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Ovid: Oxford Handbook of General Practice

Editors: Simon, Chantal; Everitt, Hazel; Kendrick, Tony Title: Oxford Handbook of General Practice, 2nd Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 8 – Miscellaneous topics Chapter 8 Miscellaneous topics Complications of surgery and injury that might be seen in general practice Wound infection Risk factors

  • Malnutrition
  • DM
  • Carcinomatosis
  • Steroid therapy
  • Infection near the site of incision
  • Contamination of the wound

Presentation Suspect if a wound becomes painful. Look for swelling, erythema, wound tenderness, ± pus. Management If pus is present, send a swab for M, C&S:

  • If the wound is indurated and infection localized to the wound, suspect Staphylococcus infection. Treat with flucloxacillin 250-500mg qds (or erythromycin 250-500mg qds if penicillin allergy).
  • If there is cellulitis around the wound, suspect Streptococcus. Treat with penicillin V 250-500mg qds or erythromycin 250-500mg qds.
  • If foul smelling, suspect anaerobes. Treat with metronidazole 400mg tds.

Give adequate analgesia; dress the wound frequently; review regularly; allow pus to drain. Refer back to the operating surgeon if simple measures are ineffective. Wound dehiscence Breakdown of a surgical wound—usually abdominal. May be partial or complete.

  • Partial breakdown—skin remains intact but muscle layers break down → incisional hernia. Typically, the patient feels something ‘give’ ± sudden ↑ in pain and pink fluid discharge. Refer for urgent reassessment by the operating surgeon.
  • Complete dehiscence—wound breaks down entirely. The patient becomes shocked and distressed. Lie flat; give strong opiate analgesia; cover the wound with a sterile pack soaked in saline; admit as a ‘999’ emergency.

Risk factors

  • Malnutrition
  • Obesity
  • ↑ intra-abdominal pressure e.g. from coughing
  • Wound infection
  • Haematoma formation
  • Ascites draining through a wound

Fistula formation Abnormal communication forms between one organ and another—see Table 8.1. Refer any suspected case urgently back to the operating surgeon. Risk factors

  • Malnutrition
  • Carcinomatosis
  • Wound infection
  • Distal obstruction

DVT p.364 Pulmonary embolus p.1054

Table 8.1 Presentation of fistula
Connection Presentation
Bowel → skin Faecal discharge through wound
Bladder/ureters → skin Clear, watery discharge which smells of urine
Bowel → vagina Faeculent material in vagina
Bladder → vagina Leakage of urine per vaginum
Bowel → bladder Air or faeculent material in urine; recurrent UTI

P.197
UTI Common after any procedure in which the bladder has been instrumented. Send an MSU if suspected. If symptoms are unpleasant, treat with trimethoprim 200mg bd for 7d. without waiting for the result. Dysuria and ↑ frequency are common for 2-3wk. after TURP. Suspect UTI if symptoms worsen >1wk. post-op. Acute retention of urine p.690. Subphrenic abscess Rarely follows 7-21d. after generalized peritonitis— particularly after acute appendicitis. Presentation General malaise, swinging fever, nausea, and loss of weight ± pain upper abdomen which radiates to the shoulder tip. Breathlessness can be associated due to reactive pleural effusion or lower lobe collapse. Examination may reveal subcostal tenderness ± liver enlargement. Investigations FBC (leucocytosis); CXR; USS. Management If suspected, admit acutely for surgical assessment. Compartment syndrome Crush injury, fracture, prolonged immobility or tight splints, dressings or casts can result in ↑ pressure within muscle compartments → vascular occlusion, hypoxia, necrosis and further ↑ pressure. Signs: swelling, severe pain, distal numbness, redness, mottling, blisters. Refer as an emergency for orthopaedic assessment—a fasciotomy may be needed to relieve the pressure. Reflex sympathetic dystrophy (algodystrophy, complex regional pain disorder) Pain ± vasomotor changes in a limb → loss of function. Most common in the hand and wrist. Usually follows trauma (but the trauma may be trivial and signs may appear weeks or months later). Signs: Pain at rest exacerbated by movement and light touch, swelling, discoloration, temperature changes, abnormal sensitivity, sweating, and loss of function. X-ray may show osteopoenia. Management Physiotherapy (improves prognosis if started early); analgesia (NSAIDs). Refer to pain clinic and/or rheumatology for IV bisphosphonates (responds well if treated early) and ‘mirror’ therapy. P.198
Time off work The longer a patient is off work, the lower the chances of returning— <50% of people who have been absent for >6mo. ever return to work.

  • Wherever possible, suggest work adjustments rather than signing the patient off work. Can be done through the ‘remarks’ section of the Med3 form (p.201)
  • Suggest work adjustments if the patient is off sick to enable early return to work (can be done in the remarks section of the Med3 form)
  • Suggest graduated work/transitional arrangements to ease the patient back into work.
  • Involve occupational health professionals

Post-operative time off work See Table 8.2 These are not hard and fast rules—alter them to fit individual circumstances (e.g. laparoscopic procedures often entail less time off than open procedures; patients performing hard manual jobs may require more time off work) Time off work for emergencies In many cases, patients have the right to take time off work to deal with an emergency involving someone who depends on them, but they may only be absent for as long as it takes to deal with the immediate emergency. Dependants include spouse or partner, children, parents, or anyone living with the patient as part of their family. Others who rely wholly on the patient for help in an emergency may also qualify. Emergencies include situations in which a dependant:

  • is ill and needs help
  • is involved in an accident or assaulted
  • needs the patient to arrange their longer-term care
  • needs the patient to deal with an unexpected disruption or breakdown in care, such as a childminder or nurse failing to turn up
  • goes into labour
  • dies and the patient needs to make funeral arrangements or to attend the funeral.

The legal right only covers emergencies and employers do not have to pay for time taken off. Certification of time off work p.200

Table 8.2 List of expected time off work for uncomplicated procedures
Operation Minimum expected (wk.) Maximum expected if no complications (wk.)
Angiography/angioplasty <1 4
Appendectomy 1 3
Arthroscopy <1 <1
Cataract surgery 2 4
Cholecystectomy 2 5
Colposcopy ± cautery <1 <1
CABG or valve surgery 4 8
Cystoscopy <1 <1
D&C, ERPC, or TOP <1 <1
Femoro-popliteal grafts 4 12
Haemorrhoid banding <1 <1
Haemorrhoidectomy 3 6
Hysterectomy 3 7
Inguinal or femoral hernia 1 3
Laparoscopy ± sterilization <1 <1
Laparotomy 6 12
Mastectomy 2 6
Pacemaker insertion* <1 <1
Pilonidal sinus** <1 <1
Retinal detachment <1 Avoid heavy work, lifelong
Total hip or knee replacement 12 26
TURP 3 6
Vasectomy <1 <1
* Driving—see p.203.
** If time off for dressings is allowed.

P.199
P.200
Certifying fitness to work Own occupation test Applies to those claiming for the first 28wk. of their illness:

  • statutory sick pay from their employer
  • incapacity benefit if the patient has done a substantial amount of work in the 21 wk. prior to the illness

The doctor assesses whether the patient is fit to do their own job. Personal capability assessment (formerly the ‘All work test’): Assesses a patient on a variety of different mental and physical health dimensions for ability to work. Not diagnosis dependant. Applies to:

  • everyone after 28wk. incapacity
  • those who do not qualify for the own occupation test from the start of their incapacity

Claimants are sent form IB50 to complete themselves and are asked to obtain form Med4 from their GP. If the Department of Work and Pensions (DWP) is not happy to continue paying their benefit on the basis of these reports, the applicant is called for a medical examination. Conditions which exempt patients from further examination are:

  • Receipt of highest rate care component of Disability Living Allowance (DLA), Constant Attendance Allowance, or >80% disabled for other benefit purposes
  • Terminal illness
  • Tetraplegia or paraplegia, hemiplegia, progressive neurological or muscle wasting disease
  • Registered blindness
  • Persistent vegetative state
  • Severe mental illness or dementia
  • Progressive immune deficiency (including AIDS)
  • Severe learning disabilities
  • Active and progressive polyarthropathy
  • Severe progressive cardio-respiratory disease which persistently limits exercise tolerance.

Private certificates Some employers request private certificates in the 1st week of sickness absence. They should request them in writing. If the GP chooses to provide the service, (s)he may charge both for a private consultation and the provision of a private certificate. The company should accept full responsibility for all fees incurred by the patient. Permitted work Incapacity benefits do allow very limited worktherapeutic work (must be done as part of a treatment programme and in an institution which provides sheltered work for people with disabilities); voluntary work; local authority councillor; disability expert on an appeal tribunal or member of the Disability Living Allowance advisory board (not >1d./wk.). Disability Discrimination Act 1995 Some circumstances require employers to make reasonable adjustments for an employee with a longterm disability. Advise patients to seek specialist advice. P.201
Disability employment advisors Provided by the Employment Service to assist disabled patients to get back to work. Contacted by:

  • writing a comment to the effect that intervention would be helpful in the comments box on form Med3 or
  • writing to the local jobcentre (with the patients’ permission)

Useful information Department of Work and Pensions. Medical evidence for statutory sick pay, statutory maternity pay, and social security incapacity benefit purposes: A guide for registered medical practitioners. IB204. June 2004. http://www.dwp.gov.uk Disability Discrimination Act. http://www.disability.gov.uk Forms for certifying incapacity to work SC1—self-certification form for people not eligible to claim statutory sick pay who wish to claim incapacity benefit. Certify first 7d. of illness. Available from local jobcentre Plus offices and GP surgery. SC2—as SC1 but for people who can claim statutory sick pay. Available from employer, local Jobcentre Plus offices, and GP surgery. Med 3—filled in by GP or hospital doctor who knows the patient. For periods of incapacity to work likely to be >7d. If return within 14d. is forecast, give fixed date of return (‘closed certificate’). If longer, specify a period of time (e.g. 2mo.) (‘open certificate’). Before the patient returns to work, reassess and give further certificate with fixed date of return. Only one Med3 can be issued per patient per period of sickness. If mislaid, reissue and mark ‘duplicate’. Med 4—see personal capability assessment (opposite). Only completed once for any period of incapacity from work. Med 5—can be used if:

  • a doctor has not seen the patient but on the basis of a recent (<1mo.) written report from another doctor is satisfied that the patient should not work—the certificate should not cover a forward period of >1mo.;
  • the patient returned to work without receiving a closed certificate (see Med3 above);
  • >1d. since the patient was seen (so Med3 or Med4 cannot be issued) but it is clear the disability is ongoing.

Med 6—when it is felt that putting a diagnosis on a Med3/Med4 would be harmful either directly to a patient or through their employer knowing their diagnosis. A vague diagnosis is put on the form and a Med6 completed which requests the Department of Works and Pensions (DWP) to send a form to obtain more precise details. RM 7—form sent to DWP which requests review of the patient by them sooner than would usually be undertaken. Mat B1—signed by doctor or midwife. Provided to pregnant women once within 20wk. of EDD. Enables her to claim statutory maternity pay and other benefits (p.112). P.202
Fitness to drive Driving licence holders (or applicants) have a legal duty to inform the DVLA of any disability likely to cause danger to the public if they were to drive. Driving licence types

  • Group 1—ordinary licence for driving a car/motorcycle. Old licences expire at 70th birthday and then must be renewed 3yrly. Applicants are asked to confirm they have no medical disability. If so, no medical examination is necessary. New photocard licences are automatically renewed 10yrly until age 70y. Minimum age 17y. (16y. if disabled).
  • Group 2—enables holders to drive lorries and buses. Min. age 21y. Initially valid until 45th birthday, then renewable every 5y. until 65th birthday. >65y., renewable annually. Medical examination is needed to renew Group 2 licences. Applicants must bring form D4 (available from post offices) with them. Examinations take ~ ½ h. A fee may be charged by the GP.

Determining fitness to drive Patients with any disorder which may cause danger to others if they drove, should be advised not to drive and contact the DVLA. The DVLA gives advice on when they can restart. Driving after surgery Drivers do not need to notify the DVLA unless a condition likely to affect safe driving persists >3mo. (certain exceptions apply for neurological and cardiovascular disorders). It is the responsibility of the driver to ensure that he/she is in control of the vehicle at all times. It might also be advisable for the driver to check with his/her insurer before returning to drive after surgery. Consider:

  • Recovery from the surgical procedure
  • Recovery from anaesthesia (sedation and cognitive impairment)
  • Distracting effect of pain
  • Impairment due to analgesia (sedation and cognitive impairment)
  • Physical restrictions due to the surgery or the underlying condition

Disabled drivers who want to learn to drive or return to driving following onset of their disability should have an assessment of their driving ability and/or advice on controls and adaptations needed. Licences may be limited to adapted vehicles. A list of driving assessment centres can be obtained from the DVLA website. Information sheets are available from: MAVIS Tel:01344 661 000 http://www.dft.gov.uk/access/mavis Seatbelt exemption GPs can sign a form to exempt patients (e.g. those with colostomies) from having to wear a seatbelt. Consider very carefully the reasons for exemption in view of the weight of evidence in favour of seatbelts. A fee can be charged for this service. patients on low income can apply for a free medical examination on a form available from: Department for Transport, Road Safety Division 1. Zone 2/11, Great Minster House, 76 Marsham Street, London SW1P 4DR Tel:020 7944 2046. P.203
Breaking confidentiality When a patient continues to drive despite advice by a doctor to stop, a doctor has an obligation to breach confidentiality and inform the DVLA.

  • If the patient does not understand the advice to stop driving, inform the DVLA.
  • If the patient does understand, explain your legal duty to inform the DVLA if they do not stop driving. If they still refuse, offer a second medical opinion (on the understanding they stop driving in the interim).
  • If the patient still continues driving, consider action such as recruiting next-of-kin to the cause (but beware of breach of confidentiality).
  • If all else fails, inform the DVLA in confidence. Before doing this, write to the patient to inform him/her of your intended actions. Once the DVLA has been informed, you should also write to the patient, to confirm that a disclosure has been made. Consider contacting your medical defence organization for advice.

Further information DVLA At a glance guide to the current medical standards of fitness to drive for medical practitioners, Available from http://www.dvla.gov.uk Medical advisers from the DVLA can advise on difficult issues. Contact: Drivers Medical Unit, DVLA, Swansea SA99 1TU or Tel: 01792 761119 Mobility Advice and Vehicle Information Service (MAVIS) http://www.dft.gov.uk/access/mavis Certificates of exemption from compulsory seatbelt wearing can be obtained from: Department of Health, PO Box 777, London SE1 6XH; Tel: 08701 555455 (NHS Responseline); Email: doh@prologistics.co.uk P.204
Brief guide to DVLA fitness to drive criteria Any person driving (or attempting to drive) on the public highway or other public place whilst unfit due to any drug, whether prescribed or illicit, is liable to prosecution. Neurology

  • Single seizure/fit/epilepsy/undiagnosed loss of consciousness: Licence revoked. Specified seizures with identifiable non-recurring, proking cause (e.g. at the time of stroke or intracranial surgery) may be dealt with on a case-by-case basis by the DVLA.
    • Group 1—seizure free for 1y. to regain licence.
    • Group 2—seizure free without medication for 10y. to regain licence (or 5y. if cause of collapse unknown).
  • Withdrawal of antiepileptic medication: Licence not revoked but no driving during period of withdrawal and for 6mo. without medication.
  • Single CVA/T/A/episode amaurosis fugax:
    • Group 1—1mo. off driving. Restart when clinically fit thereafter.
    • Group 2—licence revoked. Review after 5y.
  • Recurrent CVA/T/A/amaurosis fugax:
    • Group 1—stop driving until attacks controlled for 3mo.
    • Group 2—licence revoked.

Cardiovascular disease

  • Hypertension: If asymptomatic, continue driving.
    • Group 2—stop driving if systolic >180 or diastolic >100mmHg until BP controlled.
  • Arrythmia: Stop driving.
    • Group 1—until attacks controlled.
    • Group 2—licence revoked until arrythmia controlled >3mo. and renewed only if the left ventricular ejection fraction is >0.4.
  • Pacemaker insertion—(includes box change):
    • Group 1—stop driving for 1wk.
    • Group 2—stop driving for 6wk.

    Other implantable defibrillator devices—see DVLA guidance.

  • Stable angina:
    • Group 1—stop driving if attack whilst at the wheel until symptoms controlled.
    • Group 2—licence revoked until symptom free >6wk. Renewal requires medical examination and exercise ECG.
  • Unstable angina/MI/CABG:
    • Group 1—stop driving for 1mo. Restart when clinically fit thereafter.
    • Group 2—licence revoked. Reviewed after 6wk. with medical examination and exercise ECG.
  • Coronary angioplasty:
    • Group 1—stop driving for 1wk. Restart when clinically fit thereafter.
    • Group 2—licence revoked. Reviewed after 6wk. with medical examination and exercise ECG.
  • Postural hypotension/syncope: If cause is clear and not sudden or disabling, continue driving.

P.205
Diabetes mellitus

  • Controlled by diet/oral hypoglycaemics: Continue driving if adequate control, unless related problems (e.g. loss of visual acuity, CHD, CVA).
  • Controlled with insulin: Stop driving if poor control, related problems that prevent driving, frequent hypoglycaemic episodes, or inability to recognize hypoglycaemia.
    • Group 2—if issued after 1.4.1991, licence revoked. If issued before then, DVLA considers each case individually.

Psychiatric conditions

  • Dementia:
    • Group 1—stop if pose danger to public. Annual review.
    • Group 2—licence revoked.
  • Anxiety, depression, other neuroses:
    • Group 1—unless severe, continue driving. Stop if severe (especially if suicide at the wheel might be a possibility) or if medication inhibits ability to drive.
    • Group 2—licence revoked if serious acute mental illness. Restored if symptom free and stable for ≥6mo.
  • Psychosis:
    • Group 1—licence revoked. Restored if well and stable for ≥3mo., compliant with treatment, free from adverse drug effects which would impair driving. Specialist report required.
    • Group 2—licence revoked for 3y. Restored if stable and off antipsychotic medication which might affect ability to drive. Specialist report required.
  • Drug or alcohol misuse or dependency: DVLA arranges assessment prior to licence restoration.
    • Group 1—6mo. off driving (1y. after alcohol or drug-related seizure or detoxification for alcohol, opiate, cocaine, or benzodiazepine dependence).
    • Group 2—licence revoked for 1y. (3y. if alcohol dependence or misuse of opiates, cocaine, or benzodiazepines; 5y. if alcohol- or drug-related seizure).

Conditions affecting vision

  • Visual acuity:
    • Group 1—able to read in good light (with glasses or contact lenses) a number plate containing figures 79mm high and 57mm wide at a distance of 20.5m (20m where the characters are 50mm wide).
    • Group 2—corrected vision of 6/9 (best eye) and 6/12 (other eye). Stop driving if uncorrected acuity in either eye >3/60.
  • Night blindness: Stop driving.
  • Colour blindness: No restrictions.
  • Visual field defects: Stop driving.
    • Group 1—restore if able to meet DVLA criteria.
  • Diplopia: stop driving.
    • Group 1—can resume if controlled (e.g. by wearing patch).

Miscellaneous

  • Sleep apnoea: Stop driving. Restart when symptoms adequately controlled.

P.206
Fitness to make decisions A GP asked to give an opinion on a patient’s mental capacity, should:

  • Have access to the patient’s records and ideally know the patient
  • Seek information from friends, relatives, and carers
  • Examine the patient, assess type and degree of deficit and ability to comply with the specific requirements listed for each situation
  • Decide if assessment should be postponed while measures are taken to improve capacity
  • Record all the above information

Even if a doctor thinks a proposed action is in the patient’s best interests, he/she must not judge the patient capable if that is not clearly the case. If in doubt, seek a second opinion. Power of attorney Covers financial matters only.

  • Ordinary power of attorney: Ceases to have effect if the patient (donor) becomes mentally incapable; the donor must understand the nature and effect of what he or she is doing.
  • Enduring power of attorney (EPA): Continues if the donor is mentally incapable, provided it is registered with the Court of Protection. The donor must understand that the:
    • Attorney will be able to assume complete authority over the person’s affairs and do anything with the donor’s property that the donor could have done;
    • Authority will continue if the donor becomes mentally incapable and is irrevocable while the donor remains incapable.

In Scotland, an ordinary power of attorney signed after January 1991 remains valid even if the donor becomes mentally incapable. Court of Protection If a person, by reason of mental disorder, becomes incapable of managing his or her affairs but has not previously signed an EPA, it may be necessary for someone, usually the nearest relative, to apply to the Court of Protection for the appointment of a ‘receiver’ to do so. The medical practitioner will be asked to complete form CP3. Alternatively, if the patient’s affairs are simple (e.g. state pension), direct arrangements can be made with relevant authorities. Testamentary capacity The capacity to make a will. Anyone can make a will provided:

  • They understand the nature and effect of making a will, extent of property being disposed of, and claims others may have on that property;
  • The decision is not the result of their condition (e.g. due to a delusion).

Decisions don’t have to seem rational to others, especially if consistent with premorbid personality. P.207
Capacity to consent to medical treatment p.60 Advance directives Statements in which a person makes a decision about medical treatment in case he or she becomes incapable of making that decision later.

  • Respect any refusal of treatment given when the patient was competent, provided the decision is clearly applicable to present circumstances, and there is no reason to believe that the patient has altered that decision.
  • It is legally binding if it is clearly established, applicable to the current situation, and was made without undue pressure from others.
  • The BMA recommends doctors should not withhold ‘basic care’ (e.g. symptom control) even in the face of a directive which specifies that the patient should receive no treatment.
  • Where an advance statement is not available, take patients’ known wishes into consideration.

Further information The Law Society and the BMA (1995) Assessment of mental capacity; guidance for doctors and lawyers. BMA. BMA local offices. Medical defence organizations: p.79 P.208
Fitness for other activities Fitness to fly Passengers are required to tell the airline at the time of booking about any conditions that might compromise their fitness to fly. The airline’s medical officer must then decide whether to carry them or not. Hazards of flying

  • Cabin pressure—oxygen levels are lower than at ground level and gas in body cavities expands 30% in flight
  • Inactivity and dehydration
  • Disruption of routine
  • Alcohol consumption
  • Stress and excitement

Contraindications to flying

  • Respiratory disease—
    • Suspected pneumothorax/pneumomediastinum—patients should not fly for 14d. after complete resolution of pneumothorax.
    • Chronic lung disease—if a patient can walk >50m. without getting breathless, s/he should be fit to fly. Supplementary oxygen can be provided in flight for patients unable to walk this far but the patient must pre-book this with the airline and there is usually a charge.
  • Heart disease—Patients should not travel if they have unstable angina, poorly controlled heart failure, or an uncontrolled arrythmia, Patients should also refrain from travelling <10d. post uncomplicated Ml (3–4wk. if complicated recovery) and for 3–5d. post angioplasty.
  • Thrombo-embolic disease—Patients should not travel with a DVT before established on anticoagulants.
  • Neurological disease—Patients should not travel for 3d. post stroke or, if epileptic, within 24h. of a grand mal fit.
  • Infectious disease—Patients must not travel with untreated infectious disease.
  • Psychiatric illness—Patients should not travel if they have disturbed or unpredictable behaviour that could disrupt the flight.
  • Fractures—Flying restricted for 24–48h. (depending on the length of the flight) after the plaster cast has been fitted.
  • Haematological disease—Anaemia (<7.5g/dl) and recent sickling crisis may restrict flying.
  • Pregnancy—Most airlines will not carry women >36wk. pregnant (3rd trimester if multiple pregnancy), or with history of premature delivery, cervical incompetence, bleeding, or ↑ uterine activity.
  • Ear problems—Flying with otitis media or sinusitis can result in pain ± perforation of the ear drum. Patients are advised not to fly until symptoms resolve.
  • Babies <2d. old should not fly (preferably <7d. old).
  • Surgery—Patients should not travel <10d. post surgery to the chest, abdomen, or middle ear. Any other procedure where gas is introduced into the body also needs careful consideration.

P.209
Precautions

  • Carry all regular medication, especially relief medications (e.g. salbutamol, GTN spray) in the cabin;
  • For people who have to time their medication carefully, keep to times medication was taken at home for duration of flight (e.g. diabetics— take snacks to eat and take insulin at normal times);
  • Drink plenty of liquid (non-alcoholic) to prevent dehydration;
  • Do calf exercises/get up and walk up and down at intervals to prevent venous stasis in legs (for those at risk of venous thromboembolism, worth using prophylactic aspirin 75mg od and compression stockings for flight);
  • Pre-warn airlines of special needs so that they can accommodate them (e.g. extra leg room, special diet, oxygen in-flight, transport to and from plane).

Fitness to perform sporting activities GPs are commonly asked to certify fitness to perform sports. Normally, the patient will come with a medical form. If there is a form, request to see it before the medical. If there is no form and you are unsure what to check, telephone the sport’s governing body or the event organizer. A fee is payable by the patient. Many gyms and sports clubs also ask older patients and patients with pre-existing conditions or disabilities to check with their GP before they will sign them on. Assuming that a suitable regime is undertaken, most people can participate in some form of sporting activity. Consider the patient’s baseline fitness, check BP and medications, and recommend a gradual introduction to any new forms of exercise. HOCM (p.352) can cause sudden death during sport. It is difficult to exclude on clinical examination—if there is a FH or systolic murmur refer to cardiology before recommending new intense activity. Pre-employment certification It is becoming increasingly common for GPs to be asked about the ‘medical’ suitability of candidates to perform a job. This is not part of the GP’s terms of service and, therefore, a GP can refuse to give an opinion. In all cases where an opinion is given, a fee can be claimed. Common examples are:

  • Ofsted forms for childminders
  • Care home staff—proof of ‘physical and mental fitness’
  • Food handlers—certificates of fitness

Remember—signing a form may result in legal action against you should the patient NOT be fit to undertake an activity. Where possible include a caveat e.g. ‘based on information available in the medical notes, the patient appears to be fit to…although it is impossible to guarantee this.’ If unsure, consult your local LMC or medical defence organization for advice. P.210
Confirmation and certification of death The death certification process in England and Wales is currently under review and likely to change in the near future. English law does not require a doctor:

  • To confirm death has occurred or that ‘life is extinct’. A doctor is only required to certify what, in their opinion, was the cause.
  • To view the body of a deceased person. There is no obligation to see/examine a body before issuing a death certificate.
  • To report the fact that death has occurred.

English law does require the doctor who attended the deceased during the last illness to issue a certificate detailing the cause of death. Certificates are provided by the local registrar of births, marriages, and deaths. A special certificate is needed for infants of <28d. old. Death in the community 1/4 occur at home. Expected deaths In all cases, advise to contact the undertakers and ensure the patient’s own GP is notified.

  • Patient’s home: Visit as soon as practicable.
  • Residential/nursing home: If possible, the GP who attended during the patient’s last illness should visit and issue a death certificate. The ‘on-call’ GP is often requested to visit. There is no statutory duty to do this, but it is reassuring for the staff at the home and often necessary before staff are allowed to ask for the body to be removed.

Unexpected and/or ‘sudden’ death If called, advise the attendant to call 999. Visit and take a rapid history from any attendants. Then:

  • Resuscitate if appropriate: Drowning and hypothermia can protect against hypoxic neurological damage; brains of children <5y. old are more resistant to damage.
  • Report the death to the coroner: If any suspicious circumstances or circumstances of death are unknown/unclear, call the police.

Alternatively, if police or ambulance service is already in attendance and death has been confirmed, suggest the police surgeon is contacted. Cremation The Cremation Acts of 1902 and 1952 require 2 doctors to complete a certificate to establish identity and that the cause of death is not suspicious before a person can be cremated. A fee is payable to each doctor by the person arranging the funeral. It has 2 parts:

  • Part B: Completed by the patient’s usual medical attendant—usually his/her GP.
  • Part C: Completed by another doctor who must have held full GMC registration (or equivalent) for ≥5y. and is not connected with the patient in any way, nor directly connected with the doctor who issued part B—usually a GP from another practice.

pacemakers and radioactive implants must be removed from the deceased before cremation can take place. Further information on completing cremation forms Home Office http://www.homeoffce.gov.uk/docs2/compcrembc.html P.211
Deaths which must be reported to the coroner

  • Sudden or unexpected deaths
  • Accidents and injuries
  • Industrial diseases e.g. mesothelioma
  • Service disability pensioners
  • Deaths where the doctor has not attended within the past 14d.
  • Deaths arising from ill treatment e.g. abuse, neglect, starvation, hypothermia
  • Cause of death unknown
  • Deaths <24h. after hospital admission
  • Poisoning (chronic alcoholism and its sequelae are no longer notifiable per se)
  • Medical mishaps (including anaesthetic complications, short- or longterm complications of operations, drugs—whether therapeutic or addictive)
  • Abortions
  • Prisoners
  • Stillbirths (when there is doubt about whether the baby was born alive)

Notification of death to the coroner The coroner can be contacted via the local police. Reporting to the coroner does not automatically entail a post-mortem. The coroner, once circumstances of death are clear, may advise the GP to tick and initial box A on the back of the certificate, which advises the Registrar that no inquest is necessary. Deaths which MUST be reported to the coroner are listed in the box above. In Scotland, deaths are reported to a procurator fiscal. The list of reportable deaths is the same, with the addition of deaths of foster children and the newborn. Recording deaths at the practice Death registers are useful. Routine communication of deaths to all members of the primary healthcare team and other agencies involved with the care of that patient (e.g. hospital consultants, social services) avoids the embarrassing and distressing situation of ongoing appointments and contacts being made for that patient. Record the death in the notes of any relatives/partner registered with the practice. Benefits available after a death

  • For widows/widowers: p.101
  • Funeral payment: p.104

Patient advice and support Department of Work and Pensions (DWP)

Scottish Executive ‘What to do after a death in Scotland’. Available from http://www.scotland.gov.uk/library5/social/waad-oo.asp Office of Fair Trading. ‘Arranging funerals’. http://www.oft.gov.uk P.212
Organ donation <5500 people in the UK are waiting for an organ transplant that could save or dramatically improve their life, but <3000 transplants are carried out each year. There is a desperate need for more donors. In 2003, ~400 people died while waiting for a transplant. Absolute contraindications to any organ donation

  • Untreated systemic infection
  • HIV
  • Hepatitis B or C
  • Alzheimer’s disease and other diseases of unknown aetiology (e.g. MS, motor neurone disease)
  • Creutzfeld-Jacob disease
  • Any high-risk factor for HIV (defined by DoH as: homosexual men, prostitutes, history of IV drug abuse, haemophiliacs, people who have had sexual relations with local people from Africa south of the Sahara since 1977, sexual partners of people in these groups)

Donor cards and the NHS Organ Donor Register Potential donors should always discuss their wishes with their relatives. They can register their desire to donate their organs after death by adding their names to the NHS Organ Donor Register and/or obtaining an organ donor card. Contact the NHS Organ Donor Line Tel: 0845 60 60 400 or sign up on-line at http://www.uktransplant.org.uk Live donation Certain tissues can be donated whilst a donor is alive:

  • Blood: Contact the Blood Transfusion Service Tel: 0845 7 711 711 http://www.blood.co.uk (in South, Mid, East, and West Wales Tel: 0800 25 22 66 http://www.welshblood.org.uk). New donors age 17–59y. are accepted and donors can continue giving blood until age 70.
  • Bone marrow: Contact the British Bone Marrow Registry Tel: 0845 7 711 711 http://www.biood.co.uk (in South, Mid, East, and West Wales contact the Welsh Bone Marrow Registry Tel: 0800 371 502 http://www.wefshblood.org.uk). A blood sample is taken on registration to allow tissue matching. Donation involves a small operation in which bone marrow is harvested—usually from iliac crests.
  • 1 kidney, part of lung, liver, or SI: Usually close relatives. Removal of the organ/part-organ involves a major operation for the donor. Risks to donor must be weighed vs. benefits to recipient.

Donation after death Table 8.3

  • Heart-beating donation: Donors must be maintained on a life-support machine at the time of death and until the organs are removed. The role of the GP in these situations is pre-emptive (information about organ donor register/donor cards) and to support families in making the decision whether to donate. Organs that can be donated are: kidneys, hearts, livers, lungs, pancreases, corneas, heart valves, bone, and skin.
  • P.213

  • Non-heart beating donation: The most important group for GPs, as donation can occur even if the patient dies in the community. The GP must initiate removal of tissues by contacting the local organ transplant coordinator or the national blood services tissue division Tel: 07693 086823.
  • Donation of whole body for medical education: Contact HM Inspector of Anatomy (Tel: 020 7972 4342/4551). Relatives should contact the medical school with which the donor has made arrangements after their death. Medical schools arrange collection of the body and a simple funeral. Not all bodies are accepted. The donor must give authorization for donation prior to death.
  • Tissue donation after death for research purposes: Can be done in addition to donation for transplantation—organs for transplant are taken first. http://www.bodydonation.org.uk

Approach to relatives Many families find the act of donation a source of comfort. Even with a signed donor card, the relatives of the patient must give their consent to organ donation post-mortem. The Coroner For any patient normally referred to the Coroner, Coroner’s permission must be gained before tissues are removed. Further information United Kingdom Transplant http://www.uktransplant.org.uk

Table 8.3 Organs suitable for non-heart beating donation
Organ Criteria for donation Specific contraindications
Corneas >1y. old; no upper age limit Scarring/ulceration of cornea
May be retrieved up to 24h. after death Leukaemia/certain lymphomas
Malignancy otherwise is not a contraindication, neither is poor eye sight
Heart valves 3mo.-60y. Congenital valve defect
May be retrieved up to 48h. after death Rheumatic heart disease
Cardiac arrest/Ml and malignancy are not contraindications
Skin 16–85y. Prolonged steroid therapy
>1.7m tall and >70kg weight Chronic skin disease e.g. psoriasis
May be retrieved up to 48h. after death Malignancy
Bone ≥16y.; no upper age limit Any history of malignancy
May be retrieved up to 24h. after death Osteomyelitis
Rheumatoid arthritis
Traumatic bone fractures

P.214
Bereavement, grief, and coping with loss Models of grief Traditional model The bereaved person moves through phases until ‘recovery’:

  • Initial shock: Sense of unreality, detachment, disbelief, or ‘numbness’. Lasts from hours to days.
  • Yearning: Pangs of grief, episodes of intense pining, and a desire to search interspersed with anxiety, guilt, and self-reproach.
  • Despair: The permanence of the loss is realized. Despair and apathy, social withdrawal, poor concentration, pessimism about the future.
  • Recovery: Rebuilding of an identity and purpose in life.

Recent models Grief represents an oscillation between loss and restoration—focused behaviour, demonstrated by swings in mood, thoughts, and behaviour between memories of the dead person and ‘getting on with life’. Avoidance or denial of the loss is common and a part of the process. Health consequences of bereavement

  • ↑ mortality (↑ deaths from CHD, cirrhosis, suicide, accidents)— particularly in first 6mo. Risk factors: ♂ >♀, age <65y., lower social class.
  • Mental health problems: Depression, anxiety, ↑ risk of suicide, substance abuse, identification reaction (hyperchondriacal disorder— symptoms mimic those of deceased e.g. chest pain if died from Ml), insomnia, self-neglect.
  • Physical problems: Fatigue, aches and pains (e.g headaches, musculo-skeletal pain), appetite change, Gl symptoms, ↓ immune response (↑ minor infection).
  • Others: Interference with family life, education, and employment, social isolation/loneliness, ↓ income.

Role of the primary care team Develop a practice policy for dealing with bereaved patients. Flag notes. Consider staff training and active follow-up of bereaved patients. If the person who has died is registered with the practice, ensure all medical referrals/appointments are cancelled. Bereaved children Children understand what death is by 8y. and even children of 2–3y. have some understanding of death. Exclusion makes children isolated and often makes the death of someone they have known more, not less, painful. Prepare children for a death, if possible, and give them a chance to have their questions answered. If a child has problems, seek specialist help. Benefits for widows/widowers p.101 P.215
Abnormal grief reactions Whether a grief reaction is normal or abnormal depends on individual circumstances—personality, situation surrounding death, and cultural expectations. Recognized patterns of abnormal grief are:

  • Inhibited grief—grief is absent or minimal
  • Delayed grief—late onset and
  • Prolonged or chronic grief—inability to rebuild life in any way

If abnormal grief is suspected:

  • Monitor carefully
  • Consider referral for bereavement counseling e.g. to CRUSE
  • Consider clinical depression (p.968) or post-traumatic stress disorder (p.963)
  • If symptoms are persistent or worsening despite treatment, or if there is suicidal risk, refer to psychiatry for specialist advice

Risk factors for poor outcome after bereavement Predisposing factors

  • Multiple prior bereavements
  • History of mental illness (e.g. depression, anxiety, suicidal attempts or threats)
  • Ambivalent or dependent relationship with the deceased
  • Low self-esteem
  • Being male
  • Poor social or family support

Situations where the circumstances of death may cause particular problems for the bereaved

  • Sudden or unexpected death
  • Death of parent when child or adolescent
  • Multiple deaths (e.g. disasters)
  • Miscarriage, death of baby, child, or sibling
  • Cohabiting partners, same sex partners, extra-marital relationship
  • Death due to aids, suicide
  • Deaths where those bereaved may be responsible
  • Deaths from murder, high media profile, or involving legal proceedings
  • Where a post-mortem and/or inquest is required

Useful contacts CRUSE Tel: 0870 167 1677 http://www.crusebereavementcare.org.uk Royal College of Psychiatrists information leaflet. Available at http://www.rcpsych.ac.uk National Association of Widows Tel: 024 7663 4848 http://www.widows.uk.net P.216
Breaking bad news It is never easy to break bad news. GPs do it frequently. Why is breaking bad news hard?

  • Admission of failure: When we tell patients bad news, it is often an admission that we have failed. When we fail, we naturally question what we have done and, when looking at our practice in retrospect, it is easy to find fault. Feelings of guilt are common.
  • Fear of the reaction of the patient: We all have a desire to avoid unpleasantness but sharing information with patients may be a positive way forwards. Even if news is bad, it gives the patient control of the situation.

Guidelines for sharing bad news with a patient

DO DON’T
  • Plan the consultation as far as possible. Check the facts first and ensure you have all the information. Ensure privacy and freedom from interruption.
  • Set aside enough time.
  • Ask if the patient would like a relative or friend with them. Make sure you introduce your self and find out their name and relationship to the patient.
  • Make eye contact—watch for non-verbal messages. Sit at the same level as the patient.
  • Use simple and straightforward language.
  • Allow silence, tears, or anger.
  • Be prepared to go over facts again.
  • Answer questions.
  • Reflect on what the patient or relative have said to allow you to modify your understanding of their feelings.
  • Take into account the patient’s current health e.g. if in pain, then sort out the pain and schedule a further discussion when the patient is more comfortable.
  • Offer ongoing support
  • Lie or fudge the issue.
  • Get your facts wrong.
  • Break bad news in public.
  • Give the impression of being rushed or distant.
  • Give too much information. It is better to be concise—the finer points can be filled in later.
  • Interrupt or argue.
  • Say that ‘nothing can be done’—there is always something that can be done.
  • Meet anger with anger.
  • Say, you ‘know how they feel’—you don’t.
  • Be frightened to admit you don’t know something.
  • Use medical jargon
  • Leave the patient with no follow-on contact.
  • Agree to withhold information from the patient.

P.217
Common problems

  • What if the relatives don’t want you to tell the patient? With adults of sound mind, information is confidential to the patient and can only be released, even to close relatives, with the patient’s permission. Relatives who say they don’t want the patient to know often do so to protect their relative. It is important to recognize that they know your patient best. First, explore their worries and point out the difficulties of the patient not knowing. Often, once a relative realizes that the patient knows things are not right and needs help and support to face the situation, they come round to the patient being told. Stress that you will not lie to a patient if asked a direct question.
  • How do you know if the patient wants to know? Most people (80–90%) do want to know. Assume this is the case and then feel your way carefully. Give the patient ample opportunity to say they don’t want to know.
  • How do you respond to questions you cannot answer? The best way to deal with this is to say you don’t have all the answers but will answer when you can, find out what you can, and say when you don’t know.

P.218
Assault and accidents Domestic violence p.220 Victims of crime or accidents Victims need treatment of injuries and emotional support. Record information carefully, as it may be needed for legal cases. Note the date, time, and place of the event. Record injuries in detail (physical and psychological)—including measuring the size of lacerations and bruises. Arrange for photos to be taken (police may arrange this). Encourage reporting of the incident to the police (the patient will not be eligible for criminal injury compensation if it is not reported). Give patient details of local victim support groups. If the patient’s safety is an issue, contact the duty social worker for a place of safety. Rape and indecent assault If a patient reports rape or indecent assault and is willing to report the matter to the police, do not examine her/him. The case against the assailant could be won or lost on the basis of evidence gained by examination of an alleged victim, so it is best done by a doctor trained and experienced in such work. If the patient will not report the matter to the police, take a full history and note LMP, contraception, sexual history. Make a note of any injuries and take photographs, if possible and appropriate. Do not insist on examination if the patient is unwilling. Ensure a chaperone is present if any examination is attempted. Discuss the need for emergency contraception, prophylactic antibiotics (e.g. ciprofloxacin 250mg po stat), blood tests at 3mo. to exclude transmission of syphilis and 3–6mo. for exclusion of seroconversion for HIV. If at high risk for HIV transmission, refer to A&E for consideration of prophylaxis (p.499). Discuss the need for counselling and inform the patient about the victim support scheme and rape crisis centres. Arrange follow-up in 2–3wk. Criminal injuries compensation For victims of violent crimes-even if the attacker is not identified. Compensation is paid for the injury, loss of earnings, and expenses. Claim by contacting the Criminal Injuries Compensation Authority, Tay House, 300, Bath Street, Glasgow G2 4LN Tel: 0800 358 3601 http://www.cica.gov.uk Post-traumatic stress disorder (PTSD) 23% assault victims and 80% rape victims develop PTSD. ♀:♂ ≈ 2:1. Defined as significant symptoms 1mo. after the event i.e. flashbacks, nightmares, survivor guilt, mood changes, detachment, poor concentration, insomnia, anxiety, and depression. Alcohol abuse and work and relationship problems are common Symptoms may last years. See p.963. Accident prevention p.162 Child abuse p.886 Elder abuse p.221 P.219
Further information Victim Support Treating victims of crime: Guidelines for health professionals. (National office: Cranmer House, 39 Brixton road, London SW9 6DZ. Tel: 020 7735 9166 http://www.victimsupport.org) Patient information and support Victim support: Tel: 0845 3030 900; http://www.victimsupportorg Rape Crisis UK and Ireland: http://www.rapecrisis.org.uk Survivors UK: Provides resources for men who have experienced any form of sexual violence Tel: 0845 122 1201 http://www.survivorsuk.org.uk P.220
Domestic violence Used to describe physical, emotional, and mental abuse of women by male partners. Affects ~1:4 women—the most common form of interpersonal crime. 60%—current partner; 21%—former partners. ½ suffer >1 attack; 1/3 have been attacked repeatedly. General practice is often the first place in which women seek formal help but only ¼ actually reveal they have been beaten. Without appropriate intervention, violence continues and often ↑ in frequency and severity. By the time the woman’s injuries are visible, violence may be a long-established pattern. On average, a woman will be assaulted 35 times before reporting it to police. Effects High incidence of psychiatric disorders, particularly depression, and self-damaging behaviours including drug and alcohol abuse, suicide, and parasuicide. Factors preventing the woman leaving the abusive situation Loss of self-esteem makes women think they are to blame; fear of partner; disruption of the family and her children’s relationship with their father; loss of intimate relationship with partner; fall in income; risk of homelessness; fear of the unknown. Guidelines for care

  • Consider the possibility of domestic violence—ask directly.
  • Emphasize confidentiality.
  • Document—accurate, clear documentation, over time at successive consultations, may provide cumulative evidence of abuse and is essential for use as evidence in court, should the need arise.
  • Assess the present situation—gather as much information as possible.
  • Provide information and offer help in making contact with other agencies.
  • Devise a safety plan—give the phone number of local women’s refuge; advise to keep some money and important financial and legal documents hidden in a safe place in case of emergency; help plan an escape route in case of emergency.

Do not pressurize women into any course of action. If the patient decides to return to the violent situation, she will not forget the information and support given. In time, this might give her the confidence and back up she needs to break out of her situation. If children are likely to be at risk you have a duty to inform social services or police, preferably with the patient’s consent (p.885). Assaults and accidents p.218 Child abuse p.886 P.221
Elder abuse Defined as: ‘A single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’. Older people may report the abuse, but often do not. May take several forms which may co-exist:

  • Physical e.g. cuts, bruises, unexplained fractures, dehydration/malnourishment with no medical explanation, burns
  • Psychological e.g. unusual behaviour, unexplained fear, appears helpless or withdrawn
  • Financial e.g. removal of funds by carers, new will in favour of carer
  • Sexual e.g. unexplained bruising, vaginal or anal bleeding, genital infections
  • Neglect e.g. malnourished, dehydrated, poor personal hygiene, late requests for medical attention

Prevalence (in own home) physical abuse—2%; verbal abuse—5%; financial abuse—2%. Signs Inconsistent story from patient and carer, inconsistencies on examination; fear in presence of carer; frequent attendance at A&E; frequent requests for GP visits; carer avoiding GP. Management Talk through the situation with the patient, carer, and other services involved in care. Assess the level of risk. Consider admission to a place of safety—contact social services and/or police as necessary; seek advice from Action on Elder Abuse. Further information Department of Health. Domestic violence: a resource manual for health care professionals. Available from http://www.dh.gov.uk Home Office: http://www.homeoffice.gov.uk/crime/domesticviolence RCGP. Domestic violence. http://www.rcgp.org.uk Ramsay J. et al. (2000) Should health professionals screen women for domestic violence? Systematic review. BMJ 325; 314 Useful contacts Womens’ Aid: Tel: 0808 2000 247 http://www.womensaid.org.uk Action on Elder Abuse Tel: 0808 808 8141 http://www.elderabuse.org.uk Police domestic violence units Tel: 0845 045 45 45 Local authority social services departments Local authority housing departments P.222
Social factors in general practice ‘The task of medicine is to promote health, to prevent disease and to treat the sick…These are highly social functions’ H.E. Sigirist, Civilization and Disease, 1943 Deprivation Social deprivation is linearly associated with death from all causes, with no threshold and no upper limit. The most pronounced effect is with circulatory and other smoking-related disease. A similar trend is seen with infant mortality, morbidity from chronic illness (particularly musculoskeletal, cardio-vascular, and respiratory conditions) and teenage pregnancy. This is not a new problem, nor one unique to the UK. Suggestions it is due to smoking and eating habits may be partly correct, but this disparity was in evidence 80y. ago when those of social classes I and II were more likely to smoke, eat foods high in saturated fats, and take less exercise. Disparity in health is closely related to income. In the UK an ↑ proportion of the population is now living on <50% of average income than 20y. ago—the mortality gap has grown proportionately. Impact on general practice: Higher incidence of illness → ↑ requirement for primary care team services and ↑ use of out-of-hours and A&E services amongst deprived communities. This is recognized in the UK in the Carr-Hill Index which allocates funds to practices (p.38). Homelessness Bed and breakfast accommodation Adverse effects of living in temporary bed and breakfast accommodation are well documented:

  • Adults have an ↑ incidence of depression than people of similar social standing in their own homes;
  • Homeless women are 2× as likely to have problems in pregnancy and 3× as likely to require admission in pregnancy;
  • ¼ of babies born to women living in bed and breakfast accommodation are of low birth weight (national average <1:10);
  • Children from these families are less likely to receive their immunizations, more likely to have childhood accidents, and have higher incidence of minor and diarrhoeal diseases.

Sleeping rough Poor diet, poor accommodation, and lack of access to medical services are universal problems in this group. A study done in 1986 in London found 1/3 are psychotic; ¼ have severe physical problems; 2/3 have no contact whatsoever with medical services. Evidence shows that if services are provided, homeless people will use them. Divorce: Divorcees of all ages are at greater risk of premature death (2× ↑ for men aged 35–42y.) than married people—mainly from cardio-and cerebrovascular disease, cancer, suicide, and accidental death. There is also a similar ↑ in morbidity. Children of divorced parents have ↑ risk of ill health from the time of separation until adult life, with children <5y. old when their parents separate being particularly vulnerable. They are also more prone to psychiatric illness later in life and are more likely to become divorced themselves. P.223
Employment and unemployment Effects of work have been compared to effects of vitamins—we need a certain amount to be healthy; then there is a plateau, where extra doesn’t help, and too much is harmful. There is good evidence that unemployment causes both ↑ mortality (from coronary vascular disease, cancers, suicide, violence, and accidents) and ↑ morbidity (depression, IHD). Threat of unemployment alone can cause morbidity—in 1 study GP consultation rates rose by 20% and referral rates by 60% after it was announced a factory would close. Increases were found in other family members too. Refugees and asylum seekers: The Geneva Convention defines a refugee as any person who ‘owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to return it.’ Refugees are entitled to free healthcare in the UK. Consider:

  • Cultural and religious issues—p.225.
  • Physical needs—Health needs are diverse, depending on country of origin and previous level of healthcare. Always consider infectious diseases e.g. hepatitis B, HIV, TB, and malaria. Ensure refugees claim all health-related benefits available to them e.g. free prescriptions.
  • Psychological needs—Depression, anxiety, panic attacks, agoraphobia, and poor sleep are common. Symptoms are often reactions to past experiences and current situation. Social isolation, hostility, and racism compound them. Use medication, if appropriate, but also address other issues.

Although telling their story is helpful for some refugees—‘active forgetting’ is the way people cope with their difficulties in some cultures.

  • Victims of torture—May present with many non-specific health problems. Some are the result of physical trauma; most are of mixed physical and psychological origin. Considerable time and patience is needed to manage them, but it is worth it. Advice and support is available from the Medical Foundation for the Care of Victims of Torture (http://www.torturecare.org.uk).
  • Family—Many will have left other family members behind. They may not know their whereabouts, or even if they are alive or dead. The Red Cross or Red Crescent can help with tracing (http://www.redcross.org.uk).

Useful contacts Shelter advice for homeless people Tel: 0808 800 4444 http://www.shelter.org.uk RELATE relationship counselling Tel: 0845 1 30 40 16 (cost of telephone counselling—£45/h. in Summer 2004) http://www.relate.org.uk Couple Counselling Scotland Tel: 01382 640340 (Thursday 2–4 p.m.) http://www.couplecounselling.org The Refugee Council http://www.refugeecouncil.org.uk Asylum Aid Tel: 0207 247 8741 http://www.asylumaid.org.uk P.224
Multicultural medicine Britain is a multicultural and multifaith society. It is important that providers of care take into account cultural and spiritual needs. Table 8.4 is a rough guide to religious differences which affect health care. It is forcibly brief and cannot address all the many variations. Everyone is an individual, and there is a real danger of ‘pigeonholing’ patients by religion or ethnic background and making incorrect assumptions as a result. Always ask patients/family about their own preferences. Communication Effective communication is essential. Do not assume English proficiency It is important to ascertain that you understand the patient and that the patient understands you.

  • Ask the patient to let you know if s/he doesn’t understand. Consider using an interpreter (see below).
  • Speak clearly and slowly and repeat important information. Avoid jargon, confusing phrases, double negatives, and rhetorical questions.
  • Ask patients to tell you what you have said, to check comprehension.
  • Be wary of sounding condescending—English skills are not a reflection of a hearing disorder or level of intelligence.

Respect beliefs and attitudes: People have different reactions towards illness, life, and death. Ask patients to provide you with information about their own ideas e.g for newly arrived immigrants, ask: ‘Could you tell me what would happen to you if you were in your country?’ Using interpreters Interpreters are an important resource in providing a voice for patients whose proficiency in English is poor or insufficient for the situation. In general, anyone who has been in an English-speaking country for <2y. will need an interpreter. Sometimes a friend or another family member can be used, but if sensitive issues have to be discussed or it is essential that the information is translated accurately, use a professional. General tips:

  • Anticipate an interpreter will be needed where possible and pre-book someone of the same gender who speaks the same language/dialect and will be ethnically acceptable to the patient.
  • Explain that the interpreter is bound to maintain confidentiality.
  • Face and speak in the first person directly to the patient, not the interpreter. Interpreters are solely there to convey information in a language both patient and doctor can understand—not to analyse information, or decide what should or should not be conveyed.

Useful contacts Ethnologue language guide http://www.ethnologue.comlcountry_Index.asp Interpreter services (fees payable): Language line Tel: 0800 169 2879; National Interpreting Service Tel: 0800 169 5996 Babel Tree Project—Health information in 123 languages http://www.adec.org.au/babeltree NHS—Direct multilingual health information and advice Tel: 0845 4647 http://www.nhsdirect.nhs.uk

Table 8.4 Religious differences important in healthcare
Religion Dietary restrictions Fasting Transfusion/transplant Family planning Death
Buddhist Mainly vegetarian N/A No objections No objections; abortion not allowed Cremation preferred; no objections to PM
Christian None N/A No objections Some approve of natural methods only Burial or cremation; no objections to PM
Hindu Most do not eat beef; Some are strict vegetarians. Fasting involves limiting type of foods No objections No objections Strong preference to die at home. The body should not be touched by non-Hindus. All adults are cremated. No PMs unless legally required.
Muslim No pork. Other meat must have been killed in a special manner (Halal).
Alcohol is prohibited.
Fasting sunrise → sunset during Ramadan Strict Muslims may not consent to transplant Variable—strict Muslims do not approve The body should not be touched by non-Muslims.
All Muslims are buried. No PMs unless legally required.
Jehovah’s witness No foods containing blood or blood products. No alcohol N/A No blood transfusion or organ transplant.
Dialysis is usually permitted
No objections Burial or cremation. No objections to PM
Jewish No pork, rabbit or shellfish. Meat prepared in Kosher fashion. Liberal Jews may not adhere to dietary restrictions. Orthodox Jews may fast for Yom Kippur No objections Some Orthodox Jews prohibit contraception.
Most Jewish boys are circumcised 8d. after birth
Burial is preferred.
No PMs unless legally required.
Sikh No beef. Most are vegetarian. Alcohol is forbidden. N/A No objections Allowed but not openly discussed Children and adults are cremated.

P.225
P.226
Diet The role of the GP and primary care team

  • Screening—identification of obese patients and patients in need of dietary advice for other reasons.
  • Assessment—motivation to change and barriers to change.
  • Discussion and negotiation—exploration of knowledge about diet; negotiation of goals.
  • Goal setting—2–3 food-specific goals on each occasion. Set a series of mini targets which make them appear more realistic and achievable.
  • Monitoring progress.

General foods to avoid or decrease

  • Fatty meat products (sausages, salami, meat pies)
  • ≥140grams/d. (~12–14 portions/wk.) of processed and red meat (beef, lamb, pork)
  • High-fat dairy products—full-cream milk, butter, full-fat cheese
  • Full-fat spreads
  • Crisps
  • Cakes and biscuits
  • Salted peanuts
  • Canned and other pre-prepared food high in salt and sugar

The ideal diet See Figure 8.1, p.228

  • Eat a variety of foods and the right amount to maintain a healthy weight (Figure 8.2, p.229).
  • Use starchy foods (e.g. bread, rice, pasta, potatoes) as the main energy source and plenty of fruit and vegetables (>5 pieces of fruit/portions of vegetables/d.). Don’t overcook vegetables (steaming is preferable to boiling) and keep the delay between cutting fruit and vegetables to eating them to a minimum.
  • Eat plenty of fibre—good sources are: high-fibre breakfast cereals, pulses, beans, wholemeal bread, potatoes (with skins), pasta, rice, oats.
  • Eat oily fish (e.g. mackerel, herring, pilchards, salmon) at least 1–2x/wk. and cut down on cooked red or processed meat; consider substituting meat with vegetable protein (e.g. pulses, soya).
  • Choose lean meat—remove excess fat/poultry skin and pour off fat after cooking; boil, steam, or bake foods in preference to frying; when cooking with fat, use unsaturated oil (e.g. olive, sunflower), and use cornflour rather than butter and flour to make sauces.
  • Use skimmed milks—low-fat yoghurts/spreads/cheese (e.g. Edam or cottage cheese).
  • Avoid adding salt or sugar to foods and cut down on sweets, biscuits, and sticky deserts.
  • Drink at least 4–6 pints (2–3l) of fluid (preferably not tea, coffee, or alcohol) each day and avoid excessive alcohol intake (<21u/wk. for men and <14u/wk. for women—p.236).

P.227
Malnutrition 50% of women and 25% of men aged >85y. are unable to cook a meal alone. Malnutrition is not only a disease of the 3rd world, it is common amongst the elderly in the UK. Poor nutritional status Slows rate of wound healing, ↑ risk of infection, ↓ muscle strength, is detrimental to mental well-being, and ↓ the ability of elderly people to remain independent. Risk factors

  • Low income
  • Living alone
  • Mental health problems (e.g. depression)
  • Dementia
  • Recent bereavement
  • Gastric surgery
  • Malabsorption
  • ↑ metabolism
  • Difficulty eating and/or swallowing (stroke, neurological disorder, MND)
  • Presence of chronic disease (e.g. Crohn’s disease, UC, IBS, cancer, COPD, CCF)

Management

  • General nutritional advice: Encourage to eat more and ↑ consumption of fruit and vegetables; consider using nutritional, vitamin and mineral supplements (e.g. vitamin D supplements for the housebound and institutionalized);
  • Inability to prepare meals/shop: Consider referral to social services; Meals on Wheels; community dietician; community day centre; local voluntary support organization.
  • Difficulty with utensils: Consider aids/equipment (cutlery, non-slip mats).
  • Nausea: Consider antiemetics.
  • Difficulty with swallowing: Investigate the cause. If none found or unable to resolve the problem, consider pureed food and/or thickened fluids.

Useful information The Scientific Advisory Committee on Nutrition (SACN): http://www.sacn.gov.uk The British Nutrition Foundation: http://www.nutrition.org.uk

Figure 8.1 The plate model. Developed nationally to communicate current recommendations for healthy eating. It shows rough proportions of the various food groups that should make up each meal
Figure 8.2 BMI ready reckoner

P.228
P.229
P.230
Obesity Obesity is one of the most important preventable diseases in the UK. The best measure of obesity is body mass index (BMI). Recent evidence shows it is increasing and is set to take over from smoking as the number one preventable cause of disease in the UK. Classification BMI (weight in kg ÷ (height in m)2):

  • 18.5–24.9 = normal
  • 25–29.9 = overweight
  • 30–39.9 = obese
  • >40 = morbid obesity

Health risks of obesity

  • Death (BMI >30 carries 3× ↑ risk of mortality)
  • IHD
  • Hypercholesterolaemia
  • ↑ BP
  • Cerebrovascular disease
  • Type 2 DM
  • Gallbladder disease
  • Complications after surgery
  • Sleep apnoea
  • Psychological problems
  • Cancer of cervix, uterus, ovary, and breast
  • Musculoskeletal problems and arthritis
  • Ovulatory failure
  • Menstrual irregularities
  • PCOS
  • Complications in pregnancy (gestational DM, ↑ BP, pre-eclampsia), labour, and delivery
  • Stress incontinence

Waist circumference An alternative indirect measurement of body fat that reflects the intra-abdominal fat mass. Strongly correlated with CHD risk, DM, hyperlipidaemia, and ↑ BP. Measured halfway between the superior iliac crest and the rib cage in the mid-axillary line.

Table 8.5 Association of waist circumference with risk of CHD and DM
  Waist circumference ↑ risk of CHD, DM Substantial risk of CHD, DM
♂ ≥94cm (37inches) ≥102cm (40inches)
♀ ≥80cm (32inches) ≥88cm (35inches)

Risk factors Genetic predisposition (accounts for about 1/3 obesity); previous obesity and successful dieting; physical inactivity; low education; smoking cessation; female gender. Prevention Begins in childhood by instilling healthy patterns of exercise and diet. There is little evidence to show that dietary advice by GPs or practice nurses is heeded. Most influence on diet comes from national food policy, price of food, advertising, general education, and culture. Treatment When the body’s intake > output over a period of time, obesity results. Management of obesity aims to reverse this trend on a long-term basis:

  • ↓ calorie diets: All obese people lose weight on a low-energy intake. A realistic goal is weight loss of 1–2lbs (0.5–1kg)/wk. and is achievable P.231
    using diets of 1000–1500kcal/d. intake. Rates of weight loss >1kg/wk. involve loss of lean tissue rather than fat. Aim for BMI of 25. There is no health benefit of weight ↓ below this. Weight loss in the first few weeks may be higher due to water and glycogen depletion. If simple diet sheets are not effective, refer to a dietician.
  • Very low-calorie diets (<800kcal/day): Only limited place in management as this pattern of eating cannot be maintained and rebound weight gain is seen on stopping. Only use to treat morbid obesity under strict supervision.
  • Healthy diet: ↓ fat intake; ↑ proportion of unrefined carbohydrate; eat 5 portions of fruit and vegetables/d.; ↓ hidden sugars (alcohol, prepared foods); ↑ fibre—p.226 and 228.
  • Exercise: Regular aerobic exercise helps ↓ weight and improve health. Tailor advice to the individual and local facilities—p.232.
  • Drug therapy (BNF 4.5): Drugs specifically licensed for the treatment of obesity are orlistat (120mg tds with food) and sibutramine (10–15mg od—monitor BP and pulse rate closely). Consider if BMI >30kg/m 2 or >27kg/m2 in the presence of co-morbidity e.g. DM. There is little evidence to guide selection but it is logical to choose orlistat for those who have a high intake of fats and sibutramine for those who cannot control their eating. Combination therapy involving >1 anti-obesity drug is contraindicated. NICE has published guidelines on administration—summarized in the BNF.
  • Group therapy: Group activities e.g. Weight Watchers, seem to have a higher success rate in producing and maintaining weight loss.
  • Behavioural therapy: Shown to be effective individually and in groups when combined with low-calorie diets. In simplest form, involves advice to avoid situations that tempt overeating.
  • Surgery: Only consider referral as a last resort if behavioural and dietary modification have failed and BMI >40. Gastroplasty is the most common procedure. Mortality is high.
  • Follow-up on a regular basis is essential to maintain motivation.

Maintenance of weight loss Once a patient has lost weight, diet still needs to be monitored. On-going follow-up has been shown to help sustain weight loss. Weight fluctuation (yo-yo dieting) may be harmful. Essential reading National Audit Office Tackling obesity in England (2001) http://www.nao.org.uk NICE http://www.nice.org.uk

  • Guidance on the use of sibutramine for the treatment of obesity in adults (2001)
  • Orlistat for treatment of obesity in adults (2001)

National Obesity Forum http://www.nationalobesityforum.org.uk

  • Guidelines on the management of adult obesity and overweight in primary care (2002)
  • An approach to weight management in children and adolescents (2–18years) in primary care (2003)

SIGN Management of obesity in children and young people (2003) http://www.sign.ac.uk P.232
Exercise ‘Lack of physical activity is a major underlying cause of death, disease and disability. Preliminary data from a WHO study on risk factors suggest that a sedentary lifestyle is one of the 10 leading global causes of death and disability. More than 2 million deaths each year are attributable to physical inactivity.’ WHO, Move for Health, 2002 In the UK, 60% of men and 70% of women are not active enough to benefit their health. Recommended amounts of activity (DoH)

  • Adults: ≥30mins. moderate intensity exercise across the day on ≥5d./wk.
  • Children: ≥1h. moderate intensity exercise across the day every day.

Dimensions of exercise

  • Volume or quantity—quantity of activity usually expressed as kcal per day or week. Can also be expressed as MET hours per day or week, where 1 MET = resting metabolic rate.
  • Frequency—number of sessions per day or week.
  • Intensity—light, moderate, or vigorous. Light intensity = <4 METS (e.g. strolling); moderate = 4–6 METS (e.g. brisk walking); vigorous = 7+ METS (e.g. running).
  • Duration—time spent on a single bout of activity.
  • Type or mode e.g. brisk walking, dancing, or weight training.

Exercise is beneficial Regular physical activity—

  • ↓ risk of:
    • CHD—physically inactive people have ~2× ↑ risk of CHD and ~3× ↑ risk of strokes.
    • DM—through ↑ insulin sensitivitys.
    • Obesitys—p.230.
    • Osteoporosis—↓ risk of hip fractures by 1/2 s.
    • Cancer—↓ risk of colon cancer ~40%. There is also evidence of a link between exercise and ↓ risk of breast and prostate cancerss.
  • Is a useful treatment for:
    • ↑ BP—can result in 10mmHg drop of systolic and diastolic BP; can also delay onset of hypertensions.
    • Hypercholesterolaemia—↑ HDL, ↓ LDLc.
    • Post-Mlc—p.332
    • DM—improves insulin sensitivity and favourably affects other risk factors for DM including obesity, HDL/LDL ratio, and ↑BP.
    • HIV—↑ cardiopulmonary fitness and psychological well-beingc.
    • Arthritis and back pain—maintains functionc.
    • ↓ intensity of depression; ↓ anxietys.
  • Benefits the elderly:
    • Maintains functional capacity.
    • ↓ levels of disability.
    • ↓ risk of falls and hip fracture.
    • Improves quality of sleepc.

P.233
Effective interventions

  • Healthcare—↑ physical activity for 1° and 2° prevention is effective in the short term; no evidence effects are maintained long-term. Counselling for physical activity is as effective as more structured exercise sessions.
  • Workplace—interventions to ↑ rates of walking to work are effective.
  • Schools—appropriately designed and delivered PE curricula can enhance physical activity levels. A whole school approach to physical activity promotion is effective.
  • Transport—well-designed interventions ↑ walking and cycling to work.
  • Communities—community-wide approaches to physical activity promotion → ↑ activity.

Negotiating change It is possible to encourage people to ↑ activity levels. As with all lifestyle interventions, the patient must want to change.

  • If exercise levels are satisfactory, congratulate and inform about the benefits of exercise.
  • If levels are unsatisfactory, explain the benefits of a higher level of physical activity and support with health education leaflets.
  • Once the patient has agreed, advise and agree ways to do that.

You are more likely to be successful if:

  • Exercise recommended is moderate, does not require attendance at a special facility, and can be incorporated into daily life routines e.g. walking/cycling to work.
  • You suggest a graduated programme of exercise for sedentary patients (there is an ↓ risk of sudden cardiac death associated with sudden vigorous exercise).

Exercise schemes

  • Specialist rehabilitation schemes (e.g. cardiac, respiratory) are in operation in many areas. They are usually operated in association with specialist services and incorporate exercise and education for patients with specific conditions e.g. post-MI (p.332).
  • Exercise prescription schemes—collaboration between community medical services and local sports facilities. They offer low-cost, supervised exercise for patients who might otherwise find it unacceptable to visit a gym, and are accessed via GP ‘prescription’.
  • Local sports centres—many sports facilities also offer special sessions both on dry land and in the swimming pool for pregnant women, the over 50s, and people with disability.

Essential reading DoH: National Quality Assurance Framework on Exercise Referral Systems (2001) http://www.dh.gov.uk NICE: http://www.publichealth.nice.org.uk

  • Improving physical activity
  • Guidance on the preventive aspects of the CHD NSF
  • Cancer prevention: a resource to support local action in delivering the Cancer Plan

US Surgeon General Report on Physical Activity and Health http://www.cdc.gov/nccdphp/sgr/sgr.htm P.234
Smoking Facts and figures In the UK, 12 million adults (28% ♀ 26% ♂) smoke cigarettes and a further 3 million smoke pipes or cigars. Prevalence: highest aged 20–24y. Government targets aim to ↓ smoking to 26% by 2005 and to ≤24% by 2010; surveys of smokers show 70% want to stop and 30% intend to give up in <1y.—but only–2%/y. successfully give up permanently. 1% school children are smokers when they enter secondary school; by 15y., 22% are smoking. 82% of smokers start as teenagers. Government targets aim to ↓ smoking amongst children to ≤9% by 2010. Risks of smoking Greatest single cause of illness and premature death in the UK. ½ all regular smokers will eventually die as a result of smoking—120,000/y. Tobacco smoking is associated with ↓ risk of:

  • Cancers: lung (>90% are smokers), lip, mouth, stomach, colon, bladder (~ 30% ALL cancer deaths)
  • Cardiovascular disease: arteriosclerosis, coronary heart disease, stroke. peripheral vascular disease
  • DM
  • Chronic lung disease: COPD, recurrent chest infection, exacerbation of asthma
  • Dyspepsia and/or gastric ulcers
  • Thrombosis (especially if also on the COC pill)
  • Osteoporosis
  • Problems in pregnancy: PET, IUGR, pre-term delivery, neonatal and late foetal death.

Passive smoking is associated with:

  • ↓ risk CHD and lung cancer (↑ by 25%)
  • ↓ risk of cot death, bronchitis, and otitis media in children.

Nicotine withdrawal symptoms

  • Urges to smoke (70%)
  • ↑ appetite (70%—average 3—4kg weight gain)
  • Depression (60%)
  • Restlessness (60%)
  • Poor concentration (60%)
  • Irritability/aggression (50%)
  • Night-time awakenings (25%)
  • Light headedness (usually 1st few days after quitting—10%)

Helping people to stop smoking Advice from a GP about smoking cessation results in 2% of smokers stopping; 5% if advice is repeatedCE Aids to smoking cessation BNF 4.10 Prescribe only for smokers who commit to target stop date. Initially, prescribe only enough to last 2wk. after the target stop date i.e. 2wk. nicotine replacement therapy or 3–4wk. bupropion. Only offer a 2nd prescription if the smoker demonstrates continuing commitment to stop smoking. If unsuccessful, the NHS will not fund another attempt for ≥6mo. P.235
Nicotine replacement therapy (NRT) ↑ the chance of stopping -1½XN. All preparations are equally effectivec and available on NHS prescription. Start with higher doses for patients highly dependent. Continue treatment for 3mo., tailing off dose gradually over 2wk. before stopping (except gum which can be stopped abruptly). Several preparations are now licensed for use in pregnancy if unable to stop without NRT. Contraindicated immediately post MI, stroke, or TIA, and for patients with arrythmia. Bupropion (ZybanTM) Smokers (>18y.) start taking the tablets 1–2wk. before their intended quit day (150mg od for 3d. then 150mg bd for 7–9wk.). ↑ cessation rate >2x.NContraindications: epilepsy or ↑ risk of seizures, eating disorder, bipolar disorder, pregnancy/breast-feeding. Alternative therapies Some evidence hypnotherapy (p.154) is helpful in some casesS.

Figure 8.3 Management plan for smokers attending the surgery

Essential information Clinical evidence: Cardiovascular disorders: changing behaviour; smoking cessation http://www.nelh.nhs.uk NICE: (2002) Nicotine replacement therapy and bupropion for smoking cessation http://www.nice.org.uk Cochrane: Silagy C. et al. (2004) Nicotine replacement for smoking cessation http://www.nelh.nhs.uk Useful contacts Action on Smoking and Health (ASH) Tel: 020 7739 5902 http://www.ash.org.uk NHS: Smoking helpline Tel: 0800 169 0 169; pregnancy smoking helpline: Tel: 0800 169 9 169 http://www.givingupsmoking.co.uk Quit: Helpline Tel: 0800 00 22 00 http://www.quit.org.uk P.236
Alcohol Assessing drinking Suspicious signs/symptoms ↑ and uncontrolled BP; excess weight; recurrent injuries/accidents; non-specific Gl complaints; back pain; poor sleep; tired all the time. Ask Assess amount, time of day, socially or alone, daily or in binges, blackouts, situations associated with heavy drinking. Consider using the CAGE questionnaire to assess dependence:

  • Have you ever felt you should Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt bad or G uilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hang over (Eye opener)?

Risk factors

  • Previous history
  • Family history
  • Poor social support
  • Work absenteeism
  • Emotional and/or family problems
  • Financial and legal problems
  • Drug problems
  • Alcohol associated with work e.g. publican

Examination Smell of alcohol, tremor, sweating, slurring of speech, BP (↑ BP), signs of liver damage. Investigations FBC (↑ MCV); LFTs (↑ GGT identifies ~25% of heavy drinkers in general practice; ↑ AST; ↑ bilirubin). Often incidental findings. Health risk Continuum—individual risk depends on other factors too (e.g. smoking, heart disease, pregnancy). Recommended safe levels of alcohol consumption are <21u/wk. for men and <14u./wk. for women.

Table 8.6 Health risks associated with levels of alcohol consumption
Health risk Men (units/wk.) Women (units/wk.)
Low <21 <14
Intermediate 21–50 15–35
High >50 >35
1 unit = 8g alcohol = 1/2 pint of beer (if strong beer, can be as much as 1.75 units), small glass of wine/sherry, 1 measure of spirits (spirit measure in Scotland is 1.2 units).
1 bottle of 12% wine = 9 units.

Alcohol-associated problems Death ~40,000 deaths/y. in the UK are directly caused by alcohol. Social

  • Marriage breakdown
  • Absence from work
  • Loss of work
  • Social isolation
  • Poverty
  • Loss of shelter/home

Mental health Anxiety, depression and/or suicidal ideas; dementia and/or Korsakoffs ± Wernicke’s encephalopathy (p.625). P.237
Physical

  • ↑ BP
  • CVA
  • Sexual dysfunction
  • Brain damage
  • Neuropathy
  • Myopathy
  • Cardiomyopathy
  • Infertility
  • Gastritis
  • Pancreatitis
  • DM
  • Obesity
  • Foetal damage
  • Haemopoietic toxicity
  • Interactions with other drugs
  • Fatty liver
  • Hepatitis
  • Cirrhosis
  • Oesophageal varices ± haemorrhage
  • Liver cancer
  • Cancer of the mouth, larynx and oesophagus
  • Breast cancer
  • Nutritional deficiencies
  • Back pain
  • Poor sleep
  • Tiredness
  • Injuries due to alcohol-related activity (e.g. fights)

Beneficial effects of alcohol Moderate consumption (1–3u./d.) ↓ risk of non-haemorrhagic stroke, angina pectoris, and Ml. Management of alcohol abuse p.238 Patient advice and support Drinkline (government-sponsored helpline) Tel: 0800 917 8282 Alcohol Concern http://www.alcoholconcern.org.uk Alcoholics Anonymous Tel: 0845 7697555 http://www.alcoholics-anonymous.org.uk P.238
Management of alcohol abuse ‘An alcoholic is someone you don’t like who drinks as much as you do’ Dylan Thomas (1914–1953) Management strategies Figure 8.4 Patients drinking within acceptable limits Reaffirm limits. Non-dependent drinkers Brief GP intervention results in ~24% reducing their drinking. Provide information about safe amounts of alcohol and harmful effects of exceeding these. If receptive to change, confirm weekly consumption using a drink diary, agree targets to ↓ consumption, and negotiate follow-up. Alcohol-dependent drinkers Suffer withdrawal symptoms if they ↓ alcohol consumption (e.g. anxiety, fits, delirium tremens—p.1068).

  • If wanting to stop drinking—refer to the community alcohol team; suggest self-help organizations e.g. AA; involve family and friends in support.
  • Detoxification in the community usually uses a reducing regimen of chlordiazepoxide over a 1wk. period (20–30mg qds on days 1 and 2; 15mg qds on days 3 and 4; 10mg qds on day 5; 10mg bd on day 6; 10mg od on day 7; then stop).
  • Community detoxification is contraindicated for patients with:
    • Confusion or hallucinations
    • History of previously complicated withdrawal e.g. withdrawal seizures or delirium tremens
    • Epilepsy or fits
    • Malnourishment
    • Severe vomiting or diarrhoea
    • ↓ risk of suicide
    • Poor co-operation
    • Failed detoxification at home
    • Uncontrollable withdrawal symptoms
    • Acute physical or psychiatric illness
    • Multiple substance misuse
    • Poor home environment

If ambivalent/unwilling to change Provide information; reassess and re-inform on each subsequent meeting; support the family. Delerium tremens p.1068 Vitamin B supplements People with chronic alcohol dependence are frequently deficient in vitamins, especially thiamine—give oral thiamine indefinitely (if severe, 200–300mg/d.; if mild, 10–25mg/d.)G. During detoxification in the community, give thiamine 200mg od for 5–7d. Relapse Common. Warn patients and encourage them to re-attend. Be supportive and maintain contact (↓ frequency and severity of relapsesG). Consider drugs to prevent relapse e.g. acamprosate, disulfiram (specialist initiation only). Alcohol and driving p.205

Figure 8.4 Management strategy

P.239
Essential reading (1997) Addiction and dependence—II: alcohol. BMJ 315, 358–60 (2000) Managing the heavy drinker in primary care. DTB 38(8), 60–64 SIGN (2003) The management of harmful drinking and alcohol dependence in primary care http://www.sign.ac.uk Patient advice and support Drinkline (government-sponsored helpline) Tel: 0800 917 8282 Alcohol Concern http://www.alcoholconcern.org.uk Alcoholics Anonymous Tel: 0845 7697555 http://www.alcoholics-anonymous.org.uk P.240
Drugs misuse 1:10 adults report using illicit drugs in the last year. Of those presenting for treatment, opioids are the main drugs of abuse (heroin—54%; metha-done—13%), but the most frequently abused drugs are cannabis, amphetamine, ecstasy, and cocaine. 3 factors appear important:

  • availability of drugs
  • vulnerable personality
  • social pressures, particularly from peers

Detection Warning signs suggesting drug misuse:

  • Use of services: Suspicious requests for drugs of abuse (e.g. no clear medical indication, prescription requests are too frequent).
  • Signs and symptoms: Inappropriate behaviour; lack of self-care; unexplained nasal discharge; unusually constricted or dilated pupils; evidence of injecting (e.g. marked veins); hepatitis or HIV infection.
  • Social factors: Family disruption; criminal history.

Assessment Assess on >1 occasion before deciding how to proceed. Exceptions are severe withdrawal symptoms and/or evidence of an established regime requiring continuation. Points to cover:

  • General information: Check identification (ask to see an official document); contact with other agencies (including last GP)—check accuracy of report; current residence; family (partner, children); employment; finances; current legal problems; criminal behaviour (past and present).
  • History of drug use: Current and past usage; knowledge of risks; unsafe sexual practices.
  • Medical and psychiatric history: Complications of drug abuse (e.g. HIV, hepatitis, accidents); general medical and psychiatric history; overdoses (accidental or deliberate); alcohol abuse.
  • Investigations: Consider urine toxicology to confirm drug misuse; blood for FBC, LFTs, Hep B, C, and HIV serology (with consent and counselling).

Management Aims to ↓ risk of infectious diseases; ↓ drug-related deaths, and ↓ criminal activity used to finance drug habits. The GP and PHCT have a vital role—identifying drug misusers; assessing their health and willingness to modify drug abusing behaviour; and routine screening and prevention (e.g. cervical screening, contraception). General measures On each meeting consider:

  • Education: Safer routes of drug administration; risks of overdose; condom use; driving and drug misuse (p.205).
  • Hepatitis B immunization: For injecting drug misusers not already infected/immune and close contacts of those already infected.
  • Treatment of dependence: Set realistic goals. Responsibility contracts signed by GP, patient ± community pharmacist can be helpful. Review regularly. Give contact numbers for community support organizations. Seek advice and/or refer to a community substance misuse team as needed.

P.241
Specific drugs

  • Opiates: Refer to substance abuse team. Untreated heroin withdrawal reaches a peak 36–72h. after the last dose (methadone—4–6d.). Symptoms: sweating, running eyes/nose, hot and cold turns ± gooseflesh, Gl problems (anorexia, nausea, vomiting, diarrhoea, abdominal pain), restlessness and tremor, insomnia, aches and pains, tachycardia ± hypertension. Subside by 5d. (methadone—10–12d.).
  • Benzodiazepines: Taper dosage over weeks. Seek specialist advice if the patient has any chronic debilitating condition or heart disease. Withdrawal symptoms include rebound anxiety, tremor, tachycardia, tachypnoea, nausea, abdominal and muscular cramps, diarrhoea. Rarely, perceptual disturbances and seizures.
  • Stimulants (e.g. amphetamines, cocaine, ecstasy): Can be stopped abruptly. Some patients experience insomnia and depression. May require antidepressant drugs after withdrawal.
  • Hallucinogenic drugs (e.g. LSD): Can be stopped abruptly.
  • Barbiturates: Admit to hospital for supervised withdrawal. Sudden cessation may cause fits ± death.

Solvent abuse: Common amongst teenagers as solvents are easily obtained and cheap. Initial effects of inhalation are euphoria, incoordination, blurred vision, and slurring of speech. Rarely, the solvent may cause bronchoconstriction or arrhythmia and deaths, when they occur, are usually due to hypoxia, VF, or accidents whilst intoxicated. Symptoms to look for in the surgery are changes in behaviour (e.g. drop in school performance or attendance, irritability, mood swings) and local changes due to inhalation (e.g. cough, headaches, conjunctivitis). If detected, refer to the youth support agencies. Essential reading DoH (1999) Drug misuse and dependence—guidelines on clinical management http://www.dh.gov.uk Patient advice and support ‘Talk to FRANK’ (England and Wales): Government-run information, advice, and referral service. Tel: (24 hour) 0800 77 66 00 http://www.talktofrank.com ‘Know the Score’ (Scotland): Tel: 0800 587 5879 http://www.knowthescore.info Drugscope: Information about drug abuse and how to get treatment http://www.drugscope.org.uk Drugs-info: Information about substance abuse for families of addicts http://www.drugs-info.co.uk ADFAM: Support for families of addicts Tel: 020 7928 8898 http://www.adfam.org.uk Ecstasy http://www.ecstasy.org Benzodiazepines http://www.benzo.org.uk Solvent abuse Tel: 0808 800 2345 http://www.re-solv.org National Treatment Agency for Substance Abuse http://www.nhs.uk Substance Misuse Management in General Practice (SMMGP) http://www.smmgp.demon.co.uk P.242
Insomnia From the Latin meaning ‘no sleep’. Describes a perception of disturbed or inadequate sleep. ~1:4 of the UK population (♀<♂) are thought to suffer in varying degrees. Prevalence ↑ with age, rising to 1:2 amongst the over 65s. Causes are numerous. Common examples include:

  • Minor, self-limiting: Travel, stress, shift work, small children, arousal.
  • Psychological: ~½ have mental health problems—depression, anxiety, mania, grief, alcoholism.
  • Physical: drugs (e.g. steroids), pain, pruritus, tinnitus, sweats (e.g. menopause), nocturia, asthma, obstructive sleep apnoea.

Definition of ‘a good’s night sleep’

  • <30min. to fall asleep
  • Maintenance of sleep for 6–8h.
  • <3 brief awakenings/night
  • Feels well rested and refreshed on awakening

Management Careful evaluation. Many do not have a sleep problem themselves, but a relative feels there is a problem (e.g. the retired milkman continuing to wake at 4 a.m.). Others have unrealistic expectations (e.g. they need 12h. sleep/d.) Reassurance alone may be all that is required. For genuine problems

  • Eliminate as far as possible any physical problems preventing sleep e.g. treat asthma or eczema; give long-acting pain killers to last the whole night; consider HRT for sweats, refer if obstructive sleep apnoea is suspected (p.400)
  • Treat psychiatric problems e.g. depression, anxiety.
  • Sleep hygiene—see box.
  • Relaxation techniques: Audiotapes (borrow from libraries or buy from pharmacies); relaxation classes (often offered by local recreation centres/adult education centres); many physiotherapists can teach relaxation techniques.
  • Consider drug treatment: Last resort. Benzodiazepines may be prescribed for insomnia ‘only when it is severe, disabling, or subjecting the individual to extreme distress.’

Drug treatment Benzodiazepines (e.g. temazepam), zolpidem, zopiclone, and low-dose TCA (e.g. amitriptyline 25–50mg) nocte are all commonly prescribed for patients with insomnia.

  • Side-effects: Amnesia and daytime somnolence. Most hypnotics do affect daytime performance and may cause falls in the elderly. Warn patients about their affect on driving and operating machinery.
  • Only prescribe a few weeks’ supply at a time due to potential for dependence and abuse.

Beware the temporary resident who has ‘forgotten’ his/her night sedation. Complications of insomnia ↓ quality of life; ↓ concentration and memory affecting performance of daytime tasks; relationship problems; risk of accidents. 10% motor accidents are related to tiredness. P.243
Principles of ‘sleep hygiene’

  • Don’t go to bed until you feel sleepy
  • Don’t stay in bed if you’re not asleep
  • Avoid daytime naps
  • Establish a regular bedtime routine
  • Reserve a room for sleep only (if possible)—do not eat, read, work, or watch TV in it
  • Make sure the bedroom and bed are comfortable, and avoid extremes of noise and temperature
  • Avoid caffeine, alcohol, and nicotine
  • Have a warm bath and warm milky drink at bedtime
  • Take regular exercise but avoid late night hard exercise (sex is OK)
  • Monitor your sleep with a sleep diary (record both the times you sleep and its quality)
  • Rise at the same time every morning regardless of how long you’ve slept

Patient information and support Royal College of Psychiatrists: Patient information sheets http://www.rcpsych.ac.uk

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