Đang tải... (xem toàn văn)
(BQ0 Part 1 book Murtach''s general practice has contents: The nature, scope and content of general practice, the family, consulting skills, communication skills, counselling skills, difficult, demanding and angry patients, health promotion and patient education,.... and other contents.
Table of Contents Frontmatter Halftitle Dedication Title page Copyright The authors Professor John Murtagh AM Dr Jill Rosenblatt Dr Justin Coleman Dr Clare Murtagh Foreword Contents Acknowledgments Photo credits Preface 10 Making the most of your book Diagnostic strategy models Key facts and checkpoints The staff of Asclepius Red and yellow flags Clinical framework Seven masquerades checklist Diagnostic triads Evidence-based research Extensive coverage of paediatric and geriatric care, pregnancy and complementary therapies 10 Practice tips 11 Clinical photos 12 Full colour illustrations 13 Significantly enhanced index 14 Patient education resources 11 Reviewers Content consultants Survey respondents 12 Laboratory reference values 13 Normal values: worth knowing by heart 14 Abbreviations Part 1: The basis of general practice Introduction Chapter 1: The nature, scope and content of general practice Introduction Definitions Unique features of general practice Holistic approach to management Continuing care Home visits Common presenting problems Most frequent presenting symptoms in the author’s practice Symptoms and conditions related to litigation Chronic disease management References Resources Chapter 2: The family Introduction Characteristics of healthy families Families in crisis The effect of illness Guidelines for the doctor Significant presentations of family dysfunction The patient and family dynamics How to evaluate the family dynamics The genogram The family life cycle Family assessment The questionnaire1 Assessment based on the questionnaire Family-based medical counselling The BATHE technique9 Background Affect Trouble Handling Empathy Steps to bring about behaviour change Marital disharmony 10 Basic counselling of couples Some important facts Positive guidelines for success (summary)10 Making lists—a practical task Pitfalls1 Other pitfalls Possible solutions to avoid pitfalls1 11 References 12 Resources Chapter 3: Consulting skills Introduction The skills of general practice Models of the consultation Phases of the consultation The history Good questions Basic interviewing techniques Questions The open-ended question Information from other sources Problem definition Touching the patient The physical and mental examination Medicolegal guidelines for examinations Investigations Management phase of the consultation The sequence of the management interview4 Closing the session A patient management strategy Prescriptions Referral The ‘gatekeeper’ role of the GP The healing art of the doctor 10 References Chapter 4: Communication skills Introduction Communication Communication in the consultation3,4 Prepare Open Gather Non-verbal communication Interpreting body language The patient’s perspective Communicating during the physical examination or procedure Negotiate and agree on a plan 10 Close 11 Use of relationship-building skills 12 Other rapport-building techniques Mirroring Pacing Vocal copying Manage flow References Chapter 5: Counselling skills Introduction The GP as an effective counsellor Features of counselling A problem-solving approach Counselling models The PLISSIT model The Colagiuri and Craig model The value of patient-centred counselling Basics of counselling and psychotherapy Counselling strategies4,7 What counselling is not Cautions1 Patients unlikely to benefit Types of psychotherapy Cognitive behaviour therapy Mindfulness 10 Specific areas of counselling 11 Crisis management Aims of crisis intervention Principles of management Ten rules to help those in distress 12 Bereavement Stages of normal bereavement Pathological bereavement The GP as counsellor1 Long-term counselling 13 Breaking bad news Sharing bad news with a patient Basic guidelines Management Coping with patient responses Children Unexpected death Guidelines for the doctor 14 The depressed patient 15 Chronic pain 16 Problem gambling Dangers Key warning Other telltale signs First-line management Counselling approach 17 Patient education resources 18 References Chapter 6: Difficult, demanding and angry patients Introduction Management strategies Complaints A ‘heartsink’ survival kit The angry patient What is anger? Consulting strategies10 Analysing the responses Recognising distress signals Questions to uncover the true source of anger Rapport building Confrontation Facilitation, clarification Searching The drug-dependent doctor shopper12 Management References Chapter 7: Health promotion and patient education Introduction Health education Illness education Health promotion in general practice Opportunistic health promotion Methods Health goals and targets Promoting healthy lifestyle in general practice The SNAP guide6 The NEAT guide Psychosocial health promotion Patient education/hand-outs 10 References 10 Chapter 8: The elderly patient Introduction Ageing and disease Deterioration in health and the ‘masquerades’ The ‘classic’ triad4 Changes in sensory thresholds and homeostasis Establishing rapport with the elderly patient Loneliness in the elderly Doctor behaviour that can irritate and confuse elderly patients Assessment of the elderly patient History Physical examination Practice nurse Doctor ‘Rules of 7’ for assessment of the non-coping elderly patient The mini-mental state examination The clock-face drawing test Laboratory investigations Behavioural changes in the elderly Elder abuse 10 Depression and dementia Dementia (chronic organic brain syndrome)13 Management of suspected dementia Management of dementia Driving Comorbidity/associated problems15 Dementia and Parkinson disease Medication15 Available drugs for Alzheimer disease Cholinesterase inhibitors Aspartate (NMDA) antagonist 10 Complementary therapy15 11 Dementia prevention strategies 12 Causes of mild neurocognitive impairment 13 Benign senescent forgetfulness 14 Late life depression and suicide 15 Paraphrenia 16 Sarcopenia 17 Falls in the elderly Assessment Management and prevention 18 Prescribing and adverse drug reactions Factors predisposing to adverse drug reactions in the elderly1 Risk factors predisposing to medicine-related problems Starting medications15 Minimising medication problems Other tips for medication in the elderly 19 References 20 Resources 11 Chapter 9: Prevention in general practice Introduction Primary prevention Secondary prevention Tertiary prevention Relationship between types of prevention The practice of preventive medicine Optimal opportunities for prevention Mortality and morbidity considerations A global strategy for good health Behaviour modification Vascular disease Malignant disease Updated important facts about cancer in Australia* (current and immediate future) The role of immunity in cancer Asthma and other respiratory diseases Periodic health examination Aims of screening 10 The history 11 Screening for children General development 12 Screening in the elderly 13 Screening for adults 14 Immunisation 15 Adverse effects of vaccination The case for vaccines 16 Neonatal screening Genetic screening 17 Key checkpoints Resource: 18 References 12 Chapter 10: Nutrition in health and illness Introduction Protein Protein Energy malnutrition Marasmus Kwashiorkor Carbohydrates The glycaemic index (GI) Fat Nutritional assessment The general principles of optimal nutrition What is a serving?2 The Lyon Heart Study Antioxidants Prime sources of antioxidants in food9 Folate-containing foods Vitamin deficiency disorders 10 Gout 11 Dietary control of diabetes Obesity 12 Anaemia and iron 13 Guidelines for safe consumption of alcohol (current NH & MRC recommendations Healthy males and females Young people Pregnancy and breastfeeding 14 Coeliac disease 15 Foods associated with migraine 16 Nutrition and chronic simple constipation 17 Recurrent urinary calculi 18 Iodine deficiency 19 Dietary guidelines for children and adolescents in Australia (NHMRC) 20 Dietary guidelines for Australian adults (NHMRC) 21 Patient education resources Resource 22 References 13 Chapter 11: Palliative care Introduction The diseases The special role of the family doctor Support for patients and carers The Gold Standards Framework (UK) Symptom control Common symptoms The grief reaction Pain control in cancer Use of analgesics7 Step 1: Mild pain Step 2: Moderate pain Step 3: Severe pain Guidelines This problem, which can persist for at least 18–24 months (average time to restore motion is 30 months) and is usually self-limiting, can be treated with an intra-articular injection of corticosteroid but it is often unsuccessful The modern treatment is arthrographic hydrodilatation of the glenohumeral joint with a large quantity of sterile solution (to stretch the capsule) ± corticosteroid This procedure should be performed slowly to produce an audible ‘pop’ as fluid distends into the subacromial and subcoracoid bursae Another important treatment is severing adhesions under arthroscopic control The rule is: if very stiff use arthroscopy; if more mobile use a distension procedure Active exercises are important to restore function Fifty per cent of people with adhesive capsulitis do not regain full normal movement if untreated Current evidence from systemic reviews indicates that both hydrodistension and intra-articular injections are likely to be beneficial.12,17 Exercise in the acute phase can exacerbate pain but a gentle program is useful when it settles If stiffness persists, manipulation under anaesthesia and/or arthroscopic debridement of adhesions may be helpful.18 Typical pain profile—adhesive capsulitis Usually affects people in their 40s, 50s and 60s Site: around the shoulder and outer border of arm Radiation: to elbow Quality: deep throbbing pain Frequency: constant, day and night (severe cases) Duration: constant Onset: spontaneous, usually gradual, wakes the patient from sleep Offset: nil Aggravation: activity, dressing, combing hair, heat Relief: analgesics only (partial relief) Associated features: stiffness of arm, may be frozen Examination — ‘frozen’ shoulder (some cases) (typical — various active and passive movements painful and features): restricted, especially extension and at extremes of movement — resisted movements pain-free (patient compensates with scapulo-humeral movements) Diagnosis: high-resolution ultrasound (plain X-ray normal) Page 719 Bicipital tendonopathy Bicipital tendonopathy is a lesion such as fraying or tearing of the long head of the biceps, which causes pain in front of the shoulder Important signs include pain on resisted flexion of the elbow joint and on resisted supination with the elbow flexed to 90° (Speed test) and forearm pronated (Yergason test) A painful arc may be present when the intrascapular part is affected Hence it is often confused with one of the rotator cuff lesions Sometimes it is possible to elicit local tenderness by palpation along the course of the tendon in the bicipital groove This is best done when the arm is externally rotated Most active shoulder movements, especially external rotation, bring on the pain Bicipital tendonopathy usually follows chronic repetitive strains in young to middle-aged adults (e.g home decorating, weight training, tennis, swimming freestyle, cricket bowling and baseball pitching) Two complications are complete rupture and subluxation of the tendon out of its groove One treatment to consider is a corticosteroid and local anaesthetic injection at the site of maximal tenderness in the bicipital groove (see FIG 63.6 ) As a rule it is best to refer a significant lesion FIGURE 63.6 Injection placement for bicipital tendonopathy Rupture of the biceps tendon Rupture of the long head of biceps usually occurs in the older person It may be spontaneous or occur after lifting or falling on the outstretched hand The patient usually feels a tearing or snapping sensation in the shoulder The shoulder may be painful and difficult to move The upper arm looks bruised and a lump due to rolled-up belly of biceps is obvious on flexion of the elbow Active treatment is not usually indicated but surgical intervention is appropriate for young, active people, especially those in power sports Polymyalgia rheumatica It is very important not to misdiagnose polymyalgia rheumatica in the older person (over 50 years) presenting with bilateral pain and stiffness in the shoulder girdle It may or may not be associated with hip girdle pain Polymyalgia rheumatica sometimes follows an influenza-like illness The patients seem to complain bitterly about their pain and seem flat and miserable In the presence of a normal physical examination they are sometimes misdiagnosed as ‘rheumatics’ or ‘fibrositis’ Typical pain profile—polymyalgia rheumatica Site: shoulders and upper arms (see FIG 63.7 ) Radiation: towards lower neck Quality: a deep, intense ache Frequency: daily Duration: constant but easier in afternoon and evening Onset: wakes with pain at greatest intensity Offset: nil Aggravating factors: staying in bed, inactivity Relieving factors: activity (slight relief) Associated severe morning stiffness ‘in muscles’; malaise; ± weight loss, depressi features: Diagnosis: greatly elevated ESR (can be normal) Treatment: corticosteroids give dramatic relief but long-term management can be regular review and support is essential (refer CHAPTER 32 FIGURE 63.7 Polymyalgia rheumatica: typical area of pain around the shoulder girdle Page 720 Posterior dislocation of the shoulder This is a rare form of shoulder instability, which is often misdiagnosed On first inspection there may not be an obvious abnormality of the shoulder contour Consider this condition if there is a history of electric shock or a tonic–clonic convulsion The major clinical sign is painful restriction of external rotation, which is usually completely blocked Routine shoulder X-rays following trauma should always include the ‘axillary shoot-through’ view and then the diagnosis becomes obvious Early diagnosis and management can prevent a poor outcome and perhaps litigation.15,19 Recurrent subluxation Recurrent anterior or inferior subluxations, or both, are probably more common than recurrent dislocations, yet frequently are not diagnosed Patients who complain of attacks of sudden weakness and even a ‘dead arm feeling’ lasting for a few minutes with overhead activities of the arm should be investigated for this condition The disorder is usually apparent on careful stress testing of the shoulder Air-contrast CT arthrography is considered the best investigation Surgery is usually curative while conservative treatment often fails for younger patients Glenoid labrum injuries4,7 The glenoid labrum is the ring of fibrous tissue attached to the rim of the glenoid and provides volume to the cavity and stability to the glenohumeral joint Injuries to the labrum are divided into superior labrum anterior to posterior (SLAP) or non-SLAP lesions and further into stable and unstable lesions Tests to assess these injuries are the O’Brien, Crank and Speed tests (refer to various YouTube videos) Non-SLAP lesions include degenerative, flap and vertical labral tears as well as unstable lesions such as the classic Bankart lesion, where the labrum and capsule is detached from the rim (see CHAPTER 133) Shoulder instability5,16 Recurrent shoulder instability can be divided into three main types 1 Those with a tendency to generalised laxity of multiple joints including the shoulder and which tend to dislocate with minor injuries Surgery is less effective and treatment is based on improving muscular stability with physiotherapy rehabilitation 2 Those following trauma, which includes avulsion of the anterior labrum (Bankart lesion) Physiotherapy tends to be less effective and the patients often require surgical repair 3 Those with chronic rotator cuff tendonopathy/impingement who develop subtle instability Refer first to a sports physician or physiotherapist for assessment and management, preferably conservative initially The ‘apprehension’ test is useful to confirm the diagnosis of traumatic anterior instability In this test the patient lies supine while the arm is externally rotated with the elbow flexed to 90° The test is more reliable when the patient expresses apprehension that the shoulder will ‘come out’, rather than pain Osteoarthritis of the glenohumeral joint This is usually secondary to local trauma, long-standing rotator cuff lesions and multiple surgical interventions Shoulder movements are stiff and usually restricted in all directions Plain X-rays show typical osteoarthritic changes Treatment includes basic analgesics and short courses of NSAIDs plus exercises to improve mobility Patients usually manage to cope with osteoarthritis of the shoulder, but for severe pain and stiffness arthroplasty or joint replacement should be considered Acromioclavicular disorders Osteoarthritis is usually traumatic or degenerative and is relatively common in builders and sportspeople, especially rowers, and the elderly Night pain is experienced when lying on the affected side There is a full range of movement but pain on full elevation The Bell–van Riet test is diagnostic A key test for AC joint pain is the Paxinos sign, which is positive when pain is elicited on compression of the joint by placing one hand on the back of the acromion and one on the clavicle It is treated with rest and support and analgesics Intra-articular injections of corticosteroids can be used for resistant or severe cases If these measures are ineffectual, pain may be relieved by excision of the lateral end of the clavicle When to refer Persisting night pain with shoulder joint stiffness Persisting supraspinatus tendonopathy; consider possibility of rotator cuff tear or degeneration, especially in the elderly Persisting restriction of movement, such as restricted cross-body flexion (indicates capsular constriction) Persisting supraspinatus tendonopathy or other rotator cuff problem, because decompression of the subacromial space with division of the coracoacromial ligament ± acromioplasty gives excellent results Confirmed or suspected posterior dislocation of the shoulder—the most commonly missed major joint dislocation Confirmed or suspected recurrent subluxation or avascular humeral head Children with shoulder joint instability Swimmer’s shoulder refractory to changes in technique and training schedule Severe osteoarthritis of the glenohumeral joint (which usually follows major trauma) for consideration of prosthetic replacement Severe osteoarthritis of the AC or glenohumeral joint Page 721 Patient education resources Hand-out sheets from Murtagh’s Patient Education 7th edition: Exercises for your shoulder Polymyalgia rheumatica Shoulder: frozen shoulder Shoulder: tendonitis Practice tips Consider dysfunction of the cervical spine, especially C4–5 and C5–6 levels, as a cause of shoulder pain Tendonitis and bursitis are very refractory to treatment and tend to last for several months One well-placed injection of local anaesthetic and corticosteroid may give rapid and lasting relief Test for supraspinatus disorders (including swimmer’s shoulder) with the impingement tests, including the ‘emptying the can’ test Modern ultrasound is the investigation of choice for painful disorders of the rotator cuff, especially to investigate tears in tendons An elderly person presenting with bilateral shoulder girdle pain has polymyalgia rheumatica until proved otherwise Relief from corticosteroids is dramatic Although bilateral, it may start as unilateral discomfort Dysfunction of the cervical spine can coexist with dysfunction of the shoulder joints Correlation between clinical symptoms and the degree of tendon injury or failure is not reliable.18 References 1 Sloane PD, Slatt LM, Baker RM Essentials of Family Medicine Baltimore: Williams & Wilkins, 1988: 242 2 Buchbinder R Acute shoulder pain: an evidence based management approach Course Proceedings: Monash Update Course for GPs, November 2013 3 Kenna C, Murtagh J Back Pain and Spinal Manipulation (2nd edn) Oxford: Butterworth-Heinemann, 1997: 109–33 4 Rathburn JB, Macnab I The microvascular pattern of the rotator cuff J Bone Joint Surg Br, 1970; 52B: 540 5 Murrell G Shoulder dysfunction: how to treat Australian Doctor, 17 December 2004: 23–30 6 Shanahan EM, Buchbinder R The painful shoulder Medicine Today, 2009; 11 (9): 73–9 7 Elvey R The investigation of arm pain In: Grieve GP, Modern Manual Therapy of the Vertebral Column London: Churchill Livingstone, 1986: 530–5 8 Dominguez RH Shoulder pain in swimmers The Physician and Sports Medicine, 1980; 8: 36 9 McLean ID Swimmers’ injuries Aust Fam Physician, 1984; 13: 499– 500 10 Young D, Murtagh J Pitfalls in orthopaedics Aust Fam Physician, 1989; 18: 645–8 11 Hermans J et al Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review JAMA, 2013; 310 (8): 837–47 12 Expert group for Rheumatology Limb conditions In: eTG complete [Internet] Melbourne: Therapeutic Guidelines Ltd Available from: ww w.tg.org.au, accessed October 2017 13 Barton S (ed.) Clinical Evidence London: BMJ Publishing Group, 2001; 850–63 14 Robinson CM et al Frozen shoulder J Bone Joint Surg Br, 2012; 94 (1): 1–9 15 Murrell GAC, Walton JR Diagnosis of rotator cuff tears The Lancet, 2001; 357: 769–70 16 Buchbinder R, Hoving JL, Green S et al Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial Ann Rheum Dis, 2004; 63 (11): 1460–9 17 Buchbinder R, Green S, Forbes A et al Arthrographic joint distension with saline and steroid improves function and reduces pain in patients with painful stiff shoulder: results of a randomised, double blind, placebo controlled trial Ann Rheum Dis, 2004; 63 (3): 302–9 18 Page MJ et al Manual therapy and exercise for adhesive capsulitis (frozen shoulder) Cochrane Database Syst Rev 2014, Issue 8 Art No CD011275 19 Sher JS et al Abnormal findings on magnetic resonance images of asymptomatic shoulders J Bone Joint Surg Am, 1995; 77: 10–15 ... Noisy breathing and secretions7 ,11 Dyspnoea Terminal distress/restlessness7 ,11 ,12 Nausea and vomiting Wound dressings Cerebral metastases Paraplegia 10 Hiccoughs7,9 11 Depression 11 12 Weakness and weight loss 13 Delirium 14 ... and complementary therapies 10 Practice tips 11 Clinical photos 12 Full colour illustrations 13 Significantly enhanced index 14 Patient education resources 11 Reviewers Content consultants Survey respondents 12 Laboratory reference values... Sickle cell anaemia 10 11 12 13 14 15 16 17 Sickle cell trait Hereditary spherocytosis Bleeding disorders Thrombophilia CHROMOSOMAL/MICRODELETION SYNDROMES (CHILDHOOD EXPRESSION)9 Down syndrome15 Facts