

• zuclopenthixol deconate 100–400 mg IM every 2–4 wks

Resistant schizophrenia (options)

• clozapine 12.5 mg (o) bd initially increasing up to 300–600 mg/d

• olanzapine 5–20 mg (o)/d

Bipolar disorder

‘Bipolar’ is a broad term for a recurrent illness with episodes of either mania or depression with return to normal function inbetween.

DSM-5 criteria for a manic episode

1. Distinct period for at least 1 wk of abnormal and persistent elevated, expansive or irritable mood

2. Three or more of these unusual features:

   1. inflated self-esteem or grandiosity

   2. decreased need for sleep

   3. talkative/accelerated speech

   4. racing thoughts or flights of ideas

   5. distractability—as reported or observed

   6. increased goal-directed activity or psychomotor agitation

   7. excessive activity with ‘painful’ consequences

3. Marked impaired social or occupational functioning or need for hospitalisation or psychotic features

4. Episode not due to substance abuse or other medical condition

Management of acute mania

Hospitalisation

• For protection of patient and family

• Usually involuntary admission necessary

• A recent meta-analysis indicates that antipsychotics are the most efficacious drugs.

Drugs of choice

First-line:

• olanzapine 5 mg (ο) nocte initially

  or

• risperidone 0.5–1 mg (ο) nocte initially

Second-line:

• haloperidol or other antipsychotic

  or (a mood stabiliser agent)

• lithium carbonate 750–1000 mg (ο) daily in 2 or 3 divided doses increasing according to serum levels

  or

• sodium valproate 200–400 mg (ο) bd initially

  or

• carbamazepine 100–200 mg (ο) bd initially

If parenteral antipsychotic drug required: haloperidol 5–10 mg IM or IV

• Repeat in 15–30 mins if necessary (Risk of tardive dyskinesia)

• Change to oral medication as soon as possible.

Oral diazepam will complement haloperidol.

If not responding to medication consider ECT.

Maintenance/prophylaxis for recurrent bipolar disorder

• Lithium carbonate 125–500 mg (ο) bd then adjusted—continue for 6 mths

  or

• Second-generation antipsychotics eg. olanzapine 5 mg (ο) nocte or (if depression prominent)

• Lamotrigine or carbamazine or sodium valproate

• Lithium + sodium valproate effective for rapid cycling illness (4 or more episodes per yr)

Management of bipolar depression

• The mood stabilisers may have a bimodal (antidepressant and antimania effect) but add an antidepressant (e.g. SSRI, SNRI or MAOI).

• Withdraw antidepressant within 1–2 months because tend to precipitate mania. ECT is a proven effective treatment.

Diverticular disease is a problem of the colon (90% in descending colon) and is related to lack of fibre in the diet. It is usually symptomless.

Clinical features

• Typical in middle aged or elderly >40 yrs

• Diverticulosis—symptomless

• Diverticulitis—infected diverticula and symptomatic constipation or alternating constipation/diarrhoea

  • intermittent cramping lower abdominal pain in LIF

  • tenderness in LIF

  • rectal bleeding may be profuse (± faeces)

  • may present as acute abdomen or subacute obstruction

  • usually settles in 2–3 d

Investigations

• WBC and ESR—to determine inflammation

• Sigmoidoscopy

• Barium enema

• US/CT scan (acute disease)

Management

High fibre diet

Symptomatic

• Fibre supplements

• Antispasmodics

Diverticulitis (mild)

Amoxycillin + clavulanate 875 mg (o) bd, 5–10 d

Diverticulitis (complicated)

• Nil orally, IV fluids, analgesics

• Antibiotics

• (Amoxy) ampicillin IV + gentamicin IV + metronidazole IV

The term ‘dizziness’ is generally used collectively to describe all types of equilibrium disorders and, for convenience, can be classified as shown in Fig. D9.

Vertigo

Vertigo is defined as an episodic sudden sensation of circular motion of the body or of its surroundings or an illusion of motion (a rotatory sensation).

Giddiness

Giddiness is a sensation of uncertainty or ill-defined lightheadedness. It is a typical psychoneurotic symptom.

Syncopal episodes

Syncope may present as a variety of dizziness or lightheadedness in which there is a sensation of impending fainting or loss of consciousness. Common causes are cardiogenic disorders and postural hypotension, which are usually drug-induced.

Disequilibrium

Disequilibrium implies a condition in which there is a loss of balance or instability while walking, without any associated sensations of spinning. It is often described as ‘like standing on a rocking boat’ where the feeling underneath the feet is unsteady.

Specific causes of dizziness

Drugs

Drugs usually affect the vestibular nerve rather than the labyrinth. The causes, which are numerous, include antibiotics esp. the mycins and tetracyclines, anticonvulsants, cardiogenic drugs and salicylates.

Cervical spine dysfunction

It is not uncommon to observe vertigo in patients with cervical spondylosis or post-cervical spinal injury. It has been postulated that this may be caused by the generation of abnormal impulses from proprioceptors in the upper cervical spine. Some instances of benign positional vertigo are associated with disorders of the cervical spine.

Acute vestibulopathy (vestibular failure)

This term covers both vestibular neuritis and labyrinthitis, which are considered to be a viral infection of the vestibular nerve and labyrinth respectively, causing a prolonged attack of vertigo that can last for several days. It is also caused by a stroke of the inferior cerebellar arteries.

Main features

• Often follows a ‘flu-like’ illness

• Mainly affects young adults and middle age

• Generally lasts days to weeks

• Nausea and vomiting

• No hearing loss or tinnitus

• Horizontal nystagmus (in acute phase)

Treatment

• Rest in bed, lying very still.

• Gaze in the direction that eases symptoms.

• Drugs to lessen vertigo.

The following drugs can be used:

• promethazine 10–25 mg IM or IV (slow) then 10–25 mg (ο) for 48 hrs or

• prochlorperazine (Stemetil) 12.5 mg IM (if severe vomiting) or (recommended)

• diazepam (which decreases brain-stem response to vestibular stimuli) 5–10 mg IM for the acute severe attack then 5 mg (o) tds for 3 days. Also a short course of corticosteroids can promote recovery, e.g. prednisolone 1 mg/kg (up to 100 mg) ο mane for 5 d then taper over 15 d.

Outcome

Both are self-limiting disorders and usually settle over several days (e.g. 5–7) or weeks. Labyrinthitis usually lasts longer and during recovery rapid head movements may bring on transient vertigo.

Benign paroxysmal positional vertigo

This is a common type of vertigo that is induced by changing head position—particularly tilting the head backwards, changing from a recumbent to a sitting position or turning to the affected side.

Clinical features

• Affects all ages, esp. elderly

• Recurs periodically for several days

• Each attack is brief, usually 10–60 secs, and subsides rapidly

• Attacks not accompanied by vomiting, tinnitus or deafness

• Cause is probably floating tiny fragments in labyrinth

• Diagnosis confirmed by head position testing

• Tests of hearing and vestibular function normal

• Usually spontaneous recovery in wks (most return to regular activity after 1 wk)

Management

• Appropriate explanation and reassurance

• Avoidance measures: the patient quickly begins to move in a certain way and avoids attacks of vertigo

• Drugs not recommended

• Special exercises (e.g. Cawthorne–Cooksie exercises)

• Particle repositioning manoeuvres, e.g. Epley, Semont, by doctor

• Cervical traction may help

Ménière syndrome

• Commonest in 30–50 age group

• Characterised by paroxysmal attacks of:

  • vertigo

  • tinnitus

  • nausea and vomiting

  • sweating and pallor

  • deafness (progressive)

• Abrupt onset—patient may fall

• Head movements avoided—often bedridden

• Attacks last 30 mins to several hours

• Nystagmus observed only during an attack

• Examination:

  • sensorineural deafness

  • caloric test-impaired vestibular function

  • audiometry

    • Sensorineural deafness

    • Loudness recruitment

Note: Tends to be overdiagnosed.

Treatment (acute attack)

IV diazepam 5 mg or IM prochlorperazine 12.5 mg. Many use these drugs in combination.

Treatment (long term)

• Reassurance with a very careful explanation of this condition to the patient who often associates it with malignant disease

• Avoid excessive intake of salt (especially), tobacco and coffee

• Alleviate anxiety by using long-term sedation

• Referral for a neurological assessment

• Diuretic (e.g. Hygroton, Moduretic)

• Consider betahistadine (Serc) 8 mg (o) 8 hrly to prevent attacks

Surgery may be an option for intractable cases.

Vestibular migraine (migrainous vertigo)

Migraine is a relatively common and unrecognised cause of vertigo. Suspect if family history and history of vertigo for hours or days without aural symptoms. Pizotifen or propranolol used for prophylaxis.

Recurrent vestibulopathy

• Episodic vertigo ± vomiting of similar duration to Meniere

• No hearing loss, tinnitus or focal neurological signs

• Peak age 30–50 yrs, M = F

• Aetiology unknown—possibly migraine variant

Treatment is symptomatic.

Dizzy turns in elderly women

If no cause such as hypertension is found, advise them to get up slowly from sitting or lying and to wear firm elastic stockings.

Dizzy turns in girls in late teens

• Common due to blood pressure fluctuations

• Give advice related to stress, lack of sleep or excessive activity

• Reassure that it settles with age (rare after 25 yrs)

Domestic or intimate partner violence is defined by the WHO as ‘any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship’. However, the abuse can be of an elderly parent by the children or from some other member of the household to another member.

A major problem in dealing with domestic violence is that it is hidden and the victims are reluctant to divulge the cause of their injuries when visiting medical practitioners.

Possible presentations

One study defines a 3-stage sequence to the battering syndrome:

• Stage 1: woman presents with injuries in the central anterior regions of the body (face, head & torso).

• Stage 2: multiple visits to clinics, often with vague complaints.

• Stage 3: development of psychological sequelae (alcohol, drug addiction, suicide attempts, depression).

Cycle of violence

A predictable pattern that is referred to as the ‘cycle of violence’ has been identified in many marriages. It is controlled by the perpetrator while the victim feels confused and helpless. The cycle repeats itself with a tendency for the violence to increase in severity (see Fig. D10).

Management

The key to successful management is initial recognition of the problem and establishment of empathetic caring and support for the victim and family. As with an alcohol problem, the person has to admit that they have a problem before effective counselling can begin. A management strategy is presented in Fig. D11.

Suggested safety plan for an abusive incident:

• Call emergency, e.g. 000.

• Be aware of all exit routes and safety areas.

• Safely exit the house.

• Seek help and a refuge.

• Ask neighbours to call police if they hear a disturbance.

See Table D5.

• Don't shampoo every day.

• Use a mild shampoo (labelled for ‘dry or damaged hair’).

• Use a conditioner.

• Snip off the split or frayed ends.

• Avoid heat (e.g. electric curlers, hair dryers).

• Wear head protection in hot wind.

• Wear a rubber cap when swimming.

Dry mouth (xerostomia) is a symptom rather than a disease affecting 10% of the population.

Features include a burning sensation, a decrease in taste or a bad taste and fetid breath.

The commonest primary cause is salivary gland atrophy due to ageing. Secondary causes are drugs (very common), depression, anxiety, thirst, dehydration and anaemia.

Treatment

• Treat identifiable cause

• Meticulous oral hygiene

• Regular dental checks

• Sip sugarless fluids often

• Chew sugarless gum

• Use a saliva substitute (e.g. Saliva Orthana, Aquae) or frequent mouthwashes (e.g. lemon and glycerin 5–10 mL in 100 mL water)

• Use sodium fluoride 0.5% mouthwash for 5 mins each day

• Topical applications of glycerin or paraffin oil to the lips

Note: Dry eyes + dry mouth + arthritis → Sjögren syndrome.

Disorders associated with scaling and roughness of the skin include:

• atopic dermatitis—all types (e.g. pityriasis alba, nummular eczema, asteatotic dermatitis)

• ageing skin

• psoriasis

• ichthyotic disorders

• keratosis pilaris

Management

• Reduce bathing and frequency and duration of showering.

• Bathe and shower in tepid water.

• Use a soap substitute (e.g. Dove, Neutrogena or Cetaphil lotion or aqueous cream).

• Rub in baby oil after patting dry.

• Avoid wool next to skin (e.g. wear cotton).

• Use emollients (e.g. Alpha Keri lotion, Nutra D cream, QV cream).

• Use moisturisers with 10% urea (e.g. Calmurid, Dermadrate, Nutraplus, Aquacare HP).

• Use dilute corticosteroid ointment if resistant local patches.

• Advise a good diet and drink plenty of water.

Established facts

• Major risk factors for CAD include:

  • ↑ LDL cholesterol + ↓ HDL cholesterol

  • ratio LDLC/HDLC >4

• Risk increases with increasing total cholesterol (TC) levels (90% if >7.8 mmol/L)

• TG levels >10 mmol/L increases risk of pancreatitis

• Management should be correlated with risk factors

• 10% reduction in total cholesterol gives 20% ↓ in CAD after 3 yrs

Investigations

• Serum triglyceride

• Serum cholesterol and HDLC and LDLC if ≥5.5 mmol/L

• TFTs if overweight elderly female

Non-pharmacological measures

• Dietary measures:

  • Keep to ideal weight.

  • Reduce fat intake, esp. dairy products and meat.

  • Avoid ‘fast’ foods and deep-fried foods.

  • Replace saturated fats with mono- or polyunsaturated fats.

  • Always trim fat off meat, remove skin from chicken.

  • Avoid biscuits and cakes between meals.

  • Eat fish at least twice a week.

  • Ensure a high-fibre diet, esp. fruit and vegetables.

  • Keep alcohol intake to 0–2 standard drinks/d.

  • Drink more water.

  • Use approved cooking methods, e.g. steaming, grilling.

• Regular exercise

• Cessation of smoking

• Cooperation of family is essential

• Exclude secondary causes (e.g. hypothyroidism, type 2 diabetes, nephrotic syndrome, obesity, alcohol excess, esp. ↑ TG, specific diuretics)

Checkpoints

• Diet therapy effective (TG ↓, LDLC ↓) within 6–8 wks

• Continue at least 6 mths before consider drug therapy

• HRT beneficial in women (LDLC ↓, HDLC ↑)

Pharmacological measures

Use these agents in addition to diet.

Hypercholesterolaemia

Treatment should start with a statin esp. if ↑ LDLC.

Options: Choose one of the following:

• HMG CoA reductase inhibitors (‘statins’): first line

  • simvastatin or pravastatin or atorvastatin 10 mg (o) nocte, ↑ to max. 40–80 mg/d or

  • fluvastatin 20 mg (o) nocte, increase to max. 80 mg/d or

  • rosuvastatin 10–40 mg/d

Adverse effects: GIT side-effects, myalgia, abnormal liver function

Monitor: Measure LFTs (ALT and CPK) and CK as baseline

Repeat LFTs after 4–8 wks, then every 6 wks for 6 mths

If LDLC target levels not reached on a maximally tolerated statin dose, add one of ezetimibe, bile acid binding resin or nicotinic acid.

• Ezetimibe: 10 mg/d

Adverse effects: arthralgia, myalgia, myositis, liver dysfunction

• Bile acid binding resins, e.g. cholestyramine 4 g/d in fruit juice increasing to max. tolerated dose

Adverse effects: GIT side-effects (e.g. constipation, offensive wind)

Other agents

• Nicotinic acid 250 mg (o) bd with food daily increase to max. 1000 mg tds

Adverse effects: flushing, gastric irritation, gout

Minimise with gradual introduction, take with food and aspirin cover

• Fish oils (n-3 fatty acids): 6 g/d

Resistant LDLC elevation

Combined ‘statin’ and resin, e.g. cholestyramine 4–8 g (o) mane + a ‘statin’ to maximum dose or

Combined ezetimibe + statin

Moderate to severe (isolated) TG elevation

• Gemfibrozil 600 mg (o) bd or

• Fenofibrate 145 mg (o)/d

Note: Slow response monitor LFTs predisposes to gallstones and myopathy

Alternatives: nicotinic acid or n-3 fish oil concentrate 6 g (o) daily in divided doses to max. 15 g/d

Note: Reduction in alcohol intake is essential.

Management

• Provide full explanation and appropriate reassurance.

• Promote a healthy lifestyle: regular exercise; avoid smoking and excessive alcohol.

• Recommend relaxation techniques such as yoga.

• Avoid exposure to extreme cold.

• Place a hot water bottle over the painful area and curl the knees onto the chest.

Medication

Options include (trying in order):

• simple analgesics (e.g. aspirin or paracetamol)

• prostaglandin inhibitors (e.g. mefenamic acid, 500 mg tds at first suggestion of pain, if simple analgesics ineffective)

• NSAIDs (e.g. naproxen, 500 mg statim then 250 mg tds or ibuprofen) in the first 3 d of the period

• combined oral contraceptive (low-oestrogen triphasic pills preferable)

• progestogen medicated IUD (Mirena)

Painful intercourse can be considered as superficial (pain felt on insertion) or deep (pain on deep penetration).

Causes of superficial dyspareunia:

• physiological—inadequate lubrication

• provoked vestibulodynia syndrome (vestibular hypersensitivity)

• vaginitis, esp. chronic candidiasis

• vulvar dermatoses

• postnatal perineal scarring

• vulvovaginal atrophy

• incompletely ruptured hymen

• urethritis

• vaginismus

Causes of deep dyspareunia:

• endometriosis

• PID

• pelvic adhesions

• ovarian and uterine tumours

• retroverted uterus

• post natal

Management involves treating the organic cause and advice about use of lubricants, oestrogen creams and perhaps lignocaine gel.

Dyspepsia is pain or discomfort centred at the upper abdomen which is chronic or recurrent in nature.

Heartburn is a central retrosternal or epigastric burning sensation that spreads upwards to the throat.

Dyspepsia in children

Dyspepsia is an uncommon problem in children but can be caused by drugs, oesophageal disorders and gastro-oesophageal reflux in particular. It tends to be overdiagnosed and overtreated.

Gastro-oesophageal reflux

Prognosis

Reflux gradually improves with time and usually ceases soon after solids are introduced into the diet. Most cases clear up completely by the age of 9 or 10 months, when the baby is sitting. Severe cases tend to persist until 18 months.

Investigations

These are not necessary in most cases, but in those with persistent problems or complications referral to a paediatrician is recommended.

Management

• Provide appropriate reassurance with parental education.

• Changes in feeding practice and positioning will control most reflux.

• Place infant on left side for sleeping (prop up head of cot with bricks or boards to elevate it ∼10–20 degrees).

• Give smaller, more frequent feeds.

• Thicken feeds (e.g. expressed milk) with Carobel, infant Gaviscon powder, cornflour or Karicare.

• Medication not usually indicated but if persistent and complications such as painful oesophagitis use gastric acid reducing agent e.g. ranitidine or PPI e.g. omeprazole.

Dyspepsia in adults

Gastro-oesophageal reflux disease (GORD)

Features

• Heartburn

• Acid regurgitation, esp. lying down at night

• Water brash

• Diagnosis usually made on history

• Investigation usually not needed (reserve for danger signs and non-responsive treatment)—gastroscopy is the investigation of choice

• Consider barium swallow/meal and 24 hr ambulatory oesophageal pH monitoring

Management

Stage 1

• Patient education/appropriate reassurance

• Consider acid suppression or neutralisation

• Attend to lifestyle, inc. stress management:

  • weight reduction if overweight (this alone may abolish symptoms)

  • reduction or cessation of smoking

  • reduction or cessation of alcohol (esp. with dinner)

  • avoid fatty foods (e.g. pastries)

  • reduction or cessation of coffee, tea and chocolate

  • avoid coffee and alcohol late at night

  • avoid gaseous drinks

  • leave at least 3 h between evening meal and retiring

  • have main meal at midday with light evening meal

  • avoid spicy foods and tomato products

• Antacids:

  • best is liquid alginate/antacid mixture e.g. Gaviscon/Mylanta plus 20 mL, on demand or 1½–2 h before meals and bedtime

• Elevation of head of bed or wedge pillow:

  • If GORD occurs in bed, sleep with head of bed elevated 20–30 cm on wooden blocks or wedge pillow (preferable).

Stage 2

• Use PPIs (preferable) or H₂-receptor antagonists.

Reduce acid secretion (select from):

H₂-receptor antagonists (oral use for 8 wks)

• ranitidine 150 mg bd pc or 300 mg nocte or

• famotidine 20 mg bd or

• nizatadine 150 mg bd

PPI for 4 wks (very effective for ulcerative oesophagitis and reflux) (select from):

• omeprazole 20 mg mane or

• lansoprazole 30 mg mane or

• pantoprazole 40 mg mane or

• esomeprazole 20 mg mane or

• rabeprazole 20 mg mane

Note: May need to eradicate Helicobacter pylori if present.

Functional (non-ulcer) dyspepsia

This term applies to the 60% of patients presenting with dyspepsia in which there is discomfort on eating in the absence of demonstrable organic disease and can be considered in two categories:

• ulcer-like dyspepsia or

• dysmotility-like dyspepsia

Ulcer-like

Treat as for GORD but with a preference for a 4-wk trial of H₂-antagonists and cease if symptoms resolve.

Dysmotility-like dyspepsia

Features of dysmotility

• Discomfort with early sense of fullness on eating

• Nausea

• Overweight

• Emotional stress

• Poor diet (e.g. fatty foods)

• Similar lifestyle to GORD

Management

Treat as for GORD (Stage 1). Include antacids. If not responsive:

Step 1

H₂-receptor antagonists.

Step 2

Prokinetic agents: domperidone 10 mg tds or metoclopramide 10 mg tds

Peptic ulcer disease

• The two main causes are NSAIDs and H. pylori.

• Diagnose H. pylori with ¹⁴C urea breath test or serology or gastric mucosa biopsy on gastroscopy.

Use same treatment as for GORD, i.e.:

Stage 1

• General measures

• Antacids—for symptomatic relief of mild intermittent or breakthrough symptoms

Stage 2

• PPI—provide more rapid healing or

• H₂-receptor antagonists (8 wk course)

If H. pylori +ve : eradicate with combined therapy and confirm with urea breath test or repeat gastroscopy.

If H. pylori -ve : treat with full dose PPI.

Therapy to eradicate H. pylori

Treatment regimens (select from)

1. PPI + clarithromycin + either amoxycillin or metronidazole—1 wk (90–95% success)

2. PPI + amoxycillin + metronidazole—2 wks (80–85%)

3. PPI + bismuth subcitrate + metronidazole + tetracycline—2 wks

4. Other combinations

Surgical treatment

Indications include:

• failed medical treatment after 1 yr

• complications

  • uncontrollable bleeding

  • perforation

  • pyloric stenosis

• suspicion of malignancy in gastric ulcer

• recurrent ulcer after previous surgery

NSAIDs and peptic ulcers

Ulcer identified in NSAID user

• Stop NSAID (if possible).

• Check smoking and alcohol use.

• Try alternative anti-inflammatory analgesic (e.g. paracetamol or enteric-coated, slow-release aspirin).

• H₂-receptor antagonist (full dose) for 4–6 wks or misoprostol 800 mg/d (used for GU) or PPI (e.g. omeprazole 20–40 mg/d for 2–4 wks).

Prevention of ulcers in NSAID user

Try alternatives (as above). Prophylactic drugs are rarely justified but reasonable in those >75 yrs and in those with a past history of peptic ulcer.

• Misoprostol (prevents GU recurrence)

• H₂-receptor antagonist (prevents DU, not GU)

Note 1: If H. pylori is present, it should be eradicated with combination therapy.

Note 2: A useful prophylactic agent is Arthrotec 50 (diclofenac 50 mg + misoprostol 200 mg) taken orally 2–3 times/d.

Stomach cancer

Clinical features:

• usually asymptomatic early

• consider if recent onset dyspepsia in middle age

• dysphagia a late sign

• onset of anaemia

DxT: malaise + anorexia + dyspepsia + weight loss

DxT: triple loss of appetite + weight + colour

Endoscopy and biopsy is optimal test. Treat by surgical excision: may be curative if diagnosed early—5-yr survival 22%.

Dysphagia is difficulty in swallowing usually associated with a sensation of hold-up of the swallowed bolus ± pain. Its origin is either oropharyngeal (mainly neuromuscular, e.g. CVA) or oesophageal (mainly achalasia, diffuse spasm or peptic structure often secondary to reflux).

Dysphagia must not be confused with the anxiety disorder globus hystericus, which is the sensation of a constant lump in the throat without swallowing difficulty.

Mechanical dysphagia represents carcinoma until proven otherwise—a short history of rapidly progressive dysphagia and significant weight loss indicates malignant oesophageal obstruction.

DxT: dysphagia + chest discomfort + weight loss ± hiccoughs → oesophageal cancer

Investigations include manometry (achalasia etc), barium swallow (inc. video imaging) and endoscopy.

Dyspnoea is the subjective sensation of breathlessness that is excessive for any given level of physical activity.

Important causes of dyspnoea

• asthma

• COPD

• heart failure