AccessMedicine

Murtagh's Practice Tips, 8e

Murtagh’s Practice Tips is a collection of basic diagnostic and therapeutic skills that can be used in the offices of general practitioners throughout the world. The application of these simple skills makes the art of the profession more interesting and challenging, in addition to providing rapid relief and cost-effective therapy to patients. It has been written with the relatively isolated practitioner, doctor or nurse practitioner in mind. This means that a broad range of more complex procedures involving some degree of improvisation will be covered.

The art of medicine appears to have been neglected in modern times and, with the advent of super-specialisation, general practice is gradually being deskilled. The authors have been very concerned about this process, and believe that the advice in this book could add an important dimension to the art of medicine and represent a practical strategy to reverse this trend. John Murtagh has been writing and collecting these tips for over 30 years; they have been compiled by drawing on his experience, often through improvisation, in coping with a country practice for many years, and by requesting contributions from his colleagues. Doctors from all over Australia have contributed freely to this collection, and sharing each other’s expertise has been a learning experience for all of them.

John has travelled widely around Australia and overseas running workshops on practical procedures for the general practitioner. Many practitioners have proposed the tips that apparently work very well for them. These were included in the text if they seemed simple, safe and worth trying. The critical evidence base may be lacking but the strategy is to promote ‘the art of medicine’ by being resourceful and original and thinking laterally. Joining John as co-author is Justin Coleman, who likewise has a special interest in ‘Handy Hints for GPs’. These were serialised in a column in Medical Observer for many years and subsequently collated in small publications called ‘GP Tips’.

Many of the tips have previously been published in Australian Family Physician, the official journal of the Royal Australian College of General Practitioners, over the past decade or so. Practice Tips has proved immensely popular with general practitioners, especially with younger graduates commencing practice. The tips are most suitable for doctors working in accident and emergency departments. There is an emphasis on minor surgical procedures for skin problems and musculoskeletal disorders. A key feature of these tips is that they are simple and safe to perform, requiring minimal equipment and technical know-how. Regular practice of such skills leads to more creativity in learning techniques to cope with new and unexpected problems in the surgery.

Several different methods to manage a particular problem, such as the treatment of ingrowing toenails and removal of fishhooks, have been submitted. These have been revised and some of the more appropriate methods have been selected. The reader thus has a choice of methods for some conditions. Some specific procedures are more complex and perhaps more relevant to practitioners such as those in remote areas who have acquired a wide variety of skills, often through necessity. This eighth edition continues the emphasis on emergency procedures, particularly for acute coronary syndromes and on wound management.

It must be emphasised that some of the procedures are unorthodox but have been found to work in an empirical sense by the author and other practitioners where other treatments failed. The book offers ideas, alternatives and encouragement when faced with the everyday nitty-gritty problems of family practice, particularly in rural and remote practice. Evidence based medicine has been included where appropriate with helpful input from the RACGP’s HANDI project.

(Source: Preface)

Murtagh's Patient Education, 8e

This resource provides busy GPs with a carefully curated collection of concise, easy-to-understand one-page information sheets, covering the most common presenting conditions that doctors can distribute to patients providing them with helpful information to assist them with understanding their condition.

Most of the existing topics in Murtagh's Patient Education have been revised, including major updates to women's health topics; a new mental health section has been created; and 22 new sheets have been added, including:

• The Australian National Immunization Program Schedule
• Ovarian cancer
• Dengue fever
• Advanced care planning

Additionally, this edition includes major updates to additional women’s health topics such as Domestic Violence, the Combined Pill, Endometriosis, cervical cancer screening and HPV. The new topics include:

• The infection listeria
• Toxoplasmosis and Zika virus
• Genetic disorders: Cystic fibrosis and Spinal muscular atrophy (SMA)
• Body mass index and BMI ready reckoner
• Fertility awareness and family planning

Murtagh’s Diagnostic Strategies

Murtagh’s Diagnostic Strategies (MDS) has been developed as an aide memoire and readily accessible reference to assist general practitioners to follow a clinical reasoning approach to patients’ common presenting problems.

This fail-safe diagnostic model encourages doctors to focus on the probability diagnosis and the differential diagnoses for the particular presenting problem, and also to consider life-threatening causative conditions that must not be missed. The strategy challenges doctors to consider certain subtle conditions called ‘masquerades’ that are worth checking if the diagnosis remains uncertain.

The strategy can be summarised with 5 questions that doctors should ask themselves:

1. What is the probability diagnosis?

2. What must not be missed?

3. What are common pitfalls for this problem?

4. Could the patient have one of the seven masquerades?

5. What is the patient trying to tell me (psychosocial issues)?

To test the hypothesis for the probability diagnosis, doctors need to consider the key features: key history, key examination and key investigations.

This key features approach aligns with what is expected of candidates for the Key Feature Problems (KFP) component of the Royal Australian College of General Practitioners (RACGP) Fellowship examination and other similar examinations.

MDS currently covers 100 of these common problems but the methodology can be used to diagnose many other presenting problems.

Using the MDS system

When a patient presents with a specific symptom the practitioner should make a provisional diagnosis from the clinical circumstances, including the age and other demographic features of the patient. The practitioner can then compare this hypothesis with the information for that symptom in MDS.

This is best illustrated by a case history:

• Mrs KL, a 45-year-old housewife, presents with the problem of the recent onset of uncharacteristic hair loss. She has brought a plastic bag containing shed hair to the surgery. For the past three to four weeks her hair has been coming out in large clumps particularly when combing and washing.

After making a provisional diagnosis, refer to ‘Hair loss’ in MDS. You should arrive at the following key points.

1. Likely diagnoses (in order)

   Telogen effluvian

   Anagen effluvian

   Alopecia areata (diffuse type)

2. Key history

   Nature of hair loss onset—duration, quantity, rate of loss, diffuse or patchy

   Characteristics of the hair such as scales, white bulbs

   Precipitating factors—stress, fever, surgery, acute illness

   General health

   Past history—skin disorders, cancer, thyroid disorders

   Family history of hair loss

   Drug history, especially cytotoxics, amphetamines, anti-epileptics, hormone agents, cessation OCP, other

3. Key examination

   General review—emphasis on examination of the scalp and endocrine system

   Hair and scalp—look for exclamation mark hair, ‘white bulb’ hair, any bald patches and their nature, the unusual pattern of trichotillomania

4. Key investigations

   Probably none—consider hair pull test, trichogram, FBE, TFTs

Footnote: KL had telogen effluvium precipitated by the emotional stress of a home burglary 4 months previous to the shedding of the hair (with white bulbs). Aided by support and counselling the hair loss ceased within months.

The RACGP Key Feature Problems exam

MDS is also an invaluable resource for doctors preparing for RACGP Fellowship exams. In the exam, a typical case provides a brief history of the presenting problem, then the following questions:

1. List the likely causes (differential diagnoses) — up to 3.

2. What other aspects of the history would you like to explore?

3. What are the appropriate investigations? List 2 to 4.

4. What are the important features of management? List 2 to 3.

Note: Doctors may be asked to select from a list of options, especially for the differential diagnoses and investigations.

(Source: "How to Use This Resource")

John Murtagh's General Practice, 8e

The discipline of general practice has become complex, expansive and challenging, but nevertheless remains manageable, fascinating and rewarding. John Murtagh’s General Practice attempts to address the issue of the base of knowledge and skills required in modern general practice. Some of the basics of primary healthcare remain the same. In fact, there is an everlasting identity about many of the medical problems that affect human beings, be it a splinter under a nail, a stye of the eyelid, a terminal illness or simply stress-related anxiety. Many of the treatments and approaches to caring management are universal and timeless.

This text covers a mix of traditional and modern practice with an emphasis on the importance of clinical reasoning, early diagnosis, strategies for solving common presenting problems, continuing care, holistic management and ‘tricks of the trade’. One feature of our discipline is the patient who presents with undifferentiated problems featuring an overlap of organic and psychosocial components. There is the constant challenge to make an early diagnosis and identify the ever-lurking, life-threatening illness. Hence the ‘must not be missed’ catch cry throughout the text. To reinforce this awareness, ‘red flag pointers’ to serious disease are included where appropriate. The general practice diagnostic model, which pervades all the chapters on problem solving, is based on the authors’ experience, but readers can draw on their own experience to make the model work effectively for themselves.

This eighth edition expands on the challenging initiative of diagnostic triads (or tetrads), which act as a brief aide-memoire to assist in identifying a disorder from three (or four) key symptoms or signs. A particular challenge in the preparation of the text was to identify as much appropriate and credible evidence-based information as relevant. This material, which still has its limitations, has been combined with considerable collective wisdom from experts, especially from the Therapeutic Guidelines series. A key objective of this publication is to achieve a balance between science and the art of general practice. To provide updated accuracy and credibility, the authors have had the relevant chapters peer reviewed by independent experts in the respective disciplines. These consultants are acknowledged in the reviewers section. The revised editions also have the advantage of co-authorship from experienced general practitioner Dr Jill Rosenblatt. Additional authors include Dr Clare Murtagh, a general practitioner with experience in medical education, and Dr Justin Coleman, past president of the Australasian Medical Writers Association with special interests in ‘Choosing wisely’ programs and evidence-based medicine.

A comprehensive book such as this one, which presents a basic overview of primary medicine, cannot possibly cover all the medical problems likely to be encountered. An attempt has been made, however, to focus on problems that are common, significant, preventable and treatable. Recent content includes expanded material on genetic disorders and infectious diseases, particularly coronaviruses and acute respiratory distress syndrome.

John Murtagh’s General Practice is written as a user-friendly text with the recent graduate, the international medical graduate and the medical student in mind. However, all primary-care practitioners will gain useful information from the book’s content.

(Source: Preface)

John Murtagh's General Practice Companion Handbook, 8e

This companion handbook, now in its eight edition, is a condensed version of the parent text, John Murtagh’s General Practice eighth edition. It is written in response to requests from the many general practitioners, registrars and students (in particular) who believed that it would be very useful to have a pocket-sized summary of General Practice that could be carried around during work hours. The companion gives an alphabetical presentation of the vast majority of common problems—especially the nitty-gritty problems presenting in routine practice.

Updated features in this revised edition include: an emphasis on mental health; infectious diseases, including respiratory distress syndrome with reference to coronaviruses, including COVID-19; women’s health; and cardiology. In addition, there is expansion of Murtagh’s Diagnostic Strategies for Common Presenting Symptoms and also the ‘triad and tetrad’ aide-mémoire strategy to pinpoint the diagnosis of specific important conditions. There is also a focus on management, which is presented in a succinct format.

The revised companion includes several checklists, flow charts and diagrams that can be readily accessed by the busy practitioner. Examples include: BMI calculator, dermatomes, the mini-mental state examination, Snellen’s chart, heart failure and diabetes type 2 stepwise management, childhood infectious disease school exclusion times, ECG and respiratory function test pointers. The main reference used is the excellent Therapeutic Guidelines published by Therapeutic Guidelines Limited.

(Source: Preface)

Murtagh's Cautionary Tales, 3e

To practise medicine is a privilege, to practise it well is a difficult challenge, but not to learn from one’s mistakes is unforgivable.

Cautionary Tales is a collection of authentic case histories encountered over 50 years of practising medicine, especially by John Murtagh and his wife, Jill Rosenblatt, during 10 years of intense yet wonderful, general practice in a country area of Victoria, Australia. It was their privilege to be the sole practitioners to a hard-working farming community of 2700 people. The practice was located in a small township with a twelve-bed Bush Nursing Hospital. The area, which was mountainous bushland with a snow resort, was popular with tourists. Many of the tales pertain to the experience of knowing their patients so well—both professionally and personally. They reflect the intensely human side of our calling and to share them is a special privilege. It is also appropriate to ponder on the humorous side of some of our experiences as well as the inevitable tragic outcomes for so many that we remember with sadness.

The concept of, and impetus for producing, a series of cautionary tales followed the obvious fascination of my medical students who considered they learned so much from them, especially when they realised they really happened and were certainly not apocryphal, however embellished in presentation.

Experience for doctors comes from the stories of our patients and, at times, our colleagues. As doctors, we are challenged by the atypical presentation of a common disease and the typical presentation of a rare disease. Each of the case histories in this book is a cautionary tale from which we can learn and observe the humanity of general practice.

We hope that sharing our experiences and messages is an important contribution to continuing medical education. In particular, the cautionary advice about so many pitfalls is extremely useful to the inexperienced doctor facing up to the vast challenge of general practice. There has been a focus on the medico-legal dimension of the tales, so that we can develop a healthy awareness of the pitfalls of our shortcomings, especially the missed diagnosis. This medico-legal commentary has been enhanced by the co-authorship of Sara Bird, who brings her special expertise and understanding to the editorial. Sara has also provided authentic case histories from her experience in medico-legal practice. We believe that the subject matter covered in this book is a reasonably accurate reflection of the common traps facing doctors in Western medicine. The tales are presented under headings that capture the nature of the message. Authoritative commentary on relevant medico-legal advice and pitfalls is provided using the case histories as a platform. The book concludes with an overview of a strategy that may help to keep the margin of diagnostic error to a minimum.

(Source: Preface)