Overview 

Chronic Kidney Disease (CKD) is a long-term condition where the kidneys gradually lose their ability to filter waste and excess fluids from the blood. This can lead to a buildup of toxins in the body, which can cause a variety of health problems. 

You may be diagnosed with CKD if one of the following occurs: 

· Decreased kidney function as indicated by blood tests (eGFR < 60) for 3 months or more, with or without any signs of kidney damage. 

· Kidney injury that lasts for 3 or more months, with or without reduced kidney function. This can include signs like protein or blood in the urine, or structural kidney damage detected through imaging or other tests. 

Causes of CKD 

CKD can be caused by a variety of conditions, including: 

· Diabetes (high blood sugar levels over time can damage the kidneys) 

· High blood pressure (hypertension) (can damage blood vessels in the kidneys) 

· Glomerulonephritis (inflammation of the kidney's filtering units) 

· Polycystic kidney disease (a genetic disorder that causes fluid-filled cysts in the kidneys) 

· Prolonged urinary tract obstruction (due to kidney stones, enlarged prostate, etc.) 

· Recurrent kidney infections 

Who is at Increased Risk? 

Certain groups are more likely to develop CKD. You may be at higher risk if you: 

· Have diabetes or heart disease 

· Have high blood pressure (hypertension) 

· Have a family history of CKD 

· Are overweight (BMI > 30) 

· Smoke or have smoked in the past 

· Are aged 60 or older 

· Are of First Nations Australian descent (adults aged 18+) 

· Have a history of acute kidney injury 

Symptoms and Signs of CKD 

In the early stages, CKD may not show any noticeable symptoms. In fact, up to 90% of kidney function can be lost before symptoms appear. This is why it’s important for high-risk individuals to get their kidney health checked regularly (every 1-2 years, depending on risk). 

As CKD progresses, you may experience: 

· Nausea or vomiting 

· Loss of appetite 

· Fatigue or weakness 

· Sleep problems 

· Changes in urine (e.g., frequency, reduced volume, or blood in the urine) 

· Muscle cramps 

· Swollen feet and ankles 

· Dry or itchy skin 

· High blood pressure 

· Difficulty breathing 

If you experience any of these symptoms, it’s important to see a doctor for further evaluation. 

KIDNEY HEALTH CHECK:

A kidney health check is essential for people at higher risk of CKD. This includes: 

1. Blood pressure check 

2. Urine test (to check for protein or albumin) 

3. Blood test (to measure eGFR, a marker of kidney function) 

A kidney check should be done every 1-2 years depending on your risk level. 

Management of CKD 

While there is no cure for CKD, it can often be managed effectively to slow the progression of the disease. Key management strategies include: 

· Slowing the decline in kidney function (eGFR) 

· Reducing albumin (protein) in the urine 

· Controlling blood pressure (target: < 130/80) 

· Lowering cardiovascular risk 

· Preventing further kidney damage 

Management Options: 

1. Lifestyle Modifications: 

- Quit smoking/vaping 

- Dietary changes: Eat more vegetables, fruits, nuts, and seeds. Limit processed foods, added salt, and sugar. Make water your main fluid choice and avoid sugary drinks. 

- Physical activity: Aim for 2.5 to 5 hours of moderate-intensity exercise per week. 

2. Medications: 

- To control blood pressure, blood sugar, and cholesterol levels. 

- Your doctor will prescribe and explain the medications that are right for you. 

3. Dialysis or Kidney Transplant (for advanced CKD): 

If CKD progresses to the late stages, you may need dialysis or a kidney transplant. Your doctor will refer you to a kidney specialist (nephrologist) for further management. 

Collaborative Care Approach 

Managing CKD involves a team effort between your general practitioner (GP), nurses, and other healthcare professionals. This collaborative approach ensures the best care and outcomes. 

Referral to a Specialist: If your eGFR falls below 30, or if you experience a sudden decline in kidney function, uncontrolled blood pressure, or anemia, your GP may refer you to a renal specialist (nephrologist) to help create a treatment plan. 

Vaccinations for People with CKD 

It’s important for individuals with CKD to stay up to date with vaccinations, as they are at higher risk for infections. Key vaccinations include: 

· Influenza (yearly) 

· Pneumococcal (every 5 years) 

· COVID-19 

· Shingles (Herpes Zoster) 

Conclusion 

CKD is a serious condition, but with early detection, proper management, and lifestyle changes, you can slow its progression and maintain your quality of life. Regular kidney health checks are important for those at higher risk, and if you are diagnosed with CKD, working closely with your healthcare team will help you manage the condition effectively. 

People with CKD are eligible for a government funded Chronic Disease Management Plan which covers certain allied health visits. Talk to your practice nurse for more information and to arrange these services. 

Ischemic heart disease (IHD), also referred to as coronary artery disease (CAD), occurs when blood flow to the heart muscle is reduced, preventing it from receiving adequate oxygen. This reduction in blood flow is typically due to a partial or complete blockage of the coronary arteries, often caused by the build-up of fatty deposits (atherosclerosis).

Symptoms of Ischemic Heart Disease

· Chest pain or discomfort (angina): A feeling of pressure, tightness, or pain in the chest.

· Pain radiating to the neck, jaw, shoulder, or arm

· Shortness of breath: Difficulty breathing, especially during physical activity.

· Nausea and vomiting

· Sweating

· Fatigue: Unexplained tiredness or weakness.

Causes of Ischemic Heart Disease

· Coronary Artery Disease (Atherosclerosis): The build-up of plaque (cholesterol, fat, and other substances) inside the coronary arteries.

· Blood Clots: Blood clots can form in narrowed arteries and block blood flow to the heart.

· Coronary Artery Spasm: Temporary narrowing of the coronary arteries, often triggered by stress, drugs, or other factors.

Risk Factors for Ischemic Heart Disease

Individuals with the following risk factors are at higher risk of developing IHD:

· Hypertension (High Blood Pressure)

· Hypercholesterolemia (High Cholesterol)

· Diabetes

· Smoking

· Chronic Kidney Disease

· Family History of heart disease, especially if it occurred before age 60.

· Obesity

· Sedentary Lifestyle

Treatment of Ischemic Heart Disease

Treatment aims to improve blood flow to the heart and reduce symptoms. Approaches may include:

· Medications:

o To improve blood flow (e.g., nitrates, statins).

o Antiplatelet drugs (e.g., aspirin) to prevent blood clots.

o Medications to lower blood pressure and cholesterol.

· Procedures:

o Angioplasty: A procedure where a balloon is used to open blocked arteries.

o Bypass Surgery: A surgical procedure to create new routes for blood to flow to the heart muscle.

· Lifestyle Modifications:

o Healthy Diet: A diet rich in fruits, vegetables, whole grains, and lean proteins.

o Exercise: Regular physical activity to improve cardiovascular health.

o Smoking Cessation: Quitting smoking to reduce cardiovascular risk.

Prevention of Ischemic Heart Disease

· Maintain a healthy diet: Focus on a balanced diet high in fruits, vegetables, whole grains, and healthy fats.

· Engage in regular physical activity: Aim for at least 150 minutes of moderate exercise per week.

· Avoid smoking and limit alcohol consumption.

· Monitor and manage:

o Blood pressure: Keep it within a healthy range.

o Cholesterol levels: Regular screening and treatment if necessary.

o Blood sugar: Control diabetes through diet, exercise, and medication if needed.

Atrial fibrillation is a condition characterised by an irregular and often rapid heart rate.

Symptoms of Atrial Fibrillation

• Irregular Heartbeat: The heart may feel like it's fluttering or pounding in the chest.

• Fatigue: Unusual tiredness or weakness.

• Dizziness: Light-headedness or a sensation of faintness.

• · Shortness of Breath: Particularly during physical exertion.

• Chest Pain: Discomfort or pain in the chest, which may be associated with a racing heart.

Causes of Atrial Fibrillation

. Underlying Heart Conditions:

• High blood pressure (hypertension)

• Coronary artery disease

• Previous heart attacks

· Other Contributing Factors:

• Family history of AF

• Obesity

• Diabetes

• Hyperthyroidism (overactive thyroid)

• Excessive alcohol intake

Risk Factors for Atrial Fibrillation

· Age: The risk of AF increases with age.

• Heart Disease: A history of heart disease, heart surgery, or other cardiovascular conditions.

• High Blood Pressure: Poorly controlled hypertension.

• Chronic Conditions: Conditions such as sleep apnea, lung diseases, and thyroid disorders increase the risk of developing AF.

Treatment of Atrial Fibrillation

The primary goals of treatment are to restore a normal heart rhythm, control the heart rate, and reduce the risk of stroke. Treatment options include:

· Medications:

o Anti-arrhythmic Drugs (e.g., quinidine, propafenone) to restore normal heart rhythm.

• Rate Control Medications (e.g., beta-blockers, calcium channel blockers) to regulate heart rate.

• Anticoagulants (e.g., warfarin, newer anticoagulants) to prevent blood clots and reduce the risk of stroke.

· Procedures:

• Electrical Cardioversion: A procedure to reset the heart's rhythm using a controlled shock.

• Catheter Ablation: A procedure to destroy areas of the heart causing abnormal electrical signals.

• Pacemaker Implantation: A device that helps regulate the heart’s rhythm if necessary.

Prevention and Lifestyle Management

Managing risk factors and adopting healthy lifestyle habits play a crucial role in preventing and managing atrial fibrillation:

· Regular checks and management of hypertension.

• Cholesterol and Blood Sugar: Regular screeningHealthy Diet: Focus on a heart-healthy diet, including plenty of fruits, vegetables, and whole grains.

• Regular Exercise: Maintain an active lifestyle with regular cardiovascular exercise.

• Avoid Excessive Alcohol and smoking.

• Stress Management: Practice relaxation techniques to manage stress.

• Monitor and Control:

Blood Pressure: Regular checks and management of hypertension.

Cholesterol and Blood Sugar: Regular screening and treatment when necessary.

Hypertension is a condition characterized by persistently high blood pressure levels. Often referred to as the "silent killer," hypertension typically does not present any symptoms, leading many individuals to remain unaware of their condition. Without proper management, hypertension can result in severe complications, including heart disease, kidney disease, stroke, and other health issues. Early detection and ongoing control are crucial to prevent long-term damage. In many cases, blood pressure management may require lifelong treatment, although significant improvements can often be achieved through lifestyle changes.

Symptoms of Hypertension

· Asymptomatic in most cases: Often, individuals with high blood pressure do not experience any noticeable symptoms.

· When symptoms occur: These may include:

o Headaches

o Nosebleeds

o Dizziness or light-headedness

o Visual disturbances

o Chest pain

o

Diagnosis of Hypertension

Hypertension is diagnosed through repeated blood pressure measurements. There are no specific blood tests to diagnose high blood pressure; rather, consistent readings above the normal range (typically 130/80 mmHg or higher) are used to confirm the condition. Regular monitoring is essential to detect and manage hypertension early.

Why is it Important to Control Hypertension?

Uncontrolled, long-term hypertension can cause significant damage to various organs and increase the risk of serious health conditions, including:

· Coronary Heart Disease: Increased risk of angina (chest pain) and heart attacks.

· Kidney Disease: Hypertension can damage the kidneys and lead to kidney failure.

· Heart Failure: The heart's ability to pump blood efficiently can decline.

· Atrial Fibrillation: An irregular heart rhythm that increases the risk of stroke.

· Stroke: High blood pressure is a leading cause of stroke.

· Vision Impairments: Damage to the blood vessels in the eyes can lead to vision problems.

· Arterial Aneurysms: The formation of bulges in the blood vessels, which can be life-threatening if they rupture.

Management of Hypertension

Blood pressure management typically aims for a systolic reading (the upper number) around 120-130 mmHg, though treatment targets may vary based on individual health conditions.

Management involves more than just monitoring blood pressure levels. The following factors must also be considered:

· Lifestyle Factors: Smoking, diet, physical activity, and stress levels.

· Comorbidities: Conditions like diabetes, high cholesterol, and kidney disease may influence treatment plans.

· Target Organ Damage: Assessing potential damage to organs such as the heart, kidneys, and eyes.

The most effective approach to managing hypertension includes lifestyle modifications, which can either prevent or complement medical treatment.

Lifestyle Modifications for Hypertension Management

Making the following lifestyle changes is essential for controlling blood pressure:

· Healthy Diet: Follow a heart-healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, which emphasizes fruits, vegetables, whole grains, and lean proteins.

· Regular Exercise: Engage in moderate physical activity (e.g., 30 minutes of brisk walking most days of the week).

· Quit Smoking: Smoking exacerbates hypertension and increases the risk of cardiovascular diseases.

· Limit Alcohol Consumption: Excessive alcohol intake can raise blood pressure. Aim to drink in moderation.

· Manage Stress: Practice stress-reduction techniques such as deep breathing, meditation, or yoga.

Medical Management of Hypertension

For some individuals, lifestyle changes alone may not be sufficient to manage blood pressure, and medication may be required. Common classes of medications used to control hypertension include:

· Diuretics (e.g., thiazide diuretics) to help the body eliminate excess salt and fluid.

· ACE Inhibitors or Angiotensin II Receptor Blockers (ARBs) to relax blood vessels.

· Beta-blockers to reduce heart rate and the force of heart contractions.

· Calcium Channel Blockers to relax blood vessels and reduce heart workload.

· Angiotensin Receptor-Neprilysin Inhibitors (ARNIs) for people with heart failure and high blood pressure.

Dyslipidemia refers to abnormal levels of lipids (fats) in the blood, which can increase the risk of cardiovascular diseases. It is commonly characterized by:

· High levels of LDL (low-density lipoprotein), often referred to as "bad" cholesterol.

· Elevated triglyceride levels.

· Low levels of HDL (high-density lipoprotein), known as "good" cholesterol.

Risk Factors for Dyslipidemia

Several factors contribute to the development of dyslipidemia:

· Lifestyle Factors:

o Lack of physical activity: Sedentary behavior increases lipid levels.

o Poor diet: Diets high in saturated fats, trans fats, and processed foods can elevate cholesterol levels.

o Smoking: Smoking reduces HDL (good cholesterol) and increases LDL (bad cholesterol).

o Excessive alcohol intake: Alcohol can raise triglyceride levels.

· Medical Conditions:

o Diabetes: Poorly controlled diabetes can lead to abnormal lipid levels.

o Chronic Kidney Disease: Impaired kidney function can disrupt lipid metabolism.

o Hypothyroidism: Low thyroid hormone levels (hypothyroidism) can result in increased cholesterol levels.

· Genetic/Inherited Factors:

o Certain forms of dyslipidemia, such as familial hypercholesterolemia, can be inherited from parents, leading to high cholesterol levels from a young age.

Symptoms of Dyslipidemia

High cholesterol generally does not cause symptoms. It often remains asymptomatic until it contributes to serious conditions such as heart attacks (myocardial infarctions) or angina (chest pain). Regular monitoring of cholesterol levels is crucial, especially for those at higher risk.

Diagnosis of High Cholesterol

The diagnosis of dyslipidemia is typically made through a fasting cholesterol blood test, which measures the levels of various lipids, including total cholesterol, LDL, HDL, and triglycerides. For individuals at higher risk, regular lipid checks and heart health assessments are important to identify abnormal lipid levels before complications arise.

Management of High Cholesterol

Effective management of dyslipidemia involves both lifestyle changes and, in some cases, medical treatment.

Lifestyle Modifications: These are the cornerstone of managing high cholesterol and improving overall cardiovascular health:

· Dietary Changes:

o Adopt a heart-healthy diet, such as the Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diets, which focus on reducing saturated fats and incorporating more fruits, vegetables, whole grains, and lean proteins.

o Limit intake of trans fats and saturated fats found in fried foods, processed meats, and packaged snacks.

o Increase fiber intake by consuming more whole grains, fruits, and vegetables.

· Regular Exercise:

o Engage in physical activity, such as brisk walking, cycling, or swimming, for at least 150 minutes per week.

o Exercise helps raise HDL (good cholesterol) and lower triglycerides.

· Quit Smoking:

o Smoking cessation improves HDL levels and helps protect the cardiovascular system.

· Limit Alcohol:

o Moderate alcohol intake is recommended, ideally no more than one drink per day for women and two drinks per day for men.

Medical Management: If lifestyle changes alone are not enough to control cholesterol levels, medications may be prescribed. The treatment approach will depend not only on cholesterol readings but also on other factors such as smoking status, diabetes, age, and the presence of target organ damage (such as heart disease or kidney problems). Common treatments include:

· Statins: These medications lower LDL (bad cholesterol) and reduce the risk of heart disease and stroke.

· Ezetimibe: This medication helps lower cholesterol by reducing the absorption of cholesterol from food.

· Fibrates: These medications are used to lower triglyceride levels and, in some cases, raise HDL cholesterol.

· PCSK9 Inhibitors: A newer class of injectable medications that can significantly lower LDL cholesterol, particularly in individuals with familial hypercholesterolemia or those who do not respond well to statins.

Preventing High Cholesterol

Prevention is key in managing dyslipidemia:

· Adopt a heart-healthy diet from an early age.

· Engage in regular physical activity.

· Maintain a healthy weight to reduce overall cardiovascular risk.

· Monitor cholesterol levels regularly, especially for individuals with a family history of high cholesterol or other risk factors.

Type 2 Diabetes Mellitus (T2DM) is a chronic condition that affects the way your body processes blood sugar (glucose). Insulin, a hormone produced by the pancreas, helps regulate blood glucose levels. In Type 2 Diabetes, either the body doesn't produce enough insulin or the body's cells become resistant to insulin's effects, leading to elevated blood sugar levels.

Causes and Risk Factors of Type 2 Diabetes

The development of Type 2 Diabetes can be influenced by several factors:

· Insufficient Insulin Production: Over time, the pancreas may reduce its production of insulin, unable to maintain normal blood glucose levels.

· Insulin Resistance: The body’s tissues become less responsive to insulin, requiring more insulin to achieve the same effect.

· Lifestyle Factors:

o Poor diet (especially high in sugars and unhealthy fats)

o Lack of physical activity

o Obesity, which is increasingly prevalent in Australian culture, significantly increases the risk of developing Type 2 Diabetes.

o

· High-Risk Groups:

o Family history of Type 2 Diabetes: A higher risk if immediate family members have diabetes.

o Previous gestational diabetes: Diabetes during pregnancy increases the likelihood of developing Type 2 Diabetes later in life.

o Obesity: Excess body fat, especially around the abdomen, is a major risk factor.

o Indigenous Australians: There is a higher prevalence of Type 2 Diabetes in Indigenous communities.

o Pancreatic damage: Conditions like pancreatitis, often linked to excessive alcohol consumption, can impair insulin production.

o

Symptoms of Type 2 Diabetes

Type 2 Diabetes develops gradually and can remain undiagnosed for years. Initially, blood sugar levels may be normal or slightly elevated, and the condition may progress to pre-diabetes. Symptoms can include one or more of the following:

· Increased thirst and urination, especially frequent urination at night.

· Fatigue or lethargy: Feeling unusually tired or weak.

· Blurry vision: Changes in eyesight due to fluctuating blood glucose levels.

· Frequent infections: Including skin infections, abscesses, and foot infections.

· Foot ulcers: Caused by nerve damage and poor circulation in the feet.

·

Diagnosis of Type 2 Diabetes

While symptoms can offer clues, they are not sufficient for a diagnosis. Blood tests are necessary for confirmation:

· Fasting Blood Sugar Test: Measures blood sugar after an overnight fast.

· Glycated Hemoglobin (HbA1c): Reflects average blood glucose levels over the past 2-3 months.

If symptoms are present, one of these tests may be enough to diagnose diabetes. In asymptomatic patients, two elevated test results are required to confirm the diagnosis.

Management of Type 2 Diabetes

Managing Type 2 Diabetes is a lifelong commitment and requires a combination of lifestyle changes, medications, and regular monitoring. Motivating patients to maintain their treatment plan is critical for long-term success.

Lifestyle Modifications:

· Healthy Diet: Focus on a balanced diet with low refined sugars and carbohydrates. Include more fruits, vegetables, whole grains, and lean proteins. Limit saturated fats and processed foods.

· Regular Physical Activity: Engage in at least 150 minutes of moderate exercise each week. Exercise helps improve insulin sensitivity and control blood sugar levels.

· Weight Management: Maintaining a healthy weight is key in controlling blood sugar levels.

· Avoid Smoking and Excessive Alcohol: Smoking worsens insulin resistance, while excessive alcohol can cause fluctuations in blood sugar levels.

· Stress Management: Chronic stress can impact blood sugar levels, so incorporating relaxation techniques can help manage diabetes.

·

Medical Management: While lifestyle modifications are crucial, medications may also be necessary, especially if blood sugar levels remain high despite lifestyle changes. Options include:

· Oral Hypoglycemic Agents: Medications like Metformin and Gliclazide help lower blood glucose levels.

· Weekly Injections: Medications like Semaglutide are used for long-term blood sugar control.

· Insulin Injections: In some cases, insulin may be required to help control blood glucose levels.

It is important to discuss medication options with your doctor, as each has its own potential side effects.

Allied Health Management

Alongside medical treatment and lifestyle changes, regular visits to allied health professionals can support diabetes management:

· Podiatrist: To manage foot health and prevent complications such as ulcers or infections.

· Optometrist: Regular eye exams to detect diabetic retinopathy, a condition that can lead to blindness if untreated.

· Dietitian: To help create a personalized eating plan that controls blood sugar levels.

· Diabetes Educator: A healthcare professional who can provide education on managing diabetes and blood sugar monitoring.

· Exercise Physiologist: An expert in physical activity who can design an exercise program to improve insulin sensitivity.

Group Exercise: Participating in group exercise classes with an exercise physiologist can help with weight management and improve overall blood sugar control.

Routine Care for Diabetes

Regular check-ups and blood tests are essential to monitor your diabetes and prevent complications. Important tests include:

· Fasting Blood Sugar and HbA1c: To assess long-term blood sugar control.

· Kidney Function Tests (eGFR): To monitor kidney health, as diabetes can lead to kidney damage.

· Microalbuminuria (uACR): To check for early signs of kidney damage.

· ECG: To assess heart health, as diabetes increases the risk of heart disease.

Since diabetes increases the risk of fatty liver and metabolic syndrome, liver function tests (LFTs) and liver ultrasoundmay also be recommended.

Complications of Poorly Controlled Diabetes

Poorly controlled diabetes can lead to severe complications, many of which are preventable with proper management. These include:

· Heart Disease: Increased risk of heart attacks, strokes, and heart failure.

· Atrial Fibrillation: An irregular heart rhythm that increases the risk of stroke.

· Kidney Damage: Leading to chronic kidney disease.

· Nerve Damage: Loss of sensation, especially in the feet, which can lead to serious infections and foot ulcers.

· Eye Damage: Diabetic retinopathy can result in visual impairment or blindness.

· Foot Complications: Due to poor circulation and nerve damage, leading to foot ulcers, infections, and potentially amputations.

Osteoarthritis (OA) is the most common form of arthritis, affecting millions of people worldwide. It occurs when the protective cartilage in the ends of your bones wears off over time which can cause stiffness, pain and reduced movements of the affected joints.

Commonly affected joints.

Hands, knees, hips, shoulder joints and spine. But it can affect any joints.

Symptoms.

Joint pain- after prolonged walking / working / movements. When conditions get worse, you can get pain after a short walk or even during movements.

Stiffness - Typically noticeable after inactivity or when waking up in the morning.

Tenderness - Sometimes you can feel pain around the joint when you press the joint but do not feel this always.

Swelling - Around the affected joints

Reduced range of joint movements affecting flexibility of the joint

Causes and risk factors.

Aging: Wear and tear of cartilage, simply getting older increases your risk of developing osteoarthritis due to the cumulative wear joints.

Previous joint injuries: Even those from years ago, can lead to osteoarthritis later in life. This includes childhood trauma, sports injuries and work-related injuries.

Being overweight; Extra body weight places more stress on joints, especially your knees and hips.

Management.

Physical activity: Regular exercise strengthens muscles around joints, reducing strain. Low-impact activities like swimming, walking, and cycling.

Maintaining a healthy weight: Maintaining a healthy weight minimizes pressure on weight-bearing joints, such as knees and hips.

Pain management.

Panadol osteo, anti-inflammatory medicine. But always consult your doctor for pain management.

Physiotherapy: Physiotherapist can teach you exercises to strengthen the muscles around your joints, improve flexibility and reduce pain.

Joint injections: Corticosteroid or hyaluronic acid injections can provide temporary relief in severe cases. Consult your doctor to discuss this option.

Surgery: If conservative treatments fail, options like joint replacement surgery might be considered.

Prevention of Osteoarthritis;

While you cannot entirely prevent osteoarthritis, you can certainly take steps to reduce your risk or slow its progression by regular exercise, losing weight, eating healthy and avoiding injuries.

You can arrange a chronic disease management plan [care plan] to get Medicare subsidised physiotherapy visits. Please contact practice nurse.