GP 4001 Lecture Series GP 4001 Lecture Series 2006-20072006-2007

4. Dealing with 4. Dealing with undifferentiated problems in undifferentiated problems in

primary care IIIprimary care III

Presentation of Presentation of diarrhoeadiarrhoea

• Jim is a 24 year old barman Jim is a 24 year old barman who presents with a history of who presents with a history of diarrhoea for the past 3 days.diarrhoea for the past 3 days.

• What are the tasks facing What are the tasks facing the doctor?the doctor?

Acute presentations of Acute presentations of new symptoms – doctor’s new symptoms – doctor’s

taskstasks• DiagnosisDiagnosis• Treatment/ ManagementTreatment/ Management• AdviceAdvice• Prevention of future episodes if Prevention of future episodes if

possiblepossible• Deal with psychological consequences Deal with psychological consequences

– anxiety– anxiety• Deal with social consequences e.g. Deal with social consequences e.g.

workwork

Probable and possible Probable and possible causescauses

• Probable causesProbable causes• viral viral

gastroenteritisgastroenteritis• bacterial bacterial

gastroenteritisgastroenteritis• recent antibioticsrecent antibiotics• Dietary Dietary

indiscretionindiscretion• Traveller’s Traveller’s

diarrhoeadiarrhoea

• Possible causesPossible causes• ulcerative colitisulcerative colitis• diverticulitisdiverticulitis• food intolerance food intolerance

(hypersensitivity)(hypersensitivity)• drug induceddrug induced• bowel cancerbowel cancer

Ruling in and ruling outRuling in and ruling out

• Ruling in infective gastroenteritisRuling in infective gastroenteritis• rapid onset, short courserapid onset, short course• identifiable source e.g. contaminated identifiable source e.g. contaminated

foodfood• 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.

Treatment of Treatment of gastroenteritisgastroenteritis

• 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?

Management of acute Management of acute problems - problems - What doctors can What doctors can

do to help patientsdo to help patients

Management of acute Management of acute problems - problems - What doctors can What doctors can

do to help patientsdo to help patients• RReassureeassure• AAdvisedvise• PPrescriberescribe• RReferefer• IInvestigatenvestigate• OObservebserve• PPreventrevent

Patient’s ideas, Patient’s ideas, concerns and concerns and expectationsexpectations

• 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

What you need to say What you need to say to Jimto 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 It is contagious but the risk of contagion can be

limited by attention to good hygienelimited 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) No specific treatment (such as antibiotics)

requiredrequired• Dehydration is the main risk of the condition and Dehydration is the main risk of the condition and

that is easily avoided by taking fluidsthat is easily avoided by taking fluids• Needs review and further investigation only if Needs review and further investigation only if

condition (diarrhoea) persistscondition (diarrhoea) persists

Key tasks in dealing with Key tasks in dealing with acutely presenting acutely presenting

symptomssymptoms• Rule in probable cause(s)Rule in probable cause(s)• Rule out unlikely but serious possible Rule out unlikely but serious possible

cause(s) cause(s) • Clarify the patient’s ideas, concerns and Clarify the patient’s ideas, concerns and

expectationsexpectations• 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 Prescribe appropriate symptomatic therapy (if

necessary) necessary)

• Safety nettingSafety netting

Explaining the benign and Explaining the benign and self-limiting nature of the self-limiting nature of the

conditioncondition• Elicit patient’s ideas about nature of Elicit patient’s ideas about nature of

conditioncondition• Gently correct any misconceptionsGently correct any misconceptions• Draw analogies to other benign self-Draw analogies to other benign self-

limiting conditions (if appropriate)limiting conditions (if appropriate)• Stress benign nature (as appropriate)Stress benign nature (as appropriate)• Stress self-limiting nature - give likely Stress self-limiting nature - give likely

prognosisprognosis• Give guidance on review if doesn’t settleGive guidance on review if doesn’t settle

Pragmatic basis to Pragmatic basis to managementmanagement

• 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

Today’s poemToday’s poem

Jimmy had a jippy tummyJimmy had a jippy tummy

He was on and off the looHe was on and off the loo

So he went to see the doctor So he went to see the doctor

To see what she could doTo see what she could do

She ruled out anything seriousShe ruled out anything serious

And reckoned on something quite And reckoned on something quite benignbenign

She dealt with his concerns and fearsShe dealt with his concerns and fears

By telling him how it would go in timeBy telling him how it would go in time

Recommended Reading Recommended Reading II

Recommended Reading Recommended Reading II

• Pocket Essentials of General Practice by Pocket Essentials of General Practice by Colin Bradley Saunders/ Elsevier Colin Bradley Saunders/ Elsevier

ISBN 13-978-0-7020-2648-5ISBN 13-978-0-7020-2648-5 • Fraser Robin C. Clinical Method. A Fraser Robin C. Clinical Method. A

General Practice Approach. General Practice Approach. Butterworth Heinemann (ISBN 0-Butterworth Heinemann (ISBN 0-7506-1448-X)7506-1448-X)

• McWhinney Ian R. A Textbook of McWhinney Ian R. A Textbook of Family Medicine 2nd Edition. Oxford Family Medicine 2nd Edition. Oxford University Press: Oxford (ISBN 0-19-University Press: Oxford (ISBN 0-19-511518-X)511518-X)

Recommended Reading Recommended Reading IIII

• Sackett DL, et.al. Evidence-based Sackett DL, et.al. Evidence-based medicine: how to practice and teach medicine: how to practice and teach EBN 2nd edition. Churchill Livingstone: EBN 2nd edition. Churchill Livingstone: Edinburgh Edinburgh (ISBN 0-443-06240-4)(ISBN 0-443-06240-4)

• Murtagh John. General Practice: Murtagh John. General Practice: Companion Handbook 2nd edition. Companion Handbook 2nd edition. McGraw Hill: Sydney. ISBN (0-07-McGraw Hill: Sydney. ISBN (0-07-470722-1)470722-1)