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Immunisation is the cornerstone of preventive medicine. Basic diseases (diphtheria, tetanus, polio, whooping cough, measles, mumps, rubella) should be covered. Children should be immunised according to the NHMRC recommendation.

All adults should receive an adult diphtheria and tetanus (ADT) booster each 10 years.

All women of child-bearing years should have their rubella antibody status reviewed.

Other recommendations

• Influenza: annually for those with chronic debilitating diseases, persons >65, health care personnel and the immunosuppressed.

• Hepatitis B: for those at risk through work or lifestyle; infants born of HBsAg +ve mothers.

• Q fever: those at risk, esp. abattoir workers.

• Tuberculosis (BCG vaccine): infants at risk (e.g. Indochinese babies exposed to TB, health workers who are Mantoux negative).

• Pneumococcal vaccine: splenectomised persons >2 yrs, Hodgkin's lymphoma, those at high risk of pneumococcal infections.

• Meningococcal c vaccine: children and adolescents 15–19 yrs; B strain vaccine is available.

• If mild and limited: antiseptic cleansing and removal of crusts bd with an antibacterial soap or chlorhexidine or povidone-iodine. Apply mupirocin (Bactroban) tds for 7–10 d

• Daily bath with Oilatum Plus bath oil for 2 wks is helpful

• If extensive: oral di(flu)cloxacillin or cephalaxin or erythromycin for 10 d (if penicillin sensitive)

• Exclude from childcare/school settings until fully healed

• Search for a cause:

  • D—delirium, drugs (e.g. antihypertensives)

  • I—infection of urinary tract

  • A—atrophic urethritis

  • P—psychological

  • E—endocrine (e.g. hypercalcaemia); environmental: unfamiliar surrounds

  • R—restricted mobility

  • S—stool impaction, sphincter damage or weakness

• Avoid various drugs (e.g. diuretics, psychotropics, alcohol)

• Weight reduction if obese

In women:

• perform urodynamics to assess stress incontinence

• bladder retraining (instruct patient to delay micturition for 10–15 mins on impulse to void) and pelvic floor exercises (mainstay of treatment)

• physiotherapist referral

• consider a trial of anticholinergic drugs if bladder atony instability or voiding dysfunction (e.g. solifenacin 5–10 mg daily, propantheline 15 mg (o) bd or tds, tolterodine 2 mg (o) bd)

• consider surgery for stress incontinence due to urethral sphincter weakness (e.g. suprapubic urethral suspension, Burch procedure (gold standard); Aldridge sling; tension free vaginal tape procedure)

• consider injection of collagen into paraurethral region

Consider incontinence aids:

• absorbent pads and special pants

• condoms and catheters; urinary drainage bags

• absorbent sheeting

Subfertility is defined as the absence of conception after a period of 12 months of normal unprotected sexual intercourse.

Key facts and checkpoints

• Subfertility affects 10–15% of all cohabiting couples.

• The main factors to be assessed are ovulation, tubal patency and semen analysis.

• Approx. 40–50% of couples have an identifiable male factor.

• Female factors account for ∼45%: tubal problems account for ∼20% and ovulatory disorders ∼20%.

• Polycystic ovary syndrome is the most common cause of ovulatory dysfunction.

• Approx. 15% of cases have no apparent explanation.

• A significant number (25%) have combined male and female problems.

• Current specialised treatment helps 60% of subfertile couples to achieve pregnancy.

A diagnostic approach

It is important to see both partners, not just the woman.

History

A careful history should include sexual function such as adequate intercourse, past history (esp. STI or PID), occupational history, drug intake and menstrual history.

Physical examination

A general assessment of body habitus genitalia (inc. vaginal and pelvic examination), general health inc. diabetes mellitus, and secondary sexual characteristics should be noted in both man and woman. Urinalysis should be performed on both partners.

Note: testicular size (measured with orchidometer)

• normal size 15–35 mL (average 18 mL)

• small testes 15 mL; Klinefelter 7–8 mL

Essential first-line investigations

• Serum progesterone (mid-luteal/day 21) in ♀

• Basal body temperature and cervical mucus chart

• Semen analysis

• Transvaginal ultrasound

• Rubella immune status ♀

Referral

The family doctor should perform the initial investigations of a couple with subfertility, inc. temperature chart, semen analysis and hormone levels, to determine whether it is a male or female problem and then organise the appropriate referral.

Male—semen analysis:

It is advisable to obtain at least two or three samples at least 80–90 days apart. It requires a complete ejaculation, preferably by masturbation, after at least 3 days' sexual abstinence. Use a clean, dry, wide-mouthed bottle; condoms should not be used. Semen should be kept at body temperature and examined within 1 hour of collection.

Normal values:

• volume >2 mL (av. 2–6)

• concentration >15 million sperm/mL

• motility >40% after 2 h

• normal forms >4%

• velocity >30 microns/sec

Female—ovulation status:

• Educate about temperature chart and cervical mucus diary, noting time of intercourse (take temperature with thermometer under tongue before getting out of bed in the morning). Now considered of low value.

• Mid-luteal hormone assessment (21st d of cycle), i.e. serum progesterone (main first-line test for ovulation) and prolactin (refer Table I2).

Treatable causes in female subfertility are tubular disease, anovulation and endometriosis: IVF guidelines re. NICE, UK.

Treatable causes in males are rare.

Influenza causes a relatively debilitating illness and should not be confused with the common cold. The incubation period is usually 1–3 d and the illness usually starts abruptly with a fever, headache, shivering and generalised muscle aching.

• Viral organisms—influenza A, influenza B

• Avian (bird) influenza—H5N1 influenza A strain

• Swine flu—swine variety of H1N1 influenza A

Clinical criteria

• During an influenza epidemic:

• fever >38 °C plus

• one respiratory symptom:

  • dry cough

  • sore throat plus

• one systemic symptom

  • myalgia

  • headache

  • prostration or weakness

  • chills or rigors

Diagnosis

Nasal/throat swabs, PCR assay, viral culture, specific AB assay

Complications

• Tracheitis, bronchitis, bronchiolitis

• Secondary bacterial infection

• Pneumonia due to S. aureus (mortality up to 20%)

• Encephalomyelitis (rare)

• Toxic cardiomyopathy with sudden death (rare)

• Depression (a common sequela)

Management

Advice to the patient includes:

• rest in bed until the fever subsides and patient feels better

• analgesics—aspirin is effective or codeine and aspirin (or paracetamol), esp. if a dry cough

• fluids—maintain high fluid intake (water and fruit juice); freshly squeezed lemon juice and honey preparations help

• consider antiviral drugs of proven value (within 36 h), e.g.:

  • zanamivir (Relenza) (adult & child >5 yrs) 10 mg by inhalation bd for 5 d or

  • oseltamivir (Tamiflu) 75 mg (o) bd for 5 d (child: 2 mg/kg ↑ 75 mg)

Prophylaxis

Influenza vaccination offers some protection for up to 70% of the population for about 12 months.

• Correct nails properly: cut across so that the cut slopes towards the centre of the nail and do not cut towards the edges (Fig. I1).

• Fashion the toenails so that the corners project beyond the skin.

• Wear good-fitting shoes (avoid tight shoes).

• Keep toe area clean and dry.

These include the long-acting reversible contraceptives (LARC)

• medroxyprogesterone acetate (‘Depo-Provera’)

  • Dose: 150 mg by deep IM injection in first 5 days of the menstrual cycle. Same dose is given every 12 wks to maintain contraception (ok for 14 wks).

• etonogestrel (Implanon)—a third-generation progestogen

  • Dose: 68 mg by subdermal implantation for up to 3 yrs.

The main indication for this form of contraception is the desire for a highly effective method when other methods are contraindicated or disliked. Advantages are avoiding the side-effects of oestrogen and overcoming compliance problems (e.g. in the mentally handicapped). Main disadvantages are marked menstrual irregularities and delayed return of fertility.

• Wash site with large quantities of cool water.

• Apply vinegar (liberal amount) or aluminium sulphate 20% solution (Stingose) for about 30 secs.

• Apply ice for several seconds.

• Use soothing anti-itch cream or 3–5% lignocaine ointment if very painful (e.g. Dermocaine gel).

• Action plan for possible reactions: Hives (papular urticaria).

Exclude and treat

• Drugs (e.g. caffeine, alcohol, β-blockers)

• Anxiety, stress

• Depression

• Restless legs syndrome

• Sleep apnoea

• Nightmares

• Physical disorders (e.g. CCF arthritis)

• Bed-wetting

• Reflux disease

Management:

Non-drug treatments are first line.

• Give explanation and reassurance (treat cause if known).

• Try to recognise what helps patient to settle best (e.g. warm bath, listening to music).

• Establish a routine before going to bed.

• Avoid alcohol and drinks containing caffeine in evening.

• Try a warm drink of milk before retiring.

• Organise a comfortable, quiet sleep setting with right temperature.

• Sex last thing at night where appropriate is usually helpful.

• Remove pets from the bedroom.

• Try relaxation therapy, meditation, stress management.

• Consider hypnosis.

• If all conservative means fail, try temazepam 10 mg (o) or zopiclone (Imovane) 3.75–7.5 mg or zolpidem tartrate (Stilnox) 5 mg (o) at night (limit to 2 wks). Consider melatonin CR 2 mg (ο) 1–2 hrs before bedtime (best >55 yrs).

• Consider referral to a specialist in sleep disorders.

Intertrigo is skin inflammation which is caused by moisture, maceration and friction, and is strictly confined to opposing skin surfaces such as in the groin and under the breasts.

Groin rash

Common causes of a groin rash are presented in Table I3. It is important to distinguish between tinea cruris and candidiasis and the dermograms highlight the differences. Tinea cruris is described on Tinea cruris (jock itch).

Candida intertrigo

Candida albicans superinfects a simple intertrigo and tends to affect obese or bedridden patients, esp. if incontinent.

Treatment

• Treat underlying problem (e.g. diabetes, obesity).

• Apply an imidazole preparation such as miconazole or clotrimazole (use ketoconazole if resistant).

• Use Burow's solution compresses to dry a weeping area.

• Keep area dry and skin folds apart (if possible).

• Apply zinc oxide powder (e.g. Curash).

• Use short-term hydrocortisone cream for itch or inflammation (long-term aggravates the problem).

Erythrasma

Erythrasma, a common and widespread chronic superficial skin infection, is caused by the bacterium Corynebacterium minutissimum. Itch is not a feature.

Clinical features

• Superficial reddish-brown scaly patches

• Enlarges peripherally

• Mild infection but tends to chronicity if untreated

• Coral pink fluorescence with Wood's light

• Common sites: groin, axillae, submammary, toe webs

Treatment

• Erythromycin or tetracycline (oral)

• Topical imidazole

This is a clinical condition based on a history of more than 3 mths in a yr of abdominal pain (in the preceding 12 mths) or discomfort with 2 of the following (Rome III criteria):

• relieved by defecation and/or

• onset associated with change in stool frequency and/or

• onset associated with change in form (appearance) of stool (loose, watery or pellet-like)

Clinical features

• Typically in younger women (21–40)

• Any age or sex can be affected

• Cramping abdominal pain (central or iliac fossa)

• Passage of mucus

• Sense of incomplete evacuation

• Variable bowel habit (constipation more common)

• Often precipitated by eating

• Faeces sometimes like small, hard pellets or ribbon-like

• Anorexia and nausea (sometimes)

• Bloating, abdominal distension, ↑ borborygmi

• Tiredness common

• Onset and exacerbation may be associated with mental stress

IBS is a diagnosis of exclusion. FBE, ESR, stool microscopy and thorough physical examination and colonoscopy are necessary. Insufflation of air at colonoscopy may reproduce the abdominal pain of IBS.

Management

Basis of initial treatment is simple dietary modifications, stress management and other non-drug therapy:

• education and reassurance (inc. cancer absent)

• avoid foods that ‘irritate’, smoking, excess alcohol, laxatives, codeine

• avoidance of constipation

• consider a diet low in dairy products and processed foods

• high-fibre diet and ↑ fluids (for constipation without flatulence)

• consider ongoing stress management, relaxation therapies

The basis of treatment is simple dietary modification with a low-carbohydrate diet using FODMAPs, exercise, fluids (2–3 L water/day) and non-fermentable fibre. FODMAPs stands for fermentable oligosaccharides, disaccharides, monosaccharides and polyols, which are poorly absorbed. All of these carbohydrates need to be eliminated (under a dietician's guidance) and gradually reintroduced. See www.med.monash.edu/cecs/gastro/fodmap (app: the Monash University low FODMAP diet).