1. GP 4001 Lecture Series 2006-2007 4. Dealing with undifferentiated problems in primary care III

2. Presentation of diarrhoea Jim is a 24 year old barman who presents with a history of diarrhoea for the past 3 days.Jim is a 24 year old barman who presents with a history of diarrhoea for the past 3 days. What are the tasks facing the doctor?What are the tasks facing the doctor?

3. Acute presentations of new symptoms – doctor’s tasks DiagnosisDiagnosis Treatment/ ManagementTreatment/ Management AdviceAdvice Prevention of future episodes if possiblePrevention of future episodes if possible Deal with psychological consequences – anxietyDeal with psychological consequences – anxiety Deal with social consequences e.g. workDeal with social consequences e.g. work

4. Probable and possible causes Probable causesProbable causes viral gastroenteritisviral gastroenteritis bacterial gastroenteritisbacterial gastroenteritis recent antibioticsrecent antibiotics Dietary indiscretionDietary indiscretion Traveller’s diarrhoeaTraveller’s diarrhoea Possible causesPossible causes ulcerative colitis diverticulitis food intolerance (hypersensitivity) drug induced bowel cancer

5. Ruling in and ruling out Ruling in infective gastroenteritisRuling in infective gastroenteritis rapid onset, short courserapid onset, short course identifiable source e.g. contaminated foodidentifiable source e.g. contaminated food temperaturetemperature Ruling out ulcerative colitisRuling out ulcerative colitis lack of blood and mucuslack of blood and mucus lack of systemic featureslack of systemic features anaemia, wt. loss, etc.anaemia, wt. loss, etc.

6. Treatment of gastroenteritis Fluid replacementFluid replacement Remedies for vomiting and diarrhoeaRemedies for vomiting and diarrhoea otc remediesotc remedies Rx remediesRx remedies limited indications for antibioticslimited indications for antibiotics Need for extra hygieneNeed for extra hygiene Occupational issuesOccupational issues PreventionPrevention Investigation?Investigation?

7. Management of acute problems - What doctors can do to help patients R eassure R eassure A dvise A dvise P rescribe P rescribe R efer R efer I nvestigate I nvestigate O bserve O bserve P revent P revent

8. Patient’s ideas, concerns and expectations IdeasIdeas need for symptom reliefneed for symptom relief will not resolve without treatmentwill not resolve without treatment ConcernsConcerns wish to get back to normal functioningwish to get back to normal functioning contagion to otherscontagion to others impact on employmentimpact on employment ExpectationsExpectations there is a medical answerthere is a medical answer

9. What you need to say to Jim It’s most probably acute gastro-enteritisIt’s most probably acute gastro-enteritis It is not seriousIt is not serious It is contagious but the risk of contagion can be limited by attention to good hygieneIt is contagious but the risk of contagion can be limited by attention to good hygiene Should avoid handling food for others while unwellShould avoid handling food for others while unwell No specific treatment (such as antibiotics) requiredNo specific treatment (such as antibiotics) required Dehydration is the main risk of the condition and that is easily avoided by taking fluidsDehydration is the main risk of the condition and that is easily avoided by taking fluids Needs review and further investigation only if condition (diarrhoea) persistsNeeds review and further investigation only if condition (diarrhoea) persists

10. Key tasks in dealing with acutely presenting symptoms Rule in probable cause(s)Rule in probable cause(s) Rule out unlikely but serious possible cause(s)Rule out unlikely but serious possible cause(s) Clarify the patient’s ideas, concerns and expectationsClarify the patient’s ideas, concerns and expectations Explain benign and self-limiting natureExplain benign and self-limiting nature If it is deemed benign and self-limitingIf it is deemed benign and self-limiting Encourage appropriate self careEncourage appropriate self care Prescribe appropriate symptomatic therapy (if necessary)Prescribe appropriate symptomatic therapy (if necessary) Safety nettingSafety netting

11. Explaining the benign and self- limiting nature of the condition Elicit patient’s ideas about nature of conditionElicit patient’s ideas about nature of condition Gently correct any misconceptionsGently correct any misconceptions Draw analogies to other benign self- limiting conditions (if appropriate)Draw analogies to other benign self- limiting conditions (if appropriate) Stress benign nature (as appropriate)Stress benign nature (as appropriate) Stress self-limiting nature - give likely prognosisStress self-limiting nature - give likely prognosis Give guidance on review if doesn’t settleGive guidance on review if doesn’t settle

12. Pragmatic basis to management Considering all the issues in contextConsidering all the issues in context physicalphysical psychologicalpsychological socialsocial Broad based approach to managementBroad based approach to management non-drug as well as drugnon-drug as well as drug psychosocial as well as bio-medicalpsychosocial as well as bio-medical medical, other statutory and non-statutory agenciesmedical, other statutory and non-statutory agencies Need for lateral thinking & safety nettingNeed for lateral thinking & safety netting

13. Today’s poem Jimmy had a jippy tummy He was on and off the loo So he went to see the doctor To see what she could do She ruled out anything serious And reckoned on something quite benign She dealt with his concerns and fears By telling him how it would go in time

14. Recommended Reading I Pocket Essentials of General Practice by Colin Bradley Saunders/ ElsevierPocket Essentials of General Practice by Colin Bradley Saunders/ Elsevier ISBN 13-978-0-7020-2648-5 Fraser Robin C. Clinical Method. A General Practice Approach. Butterworth Heinemann (ISBN 0-7506-1448-X)Fraser Robin C. Clinical Method. A General Practice Approach. Butterworth Heinemann (ISBN 0-7506-1448-X) McWhinney Ian R. A Textbook of Family Medicine 2nd Edition. Oxford University Press: Oxford (ISBN 0-19-511518-X)McWhinney Ian R. A Textbook of Family Medicine 2nd Edition. Oxford University Press: Oxford (ISBN 0-19-511518-X)

15. Recommended Reading II Sackett DL, et.al. Evidence-based medicine: how to practice and teach EBN 2nd edition. Churchill Livingstone: Edinburgh (ISBN 0-443-06240-4)Sackett DL, et.al. Evidence-based medicine: how to practice and teach EBN 2nd edition. Churchill Livingstone: Edinburgh (ISBN 0-443-06240-4) Murtagh John. General Practice: Companion Handbook 2nd edition. McGraw Hill: Sydney. ISBN (0-07-470722-1)Murtagh John. General Practice: Companion Handbook 2nd edition. McGraw Hill: Sydney. ISBN (0-07-470722-1)