The Practitioner
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The typical presentation of heart failure in primary care is insidious, with progressive breathlessness on exertion, ankle swelling, orthopnoea or paroxysmal nocturnal dyspnoea. Not all patients will have all these symptoms, and in many patients there may be other causes. If a GP suspects heart failure, then the key blood test is B-type natriuretic peptide (BNP). ⋯ ACE inhibitors (or angiotensin receptor blockers) and beta-blockers licensed for heart failure (carvedilol, bisoprolol, nebivolol) remain the mainstay of treatment in addition to as small a dose of diuretic as possible to control any fluid retention. Aldosterone antagonism is recommended by the 2012 ESC guidance for all patients who remain symptomatic despite an ACE inhibitor and beta-blocker. If the rhythm is sinus but the heart rate is 75 beats per minute, therapy needs to be optimised, perhaps by increasing the beta-blocker dose, if possible, or by the addition of ivabradine.
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Around 1-2 people per thousand present with an acute episode of pain caused by renal stones each year. Renal colic is classically sudden in onset, unilateral, and radiates from loin to groin. Renal pelvic or upper ureteric stones usually cause more flank pain and tenderness while lower ureteric stones cause pain radiating towards the ipsilateral testicle or labia. ⋯ All patients who are managed at home should have renal tract imaging within a week by fast track referral to radiology or as an urgent urology outpatient referral as per local guidelines to rule out an obstructed urinary system. Patients with recurrent stones should be advised to maintain a copious fluid intake (>2 L/day) to reduce the concentration of the urine. A reduction in salt intake (ideally <2g/day) and animal protein in the diet can help to reduce stone formation.
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Complex regional pain syndrome (CRPS) is divided into two types. Type I occurs without obvious nerve injury. In type II, a peripheral nerve injury is present, although pain may not be limited to the distribution of that nerve. ⋯ Aggressive treatment in the early stages improves prognosis. Many cases, especially those with relatively minor symptoms, will resolve spontaneously. Patients who are symptomatically deteriorating, despite regular analgesia, neuropathic agents and physiotherapy, should be referred to a specialist.
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Constipation is the most common childhood gastroenterological problem, affecting 5-30% of children. Up to a third of these children will develop chronic constipation. The signs and symptoms of constipation in children are seldom clear and there is often a delay in seeking help in either a primary or secondary care setting. ⋯ It is important to explain to the patient and parents that the symptoms have a medical explanation and that the child has not been soiling because of bad behaviour. Once the child has been diagnosed with idiopathic constipation, it is important to assess him or her for faecal impaction as this will determine the next therapeutic step. Faecal impaction can be diagnosed by history taking and examination.