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Clinical features

• Intense itching (worse with warmth and at night)

• Erythematous papular rash

• Usually on hands and wrists

• Common on male genitalia

• Also occurs on elbows, axillae, feet and ankles, nipples of females

• Diagnosis by microscopic examination of skin scrapings

Treatment: for all types of scabies

• Permethrin 5% cream (adults and children >6 months) or

• Benzyl benzoate 25% emulsion (dilute 50:50 with water if under 10 yrs; if <2 yrs dilute 1:3)

Method for application

• Apply to clean, dry cool skin of whole body from jawline down (preferably at night time). Include under nails, flexures and genitalia. Apply to face and hair if involved.

• Leave permethrin overnight (min 8 hrs) and benzyl benzoate 24 h and wash off.

• Repeat in 1 wk.

• Complete change of clothes and bed linen: wash in hot water after treatment and hang in sun. Wash any soft toys.

• Treat all family members and contacts even if free of symptoms.

• A topical antipruritic (e.g. crotamiton cream) can be used for persistent itch (usu. up to 3 wks).

• Can use sulphur 5% cream or crotamiton 10% cream daily for 3 days in children <2 yrs.

  Note: Lindane 1% lotion is an alternative, esp. for genital scabies.

Norwegian scabies (profuse infestation with crusting)

• Add ivermectin 200 mcg/kg (o) as single dose. Consult dermatologist.

Serious problems include testicular torsion, strangulation of an inguinoscrotal hernia, a testicular tumour and a haematocele, all of which require surgical intervention. A varicocele can cause discomfort—examine in standing position.

Scrotal pain/discomfort: diagnostic strategy model

Probability diagnosis

• Trauma including haematoma, haematocele

• Torsion of a testicular appendage

• Varicocele

Serious disorders not to be missed

• Vascular:

  • testicular torsion

• Infection:

  • acute epididymo-orchitis/orchitis

  • fulminating necrotising cellulitis

  • psoas abscess

  • tuberculosis

• Cancer:

  • testicular neoplasm

Other:

• strangulated inguinoscrotal hernia

• acute hydrocele

Pitfalls (often missed)

• Referred pain (e.g. spine, ureteric colic, abdominal aorta)

Rarities:

• idiopathic scrotal oedema

• filariasis

Key investigations

Useful investigations include:

• FBE

• urine analysis, microscopy and culture

• Chlamydia detection test

• ultrasound

• technetium-99m scan.

Torsion of the testis versus epididymo-orchitis

With torsion of the testicle there is pain of sudden onset, described as severe aching sickening pain in the groin that may be accompanied by nausea and vomiting. With epididymo-orchitis the attack usually begins with malaise and fever. The testicle soon becomes swollen and acutely tender; however, elevation of the scrotum usually relieves pain in this condition while tending to increase it with a torsion.

Key facts about torsion of the testis

• Is commonest cause of acute scrotal pain in childhood.

• Is the diagnosis, until proved otherwise, of a boy or young man with intense inguinal pain and vomiting.

• Must be corrected within 4–6 h to prevent gangrene of the testis.

• US and a scan is helpful but time usually precludes this and surgical exploration is safest. Beware of delays.

Acute epididymo-orchitis

Guidelines only:

• <35 yrs: usually STI pathogens—Chlamydia, gonococcus

• >35 yrs: urinary tract pathogens—E.coli, other enteric G-negative bacteria

Treatment

• Bed rest

• Elevation and support of the scrotum

• Analgesics

• Antibiotics (all doses for 10–14 d)

• Azithromycin 1 g (o) weekly for 2 doses plus

• Doxycycline 100 mg (o) bd

• Add ceftriaxone IM single dose to cover gonococcus

• Cephalexin 500 mg (o) qid or

• Amoxycillin/clavulanate 875/125 mg (o) bd or

• Trimethoprim 300 mg (o) daily or

• Norfloxacin 400 mg (o) bd

If severe: ampi (amoxycillin) IV + gentamicin IV.

Common in hair-bearing areas of the body, esp. the scalp and eyebrows. It can also affect the face, neck, axillae and groins, eyelids (blepharitis), external auditory meatus and nasolabial folds. The pre-sternal area is often involved.

Principles of treatment

• Topical sulphur, salicylic acid and tar preparations are first-line treatment: they lift the scale and kill the yeast responsible.

• Ketoconazole is most effective as topical (preferred) or oral treatment.

• Topical corticosteroids are useful for inflammation and pruritus and best used in combination. Avoid corticosteroids if possible.

Medication: children

Scalp:

• 1% sulphur and 1% salicylic acid in sorbolene cream or

• egozite cradle cap lotion (6% salicyclic acid)

• apply overnight to scalp, shampoo off next day with a mild shampoo

• use 3 times/wk; rub scales off with baby oil or white soft paraffin

Face, flexures and trunk:

• 2% sulphur and salicylic acid in aqueous or sorbolene cream

• hydrocortisone 1% (for irritation on face and flexures)

• betamethasone 0.02–0.05% (if severe irritation on trunk)

Napkin area:

• mix equal parts 1% hydrocortisone with nystatin or ketoconazole 2% or clotrimazole 1% cream

Medication: adults

Scalp:

• ketoconazole shampoo (immediately after using medicated shampoo) twice wkly

• dexamethasone gel to scalp (if very itchy)

Face and body:

• wash regularly with bland soap

• salicylic acid 2% + sulphur 2% (±tar) in aqueous cream or

• ketoconazole 2% cream, apply once daily for 4 wks

• hydrocortisone 1% bd (if inflamed and pruritic)

The multiplication of bacteria or fungi in the blood, usually causing a systemic inflammatory response syndrome (SIRS). SIRS is defined as 2 or more of (in adults):

• temperature >38°C or <36°C

• respiratory rate >20/min

• heart rate >90/min

• WCC >12 × 10⁹/L or <4 × 10⁹/L

Septic shock is acute circulatory failure—hypotension and peripheral shut down—cool extremities, mottled skin, cyanosis. Patients with septicaemia require urgent referral.

Syphilis

Usually presents either as a primary lesion or through chance finding on +ve serology testing (latent syphilis). May be associated with HIV.

• It is important to be alert to the various manifestations of secondary syphilis (constitutional symptoms and non-pruritic generalised rash).

• Diagnosis: reagin tests, treponemal test, PCR.

Management

The management of syphilis has become quite complex and referral of the patient to a specialist facility for diagnosis, treatment and follow-up is recommended.

Recommended anti-microbial therapy

Early syphilis (primary, secondary or latent) of not more than 1 yr duration:

• benzathine penicillin 1.8 g IM as a single dose or

• procaine penicillin 1 g IM daily for 10 d

For patients hypersensitive to penicillin:

• doxycycline 100 mg (o) 12 hrly for 14 d or

• erythromycin 500 mg (o) 6 hrly for 14 d

Late syphilis: more than 1 yr or indeterminate duration:

• benzathine penicillin 1.8 g IM once wkly for 3 doses

Urethritis

Rules

• All sexually active young people aged 15–29 yrs who are at high risk and asymptomatic should be tested annually for chlamydia with a first-catch urine or genital swab.

• For a person of any age requesting an ‘STI check-up’, test for:

  • urine PCR or genital swab for chlamydia and gonorrhoea

  • serology for Hepatitis B (if not vaccinated or immune)

  • syphilis and HIV

Herpes zoster

Tendonopathy syndromes, subacromial bursitis and adhesive capsulitis

Guidelines

Most of these disorders become chronic and persist for at least 12 mths but eventually spontaneous resolution can be expected.

• The tendonopathy syndromes (rotator cuff disease) usually have unrestricted active movements but resisted movements (e.g. abduction for supraspinatus tendonopathy) are painful.

• Treatment: rest during acute phase, analgesics, peritendon injection. Imaging-guided injection, 1 mL corticosteroid with 2–5 mL 1% lignocaine.

• Sometimes surgical intervention to divide a thickened coracoacromial ligament ± acromioplasty may be nec.

• Subacromial bursitis presents in varying degrees from a ‘frozen shoulder’ to limited abduction (painful arc).

• Treatment: injection of 5 mL, LA then 1 mL corticosteroid into and around the bursa.

• Adhesive capsulitis or traumatic arthritis of the glenohumeral joint is a very painful condition with painful limitation of several active and passive movements, esp. rotation.

• Treatment is with imaging-guided injection of intra-articular steroids or hydrodilation of the joint. Referral to a consultant is advisable as modern treatments, inc. arthroscopy, give excellent results.

Rules of treatment (general)

• Pain, stiffness, ‘frozen’—arthroscopy to divide adhesions

• Pain with mobility—hydrodilation or steroid injection

Acute

Management

• Look for nasal pathology, such as polyposis and dental problems

• Analgesics

• Steam inhalations

• Pseudoephedrine tabs

If bacterial sinusitis (high fever, purulent nasal discharge):

• exclude dental root infection

• control predisposing factors

Guidelines for antibiotic treatment

Consider in severe cases with at least three of the following:

• facial pain

• persistent mucopurulent nasal discharge

• poor response to decongestants

• tenderness over the sinuses

• tenderness on percussion of maxillary, molar and premolar teeth

Antibiotics (first choice):

• amoxycillin 500 mg (o) tds for 7 d or

• (if sensitive to penicillin) doxycycline 200 mg (o) statim then 100 mg daily for 7 d or

• cefaclor 375 mg (o) bd for 7 d or

• amoxycillin clavulanate 875/125 mg (o) tds for 7 d (if poor response to above agents—indicates resistant H. influenzae)

If severe and persistent, surgical drainage may be necessary by atrial lavage or frontal sinus trephine.

Chronic

Sinusitis persisting longer than 2 wks, despite repeated antibiotic and decongestant therapy, is common in general practice. Postnasal drip with cough, esp. at night, is a feature. An empirical treatment that is effective is:

• steam inhalations with Friar's balsam or menthol (best is menthol co APP inhalation)

• vitamin C (sodium ascorbate) 2–4 g daily (a powder can be obtained and mixed with orange juice)

If an allergic basis (pale, swollen mucosa), intranasal corticosteroids.

The three main skin cancers are the non-melanocyctic skin cancers (basal cell carcinoma—BCC; squamous cell carcinoma—SCC) and melanoma. The approximate relative incidence is BCCs 80%, SCCs 15–20%, and melanomas <5%. About 80% of skin cancer deaths are due to melanoma and the rest mainly due to SCC.

Types

• Basal cell carcinoma (BCC)

• Squamous cell carcinoma (SCC)

• Bowen disorder

• Malignant melanoma

• Kaposi's sarcoma

• Secondary tumour (lung, bowel, melanoma)

Basal cell carcinoma

• Mostly on sun-exposed areas: face (mainly), neck, upper trunk, limbs (10%)

• May ulcerate easily = ‘rodent ulcer’

• Slow-growing over years

• Has various forms: nodular, pigmented, ulcerated, etc.

• Can spread deeply if around nose or ear

Management

• Simple elliptical excision (3 mm margin) is best.

• If not excision, do biopsy before other treatment.

• Radiotherapy, photodynamic therapy and imiquimod are options.

Squamous cell carcinoma

Tends to arise in premalignant conditions, such as solar keratoses, burns, chronic ulcers, leucoplakia and Bowen disorder, or it can arise de novo.

SCCs of ear, lip, oral cavity, tongue and genitalia are serious and need special management.

Management

• Early excision of tumours <1 cm with 4 mm margin.

• Referral for specialised surgery and/or radiotherapy if large, in difficult site or lymphadenopathy.

• Surgery is the treatment of choice for most tumours, not cryotherapy, imiquimod or curettage.

Bowen disorder (intradermal carcinoma)

This is SCC in situ of the skin.

Management

• Biopsy first for diagnosis

• Wide surgical excision if small

• Skin grafting may be required

  Note: Biopsy a single patch of suspected psoriasis or dermatitis not responding to topical steroids.

Malignant melanoma

Acute skin eruptions in children

The following skin eruptions (some of which may also occur in adults) are outlined in common childhood infectious diseases:

• measles

• rubella

• viral exanthem (fourth syndrome)

• erythema infectiosum (fifth syndrome)

• roseola infantum (sixth syndrome)

• Kawasaki disorder

• varicella

Acute skin eruption: diagnostic strategy model

Probability diagnosis (especially children)

• Varicella (chickenpox)

• Measles

• Rubella

• Erythema infectiosum (‘slapped cheek’ disease)

• Roseola infantum

• Other viral exanthema (e.g. enterovirus)

• Hand, foot and mouth disease

• Pityriasis rosea

• Herpes zoster (shingles)

• Drug reaction eruption

• Impetigo

• Herpes simplex

• Allergic rash (incl. contact dermatitis)

Serious disorders not to be missed

• Vascular:

  • Henoch–Schönlein purpura

  • Stevens–Johnson syndrome

  • other vasculitides

• Infection:

  • purpura of meningococcus, other septicaemias

  • primary HIV infection

  • folliculitis (e.g. Pseudomonas, Staphylococcus)

  • secondary syphillis

  • scarlet fever

Other:

• erythema nodosum

Pitfalls (often missed)

• Guttate psoriasis

• Epstein–Barr virus (EBV) mononucleosis

• Arbovirus infection (e.g. dengue, Ross River fever, Barmah Forest virus, Japanese encephalitis)

• Scabies

• Kawasaki disease

• Eczema herpeticum

• Zoonoses (e.g. listeriosis, Q fever)

Rarities:

• filovirus diseases (e.g. Ebola, Marburg virus)

• erythema multiforme

Key investigations

Many diagnoses are clinical. Consider:

• FBE/ESR/CRP

• EBV test

• HIV test

• serology for rubella, parvovirus, syphilis and other suspected infections

• viral and bacterial cultures

Secondary syphilis

The rash usually appears 6–8 wks after the primary chancre. It is relatively coarse and asymptomatic. It can involve the whole body, inc. the palms and soles.

Primary HIV infection

A common manifestation of the primary HIV infection is an erythematous, maculopapular rash. If such a rash, accompanied by an illness like glandular fever, occurs, HIV infection should be suspected and specific tests ordered.

Guttate psoriasis

The sudden eruption of small (less than 5 mm) round, very dense, red papules of psoriasis on the trunk. Usually seen in children and adolescents following a sore throat. The rash may extend to the limbs, and soon develops a white silvery scale. It may undergo spontaneous resolution or enlarge to form plaques and tends to last 6 months. Treatment is with UV light and tar preparations.

Drug eruptions

A rash is one of the most common side-effects of drug therapy, which can precipitate many different types of rash; the most common is toxic erythema. Examples are antibiotics, esp. penicillin, thiazides, antiepileptics, allopurinol, NSAIDs.

Erythema multiforme

An acute eruption affecting the skin and mucosal surfaces, mainly backs of hands, palms and forearms; also feet, toes, mouth. It is a vasculitis, the causes of which are many but mainly unknown (50%) and herpes simplex virus. Mainly seen in children and young adults.

Stevens–Johnson syndrome

A very severe and often fatal variant. Sudden onset with fever and constitutional symptoms.

Treatment

Identify and remove cause (e.g. withdraw drugs). Symptomatic treatment (e.g. antihistamines for itching). Refer severe cases—usually need hospitalisation and high doses of steroids.

Erythema nodosum

Characterised by the onset of bright red, raised, tender nodules on the shins and sometimes thighs and arms.

Causes/associations

• Sarcoidosis (commonest known cause)

• Infections (e.g. tuberculosis, streptococcal)

• Inflammatory bowel disorders

• Drugs (e.g. sulphonamides, antiepileptics, penicillin)

• Unknown (50%)

Investigations

Tests include FBE, ESR, chest X-ray (the most important), Mantoux test.

Treatment

Identify the cause if possible. Rest and analgesics or NSAIDs for the acute stage. Systemic corticosteroids speed resolution if severe episodes.

Prognosis

There is a tendency to settle spontaneously over 3–4 wks.

Hand, foot and mouth (HFM) disease

HFM disease affects both children and adults but typically children <10 yrs. The lesions develop on hands, palms and soles (usually lateral borders) and vesicles lead to shallow ulcers on buccal mucosa, gums and tongue. Caused by a coxsackie A virus.

Management

Reassurance and explanation (lesions resolve in 3–5 d). Symptomatic treatment: careful hygiene

Approximately half of the population report a sleep-related problem in 12 mths. Normal ideal sleep in a fit, young person is 7.5–8 h, with a latency less than 30 mins.

Primary insomnia

Periodic limb movements

Also referred to as nocturnal myoclonus or ‘leg jerks’, they tend to occur in the anterior tibialis muscles of the leg. Most people are asymptomatic—the diagnosis is often made during sleep studies. If troublesome, referral to a sleep clinic is appropriate.

Medication (if symptomatic)

• levodopa + carbidopa (e.g. Sinemet 100/25, 2 tabs before bedtime) or

• clonazepam 1 mg (o) nocte increasing to 3 mg (o) nocte or

• sodium valproate 100 mg (o) node

Restless legs syndrome

Narcolepsy

Sleep apnoea

Sleep apnoea refers to cyclical brief interruptions of ventilation (breathing) resulting in hypoxaemia and related biochemical effects and terminating in sleep arousal, which is often not recognised by the patient. The main type is obstructive sleep apnoea, which refers to the presence of apnoeas and hypopnoeas during sleep together with daytime dysfunction, especially sleepiness.

Predisposing causes include:

• diminished airway size (e.g. obesity, tonsillar–adenoidal hypertrophy)

• upper airway muscle hypotonia (e.g. alcohol, neurological disorders)

• nasal obstruction

Clinical effects include daytime somnolence and neuropsychiatric disturbances (e.g. depression, personality change).

The other type is central sleep apnoea, which is characterised by periodic loss of respiratory effort during sleep.

Management

Referral to a sleep disorder centre is advisable. General principles and methods:

1. lifestyle modification (e.g. weight loss, no smoking)

2. continuous +ve airway pressure (CPAP) delivered by nasal (or facial) mask

3. corrective surgery (e.g. tonsillectomy, nasal obstruction)

4. oral appliance (e.g. the mandibular advancement splint)

5. medication (e.g. amitriptyline)

Parasomnias

These are dysfunctional episodes associated with sleep, sleep stages or partial arousal. More common in children.

Nightmares (dream anxiety)

These occur later in the sleep period and are accompanied by unconscious body movements. Associated with traumatic stress disorders, drugs or drug withdrawal. Psychological evaluation with CBT is appropriate. Medications that may help includes a 6 wk trial of phenytoin, clonazepam or diazepam ( See Myoclonic jerks (periodic limb movement disorder)).

Sleep terrors

A feature of these are sharp screams, violent thrashing movements and autonomic overactivity. The sufferers may or may not awake and usually cannot recall the event. They require psychological evaluation and therapy. Similar medication as for nightmares can be used.

Sleep walking (somnambulism)

In this disorder the person performs some repetitive motor activity in bed or walks around freely. No treatment is usually required but the sleeping environment should be rendered safe if it is repetitive and problematic. Benzodiazepines can be used (with care).

REM sleep behaviour disorder

A feature is complex and elaborate motor activity (may be violent with profane verbalisation) during dreaming. More common in older males with CNS degenerative disorders.

Diagnosis: sleep studies

Treatment: clonazepam.

Sleep disorders in children

Tobacco smoking is the largest single, preventable cause of death and disease in Australia.

Methods for getting patients to quit

Several studies have highlighted the value of opportunistic intervention by the family doctor. Not only is it important to encourage people to quit but also to organise a quitting program and follow-up.

Intervention: the 5A framework:

• Ask about and document tobacco use at every opportunity.

• Assess motivation and confidence to quit: ‘Are you interested in quitting?’

• Advise all smokers to quit—diplomatically.

• Assist the smoker to quit with counselling and pharmacotherapy.

• Arrange follow-up to maintain quit advice or non-smoking (very important).

• If they say yes to quitting, make a contract (example below).

• Nicotine education: Nicotine can be used to help withdrawal from cigarette nicotine dependence. It is a temporary measure and should not be used for longer than 6 mths.

Nicotine replacement therapy (NRT)

Formulations:

• nicotine gum

• nicotine inhaler

• nicotine polacrilex (lozenges)

• nicotine transdermal patches (probably best method)—use for 12 wks

  • low to moderate dependence (10–20 cigs/d): 14 mg/24 h or 10 mg/16 h patch daily; change to 7 mg patch after 4–6 wks; aim to cease within 12 wks

  • high dependence (>20 cigs/d): 21 mg/24 h patch daily → 14 mg after 4–6 wks → 7 mg after 4–6 wks; aim to cease within 12 wks

  Note: Ongoing support and counselling (inc. anticipatory guidance) is essential. Patients must not smoke while on patches.

Other agents:

• bupropion (Zyban SR) 150 mg (o) /d for 3 d, then bd for 7 wks, is an option. Combining bupropion with NRT is not recommended

• varenicline tartrate (Champix) tablets 0.5 mg/d titrating slowly to 1 mg bd by d 7 until the end of the 12-wk course. Effective but several side effects esp. nausea

• nortriptyline 75 mg (o) daily, start 14 d before quit date, continue for 12 wks

• NB: regular follow-up for all methods essential.

• Support group recommended.

• Going ‘cold turkey’: stopping completely is preferable but before making the final break it can be made easier by changing to a lighter brand, inhaling less, stubbing out earlier or reducing the number. Changing to cigars or pipes is best avoided.

Quitting tips (advice to patient)

• Make a definite date to stop (e.g. during a holiday).

• After quitting:

  • Eat more fruit and vegetables (e.g. munch carrots, celery and dried fruit).

  • Foods such as citrus fruit can reduce cravings.

  • Chew low-calorie gum and suck lozenges.

  • Increase your activity (e.g. take regular walks instead of watching TV).

  • Avoid smoking situations and seek the company of non-smokers.

  • Be single-minded about not smoking—be determined and strong.

  • Take up hobbies that make you forget smoking (e.g. water sports).

Withdrawal effects

(DSM-5) The initial symptoms are restlessness, increased appetite, irritability, poor concentration, headache, tachycardia, insomnia, increased cough, anxiety, tension, depression, tiredness and sweating. After about 10 days most of these effects subside.

Some patients complain of a clunking, clicking or snapping hip. This represents a painless but annoying problem.

The usual causes are a taut iliotibial band (tendon or tensor fascia femoris) slipping backwards and forwards over the prominence of the greater trochanter or joint laxity.

Treatment

The two basics of treatment are:

• explanation and reassurance

• exercises to stretch the iliotibial band

If abnormal, refer to a sleep laboratory for assessment and management of obstructive sleep apnoea syndrome and other abnormalities.

If functional, give the following advice to consider.

• Treat nasal congestion (inc. hayfever).

• Obtain and maintain ideal weight.

• Avoid drugs (e.g. sedatives, hypnotics, excessive alcohol and smoking).

• Try to sleep on your side.

• Avoid sleeping on the back. If you tend to roll onto your back at night, consider sewing tennis or ping-pong balls on back of nightwear or wear bra (with tennis balls) back to front.

• Keep neck extended with a soft collar at night for neck problems.

• Provide partner with appropriate ear plugs.

• Consider a trial of an intranasal device such as the Breathing Wonder^®—intranasal plastic insert. Your pharmacist can advise you about the range of such devices.

Key examination

• On inspection, note the general appearance, look for toxicity, the anaemic pallor of leukaemia, the nasal stuffiness of infectious mononucleosis or the halitosis of a streptococcal throat.

• Palpate the neck for soreness and lymphadenopathy and check the sinus area.

• Then inspect the oral cavity and pharynx.

Key investigations

Consider:

• throat swab

• FBE

• mononucleosis test

• blood sugar

• biopsy of suspicious lesions

Symptomatic treatment of sore throat

• Most acute sore throats are caused by viral infection—treat symptomatically

• Adequate soothing fluids, inc. icy poles

• Analgesia: adults—2 soluble aspirin or paracetamol; children—paracetamol elixir (not alcohol base)

• Rest with adequate fluid intake

• Soothing gargles (e.g. soluble aspirin used for analgesia)

• Advice against overuse of OTC throat lozenges and topical sprays, which can sensitise the throat

Streptococcal tonsillopharyngitis

Four key features of GABHS throat infection

• Fever >38°C

• Tender cervical lymphadenopathy

• Tonsillar exudate

• No cough

Throat swabs are about 90% effective in isolating GABHS from the infected throat if clinical infection present. It should be treated with penicillin or an alternative antibiotic.

Indications for antibiotic therapy

• Severe tonsillitis with above features of GABHS

• Existing rheumatic heart disease at any age

• Scarlet fever

• Peritonsillar cellulitis or abscess (quinsy)

• Patients 3–25 yrs with presumptive GABHS from special communities (e.g. remote Indigenous) with a high incidence of acute rheumatic fever

One evidence-based review recommended that if a cold follows its natural course no antibiotics will be helpful. If there is a sore throat with no cough, but fever >38°C, tender neck glands and white spots in the throat, antibiotics are indicated.

Treatment for streptococcal throat (proven or suspected)

• Phenoxymethylpenicillin 25–50 mg/kg/d (o) in 2–3 divided doses for 10 d (to max. 1 g/d) or

• (If sensitive to penicillin) roxithromycin 4 mg/kg up to 150 mg (o) bd for 10 d

• Phenoxymethyl penicillin 500 mg (o) 12 hrly for 10 d or

• Roxithromycin 300 mg (o)/d for 10 d

If poorly compliant

• Benzathine penicillin 900 mg IM as single dose

  Note: Although symptoms and most evidence will disappear within 1–2 d of treatment, a full course of 10 days should be given to provide an optimal chance of eradicating S. pyogenes from the nasopharynx and thus minimising the risk of recurrence or complications such as rheumatic fever.

Quinsy

For a peritonsillar abscess treat with antibiotics (e.g. procaine penicillin IM or clindamycin) plus drainage under local anaesthetic if it is pointing. Oral penicillin treatment is likely to fail. Subsequent tonsillectomy is usually recommended.

Diphtheria (may be seen in recent overseas travellers)

Management: refer

• Throat swabs

• Antitoxin

• Penicillin or erythromycin 500 mg qid for 10 d

• Isolate patient

Candida pharyngitis

Management

• Determine underlying cause (e.g. diabetes, HIV infection, corticosteroids).

• Nystatin suspension, rinse and swallow qid.

Note: Don't forget to consider the often misdiagnosed Epstein–Barr mononucleosis.

Spinal or vertebral dysfunction can be regarded as a masquerade mainly because the importance of the spine as a source of various pain syndromes has not been emphasised in medical training.

If a patient has pain anywhere it is possible that it could be spondylogenic and practitioners should always keep this in mind.

Cervical spinal dysfunction

If the cervical spine is overlooked as a source of pain (such as in the head, shoulder, arm, upper chest—anterior and posterior—and around the ear or face) the cause of the symptoms will remain masked and mismanagement will follow.

Thoracic spinal dysfunction

The most common and difficult masquerades related to spinal dysfunction occur with disorders of the thoracic spine (and also the low cervical spine), which can cause vague aches and pains in the chest, inc. the anterior chest.

Such referred pain can mimic symptoms of visceral disease such as angina and biliary colic.

Lumbar spinal dysfunction

The association between lumbar dysfunction and pain syndromes is generally easier to correlate. The pain is usually located in the low back and referred to the buttocks or the backs of the lower limbs. Problems arise with referred pain to the pelvic area, groin and anterior aspects of the leg.

Typical examples of referral and radicular pain patterns from various segments of the spine are presented in Fig. S2.

Main indications: ITP, hypersplenism, trauma, Hodgkin/non-Hodgkin lymphoma, haemolytic anaemia. Thrombocytosis is the immediate problem, but overwhelming infection is the long-term risk in asplenic and hyposplenic patients.

Prophylaxis

• Education about risks and infections esp. malaria

• Pneumococcal immunisation: 2–3 wks preoperative, rpt 5 yrs

• Haemophilus B (once only if not immunised—2 wks prior to splenectomy)

• Meningococcus vaccine every 3–5 yrs after first doses

• Influenza vaccine—annual after first doses 2 wks prior to splenectomy

• Long-term penicillin for prophylaxis: amoxycillin daily or phenoxymethyl penicillin bd; if sensitive, roxithromycin or erythromycin daily

• Urgent hospital admission if infection develops (refer: immunisation guidelines) Resource: Victorian Spleen Service, www.spleen.org.au

The treatment of ankle ligament sprains depends on the severity of the sprain. Most grade I (mild) and II (moderate) sprains respond well to standard conservative measures and regain full, pain-free movement in 1–6 wks, but controversy surrounds the most appropriate management of grade III (complete tear) sprains (surgery or plaster immobilisation).

Beware of an underlying fracture—always X-ray if doubtful.

Grades I and II sprains

R rest the injured part for 48 h, depending on disability

I ice pack for 20 mins every 3–4 h when awake for the first 48 h

C compression bandage (e.g. crepe bandage)

E elevate to hip level to minimise swelling

A analgesics (e.g. paracetamol)

R review in 48 h, then 7 d

S special strapping

Use partial weight-bearing with crutches for the first 48 h or until standing is no longer painful, then encourage early full weight-bearing and a full range of movement with isometric exercises. Use warm soaks, dispense with ice packs after 48 hrs. Aim towards full activity by 2 wks.

Injury due mainly to sharp spines (e.g. stone fish).

• Bathe or immerse part in very warm to hot—not scalding—water (45°C).

• Consider infiltration with local anaesthetic.

A stitch in the epigastric or hypochondrium is sharp unilateral pain due to cramping in the diaphragm. It is common in children and adolescents and lasts 1/2–3 minutes.

• Stop and rest when the pain strikes during activity, especially long distance running. Then walk—don't run. Relieved by straightening up and taking very slow deep breaths followed by shallow breaths.

• Apply deep massage to the area with pulps of middle 3 fingers.

• Perform slow deep breathing.

Prophylaxis: undertake a program of abdominal breathing prior to activity.

A stroke is a focal neurological deficit lasting longer than 24 hrs and is caused by a vascular phenomenon.

A transient ischaemic attack (TIA) is a transient episode of neurological dysfunction caused by focal brain or retinal ischaemia without infarction.

A stroke in evolution is an enlarging neurological deficit, presumably due to infarction, that is increasing over 24–48 h.

The common causes of stroke are 1° intracerebral haemorrhage (10%); SAH 5% and ischaemic stroke 85%.

Stroke

Key messages

• Treat all TIAs and strokes as emergencies and admit to specialised stroke units with imaging facilities (CT and/or MRI) esp. if the unit provides thrombolytic therapy (if possible) for ischaemic stroke.

• There is a 4.5-hour absolute time frame from onset of stroke for thrombolytic therapy to be effective.

• Use the FAST mnemonic: Face (ask person to smile), Arms (raise both arms), Speech (say a simple sentence), Time to intervention 3–4 hrs (ideal)

Three proven strategies to improve outcome of acute stroke (level 1 evidence):

• giving IV plasminogen activator (rt PA) within 4–4.5 h for ischaemic stroke

• giving antiplatelet agents within 48 hrs of ischaemic stroke

• management in a stroke unit

Practice points

• CT (or MRI—preferred if available) scan is ordered on all these patients: if normal repeat in 7–10 d. Non-contrast CT scan is the emergency investigation of choice.

• Cardiac disease is a common source of emboli.

• Consider possibility of a patent foramen ovale (in 20% population) in younger people (paradoxical emboli: veins → brain).

• Sudden stroke is typical of embolism.

• Carotid and transcranial US (or an MRI) is used to investigate carotid artery and posterior circulation. (Fig. S3)

Management (best in stroke unit)

• Investigation inc. identification of risk factors

• Treat hypertension vigorously and other risk factors, e.g. ↑ cholesterol

• IV fluid, electrolyte and nutritional support

• Physiotherapy and speech therapy

• Vigorous rehabilitation with a multidisciplinary team

• Intracerebral haemorrhage (tends to ‘grow’): consider surgical evacuation for cerebellar and cerebral white matter haemorrhage

• SAH: nimodipine ± surgery

• Infarction:

  • thrombolytic therapy with rtPA (alteplase)

  • antiplatelet agents, e.g. aspirin

  • heparin not recommended (avoid steroids, mannitol and anticoagulants)

Transient ischaemic attacks

Some ischaemic syndromes

• Transient monocular blindness (amaurosis fugax)

• Transient hemisphere attacks

• The ‘locked in’ syndrome

• Vertebrobasilar (VBI), for example:

  • bilateral motor loss

  • crossed sensory and motor loss

  • diplopia

  • bilateral blurring or blindness

Investigations

• CT scan or MRI

• FBE

• 12 lead ECG and carotid imaging are essential investigations in first hours

• Blood glucose, creatinine and cholesterol

• Thyroid function tests

• Carotid duplex Doppler US (for carotid territory symptoms)

• ? ECG

• Transoeophageal echocardiography and Holter or bedside cardiac monitoring likely to improve diagnosis

• CT scan (non-contrast)/MRI

Management (Table S7)

• Aim to minimise risk of a major stroke (Table S6).

• Determine cause and correct (if possible).

• Cease smoking and treat hypertension (if applicable).

• Give statin treatment for hypercholesterolaemia.

• Antiplatelet therapy:

  • aspirin 100–300 mg/d or

  • dipyridamole + aspirin 200 mg/25 mg (Asasantim SR) (o) bd or

  • (if aspirin contraindicated) clopidogrel 75 mg (o) daily

• Anticoagulation therapy—warfarin or new oral anticoagulants (NOACs)

  • for VBI (increasing frequency TIAs)

  • for failed antiplatelet therapy

  • atrial fibrillation (selected cases) esp. >65 yrs

• Carotid endarterectomy: although its efficacy is uncertain it does appear to have a place in the management of carotid artery stenosis and the decision depends on the expertise of the unit. There is no evidence that surgery is appropriate for the asymptomatic patient with a stenosis less than 60% or the symptomatic patient with a stenosis less than 30%, but there is a significant benefit for a stenosis greater than 70% (and possibly >60% in asymptomatic patients).

• Carotid stenting has an evolving place; best determined in stroke unit.

Rules for carotid artery stenosis:

• 70–99%—intervention

• 50–69%—‘grey area’: refer

• <50%—observe

Atrial fibrillation and TIAs

Management

• Valvular disease: warfarin

• Non-valvular (lone) AP:

  • no risk factors: no therapy or aspirin 100–300 mg/d

  • risk factors: warfarin: (INR 2–3) or NOACs

  • if warfarin contraindicated: NOACs or aspirin

Indications for carotid duplex Doppler US studies

• Bruit in neck, because of significant stroke rate

• TIAs

• Crescendo TIAs (more frequent and longer lasting)

• Vertebrobasilar insufficiency symptoms

• Hemispheric stroke

• Prior to major vascular surgery (e.g. CABG)

When to refer

• Consider referral most cases

• Suspicion of SAH

• Carotid artery stenosis

• Cerebellar haemorrhage on CT scan

• Stroke in a young patient <50 yrs, consider patent foramen ovale and other rare causes

• Apply heat with direct steam from a thermos onto the closed eye or by a hot compress (helps spontaneous discharge).

• Perform lash epilation to allow drainage (incise with a D₁₁ blade if epilation doesn't work).

• Only use topical antibiotic ointment (e.g. chloramphenicol) if infection spreading locally, and systemic antibiotics if distal spread noted by preauricular adenitis.

• Patient explanation and reassurance is necessary.

• Hypertension is an uncommon association.

• It absorbs over 2 wks.

• Although no local therapy is nec., bathing with a weak salt solution twice daily can be recommended.

Preventive advice

After baby is born:

• Place to sleep on their back with no pillow (unless special reasons for placing on stomach).

• Ensure the head is uncovered.

• Breastfeeding.

• Ensure babies are not exposed to cigarette smoking (before and after birth).

• Ensure that babies do not get overheated (the sign of sweating around the head and neck indicates the baby is too hot).

• Bed coverings no more than adults require.

• Nothing else in cot (e.g. soft toys) and preferably sleep alone.

If baby is unwell, seek medical advice.

Management of SIDS

• Allow parents to see or hold baby.

• Give explanations inc. reasons for coroner's involvement.

• Provide bereavement counselling.

• Provide early contact and continuing support.

• Contact the SIDS support group.

• Revisit home.

• Provide hypnotics (limited).

• Offer advice on lactation suppression.

• Remember siblings can also experience grief reactions.

• The police and coroner must be notified.

Apparent life-threatening episode (ALTE)

ALTE or ‘near-miss SIDS’ is defined as a ‘frightening’ encounter of apnoea, colour change or choking. At least 10% will have another episode. Management includes admission to hospital for investigation and monitoring.

Guidelines for home apnoea monitoring (doubtful value):

• ALTE

• subsequent siblings of SIDS victims

• twins of SIDS victims

• extremely premature infants

Treatment

• Aspirin (for pain)

• Promethazine (for sedation/itching) only if nec.

Topical:

• Hydrocortisone 1% ointment or cream for unblistered severe cases (early) repeat in 2–3 h, then next day (not after 24 h) or

• Bicarbonate of soda paste, applied 2 hrly or

• Oily calamine lotion

Prevention

Avoid exposure to summer sunlight 10 am–3 pm (or 11 am–4 pm DST). Use natural shade, beware of reflected light from sand or water and light cloud. Use a sunscreen with a min. of SPF 30. Wear broad-brimmed hats and protective clothing.

Sweating, (excessive) perspiration, hyperhidrosis

General hyperhidrosis

• Explanation and reassurance

• Trial of probanthine aluminium chloride 20% in alcohol solution if localised area

Axillary hyperhidrosis

Treatment

• Explanation and reassurance

• See treatment of body odour

• Aluminium chloride 20% in alcohol solution (Driclor, Hidrosol); apply nocte for 1 wk, then 1–2 times wkly or as nec.

Surgery

Consider wedge resection of a small block of skin and subcutaneous tissue from axillary vault. Define sweat glands with codeine starch powder. The area excised is usually about 4 cm × 2.5 cm.