Australian Family Physician September 2007 - Nausea and vomiting
Vol 36, (9) 673–784
The theme for the September issue of AFP
is nausea and vomiting. This month's articles include the vomiting
child, understanding bulimia
nausea and vomiting in adults, functional nausea and vomiting,
chemotherapy induced nausea and vomiting, hyperemesis gravidarum,
epidemic syphilis, hepatitis in refugees and children and autism.
Herd immunity
Kath O'Connor
"She became sweaty, and she was shaking. My
daughter's not going to have any more of them." Caller,
ABC Radio National, PM, 'Calm urged over Gardasil
vaccinations', Tuesday 22 May 2007.
Letters to the editor
The opinions expressed by correspondents in this column are in no way endorsed by either the Editors or The Royal Australian College of General Practitioners
Presentations of nausea and vomiting
Helena Britt, Salma Fahridin
Nausea and/or vomiting were presented as patient
reasons for encounter at 1.6% of the 596 000 encounters
recorded in this period. Gender specific
presentation rates did not differ. Results suggest
there was an average 1.5 million presentations of
nausea and/or vomiting per year in general practice
across Australia.
The vomiting child - What to do and when to consult
Katie Allen
Vomiting is a common, nonspecific sign of a range of childhood illnesses. It may be acute or chronic and the general
practitioner has a key role in identifying whether a child needs further investigation and management.
Nausea and vomiting in adults - A diagnostic approach
Andrew Metz, Geoff Hebbard
Most people experience nausea and vomiting at some stage, but when these symptoms recur frequently they can
significantly reduce quality of life. In most cases, a thorough history, examination and simple investigations can yield a
diagnosis. Chronic nausea is a more challenging problem with its many potential causes and with a significant number
of patients remaining undiagnosed despite extensive investigation.
Functional nausea and vomiting
Nicholas J Talley
There is a group of patients who have unexplained chronic nausea and/or vomiting. In the past these patients were
labelled as having psychogenic vomiting. However, there is little evidence that such a condition exists. Rather, these
patients usually have a functional gastrointestinal disorder (functional nausea and vomiting).
Hyperemesis gravidarum - Assessment and management
Penny Sheehan
Nausea and vomiting are common symptoms in early pregnancy. In most women the condition is mild and self limiting.
A small percentage of women experience severe nausea and vomiting. This is known as hyperemesis gravidarum.
Outcomes have improved with intravenous rehydration therapy. Consequences include decreased quality of life, time off
work and secondary depression.
Chemotherapy induced nausea and vomiting - Prevention and treatment
Kynan Feeney, Michael Cain, Anna K Nowak
Chemotherapy induced nausea and vomiting (CINV)
are two of the most distressing and feared toxicities
of cancer treatment.1 Recent developments in the
understanding of the pathophysiology of CINV and the
development of new drugs make the goal of no nausea
or vomiting during chemotherapy realistic.
Understanding bulimia
Phillipa J Hay
Bulimia nervosa (BN) and related eating disorders such as binge eating disorder are common. General practitioners can
play a key role in the identification and management of BN and related eating disorders.
Diabetes monitoring - albuminuria - Frequently asked questions
Patrick J Phillips, George Phillipov
I am treating this man's blood glucose, blood
pressure and blood fats already. Why check
for microalbuminuria if it won't change my
management? Detecting microalbuniuria is important for two reasons.
The onset of microalbuminuria marks a major increase
in the risk of morbidity and mortality (Figure 1).
Microalbuminuria does not indicate early renal damage,
it is just the earliest indicator we have. By the time
microalbuminuria occurs renal biopsy would show
widespread glomerular damage. Moreover, just as the
endothelium of the glomerular has been so significantly
damaged that it now 'leaks' albumin, so the endothelium
of many other vascular beds is disrupted.
Osteoarthritis management of the knee - Treatment options post the NSAID cardiotoxicity controversy
Jan Gartlan, Mark Nelson, Graeme Jones
Osteoarthritis (OA) is a common, chronic
musculoskeletal condition affecting at least
1.2 million Australians. It is the leading cause of
pain and disability in the community, particularly
affecting women, and the seventh most commonly
managed condition in general practice. Although
the pathogenesis is not fully understood, the
factors involved include biomechanical stresses
affecting the articular cartilage and subchondral
bone, biochemical changes in the articular cartilage
and genetic susceptibility. Knee and hip joints
usually cause the most morbidity. Patients with
OA complain of pain which typically worsens with
weight bearing and is relieved with rest. They may
also have joint stiffness, particularly after a period
of inactivity.
Hepatitis in refugees who settle in Australia
Jill Benson, William Donohue
The World Health Organisation estimates that 2 billion people have been infected with hepatitis B and about 180
million people infected with hepatitis C worldwide. More than 350 million have chronic hepatitis B and 130 million have
chronic hepatitis C infection. Most infections of hepatitis B and C are from unsafe injection practices, both medical and
nonmedical; from household contacts; or, in the case of hepatitis B, from 'vertical' transmission from mother to child.
The needs of older people with asthma
Nicole E Cousens, Dianne P Goeman, Jo A Douglass, Christine R Jenkins
Asthma is an inflammatory airway disease; airway
hyper-responsiveness causes narrowing in response
to a wide range of environmental stimuli such as
allergens or exercise. This leads to symptoms such
as coughing, wheezing, breathlessness and chest
tightness. Asthma symptoms are usually associated
with pulmonary airflow obstruction, which is often
reversible with treatment.
Integrative management of nausea and vomiting
Gillian Singleton
Nausea and vomiting are common symptoms seen
in general practice. This article provides a brief
overview of some integrative therapies that have
demonstrated benefit in the management of these
symptoms, specifically nausea induced by pregnancy,
chemotherapy and surgery.
Chemotherapy in the treatment of prostate cancer - Is there a role?
Mohan Arianayagam, Jeff Chang, Prem Rashid
Prostate cancer is one of the most common cancers
in men and the incidence increases with age from 0.4
per 100 000/year in men under 45 years of age to 270
per 100 000/year in men over 65 years of age. Patients
with localised disease benefit from radical surgery or
radiotherapy while patients with locally advanced or
metastatic disease traditionally receive radiotherapy or
androgen deprivation therapy (ADT). Although most
patients initially respond to ADT, many with advanced
disease often develop cancers that are hormone or
androgen independent, rendering ADT ineffective. Men
who develop hormone independent disease have a
median survival of approximately 1 year. Systemic
chemotherapeutic agents have been long available to
treat patients with prostate cancer and particularly,
men whose cancers are unresponsive to ADT.
Children and autism - Part 1 - recognition and pharmacological management
Manya Angley, Robyn Young, David Ellis, Wilson Chan, Ross McKinnon
The paediatrician was immediately concerned;
he engaged a speech pathologist to start therapy
with Blake and ordered a range of blood tests, an
electroencephalogram (EEG), a magnetic resonance
image (MRI) of the brain and referred him to the
multidisciplinary team at the local autism association.
Results of these investigations resulted in Blake
receiving a diagnosis of autistic disorder (AD).
Epidemic syphilis exhibits diverse manifestations
Andrew M Redmond, Craig M Dancer, Andrew R Doolan, Diane F Rowling, Marion L Woods
There are recent reports of a sustained increase in
the incidence of syphilis around the world, including
in the Australian cities of Sydney and Melbourne.
Clinical challenge
Questions for this month's clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the MCQ of the College Fellowship exam. The quiz is endorsed by the RACGP Quality Assurance and Continuing Professional Development Program and has been allocated 4 CPD points per issue. Answers to this clinical challenge will be published next month, and are available immediately following successful completion online.
AFP in Practice
AFP in Practice questions are designed to get you started in a small group learning (SGL) activity in your practice or with colleagues. Requirements to earn 30 Category 1 CPD points for a SGL activity are: minimum of four and a maximum of 10 people, minimum of 8 hours of discussion in a year, and at least two GPs. Groups may include anyone else who has an interest (ie. practice nurses, community health workers, allied health professionals). A kit with all the instructions and forms you need is available online. You can also earn Category 2 points based on these questions at AFP practice challenge.
A painful gum
Keng Yin Loh, Siang Tong Kew
Case study:
This middle aged Malaysian man
presented complaining of painful gums for
a few months. He is known to have had
epilepsy since childhood.
Moving to the UK as a GP - The process explained
Richard Hays
Many Australian general practitioners may be interested in working as a GP in the United Kingdom. Since mid 2005
the process has become more difficult, complex and expensive, but the transition is still possible if the correct
process is followed. This article guides potential applicants through the complexity, providing details of each step and
citing the necessary resources.
Follow up of test results after hours
Sara Bird
This article examines a recent Coronial inquest in which the Coroner made recommendations to general practitioners
regarding the process of notification by pathology practices of abnormal and life threatening results and how GPs
respond to such notifications. An addendum to the Standards for general practices provides guidance for GPs and their staff on the systems to manage the follow up of test results outside normal general practice opening hours.
Nurse practitioners and GPs - Addressing the needs of older persons living in residential aged care
Jane Elizabeth Truscott
The Australian population is becoming progressively older, placing significant pressure on both the supply of supported
accommodation and health services. Collaboration between general practitioners and nurse practitioners over the
care of people living in residential aged care facilities has the potential to promote continuity of care, decrease
hospitalisations and readmissions, enhance patient satisfaction, reduce costs, enhance working relations between
medicine and nursing, and improve residents' access to care. It will require improved communication and the
overcoming of several attitudinal and organisational barriers.
Disenfranchised grievers - The GP's role in management
Susan Selby, Alison Jones, Teresa Burgess, Sheila Clark, Nicole Moulding, Justin Beilby
Disenfranchised grief results from a loss that is not or cannot be openly acknowledged, publicly mourned, or socially
supported. This article aims to explain the concept and varying presentations of disenfranchised grief and outlines the
importance of the general practitioner's role. Preliminary quantitative results of a study of 15 cross cultural workers reentering
Australia are presented, showing more than half experiencing grief during re-entry and all having some form of
disenfranchised grief.
Identifying unmet needs in older patients - Nurse-GP collaboration in general practice
Ian D Williams, Lorna J O'Doherty, Geoffrey K Mitchell, Karen E Williams
Australia's rapidly aging population has a high prevalence of chronic disease and disability, leading to an increased social
and economic burden. The Enhanced Primary Care program seeks to reduce this burden by promoting preventive and
coordinated care. This study aimed to identify unmet needs in community dwelling general practice patients aged 75 years and over through annual health assessments performed by a general practitioner-nurse team.
How Western Australian registrars choose training practices
Robert Moorhead
While general practice registrars receive advice on how to choose a training practice, little is known about what
underlies their decision.
Care of the haematology patient and their family - The GP viewpoint
Pam McGrath
General practitioners play an important role in both the care of patients diagnosed with a haematological malignancy,
and their families, along the continuum of care from the point of diagnosis to bereavement. There is scant research
available on this experience from the GP perspective. This article presents insights from GPs who participated in a
national study to develop a model of care in haematology.
Rural GPs' management of vehicle related trauma
Tracy Elizabeth Cheffins, Ross Blackman, Craig Veitch
There is twice the morbidity and mortality resulting from vehicle related trauma in rural and remote areas than in
metropolitan areas. Little is known about Australian rural general practitioners' management of those affected.