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International Primary Care Association

Clinical Focus Primary Care

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A 51 year old man had direct trauma to the left shoulder whilst playing rugby. He had swelling and tenderness around the clavicle. Breath sounds and percussion sounds were normal on both sides. There was no evidence of direct injury of the chest wall. The patient was haemodynamically stable and neurovascular examination was normal. Examine his shoulder X ray (Figure 1)

Within the last year of life many patients are likely to need an integrated palliative approach involving primary care, community nursing and when complex, specialist palliative care. Others may also need palliative care for symptom control and Advance Care Planning (ACP) alongside ongoing interventions for their underlying disease prior to the last year (especially in non-malignant disease when prognostication can be difficult). In these cases, patient need rather than prognosis should ultimately guide your approach.

Following an overview of the public health need for palliative care, trajectories of illness and ACP we present three case studies, identifying key learning points and providing relevant overviews of basic management approaches to common symptoms in palliative care.

‘Legal highs’ are more properly known as Novel Psychoactive Substances (NPS): in the UK, following legislative changes in 2016, all current and future such compounds are proscribed. There are over 560 NPS, and their consumption is common. Most individuals who take NPS, or any other recreational drugs, do not develop significant physical or mental health problems, but a considerable number will do so, and many will first present to primary care.

Despite their large number, NPS can be broken down and considered under four main classes: ‘stimulants’, which are drugs like cocaine, ecstasy, and amphetamine; ‘cannabinoids’, which are drugs like cannabis; ‘depressants’ that are opioids and benzodiazepines; and ‘hallucinogens’ like ketamine and LSD. However, the wide range of NPS means that sometimes the novel drugs are more dangerous, and NPS must not be considered as ‘safer’ alternatives to more established compounds. Furthermore, NPS are available in a wider range of formulations, and GPs must enquire as to how the drug is consumed: whether swallowed, snorted, smoked, or injected, with the risk profile changing accordingly.

Good assessment requires a non-judgmental and empathic approach, and should aim to classify the drug type and method of consumption, acute and chronic physical and mental health harms, and any need and patient desire to have further care from specialist services. Acutely, benzodiazepines and antipsychotics may be prescribed for very agitated patients. Autonomic instability, hyperthermia, and altered or loss of consciousness warrant urgent transfer to the Emergency Department.

Hypertension is the persistence of elevated blood pressure - one of the most familiar medical conditions encountered in family practice. Hypertension is asymptomatic, and its management can be arduous, which is unfortunate given that its presence represents a dangerously potent herald of significant morbidity and mortality.

The Female lower urinary tract symptoms (FLUTS) are a collection of symptoms akin to the wellknown lower urinary tract symptoms (LUTS) in male counterparts. It is a common presentation in primary care consultations, particularly in women of middle to late age. Awareness of risk factors and actively looking out for these cases may be worthwhile particularly as patients may not be very forthcoming with this problem. Careful history taking, examination and assessment of its impact on quality of life (QOL) are of paramount importance. There is a need to carry out holistic assessment of these patients prior to offering management plan, which can include self-help measures, behavioural treatment, medications and surgical treatment.

This article illustrates the magnitude of the problem and will assist clinicians in primary care to identify, diagnose and manage patients with FLUTS in an evidence-based manner.


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