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GP 4001 Lecture Series 2006-2007

GP 4001 Lecture Series 2006-2007. 4. Dealing with undifferentiated problems in primary care III. Presentation of diarrhoea. 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?.

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GP 4001 Lecture Series 2006-2007

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  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. • What are the tasks facing the doctor?

  3. Acute presentations of new symptoms – doctor’s tasks • Diagnosis • Treatment/ Management • Advice • Prevention of future episodes if possible • Deal with psychological consequences – anxiety • Deal with social consequences e.g. work

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

  5. Ruling in and ruling out • Ruling in infective gastroenteritis • rapid onset, short course • identifiable source e.g. contaminated food • temperature • Ruling out ulcerative colitis • lack of blood and mucus • lack of systemic features • anaemia, wt. loss, etc.

  6. Treatment of gastroenteritis • Fluid replacement • Remedies for vomiting and diarrhoea • otc remedies • Rx remedies • limited indications for antibiotics • Need for extra hygiene • Occupational issues • Prevention • Investigation?

  7. Management of acute problems - What doctors can do to help patients • Reassure • Advise • Prescribe • Refer • Investigate • Observe • Prevent

  8. Patient’s ideas, concerns and expectations • Ideas • need for symptom relief • will not resolve without treatment • Concerns • wish to get back to normal functioning • contagion to others • impact on employment • Expectations • there is a medical answer

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

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

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

  12. Pragmatic basis to management • Considering all the issues in context • physical • psychological • social • Broad based approach to management • non-drug as well as drug • psychosocial as well as bio-medical • medical, other statutory and non-statutory agencies • Need 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/ Elsevier ISBN 13-978-0-7020-2648-5 • 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)

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

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