Practitioner最新文献

Neuropathic pain can be considered to be a clinical syndrome with multiple causes ranging from damage to peripheral nerve pathways as the level of peripheral nociceptors to abnormalities in the cortical neurons in the brain. It is defined as pain that is caused by a lesion or disease of the somatosensory nervous system and is estimated to affect 6-8% of the general population. A low threshold of suspicion in conditions associates with neuropathic pain can aid diagnosis. Data from the past decade suggest that it is found in 16-26% of patients with diabetes, 8% of patients suffering from shingles in the past three months (increasing to 40% and 75% in patients aged over 50 and 75 respectively), and 10-50% of patients following surgery. Typical neuropathic descriptors include burning, shooting electric shock pain with numbness, pins and needles or itching. After general and neurological examination the focus should turn to the affected pain area using an unaffected body part as a control. Sensory response to cotton wool, pinprick, temperature and vibration should all be assessed. This will identify the positive and negative signs found in neuropathic pain. Tinel's sign and Phalen's sign, although classically taught, have such poor sensitivity and specificity that GPs are no longer encouraged to rely on them, and they should not be used. Neuropathic pain is often poorly responsive to conventional analgesia with the mainstay of treatment being anticonvulsant and antidepressant medication. Multidisciplinary assessment and management in the specialist setting of the pain clinic is often requires.

The common presentation of coeliac disease has shifted from the historically classical symptoms of malabsorption in childhood to non-classical symptoms in adulthood such as irritable bowel syndrome-type symptoms, anaemia, chronic fatigue, change in bowel habit, abdominal pain and osteoporosis. A combination of coeliac serology and duodenal biopsy is required to diagnose coeliac disease in adults. Testing for IgA-tissue transglutaminase antibodies should be carried out as a first-line screening test. Advise patients to eat a gluten-containing diet for six weeks before their investigations to ensure the serological and histological results are not affected. A confirmatory duodenal biopsy is mandatory to ensure that patients are correctly diagnosed with coeliac disease. A lifelong strict gluten-free diet is the only effective treatment currently available. All patients should be referred to a specialist dietitian for guidance and support. Annual follow-up can begin when the disease is stable and patients are managing well on their diet.

Patients with inflammatory bowel disease (IBD) may previously have received a diagnosis of irritable bowel syndrome and there may be a delay in making the correct diagnosis. This is particularly the case in patients with ileal Crohn's disease and those under 40. Diagnosis of IBD involves endoscopy and biopsy. Histology may not be available – for example in small bowel Crohn's disease – and in this situation, typical radiological appearances help make the diagnosis. Crohn's disease can affect any part of the gastrointestinal tract – most commonly the terminal ileum or colon. Perianal involvement is also common. Intestinal inflammation in Crohn's disease can extend transmurally. Ulcerative colitis almost always affects the rectum with a variable proximal extent and continuous distribution. Inflammation affects the mucosa only. Approximately 25% of people with IBD will have extra-intestinal manifestations of the disease, involving skin, eyes, joints or the liver. There is an increased risk of colorectal cancer in patients with ulcerative colitis estimated at 2% at 10 years, 8% at 20 years and 18% at 30 years. It is important to be aware of infection risk in IBD both due to the disease itself and the impact of treatment. Flu vaccination should be offered to patients with IBD.

While the common perception of post-traumatic stress disorder (PTSD) is of an individual suffering from a single traumatic event, clinicians need to be aware of those people who have been exposed to multiple potentially traumatic events. Type 2 or complex trauma results from multiple or repeated traumatic events occurring over extended periods. Complex trauma is often associated with other adversity and stressors such as neglect, loss or deprivation. For many individuals these traumas occur at a developmentally vulnerable time with the perpetrator often in a caregiving role; thus the trauma incorporates a betrayal of trust. Disclosure can be a problem particularly with complex trauma such as sexual abuse or domestic violence, and is often incremental as trust with the clinician is formed. Patients who have experienced complex trauma should be assessed for the core symptoms of PTSD. In addition, patients should be assessed for disturbances in the three domains of emotional dysregulation, negative self-concept and interpersonal disturbances.

Bacterial meningitis and meningococcal sepsis are rare in adults. Any diagnostic delays with subsequent delay to treatment can have disastrous consequences. The decline in bacterial meningitis over the past few decades has not been accompanied by a reduction in case fatality rate which can be as high as 20% for all causes of bacterial meningitis and 30% in pneumococcal meningitis. The classic triad of neck stiffness, fever and altered consciousness is present in < 50% of cases of bacterial meningitis. Patients with viral meningitis also present with signs of meningism (headache, neck stiffness and photophobia) possibly with additional non-specific symptoms such as diarrhoea or sore throat. Suspected cases of meningitis or meningococcal sepsis must be referred for further assessment and consideration of a lumbar puncture. Most patients will fully recover. However, the sequelae of bacterial meningitis and meningococcal disease can be disabling. Many patients feel well at discharge and do not realise that they may not be able to return to all their normal duties and activities straightaway. Fatigue, headaches, sleep disorders and emotional problems are often reported in the weeks and months after discharge.

One third of all preschool children will have an episode of wheeze and many of these present to primary care. Most will fall within a spectrum of diagnosis ranging from episodic viral wheeze to multiple trigger wheeze or early onset asthma. A small proportion will have other rare, but important, diagnoses such as foreign body aspiration, anaphylaxis, gastro-oesophageal reflux, congenital anatomical abnormalities or other chronic lung diseases. Clinical assessment should try to classify children into either episodic viral wheeze or multiple trigger wheeze phenotypes. In clinical practice children rarely fit neatly into either category and the phenotype may change overtime. Clinical examination may well be normal in a child presenting with chronic symptoms. Urgent outpatient review should be considered for symptoms present from early infancy, chronic wet cough, failure to thrive or systemic involvement. The child should be referred to hospital immediately if you suspect an inhaled foreign body or anaphylaxis (after administering IM adrenaline). NICE recommends immediate referral for children with wheeze and high-risk features and also those with intermediate-risk features failing to respond to bronchodilator therapy. Children with high-risk features on assessment should be treated immediately with inhaled bronchodilator therapy. Those with intermediate risk should be treated immediately with bronchodilator therapy and reassessed 15-30 minutes later. Intermediate-risk children who respond and low-risk children can be managed at home with bronchodilator therapy via a spacer device.

Anxiety disorders are among the most common mental health disorders of childhood. Three quarters of anxiety disorders have their origins in childhood, with presentation often chronic in nature. Children with an anxiety disorder are 3.5 times more likely to experience depression or anxiety in adulthood, highlighting the importance of early diagnosis and appropriate treatment. Making a diagnosis can often prove difficult. It is important for clinicians to distinguish between normal anxiety and anxiety disorders. In the latter, symptoms may impair function and/or cause marked avoidance behaviour and significant distress. Younger children, who are less able to verbalise their anxiety, may show symptoms of regression of physical abilities (e.g. toileting, requiring carrying); increased attachment seeking behaviours (e.g. becoming more clingy); or increased physical symptoms (e.g. stomach aches). NICE quality standards recommend the need for an accurate assessment of which specific anxiety disorder the individual is experiencing, its severity, and the impact on functioning. NICE guidance for assessment of social anxiety disorder may be extrapolated to the assessment of other anxiety disorders: e.g. giving the child the opportunity to provide information on their own, and conducting a risk assessment. Where the child is experiencing significant distress or functional impairment (e.g. missing school, not taking part in age-appropriate activity), then specialist input is likely to be needed.