A

Its nature and content

General practice is a traditional method of bringing primary health care to the community. It is a medical discipline in its own right, linking the vast amount of accumulated medical knowledge with the art of communication.

Definitions

General practice can be defined as that medical discipline which provides ‘community-based, continuing, comprehensive, preventive primary care’, sometimes referred to as the CCCP model. The RACGP has defined 5 domains of general practice:

• communication skills and the doctor-patient relationship

• applied professional knowledge and skills

• population health and the context of general practice

• professional and ethical role

• organisational and legal dimensions

Unique features of general practice

Features that make general practice different from hospital or specialist-based medical practices include:

• first contact and ‘gatekeeper’

• diagnostic methodology

• early diagnosis of life-threatening and serious disease

• continuity and availability of care

• personalised care/compassion

• care of acute and chronic illness

• domiciliary care

• emergency care (prompt treatment at home or in the community)

• family care

• palliative care (at home)

• preventive care

• scope for health promotion

• holistic approach

• health care coordination

Apart from these processes, the GP has to manage very common problems including a whole variety not normally taught in medical school or in postgraduate programs. Many of these problems are unusual yet common, and can be regarded as the ‘nitty gritty’ or ‘bread and butter’ problems of primary health care.

The basic model

The use of the diagnostic model requires a disciplined approach to the problem with the medical practitioner quickly answering five self-posed questions (Table A1).

1. The probability diagnosis

This is based on the doctor’s perspective and experience of prevalence, incidence and the natural history of disease. The question is ‘for this particular patient with this specific problem/s presenting today, what is the likely diagnosis?’

2. What serious disorders must not be missed?

To achieve early recognition of serious illness the GP needs to develop a ‘high index of suspicion’. This is generally regarded as largely intuitive but is probably not so—it would be more accurate to say that it comes with experience. The serious disorders that should always be considered ‘until proven otherwise’ are listed in Table A2 and can be classified as V—vascular, I—infection (severe) and N—neoplasia esp. cancer.

Myocardial infarction, or ischaemia, is extremely important to consider as it is so potentially lethal and at times can be overlooked by the busy practitioner. Coronary artery disease may also manifest as life-threatening arrhythmias, which may present as palpitations and/or dizziness. A high index of suspicion is necessary to diagnose arrhythmias.

The concept of red flags or ‘alarm bells’ is useful in this context, e.g.:

• age >50

• sudden onset of problem

• history of cancer

• fever >37.8°C

• weight loss

• pallor

• overseas travel

• unusual vomiting

• neurological deficit

• altered cognition/consciousness

• failure to improve

• syncope at toilet

• drug or alcohol abuse

• medication e.g. steroids, biologicals

3. What conditions are often missed?

This question refers to the common ‘pitfalls’ so often encountered in general practice. This area is definitely related to the experience factor and includes rather simple non-life-threatening problems that can be so easily overlooked unless doctors are prepared to include them in their diagnostic framework. Some important pitfalls are given in Table A3.

4. The masquerades (‘chameleons’)

It is important to use a type of fail-safe mechanism to avoid missing the diagnosis of these disorders. Some practitioners refer to consultations that make their ‘head spin’ in confusion and bewilderment, with patients presenting with a ‘shopping list’ of undifferentiated or vague problems. It is with these patients that a checklist is useful.

A century ago it was important to consider diseases such as syphilis and tuberculosis as the great common masquerades, but these infections have been replaced by iatrogenesis, malignant disease, alcoholism, endocrine disorders and the various manifestations of atherosclerosis, particularly coronary insufficiency and cerebrovascular insufficiency. Endocrine disorders, often related to pituitary dysfunction (Fig. E4) is a particular challenge.

If the patient has pain anywhere, it is possible that it could originate from the spine, so the possibility of spinal pain (radicular or referred) should be considered as the cause for various pain syndromes, such as headache, arm pain, leg pain, chest pain, pelvic pain and even abdominal pain. The author’s experience is that spondylogenic pain is one of the most underdiagnosed problems in general practice.

Tables A4 and A5 provide a checklist divided into two groups of seven disorders. The first list represents the more common disorders encountered in general practice; the second includes less common masquerades although some, such as Epstein–Barr mononucleosis, can be very common masquerades in general practice.

5. Is the patient trying to tell me something?

The doctor has to consider, esp. in the case of undifferentiated illness, whether the patient has a hidden agenda for the presentation. Of course, the patient may be depressed (overt or masked) or may have a true anxiety state. However, a presenting symptom such as tiredness may represent a ‘ticket of entry’ to the consulting room. It may represent a plea for help in a stressed or anxious patient. Table A6 provides a checklist to help identify the psychosocial reasons for a patient’s malaise.

Important underlying psychosocial problems are referred to as yellow flags, e.g. Munchausen syndrome, abnormal illness behaviour, atypical signs, poor work performance, law and order incidents.

Baseball rule—for delayed diagnosis: Three strikes and you’re out—refer.

Key facts and checkpoints

The commonest causes of the acute abdomen in two general practice series were: Series 1 acute appendicitis (31%) and the colics (29%); Series 2 acute appendicitis (21%), the colics (16%), mesenteric adenitis (16%). The latter study included children.

Diagnostic guidelines

General rules

• Upper abdominal pain is caused by lesions of the upper GIT

• Lower abdominal pain is caused by lesions of the lower GIT or pelvic organs

• Early severe vomiting indicates a high obstruction of the GIT

• Acute appendicitis features a characteristic ‘march’ of symptoms: pain → anorexia → nausea → vomiting

Pain patterns

The pain patterns are presented in Figure A2. Colicky pain is a rhythmic pain with regular spasms of recurring pain building to a climax and fading. It is virtually pathognomonic of intestinal obstruction. Ureteric colic is a true colicky abdominal pain, but so-called biliary colic and renal colic are not true colics at all.

Abdominal pain in children

Abdominal pain is a common complaint in children, esp. recurrent abdominal pain.

Infantile ‘colic’ (period of infant distress)

(Syn. ‘period of purple crying’ or ‘crying and unsettled babies’.)

Typical features

• Baby 2–16 wks, esp. 10 wks

• Prolonged crying in healthy child at least 3 h/day, 3d/week for 3 months

• Crying during late afternoon and early evening

• Child flexing legs, clenching fists as if ‘stomach ache’, passes gas, red face

• Normal physical examination

Management

• Reassurance and explanation to the parents that it’s not a bowel disorder

• Pacifying methods (see Crying and fussing in infants)

• Refer to paediatrician if concerned

Medication

Avoid medications if possible but consider a trial of lactobacillus reuteri probiotics in breastfed babies.

Intussusception

Typical clinical features

Sudden onset of severe, paroxysmal, recurrent central pain with pain-free remissions.

Diagnosis

• Ultrasound (US) imaging

Treatment

• Pressure reduction by air or O₂ (preferred) or barium enema

• Surgical intervention may occasionally be necessary

Drugs

In any child esp. older complaining of acute abdominal pain, enquire into drug ingestion. A common cause of colicky abdominal pain in children is cigarette smoking (nicotine); consider other drugs such as marijuana, cocaine and heroin.

Mesenteric adenitis

This presents a difficult problem in differential diagnosis with acute appendicitis because the history can be very similar. At times the distinction may be almost impossible. In general, with mesenteric adenitis localisation of pain and tenderness is not as definite, rigidity is less of a feature, the temperature is higher and anorexia, nausea and vomiting are also lesser features. The illness lasts ~5 d followed by a rapid recovery.

Recurrent abdominal pain

Recurrent abdominal pain (RAP) occurs in 10% of school-aged children. (RAP = 3 distinct episodes of pain over 3 or more mths.) In only 5–10% of children will an organic cause be found so that in most the cause remains obscure. Consider constipation, childhood migraine, lactose intolerance.

Investigations

• Urine analysis and MSU/MCU

• FBE and ESR

• Plain X-ray (assesses faecal retention)

Specific causes of acute abdominal pain

Abdominal aortic aneurysm (AAA)

The risk of rupture is related to the diameter of the AAA and the rate of increase in diameter.

Investigations

• US (good for screening in relatives >50)

• CT scan (clearer imaging)—spiral/helical is best

• MRI scan (good definition)

Refer all cases, especially if ≥4 cm. Surgery advised if >5–5.5 cm.

Mesenteric artery occlusion

Acute intestinal ischaemia arises from superior mesenteric arterial occlusion—may be acute or chronic.

• CT scanning best definition

Management

Early surgery may prevent gut necrosis, but massive resection of necrosed gut may be required as a life-saving procedure. Early diagnosis (within a few hrs) is essential.

Acute retention of urine

Management

• Perform a rectal examination and empty rectum of any impacted faecal material; check for prostate cancer or prostatitis in the male.

• Catheterise with size 14 or 16 Foley catheter to relieve obstruction and drain. Obtain MCU. If not possible place suprapubic catheter.

• Have the catheter in situ and seek a urological opinion

• If there is any chance of recovery (e.g. if the problem is drug-induced), withdraw drug, leave catheter in for 48 h, remove and give trial of prazosin 0.5 mg bd or terazosin

• Consider simple ideas, e.g. a hot bath or stand to sound of running water

Acute appendicitis

Acute appendicitis is mainly a condition of young adults (esp. 15–25 yrs) but affects all ages (although uncommon under 3 yrs). It is the commonest surgical emergency. It is basically a clinical diagnosis.

FBE—leucocytosis: CRP ↑

Consider pelvic US in female patients.

US is 80–90% accurate for appendicitis but obesity or previous abdominal surgery affects accuracy. CT scan (95% specificity) or MRI helpful.

Management

Immediate referral for surgical removal. If perforated cover with cefotaxime (or similar) and metronidazole.

Small bowel obstruction

The symptoms depend on the level of the obstruction. The more proximal the obstruction the more severe the pain. Plain X-ray erect films confirm the diagnosis. CT scan helpful (esp. if intrinsic causation).

Management

• IV fluids and bowel decompression with nasogastric tube

• Laparotomy (not for Crohn disease) or hernia repair

Large bowel obstruction

75% caused by Ca colon: consider volvulus, ileus, constipation.

Management

Drip and suction. Surgical referral (decompression invariably required).

Perforated peptic ulcer

The clinical syndrome has three stages:

1. prostration

2. reaction (after 2–6 h)—symptoms may improve initially

3. peritonitis (after further 4 h)—severe pain

X-ray: chest X-ray may show free air under diaphragm (in 75%)—need to sit upright for 15 mins prior. Limited gastrografin meal can confirm diagnosis. CT scan is accurate.

Management

• Drip and suction (immediate nasogastric tube)

• Immediate laparotomy after resuscitation

• Conservative treatment may be possible (e.g. later presentation and gastrografin swallow indicates sealing of perforation)

Peritonitis

Can be localised, e.g. diverticulitis, appendicitis or generalised due to intraabdominal sepsis following perforation of a viscus. Can occur spontaneously with ascites. Typical signs are as for perforated peptic ulcer. Key investigations—peritoneal fluid culture and CT scan.

Management

• Surgical intervention usually required

• Antibiotics—cephalosporin or amoxy/ampicillin + gentamicin + metronidazole (IV)

Ureteric colic

Kidney (renal) colic is not a true colic but a constant pain due to blood clots or a stone lodged at the pelvic ureteric junction; ureteric colic, however, presents as severe true colicky pain due to stone movement, dilatation and spasm.

Diagnosis

• Plain X-ray: most stones (75%) are radio-opaque (calcium oxalate and phosphate). Stones <5 mm usually pass

• Intravenous pyelogram: confirms opacity and indicates kidney function (limited value)

• US: may locate calculus and exclude obstruction

• Non-contrast spiral KUB-CT is the gold standard

Management (average size adult)

• Morphine 5 mg (IV) or fentanyl 50–100 mcg IV ± metoclopramide 10 mg IM or IV or hyoscine 20 mg IM if vomiting

• Avoid high fluid intake

• Indomethacin suppositories for further pain (limited to 2/d)

Options: diclofenac 75 mg IM; ketoralac 10–30 mg IM

Biliary pain

Usually due to obstructing stone or inspissated bile (biliary sludge).

Diagnosis

• Abdominal US/DIDA or HIDA or helical CT scan

• WCC and CRP: may be ↑

Management

• Gallstone dissolution or lithotripsy

• Cholecystectomy (main procedure)

Treatment of acute cholecystitis

• Rest in bed

• IV fluids

• Nil orally

• Analgesics: morphine 2.5–5 mg IV (titrate to effect) or fentanyl 50–100 mcg IV statim then titrate to effect or Ketorolac

• Antibiotics: amoxycillin IV or IM plus gentamycin IV (if sepsis) or cephalosporins IM or IV

• Cholecystectomy

Acute pancreatitis

Diagnosis

• WCC—leucocytosis

• S. amylase or lipase (usu. × 5 increase)

• Plain X-ray, may be senital loop

• CT scan

• US (to evaluate biliary system)

Management

• Arrange admission to hospital. May require ERCP.

• Basic treatment is bed rest, nil orally, nasogastric suction (if vomiting), IV fluids, analgesics (morphine or fentanyl as above) and antiemetics IM or IV prn

Chronic pancreatitis

The pain is milder but more persistent: epigastric pain may bore through to the back. Symptoms may relapse and worsen. Investigate with CT scan and ultrasound. Weight loss and steatorrhoea may develop. Give paracetamol ± ibuprofen for pain and pancreatic enzyme supplements for steatorrhoea.

Acute diverticulitis

Occurs in <10% of patients with diverticular disease (see Diverticular disease).

Investigations

• FBE—leucocytosis: ESR ↑

• Pus and blood in stools (profuse bleeding possible in elderly)

• Abdominal US/CT scan (best—can detect fistula, abscess or perforation)

Treatment

• Nil orally

• Analgesics

• Antibiotics

  • – mild cases: amoxycillin + clavulanate bd for 5–7 d

  • – severe cases: amoxycillin IV + gentamicin IV + metronidazole IV

• Surgery for complications

Lower abdominal pain in women

A UK study of chronic lower abdominal pain in women showed the causes were adhesions (36%), no diagnosis (19%), endometriosis (14%), constipation (13%), ovarian cysts (11%) and PID (7%).

Ectopic pregnancy

Diagnosis

• Urine pregnancy tests may be +ve

• β-hCG assay (may need serial tests) if >2000 IU/L invariably +ve. If <2000 IU/L, repeat every second day to check if increasing

• Vaginal US can diagnose at 5–6 wks (empty uterus, tubal sac)

• Laparoscopy (the definitive diagnostic procedure)

Management

Treatment may be conservative (based on US and β-hCG assays); medical, by injecting intramuscular methotrexate; laparoscopic removal; or laparotomy for severe cases. Rupture with blood loss (usually about 7% of cases) demands urgent surgery.

Ruptured ovarian (Graafian) follicle (Mittelschmerz)

Typical clinical features

• Onset of pain in mid cycle

• Deep pain in one or other iliac fossa (RIF > LIF) (average 5 h)

• Often described as a ‘horse-kick pain’

• Pain tends to move centrally

• Heavy feeling in pelvis

Management

• Explanation and reassurance

• Simple analgesics: aspirin or paracetamol (acetaminophen)

• ‘Hot water bottle’ comfort if pain severe

Ruptured ovarian cyst

The cysts tend to rupture just prior to ovulation or following coitus.

• Sudden onset of pain in one or other iliac fossa

• May be nausea and vomiting

• Pain usually settles within a few hours

Signs

• Tenderness and guarding in iliac fossa

• PR: tenderness in rectovaginal pouch

Diagnosis

• US (transvaginal and abdominal views)

Management

• Appropriate explanation and reassurance

• Conservative

  • – simple cyst <4 cm

  • – internal haemorrhage

  • – minimal pain

• May need needle vaginal drainage or laparoscopic surgery

Acute torsion of ovarian cyst

Diagnosis

• US ± Doppler studies

Treatment

• Laparotomy and surgical correction

Pelvic adhesions

Pelvic adhesions may be the cause of pelvic pain, infertility, dysmenorrhoea and intestinal pain. They can be diagnosed and removed laparoscopically when the adhesions are well visualised and there are no intestinal loops firmly stuck together.

Some topical treatment regimens

Mild (comedonal ± papulo pustular)

Principle: treat comedones with a topical comedyltic (e.g. salicylic acid, retinoids) plus an antibacterial (e.g. benzoyl peroxide, azelaic acid).

First line—start with:

• use tretinoin 0.025% cream or adapalene 0.1% cream or gel, apply each night

  • if slow response after 6 weeks, add benzoyl peroxide 2.5% or 5% gel or cream once daily (in the morning)

  • maintain for 3 months and review

Alternative or add-on regimens, if persistent: clindamycin HCL 600 mg in 60 mL of 70% isopropyl alcohol (e.g. ClindaTech). Apply with fingertips twice daily.

Moderate (± trunk involvement)

• retinoid or benzoyl peroxide plus

• oral antibiotics

Oral antibiotics

Use if acne is resistant to topical agents or for inflammatory acne (moderate to severe papulopustular) ± trunk involvement. Doxycycline 100 mg/d or minocycline 50–100 mg bd for 12 wks then reduce according to response (e.g. doxycycline 50 mg for at least 6 mths to achieve maximal response). Use erythromycin 250–500 mg (o) bd if above not tolerated or contraindicated.

Other therapies

Severe cystic acne (specialist care)

• isotretinoin (Roaccutane)

• spironolactone

Females not responding to first-line treatment:

• combined low-dose oral contraceptive pill (e.g. ethinyloestradiol/cyproterone acetate (Diane-35 ED))

• Multi-system

  • – acute anaphylaxis: the onset of hypotension, bronchospasm or upper airway obstruction (features: difficult noisy breathing, wheeze/cough, tongue swelling, tightness of throat, difficulty talking, persistent dizziness or fainting)

  • – anaphylactic reactions

• Localised

  • – angioedema

  • – urticaria

Anaphylaxis and anaphylactic reactions

Treatment (adults)

First line

• Lie person flat (must not stand or walk): call for assistance

• Oxygen 6–8 L/min (by face mask) ± airway/ventilation support

• Adrenaline using autoinjector 300 mcg or 0.3–0.5 mg (1:1000) IM, best given IM in mid antero-lateral thigh (mg = mL of 1:1000 adrenaline) If no rapid improvement: repeat IM injection every 3–5 mins, then insert IV line (esp. if hypotensive)—set up an infusion 1 mg adrenaline in 1000 mL N saline (i.e. 1 mL = 1 mcg), give bolus 50 mL and then as required (best with ECG monitoring).

• Salbutamol aerosol inhalation (or nebulisation if severe)

• Infuse crystalloid solution (esp. if hypotensive), e.g. N saline (1–2 L); consider IV glucagon

• Admit to hospital (observe at least 4 h)

• Discharge on promethazine 25 mg tds + prednisolone 50 mg/d for 2 d

If not responding

Continue adrenaline every 3–5 mins:

• hydrocortisone 500 mg IV (takes 3–4 h for effect)

• establish airway (oral airway or endotracheal intubation) if required

Treatment for children (who may be pale and floppy)

• Oxygen 6–8 L/min by mask

• Adrenaline by auto-inhaler (if 10–20 kg) 125 mcg or 1:1000 (0.01 mL/kg) IM; 0.05–0.1 mL if <12 months. If poor response, repeat IM injection every 5 mins as necessary and set up infusion as for adults but lower dose of bolus.

• Admit to hospital. Observe about 4 hours (risk of biphasic reaction).

If necessary

• Hydrocortisone: 8–10 mg/kg IV

• Hypotension: colloid solutions IV (e.g. Haemaccel, stable plasma protein solution (SPPS) or Dextran 70)

• Bronchospasm: continuous nebulised salbutamol

• Upper airways obstruction

  • – mild to moderate: inhaled adrenaline (0.5 mL/kg) 1:1000 (max. 4 mL) dilute to 4 mL, with saline or water if nec.

  • – severe: intubation may be nec.

Peanut allergy

Diagnosis confirmed by demonstrating peanut-specific IgE by skin prick or RAST test. Patients should avoid peanut-containing foods and carry an anaphylaxis kit.

Adrenaline antoinjector: adult and child >30 kg—300 mcg IM; child 15–30 kg (usually 1–5 years) 0.125 mcg.

Angioedema and acute urticaria

Acute urticaria and angioedema are essentially anaphylaxis limited to the skin, subcutaneous tissues and other specific organs. They can occur together.

Treatment

Uncomplicated cutaneous swelling

• antihistamines, e.g. promethazine 25 mg (o) tds or 25 mg IM if more severe

Upper respiratory involvement

• adrenaline 0.3 mg IM

• antihistamine IM

ACS include ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTEACS), which comprise unstable angina and non-STEMIs. See Myocardial infarction and NSTEACS.

Chronic adrenal failure—usually autoimmune

Features: fatigue, a/n/v, diarrhoea, abdominal pain, weight loss, dizziness, postural hypotension, hyperpigmentation (mouth, hard palate, skin creases of palm)

Investigations: K⁺ ↑, Na⁺ ↓, glucose ↓, cortisol ↓, short synacthen stimulation test (key test); adrenal autoantibodies

NB: notorious for delayed diagnosis with possible wasting, death and Addisonian crisis provoked by stress, e.g. infection, surgery. Requires urgent resuscitation with IV fluids and hydrocortisone.

Adolescence is the name given to the psychosocial life stage which starts around the time of puberty; considered to span between the ages of 10 and 19 yrs.

Adolescent development periods

Early adolescence (10–14 yrs): ‘Am I normal?’

Middle adolescence (14–17 yrs): ‘Who am I?’

Late adolescence (17–19 yrs): ‘Where am I going?’

Hallmarks of the adolescent

The main hallmarks of the adolescent are:

• self-consciousness

• self-awareness

• self-centredness

• lack of confidence

Needs of the adolescent

Adolescents have basic needs that will allow them the optimal environmental conditions for their development:

• ‘room’ to move

• privacy and confidentiality

• security (e.g. stable home)

• acceptance by peers

• someone to ‘lean on’ (e.g. youth leader)

• special ‘heroes’

• establishment of an adult sexual role

• one good trustworthy friend

The clinical approach

Consider the mnemonic HEADS in the history:

• H—home

• E—education, employment, eating and exercise, economic situation

• A—activities, affect, ambition, anxieties

• D—drugs including cigarettes and alcohol, depression

• S—sex, stress, suicide, self-esteem, safety

During this process it is necessary to be aware of the fundamental development tasks of adolescence, namely:

• establishing identity and self-image

• emancipation from the family and self-reliance

• establishing an appropriate adult sexual role

• developing a personal moral code

• making career and vocational choices

• ego identity and self-esteem

If consulted it is necessary to conduct a physical examination and order very basic investigations if only to exclude organic disease and provide the proper basis for effective counselling. Areas of counselling and anticipation guidance that are most relevant are:

• emotional problems/depression

• significant loss (e.g. breakdown of ‘first’ love)

• sexuality

• contraception

• guilt about masturbation or other concerns

Depression, parasuicide and suicide

Up to 25% of adolescents suffer from a mental health and/or substance abuse problem, especially anxiety and depression. Difficult to treat and heavily reliant on a trusting relationship with their GP.

When dealing with adolescents it is important always to be on the lookout for depression and the possibility of suicide, which is the second most common cause of death in this group. Males successfully complete suicide 4 times more often than females, while females attempt suicide 8–20 times more often than males.

Treatment of depression

Non-pharmacological interventions (all grades)

• general support and education

• family therapy

• interpersonal psychotherapy

• CBT

Medication

• mild: not recommended

• moderate to severe: consider fluoxetine 10 mg/d ↑ to 20 mg/d (max: 80); continue for 6–12 mths after recovery

Referral to a psychiatrist is advisable.

Excessive and harmful drinking

For men, excessive drinking is more than 4 SDs/d. For women, drinking becomes a serious problem at >2 SDs/d. This level can also affect the foetus of the pregnant woman. High-risk or harmful drinking occurs at more than 6 drinks a day for men and 4 drinks a day for women.

Laboratory investigations

The following blood tests may be helpful in the identification of excessive chronic alcohol intake:

• blood alcohol

• serum GGT ↑ in chronic drinkers (returns to normal with cessation of intake)

• MCV: >98 fL (i.e. macrocytosis)

• carbohydrate deficient transferrin ↑ in chronic drinkers

Measuring alcohol intake

One SD contains 10 g alcohol—1 middy (or pot) of standard beer (285 mL), 2 middies of low-alcohol beer or 5 middies of super-light beer. These are equal in alcohol content to one small glass of table wine (120 mL), one glass of sherry or port (60 mL) or one nip of spirits (30 mL).

Approach to management

The challenge to the family doctor is early recognition of the problem. Several studies have shown that early intervention and brief counselling by the doctor are effective in leading to rehabilitation. Some of the results are very revealing:

• Patients expect their family doctor to advise on safe drinking levels.

• They will listen and act on our advice.

• Treatment is more effective if offered before dependence or chronic disease has developed.

A brief practical management plan

A six-step management plan, which has been employed in a general-practice early intervention program, is as follows:

1. Feed back the results of your assessment and specifically the degree of risk associated with their daily alcohol intake and bout drinking. Emphasise any damage that has already occurred.

2. Listen carefully to their reaction. They will need to ventilate their feelings and may respond defensively.

3. Outline the benefits of reducing drinking (e.g. save money, better health).

4. Set goals for alcohol consumption which you both agree are feasible.

   • For men: aim for fewer than 12 SDs/week.

   • For women: aim for fewer than 8 SDs/week.

   • For patients with severe ill effects and who are physically dependent on alcohol, long-term abstinence is advisable.

5. Set strategies to keep below the upper low-risk limits, e.g:

   • Quench thirst with non-alcoholic drinks before having an alcoholic one.

   • Switch to low-alcohol beer.

   • Take care which parties you go to.

   • Explore new interests, e.g. fishing, cinema, social club, sporting activity.

6. Evaluate progress by having patients monitor their drinking by using a diary. Make a definite appointment for follow-up and give appropriate literature such as Alcohol and Health. Obtain consent for a telephone follow-up. A useful minimum intervention plan is presented in Table A9.

Follow-up (long consultation 1 week later)

Review the patient’s drinking diary. Explore any problems, summarise, listen and provide support and encouragement. If appointment is not kept, contact the patient.

‘Anti-craving’ drugs

The following show a modest effect on assisting abstinence:

• acamprosate 666 mg (o) tds

• naltrexone 50 mg (o) daily (close supervision required)

A combination of these is more effective in preventing relapse than individual drugs.

Recommended treatment for early withdrawal symptoms

• Diazepam 20 mg (o) every 2–6 h (up to 60–100 mg (o) max. daily) titrated against clinical response (taper off after 2 d)

• If psychotic features, add haloperidol 0.5–2 mg (o) bd

• Thiamine 300 mg IV daily for 5 d, then 300 mg (o) daily

• Vitamin B group supplement (o) or IM daily

Features

• Patch of complete hair loss and clean scalp

• Exclamation mark hairs

• Small patches may recover spont. (~80%)

Treatment

• Topical potent topical corticosteroids (e.g. betamethasone diproprionate 0.05% cream or lotion) bd—12 wks

• Intradermal injections of triamcinolone (Kenacort A10) or

• Minoxidil 5% 1 mL, bd applied to dry scalp (for 4 or more mths) only when hair growing

Androgenetic alopecia (male pattern baldness) See Androgenic alopecia

Treatment for men

• Counsel re. accepting problem

• Alternatives—wear toupee, wig or hair transplant

Medications

• Minoxidil 5%, 1 mL, applied bd to dry scalp (at least 6–12 mths) but expensive and hair loss resumes on cessation

• Finasteride 1 mg (o) daily for min. 2 yrs. Same problem as above

Treatment for women

• Counselling

• Alternatives—hair styling, wigs, camouflage

Medications

• Minoxidil (as for men)

• Spironolactone or cyproterone acetate (specialist supervision)

The amnesias are disorders involving partial or total inability to recall past experiences. Causes include psychogenic (conversion disorder, fugue states, factitious, severe anxiety and stress, major depression etc.), Wernicke–Korsakoff syndrome (alcohol), post-trauma, transient organic states (CVA, epilepsy, hypoxia, cerebral infection, drugs, etc.), cerebral tumour, SAH, various drugs (alcohol, cannabis, antiepileptics, digoxin, methamphetamines, etc.) and transient global amnesia.

Transient global amnesia

• Benign condition of middle-aged and elderly

• Acute onset profound amnesia; also anterograde and retrograde amnesia

• State of bewilderment (e.g. ‘Where am I?’); repetitive queries

• Self-limited—usu. 4–8 (up to 24) h

• Complete resolution

• Usually single episode (20% recurrence)

• May be precipitating event (e.g. stress)

• No other neurological symptoms or signs

• Able to perform complex motor skills (e.g. driving)

• Good prognosis: complete resolution

• Investigations generally unhelpful; witness of event essential for diagnosis

• No active treatment recommended: reassurance and explanation

Anaemia is a label, not a specific diagnosis. Anaemia is defined as a haemoglobin (Hb) below the normal reference level for the age and sex of that individual. Symptoms include tiredness/fatigue, weakness, headache, faintness, effort angina and dyspnoea, palpitations, intermittent claudication.

Definition:

• Hb <130 g/L (♂)

• Hb <120 g/L (♀) <110 g/L—pregnant women, schoolchildren

Classification of anaemia

The various types of anaemia are classified in terms of the red cell size—the MCV.

Microcytic anaemia—MCV ≤80 fL

The main causes of microcytic anaemia are iron deficiency and haemoglobulinopathy, particularly thalassaemia.

Iron-deficiency anaemia

Iron deficiency is the most common cause of anaemia worldwide. The most common causes are chronic blood loss (haemorrhoids, menorrhagia, peptic ulcers, cancer, etc.) and poor diet.

Haemological investigations: typical findings

• Microcytic, hypochromic red cells

• Anisocytosis (variation in size), poikilocytosis (shape)

• Low s. iron

• ↑ Iron-binding capacity

• Low s. ferritin (NR: ♀ 15–200 mcg/L; ♂ 30–300 mcg/L, the most useful index)

• ↑ soluble transferrin receptor factor

Treatment

• Correct the identified cause

• Iron preparations:

  • – oral iron (preferred method), e.g. Ferro-Gradumet 325 mg (o) daily with orange juice or ascorbic acid until Hb is normal; can combine with folic acid

  • – parenteral iron is best reserved for special circumstances and with specialist advice. IM can cause a ‘tattoo’ effect. Give 0.5–1 g ferric carboxymaltose IV (consider cover with IV hydrocortisone 30 mins before)

Avoid transfusion if possible.

Response

• Anaemia responds after ~2 wks and is usually corrected after 2 mths

• Oral iron is continued for 3–6 mths to replenish stores

• Monitor progress with regular s. ferritin

• A s. ferritin >50 mcg/L generally indicates adequate stores

Thalassaemia

The heterozygous form is usually asymptomatic; patients show little if any anaemia. The homozygous form is a very severe congenital anaemia needing lifelong transfusional support to keep Hb >90 g/L plus iron chelators.

The key to the diagnosis of the heterozygous ‘thalassaemia minor’ is significant microcytosis quite out of proportion to the normal Hb or slight anaemia, and confirmed by finding a raised HbA₂ on Hb electrophoresis or by DNA analysis. It must be distinguished from iron-deficiency anaemia, for iron does not help thalassaemics and is theoretically contraindicated.

Macrocytic anaemia—MCV >100 fL

Vitamin B₁₂ deficiency (pernicious anaemia)

The clinical features are anaemia (macrocytic), weight loss and neurological symptoms, esp. a polyneuropathy. The serum vitamin B₁₂ is below the normal level.

Replacement therapy

• Vitamin B₁₂ (1 mg) IM injection: body stores (3–5 mg) are replenished after 10 injections given every 2–3 d + oral folate 5 mg (0) d

• Maintenance with 1 mg injections every 3 mths

Folic acid deficiency

The main cause is poor intake associated with old age, poverty and malnutrition, usually associated with alcoholism. It may be seen in malabsorption and regular medication with anti-epileptic drugs such as phenytoin. It is rarely, but very importantly, associated with pregnancy. The best test is red cell folate (N 360–1400 nmol/L).

Replacement therapy

Oral folate 5 mg/d, to replenish body stores (5–10 mg) in ~4 wks, continue for 4 months. Vitamin B12 usually given unless levels normal.

This is an oppressive retrosternal discomfort that radiates to the arms, jaw and throat. If unstable, it is considered a pre-myocardial infarct.

Management of stable angina

• Attend to any risk factors

• If inactive, take on an activity such as walking for 20 mins a day

• Regular exercise to the threshold of angina

• Relaxation program

• Avoid precipitating factors

• Don’t excessively restrict lifestyle

Medical treatment

The acute attack

• Glyceryl trinitrate 600 mcg tab or 300 mcg (1/2 tab) SL or

• Glyceryl trinitrate SL spray: 1–2 sprays; rpt after 5 mins if pain persists (max. 3 doses) or

• Isosorbide dinitrate 5 mg SL; rpt every 5 mins (max. 3 doses) or

• Nifedipine 5 mg capsule (suck or chew), if intolerant of nitrates or

• Aspirin 150 mg (o)

Advise that if no relief after 2–3 tabs, get medical advice.

Avoid nitrates if s. phosphodiesterase inhibitors used for ED in past 1–5 d.

Mild stable angina

Angina that is predictable, precipitated by more stressful activities and relieved rapidly

• Aspirin 150 mg (o)/d (use clopidogrel 75 mg (o)/d if intolerant)

• Glyceryl trinitrate (SL or spray) prn (use early)

• Consider a beta-blocker or long-acting nitrate or nicorandil

Moderate stable angina

Regular predictable attacks precipitated by moderate exertion

• As above plus

• Beta-blocker, e.g. atenolol 50–100 mg (o) once/d or metoprolol 25–100 mg (o) once/d, starting with the lowest dose and increasing as necessary

• Glyceryl trinitrate (ointment or patches) daily (12–16 h only) or isosorbide mononitrate 60 mg (o) SR tablets mane (12-h span)

If not controlled

Add a dihydropyridine Ca-channel blocker:

• nifedipine controlled release 30–60 mg (o)/d or

• amlodipine 2.5–10 mg (o) once/d

If beta-blocker contraindicated, use:

• diltiazem SR 90 mg (o) bd (max. 240 mg/d) or CR 180–360 mg (o)/d, or

• nicorandil 5 mg (o) bd, ↑ to 10–20 mg bd after 1 wk

Persistent or refractory angina

Consider ivabradine but patients require specialist evaluation for suitability for a corrective procedure (see below).

Unstable angina

Hospitalise for stabilisation and further evaluation. The objectives are to optimise therapy, give IV trinitrate and heparin and consider coronary angiography with a view to a corrective procedure such as CABG surgery or percutaneous transluminal angioplasty stenting.

Anorectal pain

The patient may complain that defecation is painful or almost impossible because of anorectal pain.

Anal fissure

Anal fissures cause pain on defecation and usually develop after a period of constipation (may be brief period) and tenesmus.

Treatment—milder cases

In a milder case of anal fissure the discomfort is slight, anal spasm is a minor feature and the onset is acute.

An acute fissure will usually heal spontaneously or within a few weeks of a high-fibre diet, warm sitz baths after bowel movements and laxatives.

Conservative management (if persistent)

• Xyloproct, Proctosedyl or Scheriproct suppositories or ointment or

• Glyceryl trinitrate ointment (Nitro-bid 2%) diluted 1 part with 9 parts white soft paraffin applied to the lower anal canal (e.g. Rectogesic 2% ointment gently inserted with a gloved finger tds for 4 wks). An alternative is 2% diltiazem cream twice daily for 6–8 weeks.

Prevention

• High-residue diet (consider the addition of bran or wheat preparations) to give soft faeces

• Avoidance of constipation with hard stools (aim for soft bulky stools)

More severe chronic fissures

The feature here is a hyperactive anal sphincter, and a practical procedure such as injection of botulinum toxin into the sphincter is necessary to solve this painful problem. Otherwise more radical surgery is necessary—lateral internal sphinecterotomy is the gold standard.

Proctalgia fugax

Main features:

• fleeting rectal pain

• varies from mild discomfort to severe spasm

• lasts 3–30 mins

• often wakes patient at night

• a functional bowel disorder

• affects adults, usu. professional males

Management

• Explanation and reassurance

• Salbutamol inhaler (2 puffs statim) or glyceryl trinitrate SL spray statim or quinine sulphate before retiring worth a trial

Perianal haematoma

Within 24 h of onset: simple aspiration of blood or surgical drainage under LA Within 24 h to 5 d of onset: express thrombus through small incision under LA (deroof skin)

Day 6 onwards: leave alone unless very painful or infected

Strangulated haemorrhoids

A marked oedematous circumferential swelling will appear if all the haemorrhoids are involved. If only one haemorrhoid is strangulated, proctoscopy will help to distinguish it from a perianal haematoma. Initial treatment is with rest and ice packs prior to haemorrhoidectomy at the earliest possible time. Relatively urgent referral is recommended.

Perianal abscess

Careful examination is essential to make the diagnosis. Look for evidence of a fistula, Crohn disease and anorectal cancer.

Treatment

Drainage via a deep cruciate incision over the point of maximal induration. If abscess is recalcitrant or spreading with cellulitis use metronidazole 400 mg (o) 12 hrly for 5–7 d + cephalexin 500 mg (o) 6 hrly for 5–7 d.

Anorectal lumps

Skin tags

The skin tag is usually the legacy of an untreated perianal haematoma. It may require excision for aesthetic reasons, for hygiene or because it is a source of pruritus ani or irritation.

Perianal warts

It is important to distinguish the common viral warts from the condylomata lata of secondary syphilis. Local therapy includes the application of podophyllin every 2 or 3 days by the practitioner or imiquimod cream by the patient.

Internal haemorrhoids

Haemorrhoids or piles are common and tend to develop between the ages of 20 and 50. The commonest cause is chronic constipation related to a lack of dietary fibre.

Treatment

The treatment of haemorrhoids is based on three procedures: injection, cryotherapy and sphincterotomy. Surgery is generally reserved for large strangulated piles. The best treatment, however, is prevention, and softish bulky faeces that pass easily prevent haemorrhoids.

Rectal prolapse

This may be of rectal mucosa (partial) or rectal wall (total). Visualisation is important for diagnosis. Surgery such as rectopexy may be necessary for complete prolapse.

Anal (faecal) incontinence

Initial approaches for this common problem include counselling, diet to produce thicker stools, pelvic floor exercises and medication such as loperamide. Otherwise refer to a colorectal surgeon for consideration for surgical repair (e.g. insertion of the Acticon Neosphincter).

Anorectal bleeding

Key history

Nature of the bleed, including fresh versus altered blood, mixed with faeces and/or mucus, in toilet bowl or on underwear. Quantity of bleeding: slight, moderate or torrential. Associated symptoms (e.g. weight loss, constipation, diarrhoea, pain, weakness, presence of lumps, urgency, unsatisfied defecation, recent change of bowel habit).

Key examination

• General inspection (evidence of anaemia) and vital signs

• Abnormal examination, anal inspection, digital rectal examination, proctosigmoidoscopy

Key investigations

• FBE and ESR

• Stool M&C

• Faecal occult blood

• Colonoscopy

• Consider abdominal X-ray, CT colonography, angiography, small bowel enema (depending on clinical findings)

Diagnostic tips

• Black, tarry (melaena) stool indicates bleeding from upper GIT: rare distal to lower ileum

• Frequent passage of blood and mucus indicates a rectal tumour or proctitis. Check for other ‘red flags’, e.g. family history, carcinoma, brisk bleeding

• If substantial haemorrhage, consider diverticular disease, angiodysplasia or more proximal lesions (e.g. Meckel diverticulum, duodenal ulcers)

• New bleeding age >50 years demands colonic investigation

• 80% of rectal tumours are within fingertip range

• In young adults, diagnosis is likely to be haemorrhoids or a fissure

See Thrombotic disorders and anticoagulation

Anxiety is an uncomfortable inner feeling of fear or imminent disaster. The criterion for anxiety disorder as defined at the International Classification of Health Problems in Primary Care (ICHPPC-2–Defined) is:

Classification of anxiety

The following list represents approximately the categories of anxiety disorders recognised by the DSM-5.

• generalised anxiety disorder

• panic disorder with or without agoraphobia

• specific phobia

• social anxiety disorder (phobia)

• phobic disorders

• separation anxiety disorder

• obsessive-compulsive disorder

• post-traumatic stress disorder

• acute stress disorder

• adjustment disorder with anxious mood

• somatoform disorder

Generalised anxiety disorder

Generalised anxiety comprises excessive anxiety and worry about various life circumstances occurring more days than not for at least six months and is not related to a specific activity, time or event such as trauma, obsessions or phobias. It is associated with three or more of the following six symptoms:

1. restlessness or feeling keyed up or on edge

2. being easily fatigued

3. difficulty concentrating or mind going blank

4. irritability

5. muscle tension

6. sleep disturbance

Management

Management applies mainly to generalised anxiety as specific psychotherapy is required in other types of anxiety. Psychological interventions are the first-line therapy. Much can be carried out by the family doctor using brief counselling and support:

• Use non-pharmacological methods

• Give explanation and reassurance

• Promote stress management techniques, inc. meditation

• Give advice on coping skills

• Avoid the use of drugs if possible

• Provide ongoing supportive psychotherapy with specialised psychotherapies, particularly CBT. Consider mindfulness therapy.

Pharmacological treatment

Acute episodes

For intermittent transient exacerbations not responding to other measures and especially with more severe symptoms.

• diazepam 2–5 mg (o) as a single dose repeated bd as required or

• diazepam 5–10 mg (o) nocte

Special notes:

• Recommended (if nec.) for up to 2 wks, then taper off to zero over next 4 wks.

• Consider beta-blockers in patients with sympathetic activation such as palpitations, tremor and excessive sweating (e.g. propranolol 10–40 mg (o) tds). However, they do not relieve the mental symptoms of anxiety.

Long-term treatment

If non-pharmacological treatment is ineffective for persisting disabling anxiety the drugs of choice are an SSRI such as:

• sertraline 25 mg (o) daily, increasing to 200 mg/day with care; SNRIs also, e.g. venlafaxine (controlled release) 75 mg (o) mane increasing gradually to 225 mg/d continue for several wks after symptoms subside and wean off after 6 mths or

• duloxetine 30 mg (o) daily initially, increasing as necessary to max. 120 mg/d

Panic disorder

Patients with panic disorder experience sudden, unexpected, short-lived episodes of intense anxiety. These tend to be recurrent and occur most often in young females. Follow DSM-5 guidelines for diagnosis.

Management

First-line: reassurance, explanation and psychological support (as for generalised anxiety).

Cognitive behaviour therapy

This aims to reduce anxiety by teaching patients how to identify, evaluate, control and modify their negative, fearful thoughts and behaviour. If simple psychotherapy and stress management fails, then patients should be referred for this therapy.

If hyperventilating, breathe in and out of a paper bag (see Hyperventilation).

Pharmacological treatment

Acute episodes:

• diazepam 5 mg (o) or

• oxazepam 15–30 mg (o) or

• alprazolam 0.25–0.5 mg (o) or

• paroxetine 20–60 mg (o)

Prophylaxis

SSRIs and venlafaxine CR are first-line pharmacotherapy.

Note: They should be introduced slowly and increased with care according to response and tolerance.

Phobic disorders

In phobic states the anxiety is related to specific situations or objects. Patients avoid these situations and become anxious when they anticipate having to meet them.

The three main types of phobic states are: simple phobias, agoraphobia, social phobias.

The 10 most common phobias (in order) are: spiders, people and social situations, flying, open spaces, confined spaces, heights, cancer, thunderstorms, death and heart disease.

Management

The basis of treatment for all phobic disorders is psychotherapy that involves behaviour therapy and cognitive therapy.

Pharmacological treatment

This should be used only if non-pharmacological measures fail.

• Agoraphobia with panic: use medications as for panic attacks

• Social phobia with performance anxiety: propranolol 10–40 mg (o) 30–60 mins before the social event or performance. Otherwise use an SSRI for problematic social phobia. Benzodiazipenes are not recommended.

Obsessive–compulsive disorder

Management

Optimal management is a combination of psychotherapeutic esp. CBT and pharmacological treatment, namely:

• cognitive behaviour therapy for obsessions

• exposure and response prevention for compulsions

Drug management includes any one of the SSRIs (proven efficacy), e.g. fluoxetine 10–80 mg (o)/d; or paroxetine 10 mg (o) daily or clomipramine

Acute stress disorder

This is abnormal anxiety related symptoms occuring within 4 weeks of a traumatic event and resolving within a 3 month period. The symptoms are grouped as intrusive phenomena, hyperarousal phenomena and avoidance of reminders. Treatment is based on debriefing and counselling.

Post-traumatic stress disorder

PTSD is the symptoms of acute stress disorder persistent for 3–6 months after exposure. Delayed PTSD is onset of symptoms at least 6 months after the stressor.

PTSD has a cluster of three features:

• re-experiencing symptoms e.g. nightmares, flashbacks

• hyperarousal phenomenoma e.g. irritability, sleep disturbance

• avoidance and numbing

Treatment

This is difficult and involves counselling, the basis of which is facilitating abreaction of the experience by individual or group therapy. The aim is to allow the patient to face up openly to memories. Persistent symptoms are an indication for referral for specialist-administered trauma-focused psychological therapy.

Pharmacological treatment

There is no specific indication for drugs but medication can have benefit in the treatment of panic attacks, generalised anxiety or depression. A SSRI is the first-line agent, then mirtazapine.

Associations to consider:

• blood dyscrasia, denture pressure, Crohn disease, coeliac disease pernicious anaemia, Behcet disease, iron deficiency, excessive stress

Minor ulcers: <5 mm in diameter—last 5–10 d

Major ulcers: >8 mm in diameter—last weeks and heal with scarring. Refer a non-healing ulcer for biopsy within 3 wks of presentation.

Treatment methods (use early when ulcer worse)

Consider applying a wet, squeezed-out, black teabag directly to the ulcer regularly (the tannic acid promotes healing).

Symptomatic relief

• Apply topical lignocaine gel or paint (e.g. SM-33 adult paint formula or SM-33 gel (children) every 3 h). If applied before meals, eating is facilitated or

• Eutectic EMLA cream 5 g applied on a cotton bud for 5 mins

Healing

One of the following methods can be chosen:

• Triamcinolone 0.1% (Kenalog in orobase) paste apply 8 hrly and nocte (preferred method) or

• Hydrocortisone lozenges dissolved on ulcer qid or

• Beclomethasone dipropionate spray onto ulcer tds or

• Dissolve 1 g sucralfate in 20–30 mL, of warm water. Use this as a mouth wash

Major ulceration—consider:

• oral prednisolone 25 mg daily 5–7 days or

• injection of steroids into base of ulcer

The various causes of the painful arm can be considered with the diagnostic model (Table A13).

Pulled elbow

• Child under 8 yrs, usually 2–5 yrs

• Child refuses to use arm, which may be limp by the side

Treatment

• Parental help

physical manoeuvres to consider

• Manoeuvre A: Supination flexion: Support radial head with one hand, flex elbow, then suddenly twist forearm into full supination or supinate the forearm, then flex the elbow

• Manoeuvre B: Hyperpronation flexion: support radial head, fully pronate forearm, then flex elbow

• Manoeuvre C: Gently alternate supination and pronation with elbow slightly flexed.

Note: If uncooperative, send home in sling (may resolve itself)

Tennis elbow

Management

• Rest from offending activity

• RICE and oral NSAIDs if acute

• Exercises-strengthening, e.g. dumbbell exercise over table—palm facing down for lateral epicondylitis; palm facing up for medial epicondylitis or towelette wringing exercise

Additional (if refractory):

• steroid/LA injection (max. 2)

• manipulation or

• surgery

Olecranon bursitis

For chronic recurrent traumatic bursitis with a synovial effusion:

• partial aspiration of fluid

• inject corticosteroid through same needle

Trigger finger/thumb

Consider an injection of 1 mL of long-acting corticosteroid with LA into the tendon sheath adjacent to the swelling. Otherwise surgical release repair.

Game keepers thumb (skiers thumb)

Disruption of ligaments of metacarpophalangeal joint and possible fracture of base of proximal phalanx. Diagnosis on stress views on X-ray. May require surgical repair.

Raynaud phenomenon and disorder

Exclude and treat underlying causes, e.g. CTDs.

Treatment (options)

• Total body protection from cold—layered clothing, electric blanket at night

• Gloves, mittens and thick woollen socks

• Avoid smoking

• Vasodilators (e.g. amlodipine (o) 5–20 mg/d or nifedipine SR 30–60 mg/d) in cold weather

• Topical glyceryl trinitrate ointment—over radial artery or dorsum of hand

• Consider sympathectomy

Chilblains

(See Chilblains)

Carpal tunnel syndrome

Pain in the arm, possibly radiating to shoulder. Paraesthesia of pulps of thumb, index, middle and half of ring finger. Exclude rheumatoid, granulomatous disorders, endocrine disorders, Paget disease, hypothyroidism, amyloidosis.

Treatment (options)

• Surgical decompression (best)

• Injection of LA corticosteroid into tunnel

• US therapy

• Neutral wrist splints (bedtime)

Key history

Note the pattern of joint involvement (monoarticular or polyarticular), immediate and more recent history, family history and drug use.

Enquire whether the joint pain is acute or insidious and confined to specific joints or fleeting as in rheumatic fever.

Key examination

A systematic examination of the affected joint or joints should look for signs of inflammation, deformity, swelling and limitation of movement.

Searching for associated systemic disease such as connective tissue disorders and infection demands examination of the chest, heart and abdomen.

Key investigations

• FBE

• ESR & CRP

• Uric acid

• Urine analysis

• Joint X-rays

• Synovial fluid analysis and culture Red flag pointers for polyarthritis

  • fever

  • weight loss

  • profuse rash

  • lymphadenopathy

  • cardiac murmur

  • severe pain and disability

  • malaise and fatigue

  • vasculitic signs

  • two or more systems involved

• RA factor

• Autoantibodies (ANA, dsDNA, ENA), anti-CCP antibody (for RA)

• Other tests according to findings of tests for infection (e.g. specific serology, blood culture)

Osteoarthritis

Treatment (optimal)

• Explanation: patient education and reassurance that arthritis is not the crippling disease perceived by most patients. Consider CBT.

• Rest: during an active bout of inflammatory activity only.

• Exercise: a graduated exercise program is essential to maintain joint function. Aim for a good balance of relative rest with sensible exercise.

• Heat: recommended is heat packs, a hot water bottle, warm bath or electric blanket to soothe pain and stiffness. Advise against getting too cold.

• Diet: if overweight it is important to reduce weight to ideal level.

• Physiotherapy: referral should be made for specific purposes such as exercises and supervision of a hydrotherapy program.

• Occupational therapy: refer for advice on aids in the home.

• Simple analgesics (regularly for pain): paracetamol is the basic analgesic (avoid opioids such as codeine or dextroproproxyphene preparations and aspirin if recent history of dyspepsia or peptic ulceration).

• NSAIDs and aspirin: the first-line drugs for more persistent pain or where there is evidence of inflammation. The risk versus benefit equation always has to be weighed carefully. As a rule, NSAIDs (e.g. ibuprofen) should be used sparingly if possible. Aim for short courses of 14–20 d. The COX2 specific inhibitors should be considered where there is an indication for an NSAID but the risk of NSAID-induced ulceration and bleeding is high.

• Consider duloxetine for some people when pain relief is inadequate.

• Intrarticular corticosteroids: as a rule IA corticosteroids are not recommended but occasionally can be very effective for an inflammatory episode of distressing pain (e.g. a flare-up in an osteoarthritic knee).

• Referral for surgical intervention: for debilitating and intractable pain or disability. Examples include OA of hip, knee, shoulder, first CMC joint of thumb and first MTP joint.

Rheumatoid arthritis

Investigations

• ESR usu. raised according to active disease

• Anaemia (normochromic and normocytic) may be present

• Rheumatoid factor— +ve in ~70–80%, not specific

• Anti-cyclic citrinullated peptide AB test—specific

• X-ray changes

Management principles

Give patient education, support and appropriate reassurance. The diagnosis generally has distressful implications so the patient and family require careful explanation and support. It should be pointed out that the majority of patients have little or no long-term problems. Refer to rheumatologist for shared care—this referral is very important to outcome.

Specific advice

• Rest and splinting: this is necessary where practical for any acute flare-up of arthritis.

• Exercise: it is important to have regular exercise esp. walking and swimming. Hydrotherapy in heated pools.

• Referral to physiotherapists and occupational therapists: expertise in exercise supervision, physical therapy and advice regarding coping in the home and work is important.

• Joint movement: each affected joint should be put daily through a full range of motion to keep it mobile and reduce stiffness.

Pharmaceutical agents

1. simple analgesics (e.g. paracetamol)

   NSAIDs (use with caution)

2. glucocorticoids: prednisolone 5–10 mg (o)/d (max 15 mg/d)

   Consider: in severe disease or failure of other agents

3. DMARDs, e.g. hydroxychloroquine

   gold compounds (IM or orally)

   D-penicillamine

   sulfasalazine

   immunosuppressive agents, e.g. methotrexate (the ‘backbone’ of therapy), azathioprine, cyclophosphamide, leflunomide, ciclosporin

   fish body oil (Omega-3)

Standard initial drug therapy RA

• methotrexate 5–10 mg (o)/wk, ↑ to max. 25 mg depending on clinical response and toxicity + folic acid 5 mg tds. Introduce early if indicated.

For failed therapy

• consider standard triple combination therapy, e.g.

  methotrexate + sulfasalazine + hydroxychloroquine

Consider (if remission not achieved with methotrexate): addition of a biological DMARD, e.g. adalimumab, entanercept, anakinra, golimumab.

Connective tissue disorders

The main CTDs have the common feature of arthritis or arthralgia. They include SLE, scleroderma, polymyositis and Sjögren syndrome. Other common features include vasculitis and multisystem involvement. They are autoimmune diseases and should be referred for shared care.

Systemic lupus erythematosus (SLE)

Arthritis is the commonest clinical feature of SLE (over 90%). It is a symmetrical polyarthritis involving mainly small and medium joints, esp. the proximal interphalangeal and carpal joints of the hand.

The initial presentation is similar to rheumatoid arthritis. If suspected, test ANA and, if +ve, DNA and ENA Antibodies (Abs).

DxT: polyarthritis + fatigue + skin lesions → SLE

Investigations

• ESR—proportional to disease activity

• Antinuclear antibodies—+ve in at least 95%

• ds DNA Abs → 95% specific for SLE but present in only 60%

• ENA Abs, esp. Sm—highly specific

• Rheumatoid factor—+ve in 50%

• LE test—inefficient and not used

Drug treatment

• Mild—NSAIDs/aspirin (for arthralgia)

• Moderate—low-dose antimalarials (e.g. hydroxychloroquine)—up to 6 mg/kg once/d for 3 mths, then 200 mg/d long term

• Moderate to severe—corticosteroids (mainstay drug); immunosuppressive drugs (e.g. azathioprine, methotrexate + folic acid); bDMARDs useful for severe arthralgia

• Consider fish body oil 0.2 mg/kg (o) daily (usually 2.7 g)

Scleroderma

This can present as a polyarthritis affecting the fingers of the hand in 25% of patients, esp. in the early stages. Scleroderma mainly affects the skin, presenting with Raynaud phenomenon in over 85%.

DxT: finger discomfort + arthralgia + GORD (± skin tightness) → scleroderma

Investigations (no specific diagnostic tests)

• ESR may be raised

• Antinuclear Abs → 90% +ve

• Rheumatoid factor—+ve in 30%

• Antinucleolar and anticentromere Abs—specific

Treatment

• Analgesics and NSAIDs for pain

• Avoid vasospasm (no smoking, β blockers, ergotamine)

• CCBs as for Raynaud

• D-penicillamine for skin or systemic involvement

• Proton-pump inhibitors for GORD

Polymyositis and dermatomyositis

Arthralgia and arthritis occur in ~50% of patients and may be the presenting feature before the major feature of muscle weakness and wasting of the proximal muscles of the shoulder and pelvic girdles appear. The small joints of the hand are usually affected and it may resemble rheumatoid arthritis. Polymyositis + associated rash = dermatomyositis.

Sjögren syndrome (SS)

SS is the dry eyes (kerato conjunctivitis sicca) in absence of any other autoimmune disease.

DxT: dry eyes + dry mouth + arthralgia → Sjögren syndrome

Diagnosis: +ve ENA. Ro (SSA). La (SS-B) Abs

Treatment: symptomatic for sicca; hydroxychloroquine or steroids for arthritis

Crystal arthritis

Arthritis, which can be acute, chronic or asymptomatic, is caused by a variety of crystal deposits in joints. The three main types of crystal arthritis are monosodium urate (gout) (see Gout), calcium pyrophosphate dihydrate and calcium phosphate (usually hydroxyapatite).

The spondyloarthropathies

The spondyloarthropathies are a group of disorders with common characteristics affecting the spondyles (vertebrae) of the spine. Apart from back pain this group tends to present with oligoarthropathy in younger patients (see The spondyloarthritides).

The group includes: ankylosing spondylitis; reactive arthritis; inflammatory bowel disease (enteropathic arthritis); psoriatic arthritis; juvenile chronic arthritis; unclassified spondyloarthritis—partial features only.

Ankylosing spondylitis

This usually presents with inflammatory back pain (sacroiliac joints and spine) and stiffness in young adults and 20% present with peripheral joint involvement before the onset of back pain. It usually affects the girdle joints (hips and shoulders), knees or ankles.

Key clinical features

• Insidious onset of discomfort

• Age less than 40 yrs

• Low back pain persisting for >3 mths

• Associated morning stiffness >30 mins

• Improvement with exercise or NSAIDs, not relieved by rest

• Sacroiliitis

• Limitation of lumbar spinal motion in sagittal and frontal planes

Reactive arthritis

This is a form of reactive arthropathy in which non-septic arthritis and often sacroiliitis develop after an acute infection with specific venereal or dysenteric organisms.

Enteropathic arthritis

Inflammatory bowel disease (ulcerative colitis, Crohn disease and Whipple disease) may be associated with peripheral arthritis and sacroiliitis.

Psoriatic arthritis

Like Reiter syndrome, this can develop a condition indistinguishable from ankylosing spondylitis. It is therefore important to look beyond the skin condition of psoriasis, for ~5% will develop psoriatic arthropathy.

Management principles of spondyloarthropathies

• Identify the most active elements of the disease and treat accordingly.

• Provide patient and family education with appropriate reassurance.

• Refer for physiotherapy for exercises, postural exercises and hydrotherapy.

• Pharmacological agents:

  • – NSAIDs (e.g. indomethacin 75–200 mg/d) to control pain, stiffness and synovitis

  • – sulfasalazine (if NSAIDs ineffective)

  • – intra-articular corticosteroids for severe monoarthritis and intralesional corticosteroids for enthesopathy

  • – immunosuppressive agents, e.g. methotrexate, for severe cases

Viral arthritis

Viral polyarthritis is common. Features are acute onset, symmetric inflammation of hands and feet, rash for about 24 hours. Viral causes include influenza, parvovirus, rubella, hepatitis B and C, varicella. Usually settles quickly. Treat with NSAIDs if necessary.

Lyme disease and lyme like disease

Lyme disease (known as Lyme borreliosis) is caused by a spirochete, Borrelia burgdorferi, and transmitted by Ixodes ticks, in particular the deer tick. It is not endemic in Australia and is usually seen in travellers from affected regions.

Diagnostic serology should be considered for patients with a history of tick bites, typical rash (a doughnut-shaped red rash ~6 cm in diameter) at the bite site, heart disorders (esp. arrhythmias), unusual joint arthralgia or CNS disease (usually large joints, e.g. knees).

Treatment

After removing the tick (see Tick bites), treatment is with penicillin, tetracycline or cephalosporins (e.g. doxycycline 100 mg bd for 21 d).

The vasculitides

The vasculitides or vasculitis syndromes are a heterogeneous group of disorders involving inflammation and necrosis of blood vessels, the clinical effects and classification depending on the size of the vessels involved.

More common causes are the small vessel vasculitis effects associated with many important diseases such as rheumatoid arthritis, SLE, infective endocarditis, Henoch–Schonlein purpura and Hepatitis B. Skin lesions and arthritis are usually associated with these disorders.

The major vasculitides are:

• polyarteritis nodosa

• giant cell arteritis/polymyalgia rheumatica

• Wegener’s granulomatosis

• Behcet syndrome

• Churg–Strauss vasculitis

• Takayasu’s arteritis The problem is fatal kidney disease if undiagnosed. If suspected order an ANCA test.

Definition of good control of asthma

• Minimal symptoms during day and < 2 days a week

• No nocturnal waking due to asthma

• No limitation of physical activity

• Minimal need for reliever medication

• No overuse of β₂-agonist

• No exacerbations

• No side-effects of medication

• Normal lung function FEV₁ ± PEFR >80% predicted of best

Pharmacological agents to treat asthma

It is useful to teach patients the concept of the ‘preventer’ and the ‘reliever’ for their asthma treatment.

‘Preventer’ drugs or anti-inflammatory agents

These medications are directed toward the underlying abnormalities bronchial hyper-reactivity and associated airway inflammation. They are underused in practice.

Treatment with a preventer medication is recommended if asthma episodes >3/wk or those who use SABA >3 times/wk.

Corticosteroids

Inhaled: Types—beclomethasone, budesonide, ciclesonide, fluticasone (long acting). Dose range: 400–1600 mcg (adults); aim to keep below 400 mcg (children), 1000 mcg (adults)

Note: Rinse mouth out with water and spit out after using inhaled steroids.

Oral

Prednisolone is used mainly for exacerbations, given with the usual inhaled corticosteroids and bronchodilators.

Dose: up to 1 mg/kg/d for 1–2 wks

Sodium cromoglycate (SCG)

This mast cell stabiliser is available as dry capsules for inhalation, metered dose aerosols or as a nebuliser solution. The availability of the metered aerosol and spacer has helped the use of SCG in the management of asthma in children.

Nedocromil sodium

A newer non-steroid cromolyn metered aerosol. The initial dose is 2 inhalations qid.

Leukotriene antagonists

These new agents, which include montelukast and zafirlukast, are very useful for seasonal asthma and aspirin-sensitive asthma and may reduce the need for inhaled steroids.

‘Reliever’ drugs or bronchodilators

The three groups of bronchodilators are:

• the β₂-adrenoceptor agonists (β₂-agonists)

• methylxanthines—theophylline derivatives

• anticholinergics

B₂-agonists

Oral administration of B₂-agonists is rarely required.^* The inhaled drugs produce measurable bronchodilatation in 1–2 mins and peak effects by 10–20 mins. The traditional agents such as salbutamol and terbutaline are short-acting preparations (SABA). All patients should be prescribed a reliever. The new longer acting agents (LABA) include salmeterol, vilanterol and eformoterol. LABA should only be used in combination, not as monotherapy.

Combination therapy

• Inhaled corticosteroids (ICS) + LABA

Rules: use for moderate–severe asthma

• The different types should be used in different ways.

• When stabilised, drop LABA component and return to ICS.

Fixed dose combination medication:

• fluticasone + salmeterol = Seretide

  MDI: 50/25; 125/25; 250/25 mg

  Dose: adults: 2 inhalations bd; children 4–12: 2 inhal 50/25 bd

  Accuhaler: 100/50; 250/50; 500/50

  Dose: adults: 1 inhal bd; children 4–12: 1 inhal 100/50 bd

• budesonide + eformoterol = Symbicort

  Turbuhaler: 100/6; 200/6; 400/12

  Dose: 1–2 inhal bd, according to age and need children >12: 100/60 or 200/6

• fluticasone + eformoteral = Flutiform (MDI)

• fluticasone + vilanterol = Breo ellipta (dry powder for inhalation)

Maintenance plan for persistent asthma—adult (example)

• Inhaled short acting B-agonist, prn

• Inhaled steroid (dose according to severity) (can use a cromolyn if milder asthma)

If more severe with inadequate control, stepwise options to add:

• longer acting inhaled steroid bd (if using shorter acting steroid which should be ceased); SABA prn. for symptom relief

• long acting B-agonist separate or combined with above

• consider inhaled ipratropium

• consider leukotriene antagonist

• oral prednisolone prn

For attack

• High dose inhaled bronchodilators (spacer preferred)

  • <25 kg up to 6 puffs

  • 25–35 kg 8 puffs

  • >35 kg 12 puffs

Prophylactic agents

This term is reserved for those medications that are taken prior to known trigger factors, particularly exercise-induced asthma.

Exercise-induced asthma

B-agonist inhaler (puffer); two puffs immediately before exercise last 1–2 h. LABAs are more effective.

• Cromoglycate or nedocromil, two puffs (5–10 mins before)

• Montelukast 10 mg (less in children ≥2 yrs) (o) daily 1–2 h before

• Combination B-agonist + cromoglycate or nedocromil

Asthma action plan (example)

If you are distressed with severe asthma:

• Call an ambulance and say ‘severe asthma attack’ (best option) or

• Call your doctor or

• If you are having trouble finding medical help, get someone to drive you to the nearest hospital

• Follow the ‘4 × 4 × 4’ rule with reliever medication but keep using your bronchodilator inhaler continuously if you are distressed

The acute asthma attack

Adult dosage

• Continuous nebulised salbutamol with O₂ 8 L/min (if nebuliser not available: 6–12 puffs of B-agonist inhaler, preferably with spacer, using one loading puff at a time following by 4–6 breaths). Aim to maintain SpO₂ > 95% with O₂.

• Insert IV line

If slow response

• A second nebuliser using salbutamol 2 mL, ipratroprium bromide 2 ml, with 4 ml, N saline

• Hydrocortisone 250 mg IV statim

If poor response or if in extremis

• Magnesium sulfate 25–100 mg/kg (max. 1.2–2 g) IV over 20 minutes

• Adrenaline 0.5 mg 1:1000 IM or 1:10 000 IV (1 mL, over 30 seconds) with monitor or Salbutamol 200–400 mcg IV over 2 mins

• Chest X-ray to exclude complications

• Arterial blood gases/pulse oximetry then

• IV infusion of salbutamol and hydrocortisone

Thunderstorm asthma

Caused by high winds preceding a storm stirring up massive amounts of rye grass pollens which rupture, releasing allergens. Those most vulnerable to asthma attack are those with a history of allergy and especially poorly controlled asthma. At risk people should stay inside with windows and doors closed, take preventer medication, follow action plans and ensure ready supply of reliever drugs. Treatment is with salbutamol spray, followed by corticosteroids.

Children

Should be referred to an intensive care unit:

• < 6 yrs: salbutamol, 6 puffs (can repeat 3 times), if severe add ipratropium bromide 4 puffs

• ≥ 6 yrs: Salbutamol 12 puffs (can repeat 3 times), if severe add ipratropium 8 puffs

• Continuous nebulised 0.5% salbutamol via mask

• Oxygen flow 6–8 L/min through nebuliser (best option)

• IV infusion of:

  • – salbutamol 5 mg/kg/min

  • – hydrocortisone 4 mg/kg statim, then 1–2 mg/kg for 2 more days

Common mistakes in children

• Using assisted mechanical ventilation (can be dangerous—main indications are physical exhaustion and cardiopulmonary arrest)

• Not giving high flow oxygen

• Giving excessive fluid

• Giving suboptimal bronchodilator therapy

Asthma in children

Key checkpoints

• Seek specialist advice for children under 6 mths of age

• Bronchodilators, inhaled or oral, are ineffective under 12 mths

• The delivery method is a problem in children and Table A13 gives an indication of what systems can be used at various levels

• In the very young (e.g. 1–2 yrs) a spacer with a face mask can deliver the aerosol medication

• It is recommended to wash spacers in soapy water or detergent and leave to dry on a towel every 7 d

• The PEF rate should be measured in all asthmatic children older than 6 yrs. It is unreliable before 7 yrs.

• Turbuhaler is usually not practical under 7–8 yrs

Prophylaxis in children

The non-steroid medication montelukast (oral) and SCG or nedocromil by inhalation are the prophylactic drugs in childhood chronic asthma of mild to moderate severity.

If there is no clinical response to the cromolyns, use inhaled cortico steroids, but the risks versus benefits must always be considered. Aim for a maintenance of 100–250 mcg of beclomethasone dipropionate or equivalent (higher doses best with specialist co-care), which keeps the child symptom-free. One or two attacks only is not an indication to start corticosteroids.

Leukotriene antagonists (e.g. montelukast 5 mg chewable tablet nocte) in those aged 6–14 yrs is another option.