Palpitations: when you hear hoof beats don’t forget to think zebras

24 Apr 2017

In general practice palpitations are reported in around 8 per 1,000 persons per year. The differential diagnosis includes cardiac and psychiatric causes, as well as numerous others e.g. anaemia, hyperthyroidism, prescribed medication, caffeine and recreational drugs. Factors that point towards a cardiac aetiology are male sex, irregular heartbeat, history of heart disease, event duration > 5 minutes, frequent palpitations, and palpitations that occur at work or disturb sleep.

Artefact mimicking torsades: treat the patient not the ECG

22 Feb 2017Registered users

There has been a marked increase in the availability and use of ECG machines in general practice. In 2008, Day and colleagues reported that 85% of GPs who responded to their survey had an ECG machine and that 91% of them used it at least once a week.  We report a case in which artefact was misinterpreted as torsades de pointes, often referred to simply as torsades. Our patient did not suffer any harm and did not have any unnecessary investigations, yet inappropriate treatment was administered making the potential for harm a real possibility. We describe the ECG features which differentiate artefact from torsades and review common sources of ECG artefact, in both hospital and general practice.

Ulnar nerve injury on removal of a contraceptive implant

15 Dec 2016Registered users

The close proximity of contraceptive implant placement to the course of the ulnar nerve can result in injury. Several factors have been implicated in this complication including: low BMI, erroneous placement of the implant, implantation over the brachial groove, and migration of the implant from its original insertion. Clinicians should familiarise themselves with the vulnerable neurovascular structures in the area and refer promptly to a specialist if any neurological symptoms develop during placement or removal of these devices.

The case of the migrating IUD

22 Dec 2015Registered users

A 30-year-old lady presented to the gynaecologist with persistent vaginal bleeding following insertion of an IUD. A transvaginal ultrasound showed a normal uterus, normal ovaries and no adnexal masses or free fluid. It was assumed that the IUD had fallen out. Around the same time she presented to her GP with a short history of dysuria, intermittent visible haematuria and recurrent UTI. Eventually, she was referred to the urology department for further investigation and underwent flexible cystoscopy, which showed the presence of an IUD within the bladder.

A case of recalcitrant bacterial conjunctivitis

05 Dec 2013Paid-up subscribers

It is important to be vigilant for retained foreign bodies as a cause of recalcitrant bacterial conjunctivitis, even in the absence of foreign body sensation. A relapsing-remitting history should prompt referral to an ophthalmology department. All patients presenting with a red eye should be asked specifically about contact lens wear, and causes of conjunctivitis other than those bacterial in nature — such as viral and chlamydial infections or allergy — should be borne in mind.

A case of persistent hemifacial weakness

25 Jul 2013Paid-up subscribers

Bell’s palsy has a typical presentation of sudden onset, mild otalgia, altered facial sensation and/or taste, with no obvious prodrome. It represents over half of hemifacial weakness cases in primary care. However, as a diagnosis of exclusion, there are a number of key clinical features of more sinister diagnoses that must be considered.

A patient with Lyme arthritis presenting in general practice

21 Feb 2013Paid-up subscribers

Lyme disease, also known as Lyme borreliosis, is caused by infection with Borrelia burgdorferi sensu lato (B. burgdorferi s.l.) complex, a Gram-negative spirochaete bacterium. Infection in humans takes place through tick bites. The work-up of Lyme arthritis should include a careful history including residence in, or time spent visiting, an endemic region, previous history of tick bite(s), and erythema migrans.

Ramsay Hunt syndrome presenting in primary care

22 Mar 2010Paid-up subscribers

Ramsay Hunt syndrome is a lower motor neurone weakness of the seventh (facial)cranial nerve caused by reactivation of the herpes zoster virus.

March 2007: Achieving optimum pain control in terminally ill patients at home

01 Mar 2007Paid-up subscribers

How is breakthrough pain best managed? When should you use a syringe driver? How do you calculate doses when switching opioids?