Chapter 18: Miscellaneous

Temperature can be measured by many methods. These include the following thermometers:

• mercury thermometer

• digital electronic pacifier

• digital peak hold LED thermometer

• digital infrared aural

• electronic probe

• forehead thermometer (temporal area).

The favoured general instruments for oral and rectal use are the digital peak hold and mercury thermometers, although the mercury type is now less popular and not favoured for infant use by the American Academy of Pediatricians.

Table 18.1 gives a basic guide to interpreting the temperature values obtained.

The mercury thermometer

Basic rules of usage

1. Before use, shake down to 35–36°C.

2. After use:

   • shake down and store in antiseptic

   • do not run under hot water

   • wipe rectal thermometers with alcohol and store separately.

3. Recording time is 3 minutes orally, 1 to 2 minutes rectally.

Oral use

1. Place under the tongue at the junction of the base of the tongue and the floor of the mouth to one side of the frenulum—the ‘heat pocket’.

2. Ensure that the mouth is kept shut.

3. Remove dentures.

Note: Unsuitable for children 4 years and under, especially if irritable.

Rectal use

A suitable route for babies and young children under the age of 4.¹

Method

1. Lubricate the stub with petroleum jelly.

2. Insert for 2–3 cm (1 inch).

3. Keep the thermometer between the flexed fingers with the hand resting on the buttocks (Fig. 18.1).

Don’t

• Dig thermometer in too hard.

• Hold it too rigidly.

• Allow the child to move around.

Axillary use

Although unreliable, it is practical for young children and gives a helpful guide. If used it should be placed high in the axilla for 3 minutes.¹

Groin use

This route is not ideal but is more reliable than the axilla. It closely approximates oral temperature.

In infants, the thigh should be flexed against the abdomen.

Vaginal use

Mainly used as an adjunct to the assessment of ovulation during the menstrual cycle. Should be placed deeply in the vagina for 5 minutes before leaving the bed in the morning.

Digital peak hold thermometer

This popular instrument is also useful for oral and rectal measurement, especially in children.

Infrared aural (ear drum) use²

The temperature can be measured in 3 seconds with an infrared device placed in the ear canal (e-2 therm). Hold the child’s head firmly so that it does not move. Wait 2 minutes before taking the temperature in the same ear. There is much debate about its efficacy but it appears to be worthwhile as it is a simple method and in general practice the benefits of convenience outweigh possible lack of accuracy. The normal range is the same as for rectal temperature.

Digital electronic pacifier (dummy) thermometer

This is a popular method in infants and younger children, favoured by many paediatricians in the USA.

Ankle-jerk technique

The method, illustrated in Figure 18.2a, provides a good opportunity to see and feel for a doubtful reflex. It is readily performed on a patient lying prone to allow examination of the back.

Method

1. Lift the foot slightly off the examination couch and hold it so that the Achilles tendon is under slight tension.

2. With the plessor held in the other hand, tap the tendon.

Alternatively, have the patient kneel on a chair with the feet freely suspended over the edge (Fig. 18.2b). Ask him or her to grasp the back of the chair firmly; this adds an element of reinforcement, which tends to increase the reflex. Tap the Achilles tendon in the usual way.

Uncooperative children

Children under 10 years of age have a disturbing tendency to tense their arms and legs at the wrong moment. Give them a squash ball or similar rubber object and instruct them to squeeze the ball as hard as possible on the count of 3.

Test the required reflex during this distraction.

Also known as Ekbom syndrome, this consists of poorly localised aching in the legs (a crawling sensation) and spontaneous, continuous leg movements. Organic causes that need to be excluded include the neuropathies caused by diabetes, uraemia, hypothyroidism and anaemia. However, it is generally a functional disorder affecting the elderly, and results in marked insomnia.

Management

• Diet: Eliminate caffeine and follow a healthy diet.

• Medications (last resort): Taken before bed time, these include paracetamol, hypnotics, tricyclic antidepressants, clonazepam, levodopa and propranolol. First choice is paracetamol 1000 mg (0) or clonazepam 1 mg, 1 hour before retiring.

• Exercises: These involve stretching of the hamstrings and posterior leg muscles for at least 5 minutes before retiring (Fig. 18.3). Exercise (a) demonstrates hamstring stretching; (b) illustrates calf muscle stretching; (c) stretches all posterior muscles of the lower limb, especially the hamstrings. The patient lies on his or her back and uses a 1.2 m (4 foot) length of rope or flat tape to lift the leg. This exercise should be repeated to produce effective stretching.

For severe persistent nightmares, give a trial of phenytoin (in recommended dosage) for 4 weeks and review.

Consider underlying causes such as drugs and electrolyte disturbances.

Physiological muscle-stretching and relaxation techniques may be effective in the prevention of nocturnal cramps. Other strategies include keeping well hydrated, avoiding caffeine before retiring and taking magnesium supplements, e.g. magnesium orotate, Crampeze^®.

Exercise 1

1. Get the patient to stand bare-footed approximately 1 m (3 ft) from a wall, leaning forwards with the back straight and outstretched hands against the wall.

2. Then get them to lift the heels off the floor and then force the heels to the floor to produce tension in the calf muscles.

3. They should then hold for 30 seconds and repeat 5 to 6 times.

An alternative is to keep the heels on the floor and climb the hands up the wall.

Patients should do these exercises 2 to 3 times a day for 1 week, then each night before retiring (Fig. 18.4).

Exercise 2

This can follow Exercise 1 before retiring.

The patient should rest in a chair with the feet out horizontally to the floor, with support from a cushion under the Achilles tendon, for 10 minutes.

Drug treatment

• Quinine sulfate 300 mg nocte

• Biperiden 2–4 mg nocte

• Magnesium compound (e.g. Crampeze^®), two capsules bd

The effectiveness of quinine has to be considered against the risk of thrombocytopenia or other complications. Its use is not recommended. The evidence for other drugs such as biperiden or baclofen is poor.

Quinine drinks

Consider quinine-containing drinks, e.g. tonic water or bitter lemon, last thing at night.

Baking soda (sodium bicarbonate)

Consider a half-teaspoon of baking soda in half a glass of water at the onset of the cramp.

Venepuncture

Venepuncture, whether for blood collection, the introduction of intravenous drugs or cannulation, can be very difficult in some patients whose veins are not dilated.

Methods

• Rub glyceryl trinitrate (GTN) ointment (e.g. Nitro-Bid^® Nitrolate) over the vein that you wish to puncture.

  or

• Give the patient one-half of an Anginine^® tablet sublingually, provided there are no contraindications to glyceryl trinitrate use. The veins will soon appear.

Painful heels

Some patients, particularly elderly diabetics with small-vessel disease, develop painful heels. Glyceryl trinitrate ointment or transdermal pads applied to the painful area can provide considerable relief.

The transdermal pads (e.g. Nitro-dur^®, Minitran, Transiderm-Nitro^®) are applied once daily and the ointment applied twice daily in a small amount under tape.

Chilblains

Apply GTN ointment over the painful chilblains as necessary. Advise use of plastic gloves or immediate washing of hands (to avoid headache).

Other tips for chilblains include taking rum at night or nifedipine for prevention.

Tendonopathy

The use of transdermal GTN patches to treat tendonopathies such as Achilles and lateral epicondyle tendonopathies has been advocated by many therapists. The usual dose is 1.25 mg per day (a quarter of a 5 mg/24 hr patch) over the affected area. One Australian study by G. Hunte and R. Lloyd-Smith (‘Topical glyceryl trinitrate for Achilles tendinopathy’, Clin J Sport Med, 2005, 15(2), p. 116–7) concluded that the method was better than a placebo, but the overall evidence is unclear and the routine treatment cannot be recommended at this point.

The woman with the urethral syndrome or bladder dysfunction who constantly wakes during the night with an urge to micturate, yet only produces a small dribble of urine, can be helped by the following.

Method

Instruct the patient to perform the following pelvic lift exercise when she awakes.

1. The patient balances on her upper back.

2. The patient then lifts her pelvis, supported by her flexed knees, and holds this position for about 30 seconds.

3. As she holds the position, the patient can also squeeze the pelvic floor inward.

4. Repeat the exercise 2 or 3 times.

Fists under the buttocks

If having difficulty viewing a cervix for smear taking, ask the patient to rest her hands, preferably as fists, under her buttocks. If necessary she can lift her buttocks slightly higher with her fists.

A small, firm cushion could be placed under the buttocks as an alternative.

If you are still having trouble have the patient cough (this is very effective).

Note: Remember to warm the metal speculum in warm water and test the comfort of the temperature on the patient’s thigh.

If you are troubled by the vaginal walls collapsing into the gap between the two blades of the bivalved speculum you can slip a condom over the blades and then cut the tip off the condom. The condom then supports the vaginal walls.

• Avoid during menstruation.

• The best time is any time after cessation of the period.

• Avoid in presence of obvious vaginal infections.

• Avoid within 24 hours after intercourse.

• Avoid within 48 hours of use of vaginal creams, pessaries or douching.

• Avoid lubrication or cleaning of cervix before pelvic examination.

Various methods can be attempted to alleviate the acute or subacute onset of priapism, especially that which is drug induced:

• ice cubes, inserted rectally

• pseudoephedrine, especially for alprostadil (Caverject^® injection or Muse^®) induced priapism.

If drug-induced priapism lasts longer than 2 hours, give the patient two pseudoephedrine tablets—repeat at 3$12$ hours if necessary.

If all fails and specialist help is remote, aspiration and irrigation should be attempted and is best performed in the first 6 to 8 hours (exclude polycythemia and leukaemia via an urgent blood film).

Under local anaesthetic and using a 16-gauge needle, aspirate thick blood from the ipsilateral corpora cavernosa through the glans penis. 20 mL of blood is drawn out at a time and the penis is then flushed with saline.

If resolution is incomplete, use a very slow injection of 10 mL of saline containing 1 mg aramine, followed by massage.

It is worth a trial in men 18–64 years with PE < 2 minutes of dapoxetine (Priligy^®) 30 mg 1–3 hours pre sex (max. 30 mg per 24 hours).

Caution: possible syncope.

After a patient has received an intramuscular injection of pethidine or morphine for the severe pain of renal colic, further pain can be alleviated by indomethacin. Suppositories are satisfactory, but limit them to two a day.

Some practitioners have submitted an anecdotal tip of getting the sufferer of ureteric colic to jump up and down vigorously on the leg of the affected side.

An effective alternative treatment is an IM injection of 75 mg diclofenac (if available), then diclofenac 50 mg (o) tds for 1 week.

When called out to make a home visit, general practitioners will need to either go to the surgery for the records or write the new notes in a notebook or on scraps of paper.

If the patient record is not required for immediate management, a practical suggestion is to carry sheets of self-adhesive, plain paper on which to take notes to include in the practice record later. This paper is available in gloss or matt finish.

Write the patient’s name in the top left-hand corner of the space and record notes in your usual style within a confined space. If you have to see two or three patients, leave a clear space between the notes for each.

On return to the surgery, cut the notes of each patient into individual blocks, strip off the backing and apply to the appropriate section of the patient’s practice file. Alternatively add the notes to the computer file.

Self-adhesive paper may be bought in widths of approximately 170 mm and in various lengths from most stationery stores (Millfix or Quick-Stick, for example, are two suitable brands.)

After administering vaccine that has a sticky label on it, such as Infanrix^®, remove the label and place it in the patient’s notes, or make a note in the computer file.

Cabbage leaves have been used in some cultures for hundreds of years in the treatment of sprains, infections and some breast problems. Recently, they have become popular in many maternity hospitals for managing breast engorgement. There appears to be an unknown substance that is absorbed from the cabbage leaf through the mother’s skin, resulting in decreased oedema and improved milk flow.

Uses

Local breast engorgement:

• blocked ducts or mastitis.

Generalised breast engorgement:

• when milk supply is greater than demand

  • early postpartum

  • sudden weaning

• when lactation suppression is required

  • after a baby dies

  • after mid-trimester abortion.

Method

1. Wash the cabbage leaves well (beware risk of contamination with dirt or pesticides) and dry. Store the cabbage in a refrigerator.

2. Cut stalks from leaves (to prevent pressure on breast) and apply the crisp leaves to the breast, avoiding the nipple area. (Cut out openings for the nipples.)

3. Remove after 2 hours (or earlier if the leaves are limp) and assess the need for further leaves.

4. Cease using leaves when engorgement settles, as prolonged use can reduce the milk supply.

5. Do not use if the patient has a history of allergy to cabbage.

Many women using this home remedy have found cool cabbage leaves soothing when their breasts are engorged. Cabbage leaves have a role as an adjunct to the management of breastfeeding problems. It is still essential to correctly position the baby on the breast and not restrict the baby’s access to the breast.

An improvised temporary ‘aerochamber’ can be made by one of three methods:

1. Plunge the end of the puffer through the bottom of a paper or polystyrene (preferable) cup.

2. Cut the end (base) off a plastic soft drink bottle and insert the end of the puffer into the mouth of the bottle.

3. Make a cruciate incision in the base of a plastic bottle to accommodate the end of the puffer and then advise the patient to breathe through the normal bottle opening.

Breaking tablets in half

When a tablet is manufactured with a line down the middle it may be easily broken, especially if it is a big tablet with a deep scored line.

Method

1. Place the tablet on a flat surface with the line uppermost.

2. Place one finger on each side of the tablet and press down firmly (Fig. 18.5).

3. The tablet will split easily.

Swallowing tablets

This method is recommended for those who may have trouble swallowing tablets.

Method 1

Try swallowing the tablet with the head bent forward.

Method 2

Simply place the tablet on the tongue and drink water through a straw with the head slightly flexed forwards. The stream of water ‘hoses’ the tablet down the throat.

Organ removal torso model

A colourful model of the human body (head to groin) can be obtained to install in the surgery. The organs can be systematically removed and explained to the patient (Fig. 18.6).

Whiteboard

A small whiteboard can be installed, either portable or fixed to the wall, in the consulting room. A Sanford Expo kit can be installed alongside the board. It consists of a set of coloured whiteboard markers which clip onto slots in the kit, and an eraser. This is ideal for explanatory sketches.

Computer education

Your patient can be briefly taken through a patient education information program (e.g. J. Murtagh’s Patient Education, 6th Edn, McGraw-Hill Australia, Sydney, 2013) on the computer screen and then take home a printout. This can be individualised by including the patient’s name on the top of the general sheet.

This visual education can be enhanced by the use of graphics, which some practitioners who have developed skills in computing are now using with amazing effectiveness.

Advise patients to check the accuracy of information on the internet.

Some people find it difficult or unaesthetic to insert a suppository digitally. An interesting method is to rearrange a disposable plastic syringe so that it is converted into a plunger for ease of insertion of the suppository.

Rearranging the syringe

• Remove the plunger.

• Cut the end off the barrel (at the narrow end).

• Place the plunger through the opposite end at this new opening.

Inserting the suppository

• Place the suppository in the syringe barrel (Fig. 18.7).

• Firmly place the flange up against the anus.

• Press the plunger rapidly.

• To kill lice, e.g. pubic lice or those on the eyelashes, apply petroleum jelly twice daily for 8 days, then pluck off any remaining nits.

• Apply to dry and cracked skin (also useful to prevent cracking), e.g. on heels.

• Apply for the protection of normal skin surrounding lesions such as warts and seborrhoeic keratoses before the application of corrosive substances, e.g. chromic acid or liquid nitrogen.

• Use as a lubricant for rectal examination.

• Use as a lubricant and sealant for the plunger on the metal ear syringe.

• For nappy rash use it in equal parts with a mixture of hydrocortisone and antifungal creams to promote length of action of the medication.

• Heated clips for subungual haematoma (see subungual haematoma)

• Removal of foreign body from nose and ears (see removal of various foreign bodies)

• Removal of wax hearing aids

• Removal of ‘stuck’ punch biopsy specimens

• Eyelid eversion (with care)

• Pin back scalp hair during minor repairs

Fine crystalline sugar (common table sugar) can be used to help reduce oedematous swelling, for example:

• paraphimosis

• rectal prolapse

• prolapsed haemorrhoids.

There are several ‘mariner’s tips’ to prevent sea sickness, especially involving the use of ginger.

• Take a ginger preparation, e.g. drink ginger ale or ginger beer.

• Place a plug in one ear.

• Look to the horizon.

• Lie down on your back for several minutes.

Breaking off the top of those stubborn ampoules can cause injury. To reduce the risk of this, it is best to use a small file; however, even these may not be effective. If you are using your hands to complete the snap, try using a gauze swab, the alcohol swab package or an appropriate-sized plaster auriscope earpiece.

Tips from medical defence

The big six presenting problems requiring extra care and follow up:

• breast lumps

• acute abdominal pain

• acute chest pain

• sick, febrile children < 2 years

• headache

• chronic dyspnoea/cough.

10 deadly sins—resulting in negligence claims

• Poor record keeping.

• No documentation of consent process.

• The altering of records with a problem.

• Failure to follow up referrals.

• Failure to follow up test results.

• Failure to check history with scripts.

• Giving phone diagnosis and treatment.

• Rushing consultations.

• Insufficient time/care to establish sound doctor–patient rapport.

• Not saying anything if something’s gone wrong.

Handball tip (for undiagnosed multiple visits problem)

• Three strikes and you’re out.

(Dr Jill Rosenblatt)

Scalp subeorrhoea

An effective treatment is ketoconazole shampoo, e.g. Sebizole or Nizoral. A second lather must be used and this kept on the scalp for 3–5 minutes (with care to protect the eyes). This presents a challenge with the elderly showering themselves or a carer assisting.

Wax in the ears

The most effective drops are carbonide peroxide, e.g. ‘Ear Clear^®’. These may be used twice daily or even hourly during waking hours and with the resultant wax dissolution, syringing can be avoided.

Patients with dementia often do not tolerate ear syringing, but sometimes they don’t tolerate ear drops every hour either.

Impaired hearing

Up to 80% of hearing aids become expensive chest-of-drawers ornaments!

Some considerations: If you can converse easily one to one, a hearing aid should not be necessary. If a hearing aid is to be used, it should be worn in the ear with the better hearing. When in a crowded room, attempt to stand or sit next to a wall for greater sound concentration. If an audiogram demonstrates R and L hearing disparity, a CT scan should be performed.

Rhinorrhoea

Clear rhinorrhoea in the elderly may be related to lactose intolerance since a dairy-free diet is known to relieve symptoms in 4 weeks. Lactose-free milk, now readily available, and yoghurt may be used as alternatives.

Long-term, intermittent oxymetazoline nasal drops or spray, e.g. Drixine^® can be effective but the preferred treatment is lubrication of the nasal passages with an oil-based preparation such as natural sesame seed oil spray, e.g. Nozoil^®.

Insomnia

Exclude underlying causes of sleep disturbance. Avoid hypnotics if possible and in particular avoid combining them with alcohol. Ideally, the use of benzodiazepines as hypnotics should be short term only.

Sleep hygiene issues need to be discussed, consider caffeine cessation from lunch time onwards and the avoidance of electronic stimulation right up to bed time.

Paraphrenia

This is isolated paranoia in the elderly and a sign of early dementia. It can cause havoc with family, neighbours and police, with accusations of theft or property trespass. Auditory hallucinations may also be present.

Risperidone or olanzapine are very effective medications for this problem. Keep in mind that risperidone can aggravate Lewy body dementia.

Faecal impaction

A useful approach is to use macrogol 3350 (Movicol^®), up to eight sachets in 6 hours on successive days with subsequent daily Movicol^® maintenance.

Trochanteric bursalgia

This presents as pain in the affected thigh, laterally, and may radiate to the lateral knee and even into the foot. Localised tenderness over the trochanteric bursa site is confirmatory and an ultrasound may add further evidence. An injection of local anaesthetic with corticosteroid is very effective in the short term. During this procedure, a gritty end-point may be detected with the needle tip.

Benign senescent forgetfulness

This popular term is also referred to as ‘aged related memory loss’ or ‘delayed recall of ageing’ or ‘mild cognitive impairment of ageing’.

This is a common sign of ageing and may be an early symptom of dementia, which certainly develops in at least 10% of cases.

Dementia prevention strategies

This program is based on the research work of Dr Michael Valenzuela, as found in his book Maintain Your Brain (HarperCollins, Sydney, 2001).³

1. Healthy blood pressure—‘a healthy heart means a healthy brain’—the strongest evidence for dementia prevention.

2. The three keys:

   1. physical: walking 30–60 minutes 3 to 4 times a week, plus strength exercises, balance and stretching exercises—reportedly known to enhance brain cell growth, brain cell interconnections and angiogenesis

   2. mentally stimulating activities

   3. social activities in company that are both fun and rewarding.

3. Alcohol control: avoid binge drinking and always promote a safe intake, i.e. 1 to 2 standard drinks with a meal for 3 days a week.

4. Diet—Mediterranean in style, oily fish 2 to 3 times a week (consider Chia seed), 2 fruits and 5 vegetables daily.

Minor problems, even trivial to us, are commonplace and sometimes the patient or parent feels ‘short changed’ with a departing derisive comment ‘thanks anyway doc’, especially after the doctor comments, ‘it should settle without treatment’. Typical problems requiring first aid include minor wounds, minor burns especially sunburn and first degree, abrasions and grazes, musculoskeletal problems including neck and back pain/spasm, upper respiratory infections and referred pain. This issue prompted a strategy to improve the therapeutic effect on the patient—physically and psychologically. Strategies include:

• time spent with education, reassurance and counselling

• appropriate limited physical examination

• providing a patient education handout

• use of topical agents especially sprays and powders.

A cupboard containing topical agents could include the following: antiseptics, analgesics, musculoskeletal agents (especially useful for massage), inhalation or other associated therapeutic commercial or OTC items:

• Betadine^® antiseptic spray or dusting powder

• Savlon^® dry antiseptic spray (also contains povidine iodine)

• Tea-tree spray

• Isopropyl alcohol spray (as disinfectant and antiseptic)

• Ego SOOV™ burns spray (antiseptic and analgesic—contains lidocaine)

• Paxyl Sunburn Relief Spray (also contains lidocaine)

• Friar’s Balsam (many uses e.g. inhalation agent, skin/wound/blister protector; sticking agent (e.g. hair suture knots)

• Eucalyptus oil spray—antiseptic and musculoskeletal discomfort relief

• Rubesal Spray (contains camphor, menthol and salicylic acid)

• Pain Away™ Sports Spray (contains multiple naturopathic products)

• Vicks^® VapoRub

  Precautions:

• Deep and clean surgical wounds, eyes and nasal passages

• Sprays containing anaesthetic agents and other agents which may cause skin hypersensitisation and antiseptics which may irritate wounds and lead to bacterial resistance.