Neonatal Age Group

Now a days, Rarely the deliveries are done at home. Still at interior places likee this GP may be called at home or baby brought to GP.

• Enlarged size of Skull, deformed skull. Could be sign of Subgleal haematoma, or Hydrocephalus, or Craniosynstosis,

• Meningocele in Lumbar or Cervical region. Spina Bifida.

• Altered censorium , Unconciousness. Could be due to post fit, or infection meningitis or septaecemia. Tuberculous infections. Trauma, or jaundice or hypoglycaemia and many other systemic illness.

• Convulsions.

• Limb weakness due to nerve injury during delivery, while pulling the baby out.

• In all above cases , don’t waste time. Don’t try to put IV line. Because babies have very fragile veins, difcult to get. Refer Baby to specialist. Let them manage further. If anything happens to Baby, you will be blamed for delay or some injection given by you.

Paediatric Age Group

Convulsions. Mainly febrile convulsions. We know the standard nursing care of a convulsing kid. Turning on one side. Clearing the saliva. No restraining. Once you get IV line give Inj Phenytoin Sodium ( Eptoin) 10 to 15mg /kg loading dose. There are newer anticonvulsants available now but this has proved over the time. Midazolam spray is also good option. But not easily available. Investigation of choice is MR Scan Brain with Epilepsy protocol. EEG or CSF examination may be required. In most of patients scan will be normal. But it is required to rule out operative causes.

• Altered sensorium or unconsciousness. Meningitis . Encephalitis. Post head injury or convulsion. Tuberculous infections. Take proper history. You will get the clues. Give first aid like securing IV line. Clearing airway. O2 if possible. ( by law we are supposed to have O2 cylender in OPD also. With intubation kit, defibrillator, etc.). Transfer to specialist hospital. Don’t waste time in scan. Let the consultant decide which scan is required.

• Head injury More common are domestic fall or injuries while playing. Minor head injury with conscious kid can be managed initially at GP level. Cleaning and dressing or stiching the CLW or wounds. TT inj. Analgesics. Scan and refer to specialist. But for major Head injury ( fall from height or RTA), / unconscious or ENT bleed, other injuries to limbs or chest abdomenetc, give first aid by dressing and IV fluid if possible . Send urgently to specialist. Do not move the neck. Till ruled out vertebral injury is considered as present.

• Headache very common complaint in this age group also. Proper history and observation will tell us genuine patient from malingering. If headache is not settling in 2 or 3 visits or if headache is becoming severe , changing the pattern or associated with vomiting or other significant symptoms or when other signs are present like cranial nerve involvement or limb involvement. Then ask for scan. Preferably MR scan. Look for any refractive error. Any ENT problem. Or Psychological problem. Sometimes parents over exaggerate the kids complaints. Its tricky situation. You feel like whole family should be treated.

• Backache and Neck pain gradually it is seen in this age group also. When I started practice it was not common, unless it started after trauma. But this over burdening school bags, lack of exercise, more watching TVs, computer and mobile phone games , poor posture while sitting, etc is responsible for increasing this problems in kids. Mostly no investigations are required initially. Reassurance , analgesics, ointment, multivitamins, physiotherapy or exercise is sufficient. Of course councelling about mobile computer TV is must. GPs are excellent councellors . if Backache or neck pain increases or changes pattern then MR scan is required.

• Delayed Mile Stones it is still a significant problem in our country. Do not delay the referral to specialist or higher centers. Initially few doctors says that wait. Kid will be normal as it grows. But it is safer to refer earliest , in this is era of comsumer protection laws. Parents do not have many children. Families are nuclear. Every kid is precious. Even if not much of treatment is available to many kids , the awareness of delayed mile stone prepares parents mind for long term treatment and expenses. Genetic examination of parents and kid is must to prevent future babies having the same.

• Poor performance at studies or Poor attention span or more active kids;- ADHD, Dyslexia etc. this is whole spectrum of disease. Awareness has increased due to social media. Careful history will give the clues. Mostly pampering by parents or sibling / pear pressure or lack of family and friend support is responsible for this. Hardly any placebo or tonic is required. Councelling does the job.

• Tumors and other intracranial lesions mostly presentation is with headache or altered behaviour or some cranial nerve involvement or long tract signs. MR scan is sufficient. Tuberculous infections very common in our country. We are capital of tuberculosis in the world. TB meningitis, tuberculomas, hydrocephalus, etc are common and treatable.

Adults Age Group whole spectrum of illness is covered in this age group

• Head injury Road trafc accidents are very common in this age group. Signifcance is more, as more male, earning member of family are involved. Alcohol addiction and lacke of safy measures with poor driving skeills are commonly causes severe head injuries. Usually GPs are the frst contact afer accident. Secure airway. Clean wounds if possible. Apply pressure dressing. Start IV line. Always aske for history of allergy if any. Do not move necke or backe. We don’t kenow at that time whether patient has spine injury. It is assumed that spine is injured unless ruled out by X Ray or MR Scan. Commonly these patients have polytrauma, chest , abdomen , limb injuries; as these are high speed accidents. Many have associated systemic illness likee hypertension , Diabetes, etc . Do not waste time in stiching or scan. Time is very important factor here. Even if head injury may appear as minor initially ; patient may worsen any time. As Extradural haematomas and oedema around damaged brain develops gradually. Initially brain tries to accommodate this rise in intracranial pressure by adjusting venous blood fow and csf fow. Till then patient may appear normal. As skeull is a closed space there is hardly any scope for brain to shif to adjust to rising ICP. So fnal deterioration happens quite fast. Remember Pascals law of Pressure and volume. Concept of Golden Hour is very important in these patients. As we don’t have TRIAGE here in our country, timely referral is very important. Patient may or may not be afording. But he should reach hospital for emergency treatment. Legally you are also safe. Handelling mob with the patient is trickey in these situation. Because everyone is emotionally charged. There is always a question of fnances. They expect us to do everything possible on earth for that patient. But not ready to shell out money or deposit. Inspite of explaining the seriousness of patient and chances of death or poor outcome of patient, relatives create huge scene in case of death. So as a GP it will be difcult to face the mob. No matter how many in that mob kenow you or your old patients. At such time they try to be safe in mob psychology. Best Mantra is “ It is always better to be Safe than Sorry.”. It’s a title of a good booke written by Dr. Lalit Kapoor. Senior member and team leader of legal cell of AMC Association of Medical Consultants. You all must read this booke. Have it in your clinic. I don’t want to scare you , but documentation is very important. As a GP we are not keeen for documentation. We will discuss at the end. Oke. Now lets move to next common.

• CVA: Cerebro Vascular Accident : haemoragic and non haemoragic.Very very common and with high morbidity . Also with high mortality immediate or late. But living with bed ridden condition is nothing but hell on earth. As a GP you will be witness and treatment partner at the both ends of this disease . As patient comes to you frst before being referred to specialist or hospital. And again backe afer discharge for routine problems for pain, fever,regular BP and Sugar checke up, Ryles tube change, Foleys catheter change, and for many more complaints. You are the front worrier for patient. From takeing care of clinical needs and investigations, to arranging drugs or services, to routine counceling to family members, to be bridge between patient and consultant, physiotherapy,etc. You are main pillar of treatment in such long debilitating diseases. MR angiography or DSA if required will give us the etiology. Further treatment could be operative or non operative depending on fndings of scan. Good hydration, maintaining proper BP little on higher side. As associated oedema or infarct requires more cerebral perfusion pressure. Recent thrombolytic drugs which can be given intra arterial via DSA catheters are also available. But time window and cost of therapy are deterrent to common people.

• Backache , Neck Pain, ( Spondylosis and Disc problems) very very common. Bread and Butter of practise. From mild positional pain to neurodeficit like limb weakness, there is huge spectrum of presentation and severity. Almost 90% don’t require any intervention. Conservative treatment is sufficient. But if pain increases or neuro deficit present or if not responding to intial treatment. Then MR scan is must. If patient is affording get screening of other spine done. It saves time and money for patient. As patients do have multiple complaints this screening of spine helps us also in understanding complete illness. Remember we are not treating scans. We are treating patients. So unless patient is fully convienced or demanding surgery, don’t try to force surgery on him / her. Failed Back Syndrome is very common. Wrong selection of Patient for Surgery. Wrong level surgery. Incomplete surgery. Wrong selection of method of surgery. Psychologically crancky patient. Are few of the causes for Failed Back Syndrome. In spite of spending big amount if patient don’t get relief of pain , then you are in deep problem. You can not face such patient again and again. Regretting that why did I do that surgery. Plus that patient is now negative propaganda for you. This is happening around . That’s why patients are not easily ready for spine surgery. Previously Orthopaedics used to do Spine surgery. This has created big phobia for spine surgeries. If you are referring a patient to specialist and also helping patient in taking the decisions. Then this Failed Back Syndrome patient will come to you also. Because you are easily approachable. Other spine conditions like intra spinal tumors, tuberculous infections of vertebra, dislocations, trauma and fractures, congenital diseases like meningocele spina bifida, kyphosis, scoliosis, etc can be treated operatively. Myelitis, cord infarction, etc are treated non operative methods. Special mention is required for married women about these back and neck pain. Its very common. Difficult to deny that nothing is wrong. Mostly psychological. May be simply she is trying to avoid heavy work. So visiting GP and mixing with other patients is socialising chance for them. Anti depressant added in prescription helps. And good ointment which gives hot feeling sensation after applying also does the wonder.

• Neuropathis , Neuralgias not common , but not difficult to diagnose also. From Trigeminal Neuralgia from top till Sciatica below. Is a clinical finding. MR Scan is required. Oxcarbemazepine, Pregabalin, Gabapen, . Antidepressant. Multivitamins, helps. Surgery is required if conservative treatment fails. Sometimes EMG / NCV is required. Other cause are common Diabetic or Leprosy or viral or drug induced neuropathies. Have high level of suscpison for neuropathis including 2nd and 8th cranial nerves in patients on AKT.

• Convulsions / TIAs sometimes they mimic. Classicaly we are used to see GTC. But Complex Partial Seizure or Absence attack can mimic TIA. Take a proper history. Rule out systemic illness. Quick general examination. Depending on findings treat and send for scan. Again here referral to specialist is always safe. Because patient can throw another convulsion or TIA progressing to full blown CVA. So it is always better that patient is kept under observation at hospital. Investigated. And treated accordingly. Need for long term treatment should be told to patient. Antiplatelet drugs, anticonvulsants, anti hypertensive drugs, anti diabetic drugs, etc. GP have great role in this. Because you are more frequently in contact of patient or relatives. Regular follow up is must for adjusting the doses or early noticing the drug side effects. Most patients who come for repeat disease are due to stopping the drugs on their own.

Geriatric Age Group / Senior Citizen Group

All systems in body are in wear and tear mode in this age group. Sathi buddhi Nathi. Satiya gaya . age group. More commonly Degenerative diseases . all above mentioned in adult age group are here also.
Special mention other than above are

• Trivial traumas are more. Minor head injuries in bathroom or at home. Not remembered by patient due to dementia. And if trauma/ fall is night then not witnessed by relatives. Chronic subdural haematoma. Is notorious in presentation. Gradual change in behaviour, headache, difficulty in walking, etc present. As history of fall and head injury few days or weeks ago is not known. Normal pressure hydrocephalus or Dementia or CVA or post ictal can also mimic like this. Get the scan done urgently. Refer to specialist. As other systemic illness are present in almost all patients.

• Same minor fall can cause vertebral fractures. Because bones osteoporotic. There can be spontaneous fracture vertebrae. Whenever there is indication that there was fall. Like some skin bluish discoloration. Contusion or abrasion of skin. Quite common because patients are on antiplatelet drugs . it is safer to get MR Scan screening of all spine done. Treatment is based on findings of the scan and neurodeficit present. Patient should not be made sit up while transporting. Neck should be supported with collar or pillows.

• Because of cerebral atrophy and degenerative changes and previous CVA or history of brain surgery etc, these patients have changed behaviour, moody, sometimes aggressive as well, forgetfulness , lack self care, un co operative behaviour, etc. all this complicates the treatment and nursing care. There is huge emotional and physical burden on the caregivers. Practically whole family is disturbed.

• As overall immunity and strength is low, recovery is also very slow. Treatment involves financial burden to family. As this elder member is not earning member. Often treatment is life long for simultenous CNS as well other system illnesses.Here the role of GP as counsellar is more, as he/she knows that family since long time. Every time it is not possible to take patient to specialist for minor health issue or for follow up. Arranging ambulance and managing man power is not easy financially and physically.

• Other degenerative illness. Parkinsonism, movement disorders, tremors, Weakness, NPH, Spondylosis, etc. main care is to be taken of the drug interactions. As patients are on many drugs with some kidney or liver disease.