| N |

The main nail problems encountered in general practice are trauma, onychomycosis, infection, ingrowing toenails, paronychia and psoriasis. Damage to the nail from trauma or disease results in nail dystrophy. The problem of nail changes due to onychotillomania, be it from excessive nail biting, picking or cleaning, should be suspected from the history and examination. Enquire whether the hands are frequently used in wet work or dirt. Look for associated skin disease (e.g. psoriasis, atopic dermatitis, lichen planus).

Onycholysis

Refers to the separation of the nail plate from the underlying nail bed and is a sign rather than a disease. This separation creates a subungual space with an air interface that gathers unwanted debris, such as dirt and keratin.

Self-induced trauma is a common cause from obsessive manipulation, inc. meticulous cleaning and frequent manicuring.

The band of discolouration at the base of the separated nail is usually in a straight line compared with other causes such as psoriasis and tinea. Tinea may be distinguished from other causes by white or yellow streaks or ‘spears’ travelling proximally in the nail.

Greenish discolouration indicates invasion by Pseudomonas pyocynae or Aspergillus.

Management

First exclude psoriasis, tinea (check toe webbing) and trauma (check history).

Fingernails

• Keep nails as short as possible.

• Avoid insertion of sharp objects under nails for cleaning out debris.

• Apply tape (micropore or similar) over free edge for months, until healed.

• Avoid unnecessary soaps and detergents—wear gloves for housework, gardening, etc.

• Keep hands out of water.

• Use a mild soap and shampoo.

• First-line treatment esp. if mild—vinegar soaks, 10 min bd

Toenails

• Exclude fungal infection (clinical tinea pedis)—culture

• Improve footwear to avoid any rubbing

Pharmaceutical treatment

• Daily application of an imidiazole (e.g. clotrimazole) or a polygene (e.g. terbinafine)

• For Pseudomonas infection soak the nails in vinegar or Milton's solution and/or apply gentamicin sulphate cream

Onychomycosis

This is fungal nail infection that mainly affects toenails. The most common form is distal lateral subungual caused by Trichophyton sp. A superficial white onychomycosis with distinct edges is also common. C. albicans and other moulds are not a common factor. Diagnosis is by culture and histology of the distal nail plate clippings placed in formalin. For more details on treatment see under tinea unguium. The treatment of choice for all types is oral terbinafine 250 mg (o)/d for 6 wks (cures 70–80%).

Onychogryphosis

Onychogryphosis, or irregular thickening and overgrowth of the nail, is commonly seen in the big toenails of the elderly and appears to be related to pressure from footwear. It is really a permanent condition. Simple removal of the nail by avulsion is followed by recurrence some months later. Permanent cure requires ablation of the nail bed after removal of nail. Two methods of nail ablation are:

• total surgical excision

• cauterisation with phenol (with care)

Brittle nails

These are age related and are usually caused by local physical factors, such as repeated water immersion, and exposure to chemicals, such as detergents, alkalis and nail polish removers. Systemic causes such as deficiency of iron and vitamins are not considered to be a common factor.

Management

• Avoid excessive hydration and trauma.

• Wear rubber gloves with cotton liners for wet work.

• Massage Vaseline or nail creams (e.g. Eulactol or Neostrat) into the nail several times daily.

• Nail polishes and hardeners (preferably without formalin) may give a good cosmetic result.

Nail apparatus melanoma

Features

• Responsible for 2–3% of all melanoma

• All age groups but esp. in 7th decade

• Presents as a longitudinal pigmented streak in the nail

• Usually diagnosed late

• Mortality >50%

• Early recognition may result in a cure

Management

• All cases require a longitudinal nail biopsy for diagnosis

• If confirmed treatment is based on Breslow thickness and level of invasion

• Level 1 or in situ–removal of whole nail apparatus

• Invasive melanoma—amputation of distal phalanx

Paronychia

Ingrowing toenails

Subungual haematoma

Methods to release blood in the acute injury phase include:

• drilling a hole by twisting a standard hypodermic needle

• using the red hot end of an extended paper clip

• piercing with the hot wire of an electrocautery unit

Penetration must be as superficial as possible.

Advise the patient that the nail will eventually separate and a normal nail will appear in 6–9 mths.

Nappy rash

The main factor is dampness due to urine and faeces. Check for faecal impaction/spurious diarrhoea. The commonest type is irritant dermatitis but consider also:

• Candida albicans (invariably present)

• seborrhoeic dermatitis

• atopic dermatitis

• psoriasis

Claimed to be worse with teething (8–12 mths).

Irritant dermatitis

• Keep the area dry.

• Change wet or soiled napkins often—highly absorbable disposable ones are good.

• Wash gently with warm water and pat dry (do not rub).

• Avoid excessive bathing and soap.

• Avoid powders and plastic pants.

• Use emollients to keep skin lubricated (acts as a barrier) e.g. zinc oxide and castor oil cream, or Vaseline, with each change.

• Standard treatment for persistent or widespread rash 1% hydrocortisone with nystatin or clotrimazole cream e.g. Hydrozole (qid after changes)—can get separate steroid and antifungal creams and mix before application. If seborrhoeic dermatitis: 1% hydrocortisone and ketoconazole ointment.

Typical profile of a narcotic–dependent person

• Male or female: 16–30 yrs

• Family history: often severely disrupted (e.g. parental problems, early death, separation, divorce, alcohol or drug abuse, sexual abuse, mental illness, lack of affection)

• Personal history: low threshold for toleration, unpleasant emotions, poor academic record, failure to fulfil aims, poor self–esteem

Many of the severe problems are due to withdrawal of the drug.

Withdrawal effects

These develop within 12 h of ceasing regular usage. Max. withdrawal symptoms usually between 36–72 h:

• anxiety and panic

• irritability

• chills and shivering

• excessive sweating

• ‘gooseflesh’ (cold turkey)

• loss of appetite, nausea (possibly vomiting)

• lacrimation/rhinorrhoea

• tiredness/insomnia

• muscle aches and cramps

• abdominal colic

• diarrhoea

Management

Management is complex because it includes not only the medical management of physical dependence and withdrawal but also of the individual complex social and emotional factors. The issue of HIV prevention also has to be addressed. Patients should be referred to a treatment clinic and then a shared care approach can be used. The treatments include ‘cold turkey’ with pharmacological support, acupuncture, megadoses of vitamin C, methadone substitution and drug-free community education programs.

Methadone maintenance programs that include counselling techniques are widely used for heroin dependence.

Naltrexone, the oral opioid antagonist, and bupremorphine, which is now the preferred agent, have a place in management.

Methadone used appropriately can save lives but if not can be fatal.

• If autonomic signs, use clonidine.

• If anxiety, use diazepam.

Cervical dysfunction

Cause

Minor injury causing dysfunction, inc. stiffness in facet joints.

Features

• Deep ache in neck

• Pain may radiate to head or suprascapular area

• Variable restriction of neck movement

• X–rays usually normal. Imaging should be selected conservatively—plain X-ray is not indicated in the absense of red flags and major trauma. MRI is the investigation of choice for radiculopathy, myelopathy, suspected spinal infection and tumours.

Management

• Education with advice, such as good posture

• Basic analgesics (e.g. paracetamol)

• Neck exercise program (crucial)

• Cervical mobilisation by appropriately trained therapist. Consider manipulation by expert (with caution) for stubborn ‘locked’ neck.

Cervical spondylosis

Cause

Degenerative disease in older persons.

Features

Dull, aching neck pain with stiffness.

Management

• Referral for physiotherapy, inc. warm hydrotherapy

• Regular mild analgesics (e.g. paracetamol)

• NSAIDs: a trial for 3 wks then review (use judiciously)

• Gentle mobilising exercises as early as possible

• Passive mobilising techniques

• Outline general rules to live by

Acute torticollis

Torticollis (acute wry neck) means a lateral deformity of the neck and is usually a transient self-limiting, acutely painful disorder with associated muscle spasm of variable intensity. Most likely due to acute dysfunction of mid-cervical facet joints.

Management

• Pain relief—consider antispasmodics (e.g. diazepam)

• Gentle mobilisation exercises

• Muscle energy therapy (very effective)

Whiplash syndrome

Treatment

• Provide appropriate reassurance and patient education.

• Compare the problem with a sprained ankle, which is a similar injury.

• Inform patient that an emotional reaction of anger, frustration and temporary depression is common (lasts about 2 wks).

• X-ray recommended.

• Rest initially but mobilise as soon as poss.

• Cervical collar (limit to 2 d)

• Analgesics (e.g. paracetamol); avoid narcotics

• NSAIDs for 2 wks

• Tranquillisers, mild—up to 2 wks

• Physiotherapy referral

• Neck exercises (as early as possible)

• Heat and massage; ‘spray and stretch’

• Passive mobilisation (not manipulation)

Management

• Wash affected site with soap and water without scrubbing.

• Encourage bleeding.

• Reassure patient risk of viral infection is very low.

• Obtain information about and blood from the sharps victim and the source person (source of body fluid). ? Hepatitis B and C or HIV +ve.

• Consider exposed person's wishes after discussing risks and benefits of treatment, including adverse effects.

It takes up to 3 mths to seroconvert with HIV.

Known Hepatitis B carrier source person

If injured person immune—no further action.

If non-vaccinated and non-immune:

• give hyperimmune Hepatitis B gammaglobulin (within 48 h)

• commence course of Hepatitis B vaccination within 24 h

Known Hepatitis C carrier source person

Follow-up HCV RNA tests at 4–6 wks and anti HCV AB and ALT levels at 4–6 mths.

Known HIV-positive source person

Refer to consultant about relative merits of drug prophylaxis and serological monitoring.

Options: double or triple antiretroviral prophylaxis within 1–2 h (check with consultant) or serological monitoring 0, 4, 6, 12, 24 and 52 wks

Unknown risk source person

Take source person's blood (if consent is given) and sharps victim's blood for Hepatitis B (HBsAg and anti-HBs), Hepatitis C (HCV AB), HIV AB and baseline ALT testing. Begin Hepatitis B vaccination if not vaccinated.

Note: Informed consent for testing and disclosure of test results for involved person should be obtained.

Website: http://www.cdc.gov

Adults

• Check whether due to medication, drug withdrawal or traumatic stress disorder and if so treat accordingly.

• 4 wk trial of phenytoin

• Diazepam or clonazepam at night can be used.

Children

• No active treatment is usually needed for parasomnias (nightmares, sleep talking or sleep walking) in children.

• Usually self-limiting

• If persistent or severe: 6 wk trial phenytoin or imipramine

Nasal fractures

Fractures of the nose can occur in isolation or combined with fractures of the maxilla or the zygomatic arch. Always check for a compound fracture or head injury and if present leave alone and refer.

Practice tips

• X-rays are generally unhelpful unless excluding other facial skeletal injuries.

• If a deformity is present, refer the patient within 7 d, ideally from days 3–5.

• Skin lacerations, i.e. compound fracture usually require early repair.

• The optimal time to reduce a fractured nose is ∼10 d after injury. The window period before union is 2–3 wks.

• Closed reduction under local or general anaesthetic is the preferred treatment.

• Open reduction is more suitable for bilateral fractures with significant septal deviation: bilateral fractures with major dislocations or fractures of the cartilaginous pyramid.

Nasal polyps

These are round, soft, pale pedunculated outgrowths arising from the nasal or sinus mucosa. They are basically prolapsed congested oedematous mucosa, described by some as ‘bags of water’. They occur in patients with all types of rhinitis but esp. allergic rhinitis. Symptoms include nasal obstruction and loss of smell.

Treatment

• Medical ‘polypectomy’: use oral steroids, e.g. prednisolone 50 mg/d for 7 d plus steroid nasal spray. Continue for at least 3 mths.

• Antibiotics for purulent nasal discharge.

• Surgery—refer for procedure which can be complex.

Nasal vestibulitis

Includes:

• Low-grade infection & folliculitis → pain, crusts and bleeding esp. if ‘picking habit’. Treat with bacitracin or mupirocin oint. for 14 d.

• Furunculosis—usu. S. aureus, may cause spreading cellulitis. Treat with minimal handling, hot soaks, systemic antibiotics, (e.g. dicloxacillin), but take swabs from the vestibule.

• Fissures: painful fissures develop at mucocutaneous junction. Treat with petroleum jelly (Vaseline) to keep moist, hot compresses and an antibiotic or antiseptic ointment if nec.

Offensive smell from the nose

Ensure no foreign body present.

• Mupirocin 2% nasal ointment—instil bd or tds for 5 d (esp. if S. aureus in nares) or

• Kenacomb ointment—instil 2 or 3 times/d

Rhinophyma

This disfiguring swelling of the nose is due to hypertrophy of the nasal sebaceous glands. There is no specific association with alcohol. More common in men >45 yrs. May be associated with rosacea.

Treatment

• Good control of rosacea may reduce the risk.

• If surgical correction is warranted, refer to a specialist.

• Carbon dioxide laser therapy is the treatment of choice.

• Shave excision is another effective therapy.

Senile rhinorrhoea

This is a common distressing problem in the elderly caused by failure of the vasomotor control of the mucosa. There are few physical signs apart from the nasal drip. The treatment is to keep the nasal passages lubricated with an oily preparation such as insufflation with an oily mixture (a suitable sesame oil based preparation is Nozoil) or petroleum jelly.

Stuffy and running nose

• Blow nose hard into disposable paper tissue or handkerchief until clear.

• Nasal decongestant for 2–3 d only

• Steam inhalations with Friar's balsam or menthol preparations—use 1 tsp to 500 mL boiled water in old container

Snuffling infant

Snuffling in infants is usually caused by rhinitis due to an intercurrent viral infection. The presence of yellow or green mucus should not usually be cause for concern.

Treatment

• Reassure the parents.

• Paracetamol mixture or drops for significant discomfort.

• Get the parents to perform nasal toilet with a salt solution (1 tsp salt dissolved in some boiled water); using a cotton bud, gently clear out nasal secretions every 2 waking h.

• Once the nose is clean, saline nose drops or spray (e.g. Narium nasal mist) can be instilled.

• Stronger decongestant preparations are not advised unless the obstruction is causing a significant feeding problem, when they can be used for up to 4–5 d.

Recommendations of the Australian Nutrition Foundation for a heart-healthy eating program are:

• eat most—vegetables, dried peas, beans and lentils, cereals, bread, fruit and nuts

• eat moderately—lean meat, eggs, fish, chicken (without skin), milk, yoghurt, cheese

• eat in small amounts—oil, margarine, reduced-fat spreads, butter, sugar

The essential components of nutrition can be classified as:

• macronutrients—proteins, fats and carbohydrates (all interchangeable sources of energy) and water

• macrominerals—sodium, chloride, potassium, calcium, magnesium phosphate

• micronutrients—water-soluble vitamins, e.g. C, B; fat-soluble vitamins i.e. A, E, D, K; and essential trace elements, e.g. Cu, I, Fe, Zn, Mn, Se

Protein

Proteins make up the greater part of plant and animal tissue and provide the amino acids essential for the growth and repair of tissue. A complete protein is one that contains all the nine indispensable amino acids, namely, histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan and valine.

Protein in animal products (meat and milk) is of high quality and that in vegetable products is lower because of a limited supply of lysine (in cereals) and methionine and cysteine (in legumes). Infants and children require 2–2.2 g protein/kg/d.

• High protein content foods—lean beef and lamb, chicken, fish, eggs, milk, cheese, soy beans

• Medium protein content foods—bread, spaghetti, corn, potatoes (cooked), rice (cooked), cabbage, cauliflower

Carbohydrates

Main source of dietary energy. Carbohydrates that are available in food are:

• sugars—sucrose, lactose, maltose, glucose, fructose

• polyols—sorbitol, xylitol, maltilol, lactilol

• starch—amylose, amylopectin

• dextrose

As long as adequate energy and protein are provided in the diet, there is no specific requirement for dietary carbohydrate. A small amount—100 g/d—is nec. to prevent ketosis.

Fat

Dietary fat, which is composed mainly of fatty acids and dietary cholesterol, is the most concentrated source of food energy. Fatty acids are classified according to the number of unsaturated double bonds:

• nil—saturated (e.g. butyric and stearic acids)

• one—monounsaturated (e.g. oleic acid)

• more than one—polyunsaturated (e.g. linoleic acid, eicosapentanoic acid [EPA], docosahexanoic acid [DHA])

The n-3 and n-6 polyunsaturated fatty acids with chain lengths of 18 or more are called essential fatty acids because they are required for vital body functions and animals, inc. humans, are unable to synthesise them.

The proportions of saturated, monounsaturated and polyunsaturated fatty acids in the diet are important determinants of health and disease. The current strategy is to reduce total fat intake and reduce saturated fats and increase unsaturated fats, esp. n–3 polyunsaturated fats.

General dietary guidelines for Australian adults (NHMRC)

Enjoy a wide variety of nutritious foods

• Eat plenty of vegetables, legumes and fruits.

• Eat plenty of cereals (including breads, rice, pasta and noodles), preferably wholegrain.

• Include lean meat, fish, poultry and/or alternatives.

• Include milks, yoghurts, cheeses and/or alternatives. Reduced-fat varieties should be chosen, where possible.

• Drink plenty of water.

Take care to

• Limit saturated fat and moderate total fat intake.

• Limit salt intake—choose foods low in salt.

• Limit your alcohol intake if you choose to drink (max. 2 SDs/d).

• Consume only moderate amounts of sugars and foods containing added sugars.

Prevent weight gain: be physically active and eat according to your energy needs.

Care for your food: prepare and store it safely.

Dietary guidelines for children and adolescents in Australia (NHMRC)

Encourage and support breastfeeding.

Children and adolescents need sufficient nutritious foods to grow and develop normally.

• Growth should be checked regularly in young children.

• Physical activity is important for all children and adolescents.

  Enjoy a wide variety of nutritious foods.

Children and adolescents should be encouraged to:

• Eat plenty of vegetables, legumes and fruits.

• Eat plenty of cereals (including breads, rice, pasta and noodles), preferably wholegrain.

• Include lean meat, fish, poultry and/or alternatives.

• Include milks, yoghurts, cheese and/or alternatives.

  • Reduced-fat milks are not suitable for young children under 2 years because of their high energy needs, but reduced-fat varieties should be encouraged for older children and adolescents.

• Choose water as a drink.

  • Alcohol is not recommended for children.

Care should be taken to:

• Limit saturated fat and moderate total fat intake.

  • Low-fat diets are not suitable for infants.

• Choose foods low in salt.

• Consume only moderate amounts of sugars and foods containing added sugars.

Care for your child's food: prepare and store it safely.