Cardiac – see CHF summary Assessment of Cardiovascular Risk Factors
Previous IHD Hypercholesterolaemia Smoking Hypertension Family history of CAD History of Diabetes Renal failure
Female Genital PAP smears Should be done every 2 years for women 18-70 for those without pathology s/s and for those who have had sex From sexual activity 70y.o. - Begin at 18-20 or two years after sex, whichever is later - Cease at 70 if have had normal smears for five years There are reminder registers Hysterectomy - PAP required if cervix not fully excised - Vaginal vault smears needed if Hx of dysplasia Grading of squamous abnormalities - HPV = atypia - CIN 1 3 = mild moderate severe dysplasia - CIS = carcinoma in situ - Invasive carcinoma - ASCUS = atypical SC of undetermined significance - LSIL = low grade squamous intraepithelial lesion - HSIL = high grade SIL - CIN = cervical intraepithelial neoplasia When to refer - If normal repeat at 2 years - If possible or definite LSIL repeat at 12 months, if over 30 with no negative smears in last 3 years refer to colposcopy or repeat in six months - High grade lesions refer to colposcopy or gynaecologist NOTE: if the patient has HPV smoking is a significant RF for developing a dysplasia to quit s/s of cc or other disorders…
advise
-
Vaginal bleeding especially postcoital Discharge Weakness
Prevention of cancer - Intercourse with one partner - Condoms if unsure of sexual Hx - PAP smears - Counseling for those at risk - Use of beta carotene has protective effect eat lots of green leaf and orange veges - NO smoking Gardisil - Females 18-26 at practice School program
BSLs
BGL 4-6 mmol/L (fasting) HbA1c < or equal to 7%
Cholesterol LDL-C < 2.5 mmol/L Total Cholesterol < 4.0 mmol/L Triglycerides < 1.5 mmol/L LFTs
Plasma bilirubin Albumin – indicates chronic liver disease if low ALT – specific to liver indicates hepatocyte damage AST – indicates hepatocytes damage ALP – indicates cholestasis GGT - raised with cholestasis and drug and alcohol
Thyroid function tests - First look for TSH - Then look for T3, T4 - Hyperthryroidism = Increased HR, Sweating, tremor, anxiety, Increased appetite, Weight loss, Intollerance to heat - Hypothyroidism = Cretinism (if present at birth), Mental and physical slowness, Sensitivity to cold, Decreased pulse, Weight gain, Thickening of skin myxoedema
See immunisation schedule
With a sore throat you need to determine whether it is not deep neck pain, get them to point to the area that is sore, enquire about other s/s e.g. fever, metallic taste
Usually viral treat symptomatically - Soothing fluids including icy poles - Analgesia 2 paracetamol or soluble aspirin for adults, paracetamol elixir for kids - Rest with adequate fluids - Soothing gargles e.g. soluble aspirin - Advice against overuse of OTC lozenges and topical sprays
1. Viral pharyngitis 2. Strep tonsillitis 3. Chronic sinusitis with postnasal drip What not to miss - CV – angina, MI - Neoplasia – of oropharynx, tongue\ - Severe infections – acute epiglottitis, peritonsillar abscess, pharyngeal abscess, diphtheria, HIV Pitfalls often missed - Foreign body - EBV - Candida (infants and steroid inhalers) - STIs (gonococcal, herpes, syphilis) - Reflux oesophagitis pharyngitis - Irritants e.g. cigarette - Chronic mouth breathing - Apthous ulceration - Thyroiditis Strep tonsillopharyngitis 1. Fever >38 2. Tender cervical lymph 3. Tonsillar exudates 4. NO cough Dx with throat swab Tx with penicillin
Most common cause of a cough
-
How would you describe it, how long present for? Do you cough up sputum, describe? Any blood in sputum and how much? Is there burning in your throat or chest? Any other s/s? Smoker? Chest pain or fever, shivers or sweats? Wheeze?
-
Previous attacks of wheezing or hay fever? Hx of asthma? Lost weight? Anyone in family with TB or persistent cough? Smoker? Exposure to smoke? Work? Work history? Exposure to asbestos? Do you keep birds? Foreign body? Recent operation? Swelling in legs? Timing of cough – day or night? Associations – posture, food, wheeze, breathlessness?
-
General inspection Lymphadenopathy Lungs and CV system Inspect sputum
-
Hg, blood film and WCC Sputum for cytology ESR (high with bacterial infection, bronchiectasis, TB, lung abscess, bronchial cc) Respiratory function tests Radiology – CXR Skin tests
-
What not to miss - LV failure - Carcinoma of lung - TB, pneumonia, influenza, lung abscess, HIV - Asthma - Cystic fibrosis - Foreign body or pneumothorax
Check for masquerades - Depression, diabetes, drugs - Anaemia, thyroid disorder, spinal dysfunction, UTI
Most depression is transient but 10% is significant Major depression diagnostic criteria (at least five of these for more than two weeks) 1. Depressed mood 2. Loss of interest or pleasure 3. Significant appetite or weight loss or gain (usually poor appetite) 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation
6. 7. 8. 9.
Fatigue or loss of energy Feelings of worthlessness or excessive guilt Impaired thinking or concentration; indecisiveness Suicidal thoughts
Minor depression is where fluctuations occur due to environmental influences, Dx is based on 2-4 s/s of the above list including 1 & 2 Depression does occur in children and is characterized by feelings of worthlessness and despair
--
Is there a suicide risk Do they need inpatient assessment Is referral to a specialist psychiatrist indicated
-
Psychotherapy – education, reassurance, support, CBT CBT: teaching pt’s new ways of positive thinking which have to be relevant and achievable for the patient Pharmacological Electroconvulsive treatment
-
Drug therapy: - First line: Selective serotonin reuptake inhibitors - Second line: tricyclic antidepressants About antidepressants - There is not one ideal type - TC can be given once daily - Delay in onset of 1-2weeks - Each drug should be trialed for 4-6 weeks before changing Tx - Swapping from one agent to another may be beneficial - Do not mix AD - Consider referral if failed - Full recovery may take 6 weeks or longer - Continue Tx at maintenance levels for 6-9 months, relapse is common Serotonin syndrome Agitation, nausea, headache, tremor, tachycardia – may happen when switching between AD due to an inadequate ‘without period’ – 2 weeks for most
PAIN acronym for Abdominal Pain P pancreatitis P perforated viscous P peritonitis A acute cholecystitis A appendicitis A acute diverticulitis I intestinal ischaemia N number of others (volvulus, toxic megacolon)
Most cases need surgical referral, causes listed in Murtagh’s include - Inflammation, perforation, obstruction, haemorrhage, torsion (ischaemia) Most common presentations in GP land include acute appendicitis, colic General rules Usually upper pain is upper GIT lesions and lower pain is lower GIT lesions Colicky midline umbilical/abdominal pain vomiting distension small bowel obstruction Midline lower pain distension vomiting large bowel obstruction Usually acute abdo’s with a surgical cause have pain followed by vomiting
Mesenteric aa occlusion to be considered in elderly with arteriosclerotic disease or AF
Most common causes of AA are… - Acute appendicitis, acute gastroenteritis, irritable bowel syndrome, various ‘colics’, ovulation pain, mesenteric adenitis is common in kids Things not to miss - MI, ruptured AAA, dissecting aneurysm, mesenteric aa occlusion - Neoplasia – large or small bowel occlusions - Infections – salpingitis, peritonitis, pancreatitis - Ectopic pregnancy - SBO - Volvulus - Perforated viscous - Duodenal ulcer - Colonic diverticulum - Colonic cancer
Pitfalls - Appendicitis - Pulmonary causes - Faecal impaction (elderly) - Herpes zoster Red flag symptoms - Collapsing at toilet (intra-abdo bleeding) -
Light headedness Progressive intractable vomiting Progressive abdo distension Progressive intensity of pains
Red flag signs - Pallor and sweating - Hypotension - AF or tachycardia - Fever - Rebound tenderness/guarding
-
Decreased urination
-
What type of pain – constant, waning How severe 1-10 Any previous attacks – anything else with the pain Exacerbating/relieving factors Milk, food or antacid effect on pain Sweats or chills, burning urine Bowels behaving normally? Diarrhoea, blood in stool? Anything different about urine?
--
Medications? Aspirin? Smoking? Heroin? Cocaine? Alcohol? Milk? Travel history Menstrual history – mid cycle? Family Hx of abdo pain? Hernia? Operations on abdo? Appendix removed?
-
Appearance Oral cavity Vital signs HR and lung check for upper abdo pain Abdo – inspect, palpate, percuss, auscultation Inguinal region for hernia Rectal exam Vaginal exam Urine analysis – WCC, RCC, glucose, ketones
-
Hb – anaemia due to blood loss WCC – infection and ESR (also high in cc and Crohn’s), CRP LFT Serum amylase and lipase for pancreatitis Pregnancy test Urine – blood, WCC, bile, ketones Faecal blood – interssusception (redcurrent jelly), Crohn’s disease, ulcerative colitis XR of abdo CXR for perforated ulcer (if air under diaphragm)
-
Vascular problems Ruptured ulcer Biliary disorders Volvulus Carcinoma
-
Gastroenteritis – bacterial or viral Dietary indescretions AB reactions
-
IBS Drug reaction Coeliac disease Chronic infections
How much, how often, nature of stool? Associated with vomiting? Travel history? Daycare/work environment? Associated with certain foods? Abdominal pain or bloating? Medication history?
Most common causes = psychological distress, depression Other causes - Psychiatric disorders – anxiety, depression - Lifestyle – workaholic, lack of exercise, mental stress, bad diet, obesity - Organic – CHF, anaemia, malignancy, thyroid, respiratory - Unknown – chronic fatigue syndrome
Stress depression viral/post viral infection sleep disorders (sleep apnoea) - Don’t miss cancer, cardiac problems, anaemia, HCV - Pitfalls = food intolerance, Coeliac disease, chronic infection, drugs, lack of fitness
-
Sleep pattern Weight fluctuations Energy, performance, ability to cope Sexual activity Suicidal ideas Self medications Precipitating factors – postpartum, postoperative, associated with chronic illness, bereavement, pain, retirement, medication Work history and diet history
-
Hb ESR/CRP ECG Thyroid function tests LFT Kidney function tests BSL Iron Tissue markers for malignancy Referral to a sleep disorder laboratory for sleep apnoea studies
Common problems include instability, stiffness, impingement, RC tear, AC joint pain and arthritis
-
PHx - SOCRATES Did you have any injury even minor before pain started? Does the pain keep you awake? Is there pain or stiffness in your neck? Is there pain or restriction when touching your shoulder blades? Pain with sport? Explain the restriction – i.e. how much could you lift without pain?
-
Inspect, palpate, movements (resisted, active and passive)
Causes of pain aside from trauma, fracture and dislocation - Dysfunction (cervical or AC joint), spondylosis, bursitis, RC disorders, tendinopathy, tendonitis, rheumatoid inflammation, osteoarthritis
Common disorders of the feet and toes - Fracture of toes - Foot strains - Ingrown toenails - ‘black nails’ - Bony outgrowth of under the nail - Calluses - Athlete’s foot (Tinea pedis) - Plantar warts Tx specific to cause
-
Polyuria Polydipsia Weight loss Tired and fatigued Characteristic breath Propensity for infections
BGL 4-6 mmol/L (fasting) HbA1c < or equal to 7% LDL-C < 2.5 mmol/L Total Cholesterol < 4.0 mmol/L Triglycerides < 1.5 mmol/L Blood Pressure < or equal to 130/80 mm Hg BMI < 25 Urinary albumin excretion < 20µg/min (overnight) o o <20mg/L (spot collection) Cigarette consumption zero Alcohol intake (per day) o < 2 standard drinks per day Physical Activity o At least 30 minutes a day walking (or equivalent) 5 or more days per week
The ABC of diabetic care This is an effective management plan referred to by texts is the ‘ABC’ of diabetic care (Murtagh 2008, p.1326), specifically this refers to: A. HbAIc < 7% B. BP < 130/80 C. Cholesterol < 4mmol/L NEAT diabetic management plan NEAT is a handy mnemonic that can be easily taught to patients in order for them to have a better understanding of how to control their diabetes and other associated conditions such as dyslipidaemia N ==Exercise Nutrition (aminutes healthy per diet)day five times per week) E (30 A = Avoidance of toxins (alcohol, tobacco, sugar, salt) T = Tranquility (stress relieving activities) Other considerations - Diabetic educator - Nutritionist, exercise physiologist - Refer to ophthalmologist, podiatrist if necessary - Assess for peripheral neuropathies - Assess vision - Assess CV health
-
Assess family Hx, social Hx (alcohol, smoking occupation, diet, psychosocial, living arrangements), medications, current conditions, immunisations
-
Fluvax and pneumovax
General inspection Weight o o Hydration o Endocrine facies o Pigmentation
o Legs Inspection: o Inspection of the skin for hair loss, infection, atrophy, ulceration, injection sites, pigmented scars, or cracking Muscle wasting o Palpation: o Temperature of the feet and hands for vessel pathology Peripheral pulses (femoral, Popliteal, posterior tibial, Dorsalis pedis) o Arms Inspection: o Injection sites o Skin lesions Palpation: o Pulse
Eyes Fundi for cataracts or retinal disease o Mouth Any signs of infection o Neck Carotid arteries palpated and auscultated o Chest o Signs of infection Other o Oedema: inspections for peripheral oedema, pitting oedema and sacral oedema
Assess coordination, sensation of limbs; assess foot and toe health, look for ulcers or infection, ask about footwear, look at quality of skin, assess for nail infections Assess bladder and sexual function Assess end organ damage – LFTs, BP etc
Most common type or arthritis, degenerative disease of cartilage may be primary or secondary to trauma, mechanical problems or inflammatory disorders -
OA is usually symmetrical Pain worse on initiating movement and loading
-
Pain eased at rest Associated with stiffness especially after activity in contrast to RA Main joints involved = first CMC joint of thumb, first MTP joint of great toe, DIP joints of hands Hips, knees and shoulders also involved
-
Pain – worse at end of day, aggravated by use, relief by rest, worse in cold and damp Variable morning stiffness, and variable disability
-
Hard and bony swelling
--
Crepitus Signs of inflammation Restricted mmts Joint deformity
Clinical and radiological - XR findings: joint space narrowing, sclerosis of subchondral bone - Formation of osteophytes on the joint margins - Cystic areas in subchondral bone - Altered shape of bone ends -
Explanation and reassurance including handouts Control pain and maintain function with appropriate drugs Suggest judicious activity, exercise and physical therapy Consider factors lowering the coping threshold (e.g. stress, depression, overactivity) Refer for surgical intervention for debilitating and intractable pain or disability
1. Explanation – not the ‘crippling disease’, information 2. Exercise – graduated program to maintain joint function, aim for a good balance of relative rest with sensible exercise, stop or modify any exercise or activity that increases the pain …systemic reviews show info + exercise help 3. Rest – rest during an active bout of inflammatory activity only – prolonged bed rest contraindicated 4. Heat – e.g. hot water bottle, warm bath, electric blanket to sooth. Advise against getting too cold 5. Diet – if fat get thin! Obesity increases risk of OA, no specific diet is shown to reduce or
OA ofsuggest nutritious balanced diet 6. cause Correction predisposing factors and aids – the following may help: weight reduction, walking stick, heel raise for leg length disparity, back brace, elastic or hinged joint support 7. Physio – referral for posture disparity, hydrotherapy program, heat therapy and advice on simple home heat measures, exercises 8. OT – for aids in the home and to achieve more efficient ADLs 9. Simple analgesics – regularly for pain, take before activity: NSAIDs and simple anal reduce pain but there is no good evidence that NSAIDs are any better 10. NSAIDs and aspirin – F. line drugs for persistent pain, warn of risk of gastric bleed, ulceration, kidney function, hepatotoxicitiy
11. COX 2 inhibitor 12. Intra articular corticosteroids 13. Viscosupplementation 14. Complimentary therapy – glucosamine 15. Contraindicated drugs = immunosuppressants and oral CS
-
Heartburn Acid regurgitation Water brash
--
Dx usually on Hx Ix usually not needed
1. Education – consider acid suppression, neutralisation; stop smoking; reduce alcohol; avoid fats; reduce caffeine especially at night; avoid gassy drinks; increase fibre; small regular meals; avoid spicy food; use antacids If no relief use antacid consider PPI
Caused by allergens common in occupational situations often by - Cosmetics - Topical AB or anaesthetics - Topical antihistamines - Plants - Dyes, perfumes - Rubber, latex Prednisolone, wash with water Atopic dermatitis is associated with itch, family history of atopy, trigger factors, dry skin, relapse
-
Mechanism of injury SOCRATES
--
What have they taken? Done this before? Affecting their life? Done at work? Occupation?
Ankle – forced eversion causes most strains -
Ankle gives way Difficulty weight bearing Discomfort mild to severe Bruising, may take 12-24h may have functional instability
-
Note swelling, bruising Palpate over bony landmarks and ligaments Test joint laxity and ROM Do anterior draw sign
Look for underlying fracture- lateral malleolus or base of MT 5: can they walk without discomfort straight after the injury -
Inability to weightand bear immediately after Marked swelling bruising soon afer Marked tenderness over bony landmarks Marked pain on mmt Crepitus on palpation and mmt Special circumstances (litigation potential) Bone tenderness
OTAWA rules generally indicated XR if there is bony tenderness and an inability to weight bear Management 1. Grade I (mild) = RICARS 48h, or until standing not painful (A = analgesics, R= review in a week, S = strapping) 2. Grade II (moderate) = RICE for 48h, no weight bearing for 48h possibility of crutches, ice packs over strapping 3. Grade III (severe) = appropriate referral if complete tesar, initial Mx = RICEAR and XR to exclude fracture consider surgical repair, plaster immobilisation, strapping and physiotherapy
Reddened, adherent, scaly thickenings on light exposed areas with potential for malignant change - Usually on face, ears, scalp - Dry rough adherent scale - Discomfort on rubbing
-
Reduce to sun May go exposure spontaneously Liquid nitrogen if superficial or imiquimod Surgical excision Biopsy if doubtful
Method of action = inhibition of hypothalamic and pituitary function leading to anovulation. Efficacy – pregnancy rate is 1-3/100 women per year.
When commencing take menstrual history and history of contraception can be taken effectively until 50 y.o. and cover starts immediately if it is started on day one of the cycle. Once over 50, stop and measure FSH and oestradiol levels to determine if menopause.
Can start once menstruation has commenced - Monophasic low dosed combined preparation is best
Low dose monophasic COC (combined oral contraception)
Commence with less androgenic progestogen e.g. Diane Use high dose monophasics for breakthrough bleeding on low dose, to control menorrhagia, on low dose pill failure -
Pregnancy First 2 weeks post partum Hx of thromboembolic disease Cerebrovascular disease Focal migraine CAD Recent impaired liver function
-
Heavy smoker Undiagnosed abnormal bleeding Breast feeding Four weeks prior to surgery or 2 weeks after Hypertension Diabetes Severe depression
-
Reduce menstrual cycle disorders Reduction in incidence of PID Reduction in ovarian and endometrial cc Reduced thyroid disorders
-
DVT, pulmonary embolism, kidney thrombosis MI, stroke Commonly seen s/e = amenorrhoea, breakthrough bleeding, breast fullness or tenderness, depression, libido loss, headache, nausea vomiting, weight gain
-
Periods are shorter, regular and lighter, no break from pill is necessary Drugs interacting = vitamin C, Antibiotics, oral hypo’s Diarrhoea and vomiting may reduce its effectiveness
-
Yearly return visits are needed to update Hx and repeat PAP’s
-
Keep going, take a pill ASAP and keep with the normal cycle If in week three omit the pill free interval Condoms or abstinence should be used for seven days in the following: 2 for 20 – if two or more 20micrograms are missed, 3 for 30: if three or more 30-35 mcg are missed
Seven day rule for the missed or late pill (>12 hours late) - Take forgotten pill ASAP, even if it means taking two pills in one day - Take next pill at usual time and finish course - If you forget to take it for more than 12 hours use condoms for a week -
If the 7 days run beyond the last hormone pill then miss the inactive pills and start new packet – you may miss a period
Menstrual disorders: menorrhagia (heavy bleeding)/ dysmenorrhoea (painful) Other forms of contraception - Rhythm - Withdrawal - Spermicide - IUD - Vaginal ring - OCP - Implant - Injections
Usually self limiting problem 1-3 days - Abdo cramps - May have constitutional symptoms (fever, malaise, nausea, vomiting) - Other meal sharers affected food poisoning - Consider dehydration - Consider enteric fever Diarrhoea after visiting less developed countries may have a protozoal infection if fever and blood suspect amoebiasis.
--
Hydration Antiemetic if severe vomiting Antidiarrhoeal agents Rest Diet – don’t eat but drink small amounts of clear fluids until it settles Eat low fat foods Avoid alcohol, caffeine, spicy food, raw fruit, smoking On day three add dairy and lean meat
Usually minor and self-limiting, but serious causes shouldn’t be overlooked Cough can be: o Chronic bronchitis Asthma o Psychogenic basis o o URTI o Postnasal drip (most common), mainly from chronic sinusitis, tracking down the larynx and trachea during sleep Others o Haemoptysis (coughing blood) URTI (24%) o Acute/chronic bronchitis (17%) o Bronchiectasis (13%) o o TB (10%) o Unknown (22%) o Carcinoma (4%) Drugs can be a cause (cytotoxic drugs, ACE-inhibitors, beta-blockers, inhaled steroids)
Respiratory systems review if appropriate Key questions about the cough: o Describe the cough o o
o o
o o o o o
How long Sputum (presence, amount, colour, blood) Other symptoms Chest pain, fever, shivers, sweats Wheeze Previous attacks Presence of asthma in family Weight loss Presence of TB in family
o
o o
o
o
o
o
Presence of persistent cough in family Smoking (how much) Smoke/fume exposure (plus other occupational exposures) Keep birds at home, or birds nesting nearby Foreign body ‘gone down the wrong way’ Recent operation or being confined to the bed Swelling of legs
Lung exam Fine crackles: pulmonary oedema of heart failure, interstitial pulmonary fibrosis, o early lobar pneumonia o Coarse crackles: resolving pneumonia, bronchiectasis, TB Cardiovascular exam Inspect sputum Clear white: normal, uninfected o Yellow/green (purulent): cellular material, +/- infection, asthma (eosinophils), o bronchiectasis o Rusty: lobar pneumonia (blood) Thick and sticky: asthma o Profuse, watery: alveolar cell carcinoma o Thin, clear mucoid: viral infection o
o o o
Redcurrant jelly: bronchial carcinoma Profuse and offensive: bronchiectasis, lung abscess Pink frothy sputum: pulmonary oedema
Blood tests (general) Sputum cytology and culture ESR (elevated with bact. infection, bronchiectasis, TB, lung abscess and bronchial carcinoma) Respiratory function tests Radiology o Plain chest X-ray o
Tomography (more precise, can show cavitation) Bronchiography (shows bronchiectasis, very unpleasant) CT scanning o V/Q isotope scan (for pulmonary infarction) o Skin tests Lung biopsy Bronchoscopy o
It is important to remember that all that is needed initially for investigating a chronic cough is a plain chest X-ray.
Probability diagnosis (most common): URTI Postnasal drip Smoking Acute bronchitis Chronic bronchitis Dry vs productive: Dry cough URTI, LRTI (viral, o mycoplasma) o Inhaled irritants (smoke, dust, fumes) Inhaled foreign body (early o response) Bronchial neoplasm o o Pleurisy o
o o o o
Productive cough Chronic bronchitis o Bronchiectasis o o Pneumonia o Asthma Foreign body (later response) o Bronchial carcinoma o Lung abscess o o TB (when cavitating)
Interstitial lung disorders (pneumoconiosis, sarcoidosis) TB LV failure GORD, hiatus hernia Postnasal drip
Serious disorders not to be missed include: Cardiovascular (LV failure) Neoplasia (lung ca) Severe infections (TB, pneumonia, influenza, lung abscess, HIV)
Asthma Cystic fibrosis Foreign body Pneumothorax
Early months of life: o Milk inhalation/reflux Asthma o Toddler/preschool child Asthma o
o o o o o o o
Acute coryza (common cold)
Influenza
Acute bronchitis
Bronchitis Whooping cough Cystic fibrosis Croup Foreign body inhalation TB Bronchiectasis
Early school years Asthma o Bronchiits o o Mycoplasma pneumonia
Adolescence o Asthma o Psycholenic o Smoking
Highly infections URTI, mistakenly referred to as ‘the flu’ Mild systemic upset, prominent nasal symptoms Headache, malaise, (fever), tender eyes, runny nose, sneezing, sore throat, cough, (myalgia) Possible complications: sinusitis, otitis media, bronchopneumonia Advise rest, analgesics (paracetamol or aspirin), steam inhalations (for blocked nose), cough mixture (dry cough), gargling aspirin in water or lemon juice for sore throat, vitamin C/echinacea/zinz (clinical trials inconclusive) Relatively debilitating illness, do not confuse with the common cold Abrupt commencement (1-3 days) Fever >38C + 1 resp symptom + 1 systemic symptom Dry cough, sore throa, coryza, prostration/weakness, myalgia, headache, rigors/chills Possible complications: secondary bacterial infection, S. aureus pneumonia (20% mortality), depression, encephalomyelitis Advise rest, analgesics (aspirin, codeine+aspirin, codeine+paracetamol), high fluid intake Rx: antivirals (neuraminidase inhibitors: zanamivir 10mg by inhalation AND oseltamivir 75mg bd) – must be commenced within 36 hrs of onset and given for 5 days Prophylaxis: immunisation Acute inflammation of the tracheobronchial tree, usually follows URTI Generally mild and self-limiting, may be serious in debilitated patients Cough and sputum (main symptoms), wheeze and dyspnoea, usually viral, scattered wheeze on auscultation, fever or haemoptysis (uncommon) Can complicate chronic bronchitis Usually improves spontaneously in 4-8 days in healthy patients Rx: symptomatic; inhaled bronchodilators for airflow limitation, antibiotics
Pneumonia
usually not needed If evidence of acute bacterial infection with fever, increased sputum volume/purulence: o Amoxicillin 500mg (8 hourly for 5 days) or o Doxycycline 200mg statim, then 100mg daily for 5 days Inflammation of lung tissue. Usually presents as acute illness Cough, fever, purulent sputum, physical signs and X-ray changes if consolidation Initial presentation can be confusing if systemic without respiratory symptoms Community –acquired pneumonia (CAP): People who have not been to hospital recently, not institutionalised or immunocompromised Usually S. pneumonia Treatment usually empirical (5-10 days for most bacterial causes, 2 weeks for Mycoplasma or Chlamydia and 2-3 weeks for Legionella) Often history of viral respiratory infection Rapidly ill with high temperature, dry cough, pleuritic pain, can be rusty-coloured sputum, rapid and shallow breathing, consolidation on examination and X-ray Atypical pneumonias: Fever, malaise, headache, minimal respiratory symptoms, nonproductive cough, no consolidation, chest X-ray (diffuse infiltration) incompatible with chest signs Causes include o Mycoplasma pneumonia (most common) (adolescents and young adults), treat with roxithromycin or doxycycline o
Chronic persistent cough
Bronchial carcinoma
Legionella pneumophilia prodromal influenza-like illness, dry cough, confusion, diarrhoea, very high fever, lymphopenia with moderate leucocytosis, hyponatraemia, treat with azithromycin IV, erythromycin (IV or o) plus ciprofloxacin or rifampicin (if very severe) o Chlamydia pneumoniae (similar to mycoplasma), Chlamydia psittaci (psittacosis) o Coxiella burnetti (Q fever) Cough not associated with a viral respiratory infection that lasts more than 2 weeks: persistent Cough lasting 2 months or more: chronic cough Divided into productive/non-productive (see table) Can be a feature of GORD Features: 50-70yrs, only 10-25% have symptoms at time of diagnosis, if symptoms, advanced andprognosis), not resectable Small cell then lung usually carcinoma (poorer non-small cell lung cancer (SCLC, NSCLC) Local: cough (42%), chest pain (22%), wheezing (15%), haemoptysis (7%), dyspnoea (5%) General: anorexia, malaise, unexplained weight loss Other: unresolved chest infection, hoarseness Symptoms from metastases Investigations: chest X-ray, CT scan, fibre-optic bronchoscopy, PET scan, fluorescence bronchoscopy, tissue diagnosis Management: refer to respiratory physician; main aim is resection for NSCLC, but that is not an option for SCLC because they metastasize so quickly.
Radiotherapy and chemotherapy. Bronchiectasis Dilation of the bronchi when their walls become inflamed, thickened and irreversibly damaged, usually following obstruction followed by infection Predisposing factors: whooping cough, measles, TB, inhaled foreign body, bronchial carcinoma, cystic fibrosis, congenital ciliary dysfunction) Left lower lobe and lingual are the most common sites Chronic cough, worse on waking, mild cases: yellow/green sputum after infection Advanced: profuse purulent offensive sputum, persistent halitosis, recurrent febrile episodes, malaise, weight loss Episodes of pneumonia Haemoptysis (amount is variable) On examination: clubbing, coarse crackles over infected areas (usually lung base), bronchial breath sounds, normal or decreased vocal fremitus, resonant to dull percussion note Investigations: chest x-ray, sputum examination (for resistant pathogens), CT, Management: explanation, preventative advice, postural drainage (10-20 minutes x 3/day), antibiotics according to organism, bronchodilators if evidence of bronchospasm Tuberculosis Pulmonary TB may be symptomless and detected by mass X-ray screening Respiratory: cough, sputum (mucoid, then purulent), haemoptysis, dyspnoea, pleuritic pain General: anorexia, fatigue, weight loss, low grade fever, night sweats (all usually insidious) Examination: clubbing, may be no respiratory signs, or sings of fibrosis, consolidation or cavitation (amphoric breathing) Investigations: chest X-ray, micro and culture sputum, ESR, tuberculin test (unless BCG vaccination) Management: notifiable disease; hospitalisation usually not necessary, monthly follow-up is recommended (inc. sputum smear and culture), multiple drug therapy indicated to guard against resistant organisms (rifampicin + ethambutol + isoniazid + pyrazinamide daily for 2+ months, followed by rifampicin + isoniazid for 4 months if the organism is susceptible to these drugs)
HPx, PHx, FHx, SHx Key questions: o General health? o Nature of the pain? Presence of injury? o Worse morning/night? o o How is sleep? o Rest’s effect? Activity’s effect? o Worse sitting/standing? o o Worse when coughing/sneezing/straining?
o o
o
o o
Effect of long walk? Hx of psoriasis, diarrhoea, penile discharge, eye trouble or severe joint pain? Medications, particularly anticoagulants? Extra stress at work/home? Feel tense/depressed/irritable?
Compare inflammatory and mechanical injury: Feature History
Nature
Stiffness
Inflammatory Mechanical Insidious Precipitating onset injury/previous episodes Aching, Deep dull ache, throbbing sharp if root compression Severe, Moderate, prolonged transient Morning
stiffness Effect of Exacerbates rest Effect of Relieves activity Radiation More localised Bilateral or alternating Intensity Night, early morning
Relieves Exacerbates Usually diffuse Unilateral
End of day, following activity
1. Inspection (posture, movement, symmetry, wasting, deviation, scoliosis (usually away from painful side), lordosis) 2. Active movements (to reproduce the patient’s symptoms) o Forward flexion o Extension o Lateral flexion 3. Provocative tests (to reproduce the patient’s symptoms) o Slump test (positive: suggests disc disruption) Get patient to sit and slump, chin on chest, lift affected leg, then unaffected leg, then both Positive if back or leg pain is reproduced 4. Palpation (to detect level of pain) Commence at spinous processes of L1, move to L5, over sacrum and coccyx o o Apply pressure to either side of spinous processes, with a ‘rocking movement’ three or four times, note pain Three sites at each spinal level: centrally, unilateral (right and left sides, 1.5cm from midline), transverse pressure to the sides of the spinous processes Neurological examination of lower limbs if symptoms extend below buttocks o Quick tests: walking on heels (L5), walking on toes (S1) o Specific nerve root tests (L4, L5, L6) for sensation, power, reflexes Doing knee jerk and ankle jerk reflex tests can test these quickly o Testing of related joints (hip, sacroiliac) Assessment of pelvis and lower limbs for any deformity (e.g. leg shortening) General medical examination, including rectal examination o
5.
6. 7. 8.
Screening tests: o Plain X-ray o Urine examination ESR-CRP o Serum alkaline phasphatase o o Prostatic specific antigen Specific disease Ix Procedural and preprocedural diagnostic tests (reserved for chronic undiagnosed/unabated disorders), e.g. CT, myelography, radiculography, discography, MRI
Rule out psychogenic (problems at home, school, sport) Rule out organic disease (osteomyelitis, TB, ‘discitis’) Rule out tumours (benign osteoid osteoma, malignant osteogenic sarcoma, osteoid osteoma) In older children/adolescents, more likely to be inflammatory, congenital or from developmental anomalies and trauma Prolapsed intervertebral disc (with marked spasm, stiff spine and lateral deviation) Ankylosing spondylitis (early onset)
Most common is traumatic Disc prolapsed and facet joint very common Degenerative joint disease also common, can present as spinal stenosis with claudication
and nerve root irritation Consider malignant disease, degenerative spondylolisthesis, vertebral pathological fractures and occlusive vascular disease
Syndrome A (surgical emergency) – spinal cord or cauda equine compression (saddle + distal anaesthesia, UMN or LMN lesion evidence, loss of sphincter control, weakness of legs peripherally). Rare. Syndrome B (probable surgical emergency) – large disc protrusion, paralysing nerve root (anaesthesia or paraesthesia of leg, foot drop, motor weakness, absence of reflexes). Uncommon. Syndrome C – posterolateral disc protrusion on nerve root or disc disruption (distal pain with/without paraesthesia, radicular pain (sciatica), positive dural stretch tests). Common.
Syndrome D –(unilateral, disc disruption dysfunction or unknown (non-specific) causation (lumbar pain centralororfacet bilateral), +/- buttock and posterior thigh pain). Very common. Spondylolisthesis Lumbar spondylosis Malignant disease Non-organic back pain (e.g. psychogenic)
Advice to stay active Reassurance of likelihood of cure
Relative rest Patient education Heat (first 2-4 weeks of LBP) Exercise (extension, flexion, isometric, swimming) Pharmacological agents (paracetamol, codeine, NSAIDs (any)) Injection techniques (trigger point with local anaesthetic, chymopapain, facet joint injection with corticosteroids, epidural injections) Physical therapy o Passive spinal stretching o Spinal mobilisation (within the range of movement of the joint) Spinal manipulation: a high velocity thrust at the end range of the joint – more o effective, produces faster response but requires accurate diagnosis and greater skill; adverse effects can be serious
The management of ‘mechanical’ back pain depends on the cause. Since most of the problems are mechanical and there is a tendency to natural resolution, conservative management is quite appropriate. The rule is ‘if patients with uncomplicated back pain receive no treatment, on-third will get better within 1 week and by 3 weeks almost all the rest of the other two-thirds are better’. Clinicians should have a clear-cut management plan with a firm, precise, reassuring and conservative clinical approach. The problems can be categorised into general conditions:
Acute pain = pain less than 4 weeks
Subacute pain = pain 4-12 weeks Chronic pain = pain greater than 3 months
Acute low back pain
Sciatica with or without low back pain
Common problem caused by facet joint dysfunction and/or limited disc disruption, usually responds well to treatment Typical patient 20-55 years, well, no radiation of pain below the knee Management: Back education program Encouragement of normal daily activities according to degree of comfort Regular non-opioid analgesics (e.g. paracetamol) Physical therapy: stretching of affected segment, muscle energy therapy, spinal mobilisation of manipulation (if no contraindication on first visit) Prescribe exercises Review in about 5 days (probably best time for physical therapy) No investigation needed initially Most patients can expect to be relatively pain free in 14 days and can return to work early Sciatica is a more complex and protracted problem to treat, but most cases will gradually ettle within 12 weeks Acute: Back education program Resume normal activities as soon as possible Regular non-opioid analgesics with review as the patient mobilises NSAIDs for 10-14 days, then cease and review Walking and swimming Weekly or 2-weekly follow-up
Consider a coarse of corticosteroids for severe pain, e.g. prednisolone (tapered therapy) Chronic: Reassurance that problem will subside (Assuming no severe neurological defects) Consider epidural anaesthesia (if slow response) Refer for surgical intervention if: bladder/bowel control disturbance, perineal sensory change, progressive motor disturbance, severe prolonged pain or disabling pain, failure of conservative treatment Uncomplicated chronic back pain: Back education program and ongoing support Encouragement of normal activity Exercise program Analgesics (e.g. paracetamol) NSAIDs for 14 days (if inflammation, i.e. pain at rest, relieved by activity) and review Trial of mobilisation or manipulation (at least three treatments) if no contraindications Consider trigger point injection Multidisciplinary team approach Prevention of further back pain: Education about back care, including a good layperson’s reference Golden rules to live by: how to lift, sit, bend, play sport and so on Exercise program, tailor-made program for the patient Posture and movement training
Chronic back pain
When to refer:
Myelopathy, especially acute cauda equina compression syndrome Severe radiculopathy with progressive neurologic deficit Spinal fractures Neoplasia or infection Ungdiagnosed back pain Paget’s disease Continuing pain of 3 months duration without a clearly definable cause
Diagnosis based on systematic history, examination and experience; refer if in doubt
Three basic questions: 1. Where is the rash and where did it start? 2. How long have you had the rash? 3. Is the rash itchy? Is it mild, moderate, severe? Questions to consider for yourself 1. Could this be a drug rash? 2. Has this rash been modified by treatment? 3. Do any contacts have a similar rash?
Further questions for the patient: 1. Do you have contact with a person with a similar eruption? 2. What medicine are you taking or have you taken recently? 3. Have you worn any new clothing recently? 4. Have you been exposed to anything different recently? 5. Do you have a past history of a similar rash or eczema or an allergic tendency (e.g. asthma)? 6. Is there a family history of skin problems?
Then, of course, general history as appropriate.
There are two phases to the examination. Characteristics of the individual lesion: Must determine whether the lesion involves the dermis alone or whether the epidermis is involved o Epidermis: there will be scaling, crusting, weeping, vesiculation, or combination of these Dermis: lump, papule or nodule o No lesion ever involves the epidermis without involving the dermis as well o Colour, shape, size Feel the lesion: firm or soft? Does it have a clearing centre and an active edge? Distribution of the lesions: Must decide whether they are localised or widespread o Widespread: are they distributed centrally, peripherally or both? o A specific location can help the diagnosis Are the lesions all at the same stage of eruption/evolution? An examination of the whole body is appropriate, and in every case examine the mouth, scalp, nails, hands and feel.
Skin scrapings for dermatophyte diagnosis Patch testing (to determine allergens in allergic contact dermatitis) Biopsies (punch or shave) Hair (for microscopy and root analysis)
Key facts: Fever can have an important physiological role Normal body temperature is 36-37.2 o Oral temperature is about 0.4 lower than core Axillary is 0.5 lower than core o Rectal, vaginal and ear drum temperatures reflect core termperature o o There is a normal diurnal variation of 0.5-1 Fever is >37.8
A fever due to infections have an upper limit of 40.5-41.1, but hyperthermia and hyperpyrexia have no upper limit Infection is the most important cause Symptoms associated with fever include sweats, chills, rigors and headache General causes include: o Infections, malignant disease, mechanical trauma, vascular accidents, immunogenic disorders, acute metabolic disorders (e.g. gout), and haemopoetic disorders o Drugs (allopurinol, antihistamines, barbiturates, cephalosporins, cimetidine, methyldopa, penicillins, esoniazid, quinidine, phenolphthalein, phenytoin, procainamide, salicylates, sylphonamides), mainly because of hypersensitivity. Drug fever should subside by 48 hours after discontinuation 50% of acute HIV infections present with fever and an associated infection like glandular fever, so think of it
Consider fever in three categories:
Less than 3 days duration: Often self-limiting viral infection of respiratory tract o But, be vigilant for other infections (UTI, pneumonia, other infection etc.) o o Routine urine analysis (especially females) o Majority of patients can be managed conservatively Between 4 and 14 days duration: o Less common infection should be suspected (since the viral infections should have subsided) o Checklist: Influenza, sinusitis, Epstein-Barr mononucleosis, enteroviral infection, infective endocarditis, dental infections, hepatobiliary infections, abscess, pelvic inflammatory disease, cytomegalovirus infection, lyme disease, travel-acquired infection (typhoid, dengue, hepatitis, malaria, amoebiasis), zoonosis (brucellosis, Q fever, leptospirosis, psittacosis), drug fever Intermittent fever (a peak every four days): o Malaria, CMV, EBM, other pyogenic infections o Remittent fever (temperature returns towards normal but is always elevated) Collections of pus (abscesses, wound infection, empyema, carcinoma) Undulant fever (several days of fever, several days of non-fever): o Brucellosis, lymphomas (Hodgkin’s) o Continuous Viral infections, e.g. influenza o
Quotidian fever (daily recurrence): Pseudomonas, gonococcal endocarditis (for e.g.) Fever of undetermined srcin (>3 weeks, >38.3, undiagnosed after 1 week of intensive study) Mainly unusual manifestations of common diseases o o The longer the duration, the less likely the cause is infection o Common causes: Infection (40%) Malignancy (30%) Immunogenic (20%) Factitious (1-5%)
Unknown (5-9%)
Children with fever:
Don’t treat low grade fevers With high grade, treat the cause, increase fluids, paracetamol or ibuprofen
Elderly with fever:
Any fever is significant with the elderly Viral infection a less common cause Sepsis until proven otherwise (think lungs or urinary tract)
History:
Past history Occupation Travel history Sexual history Social history (IV drug use, animal contact) Medication
Physical examination:
Needs to be done more than once, on separate occasions Skin – look for rashes, vesicles and nodules Eyes – ocular fundi
Temporal Abdomen arteries – organomegaly Rectal and pelvic examination Lymph nodes Blood vessels (esp. legs, ?thrombosis) Urine
Investigations:
Bloods (Hct, WBCs, ESR, CRP), blood chemistry and cultures Chest X-ray and sinus films Urine analysis and culture Further Ix if necessary: Stool (and sputum) microscopy and culture o o Screening (HIV, typhoid, EBM, Q fever, psittacosis, CMV, toxoplasmosis, syphilis, o o o o o o o
rheumatic fever, others) Upper GIT series CT, US for neoplasia MRI for nervous system lesions Echocardiography (for suspected IE) Aspiration, needle biopsy Laparoscopy for suspected pelvic infection Tissue biopsies as indicated
History of hypertension Method/date of srcinal diagnosis o o Known duration and levels of elevated BP o Symptoms that may indicate the effect of hypertension on the body (headache, dyspnoea, chest pain, claudication, ankle oedema and haematuria) Presence of other diseases and risk factors o History of CV disease or peripheral vascular disease, kidney disease, DM, recent weight gain Obesity, hyperlipidaemia, smoking, salt intake, ETOH, exercise levels, analgesic o intake o Asthma, psychiatric illness Family history of any of the above Medication history Alcohol intake
Cardiovascular examination o Volume and timing of radial and femoral pulses o BP in arm and leg, comparison of BP in both arms Remember fundoscopy to check for hypertensive retinopathy
Routine:
Recommended:
Plasma glucose Serum total and HDL cholesterol, fasting serum TGs Serum creatinine/eGFR Serum uric acid, K, Na+, Hct, haemoglobin Urinalysis, ECG
Echocardiogram Carotid, femoral ultrasound CRP, microalbuminuria, quantitative proteinuria
Aim is to get levels to 140/90 mmHg or less. Base treatment on assessment of all cardiovascular risk factors. Start with non-pharmacological treatment strategies:
Weight reduction Alcohol intake reduction Sodium intake reduction Icreased exercise Reduction of stress Other dietary factors (lactovegetarian diets and magnesium supplementation, high calcium and low in fat and caffeine, avoid licorice) Smoking cessation Management of sleep apnoea
Pharmacological:
Useful drug combination: o Diuretic PLUS beta-blocker OR ACE inhibitor OR AT-2 receptor antagonist Beta-blocker PLUS diuretic PLUS calcium antagonist (except verapamil and o diltiazem) o Alpha-blocker PLUS diuretic PLUS beta-blocker ACE inhibitor, AT-2 receptor antagonist and diuretic combinations should be used in patients with congestive heart failure Beta-blockers and calcium channel blocker combinations should be used in patients with coronary heart disease ACE inhibitor, AT-2 receptor antagonist and verapamil and diltiazem should be used in patients with metabolic risk (diabetes, lipids)
SOCRATES Can you describe your headaches? How often do you get them? Can you point to exactly where in the head you get them? Do you have any pain in the back of your head or neck? What time of day do you get the pain? Do you notice any other symptoms when you feel the headache? Do you feel nauseated and do you vomit? Do you experience any unusual sensations in your eyes, such as flashing lights? Do you get dizzy, weak or have any strange sensations? Does light hurt your eyes?
Do you get blurred vision? Do you notice watering or redness of one or both of your eyes? Do you get pain or tenderness on combing your hair? Are you under a lot of stress or tension? Does your nose run when you get the headache? What medications do you take? Do you get a high temperature, sweats or shivers? Have you had a cold recently? Have you ever had trouble with your sinuses? Have you had a knock on your head recently? What do you think causes the headaches?
Inspect the head, temporal arteries and eyes (ophthalmoscope) Take vitals (BP, temp etc.)
Bloods (?anaemia, ?leucocytosis with bacterial infection, ?temporal arteritis indicated by ESR) Radiography: o Chest (cerebral malignancy), skull (brain tumour, Paget’s disease with deposits in skull), cervical spine X-ray
Palpate temporal arteries, facial neck muscles, cervical spine and changes sinuses Mental state examination: mood,and anxiety-tension-depression, mental Special signs: o Palpate over C2 and C3 areas of the cervical spine, if tender it indicates spinal srcin of headache
CT scan (brain tumour, cerebrovascular accidents, subarachnoid haemorrhage) Radioisotope scan for specific tumours and haematoma o MRI if necessary Lumbar puncture: for diagnosis of meningitis or suspected SAH if CT is normal o o
Probability diagnosis:
Acute: respiratory infection Chronic: tension-type headache, combination headache, migraine, transformed migraine
Serious disorders not to be missed:
Cardiovascular issues (SAH, ICH, carotid or vertebral artery dissection, temporal arteritis, cerebral venous thrombosis) Neoplasia (cerebral tumour, pituitary tumour) Severe infections (meningitis, encephalitis, intracranial abscess) Haematoma Glaucoma Benign intracranial hypertension Often missed: o Cervical dysfunction o Exertional headache o Dental disorders o Post-traumatic headache Vision problems Post-spinal procedure o o Sinusitis Sleep apnoea o o o Ophthalmic herpes zoster Also keen in mind depression, diabetes, drugs, anaemia, thyroid disorder and
psychogenic causes Diagnostic clue for migraine vs tension headache:
FHx, onset before 20 years, prodromata, unilateral, throbbing, less than 1/week, lasts <24hrs, vomiting, aggravated by the pill and alcohol = MIGRAINE Bilateral, constant, continuous daily, relieved by alcohol = TENSION HEADACHE
Some of the common types of headache Tension headache
Migraine
Symmetrical, bilateral tightness Last hours, recur each day Associated with cervical dysfunction, stress, tension (although patients do not realise) 75% females ‘Dull ache’, or ‘tightness’ Aggravated by stress, overwork, skipping meals Relieved by alcohol Associated with perfectionist personality, anxiety/depression On examination: muscle tension, scalp tender to touch, ‘invisible pillow’ sign may be positive Management: educate about tension, stress, stress management, mild analgesics (paracetamol, aspirin) The ‘sick’ headache, has various types, affects 1 in 10, more common in females, caused by vasospasm ‘Classic migraine’ (headache, vomiting and aura), ‘Common migraine’ (no
aura) the best known Most important trigger factor is stress Can be unilateral or bilateral, last 4 to 72 hours, onset is paroxysmal, offset is spontaneous Aggrivated by tension and activity Relieved by sleep and vomiting Associated with vomiting (90%), visual or sensory aura Exogenous causes include some foods (chocolate, oranges), alcohol, drugs (vasodilators, oestrogens, nitrites etc.), glare, emotional stress, head trauma, allergens, climatic change, excessive noise and perfume Endogenous causes include tiredness, stress, exercise, hormonal changes, hunger, FHx
Cluster headache
Combination headache
Others
Management: Counselling and advice on what to do during attack and what to avoid Acute attack: aspirin or paracetamol, rest in a quiet dark room with cold packs on forehead or neck, do not watch television or move too much Medication: aspirin/paracetamol + antiemetic (metoclopramide). Other medications are used in emergency situations. There are prophylactic options also Paroxysmal clusters of unilateral headache, usually occurs nightly. Very pronounced cyclical nature 6:1 males Tip: retro-orbital headache + rhinorrhoea + lacrimation = cluster headache Occurs over one eye, always same side, radiates to frontal and temporal regions Severe pain, 1-3 times a day, like clockwork, for 15 minutes to 2-3 hours, spontaneous offset Aggravated by alcohol Relieved by drugs Assocaited with FHx, rhinorrhoea on ipsilateral nose, lacrimation, flushing of forehead Management: Consider 100% oxygen therapy (usually good response) Sumatriptan IM or ergotamine medihaler or rectally Metoclopramide IV + dihydroergotamine IV Consider greater occipital nerve block with local anaesthetic Intense drug prophylaxis is available for once a cluster starts. ‘Combined’/’mixed’ headaches are common and often diagnosed as psychogenic or typical migraine Usually unilateral on whole half of head except below the eye anteriorly Combination of varying degrees of: tension and/or depression, cervical dysfunction, vasospasm, drugs Can last for days, weeks or months, heavy deep ache at every waking moment Often related to stress and adverse working conditions, sometimes follows an accident Management: Go through the possible causes and use a stepwise ‘trial by elimination’ process Temporal arteritis (inflammation of the temporal artery) Frontal sinusitis Raised intracranial pressure Intracerebral tumours
Subarachnoid haemorrhage Meningitis Drug rebound headache Chronic paroxysmal hemicranias Post-lumbar-puncture headache Trigeminal neuralgia Hypertension headache Benign intracranial hypertension Headaches related to specific activities: sex headache, cough and ewxertional headache, gravitational headache, ‘ice-cream’ headache
SOCRATES Can you explain in detail how the injury happened? Did you land awkwardly after a leap in the air? o o Did you get a direct blow? From what direction? Did your leg twist during the injury? Did you feel a ‘pop’ or a ‘snap’? Did your knee feel wobbly or unsteady? Did the knee feel as if the bones separated momentarily? How soon after the injury did the pain develop? How soon after the injury did you notice swelling? Have you had previous injury or surgery to the knee? Were you able to walk after the injury or did you have to be carried off the ground or court? Does this involve work care compensation? If there is no history of injury Does the pain come on after walking, jogging or other activity? o o How much kneeling do you do? Scrubbing floors, cleaning carpets? o Could there be needles or pins in the carpet? o Does your knee lock or catch? Does swelling develop in the knee? o o Does it ‘grate’ when it moves? o Does the pain come on at rest and is there morning stiffness? o Do you feel pain when you walk on steps or stairs?
Significance:
Swelling: if sudden and painful, think haemoarthrosis, torn ligaments, torn synovium or fractured bones; if intermediate rate and with stiffness, think of an effusion of synovial fluid such as in meniscal tears and milder ligamentous injuries Recurrent or chronic swelling: indicates intra-articular pathology (patellofemoral pain syndrome, osteochondritis dissecans, degenerative joint disease, arthritides) Locking: torn meniscus, loose body, torn ACL, avulsed anterior tibial spine, dislocated patella Catching: loose bodies Clicking: patellofemoral maltracking or subluxation, loose intra-articular body, or normal
Lateral knee pain: osteoarthritis of lateral compartment of knee, lesions of the lateral meniscus, patellofemoral syndrome Medial knee pain: osteoarthritis of medial compartment of knee, lesions of the medial meniscus, patellofemoral syndrome
Inspection:
Walking, standing, erect and lying supine Get the patient to squat, sit on the couch with legs hanging over the side, note abnormalities of the patella, deformities, swelling, muscle wasting Check for valgus and varus deformities
Palpation:
Concentrate on patella, patella tendon, joint lines, tibial tubercle, bursae and popliteal fossa Feel of fluid, warmth, swelling, synovial thickening, crepitus, clicking, tenderness, Baker’s cyst o Fluid effusion by pressing the patella against the femur: positive if you feel it clicking against it
Movements:
Extension, flexion, rotation (of the feet)
Ligament stability tests:
Anterior and posterior drawer tests for ACL and PCL Adduction (varus) and abduction (valgus) for LCL and MCL
Also examine the lumbosacral spine and hip joint of the affected side.
Select from:
Blood tests (RA factor tests: ANA, HLA B27; ESR, culture if suspected septic arthritis) Radiology: o Plain X-ray Special views: intercondylar, tangential, oblique, weight-bearing o Bone scan (tumour, stress fracture, osteonecrosis, osteochondritis dissecans) o o MRI (good for cartilage, menisci disorders and ligament damage) o Ultrasound (soft tissue mass, fluid collection) CT (for complex fractures) Special: examination under anaesthesia, arthroscopy, knee aspiration (for culture or crystal examination)
Probability diagnosis:
Ligamentous tears and strains (of varying degrees) (ACL, PCL, MCL, LCL) +/- traumatic synovitis Osteoarthritis Patellofemoral syndrome Prepatellar bursitis
Serious disorders not to be missed:
Acute cruciate ligament tear Vascular disorders: DVT, superfiucial thrombophlebitis Neoplasia (primary, metastasis) Severe infection (Septic arthritis, tuberculosis) Rheumatoid arthritis Juvenile chronic arthritis Rheumatic fever
Often missed:
Referred pain from back or hip Foreign bodies Intraarticular loose bodies Osteochondritis dissecans Osteonecrosis Osgood-Schlatter disorder Meniscal tears
Factures around knee Pseudogout, gout Ruptured popliteal cyst Sarcoidosis Paget’s disease Spondyloarthropaty
Anxiety is an uncomfortable inner feeling of fear or imminent disaster. Defined as ‘generalised and persistent anxiety or anxious mood, which cannot be associated with, or is disproportionately large in response to a specific psychosocial stressor, stimulus or event’. Classification: Generalised anxiety disorder Panic disorder with/without agoraphobia Specific phobia Social phobia Obsessive-compulsive disorder Post-traumatic stress disorder Acute stress disorder Generalised anxiety disorder
Panic disorder
Excessive anxiety and worry about various life circumstances and is not related to a specific activity/time/event such as trauma, obsessions or phobias Check: is it hyperthyroidism? Depression? Normal anxiety? Mild, or phobia? Moderate, severe? Management: Non-pharmacological methods, explanation and reassurance Stress management techniques, meditation, avoid drugs, use ongoing psychotherapy Drugs: diazepam or oxazepam for 4 weeks, tapering dose, for short term. For long term, SSRI (venlafaxine, paroxetine etc.) or buspirone Sudden, unexpected, short-lived episodes of intense anxiety Most often in females. Recurrent. Follow DSM-IV for diagnosis
Phobic disorders
Obsessivecompulsive disorder PTSD
Management: CBT: teach patients how to identify, evaluate and control episodes Hyperventilating: breathe in and out of a paper bag Pharmacological: acute: benzodiazepine (diazepam, oxazepam, alprazolam) or SSRI (paroxetine); prophylaxis: benzodiazepine in daily divided doses Anxiety is related to specific situations or objects. Three main: simple phobias, agoraphobia, social phobias. Ten most common (in order): spiders, people and social situations, flying, open spaces, confined spaces, heights, cancer, thunderstorms, death, heart disease Management: Psychotherapy (CBT) Pharmacological: only if psychotherapy fails. Use as panic attacks for all expect social phobia with performance anxiety, where propranolol can be used. SSRI can be used for problematic social phobia Management: CBT (exposure-response therapy) and pharmacological treatment (any of the SSRIs or clomipramine) Treatment is difficult, involves counselling where abreaction of the experience is facilitated by individual or group therapy. Aim is for patients to face up openly to memories. No specific indication, but medication can be successful in treating symptoms like panic attacks, anxiety or depression associated with PTSD.
‘Dizziness’ is divided into vertigo and pseudovertigo. Pseudovertigo is further subdivided into: Giddiness or lightheadedness – a sensation of uncertainty or ill-defined o lightheadedness. Usually a psychoneurotic symptom o Fainting or syncopal episodes – sensation of impending fainting or loss of consciousness. Many causes, including cardiogenic, postural hypotension, druginduced Equilibrium disorders (see below) o Vertigo is an episodic sudden sensation of circular motion of the body or its surroundings Equilibrium disorders: Loss of balance or instability while walking, ‘like standing on a rocking boat’ without
spinning Causes include: Drugs: affecting the vestibular nerve; numerous drugs, including antibiotics, o anticonvulsants, cardiogenic, salicylates o Cervical spine dysfunction: theoretically caused by inappropriate messages from proprioceptors in damaged/repaired joints in the cervical spine Acute vestibulopathy: infection of the labyrinth or the vestibular nerve; nausea o and vomiting, no hearing loss. Treatment: lie still in bed, staring at a comfortable spot, drugs to lessen vertigo: Prochlorperazine or dimenhydrinate (Dramamine) or diazepam
o
o
o
Benign paroxysmal positional vertigo (BPPV): common, induced by changing head position, cause not entirely known Treatment: reassurance that it will pass, no drugs Menier’s syndrome: build up of endolymph; common 30-50, paroxysmal attacks of vertigo, tinnitus, nausea/vomiting, sweating and pallor, deafness. Can be abrupt, last 30min to several hours Treatment: acute attack: procholorperazine suppository and 30g urea crystals. Long term: reassurance that it is not malignant, avoid excess salt, tobacco and coffee, alleviate abnormal anxiety (fluid builds up with stress), refer for neurological treatment, diuretics (check electrolytes regularly) Vestibular migraine: vertigo can take place of the aura that precedes a migraine
Need to figure out the following questions:
Is it vertigo or pseudovertigo? Symptom pattern: Paroxysmal or continuous? o Effect of position and change of posture? o Any aural symptoms? Tinnitus? o Deafness? o Any visual symptoms? Any neurological symptoms? Any nausea or vomiting? Any symptoms of psychoneurosis? Any recent colds? Any recent head injury (even trivial)? Any drugs being taken? o Alcohol, marijuana, hypotensives, psychotropics, other drugs?
Full general examination is appropriate, pay particular attention to cardiovascular and CNS, and auditory and vestibular mechanism.
Ear disease: Wax? Drum? o Hearing tests o The eyes: Visual acuity o o
Test movements Cardiovascular system: for nystagmys Evidence of atherosclerosis o Blood pressure: supine, standing, sitting o o Cardiac arrhythmias Cranial nerves: o II, III, IV, VI, VII o Corneal response for V o VIII (auditory nerve) Cerebellum or its connections: o Gait
Coordination Reflexes o Finger-to-nose test The neck, including cervical spine General search for evidence of anaemia, polycythaemia, alcohol dependence
Haemoglobin, glucose ECG Radiology: chest x-ray, cervical spine x-ray, CT scan, MRI (for neural tumours) EEG, audiometry
o o
In children, vertigo is sinister and requires thorough investigation. In late teens, they are common, and usually due to blood pressure fluctuations (so give reassurance that it settles with age, and advise to reduce stress, get more sleep, exercise less if excessive). Also relatively common in elderly (postural hypotension due to hypertension drugs), also other possibilities as listed above. Refer if uncertain diagnosis.
Determine quickly whether oxygen and an aspirin are necessary immediately.
Meticulous history of the behaviour of the pain is the key to diagnosis.
Analysed into usual characteristics: SOCRATES
Keep in mind diabetes,toMarfan Associated symptoms query:syndrome, anaemia and SLE o Syncope (consider MI, PE, dissecting aneurysm) Pain on inspiration (consider pleurisy, pericarditis, pneumothorax and chest wall o musculoskeletal pain) o Thoracic back pain (consider spinal dysfunction, MI, angina, aortic dissection, pericarditis and gastrointestinal disorders such as peptic ulcer, cholesystitis and oesophageal spasm) Key questions: o Where exactly do you get the pain? Does it travel anywhere? o Can you give me a careful description of the pain? o o How long does the pain last and could you do anything to relieve it? o Is the pain brought on by exertion and relieved by rest? o Do cold conditions bring it on? o Do you have any other symptoms, such as breathlessness, faintness, sweating, back pain? o Is the pain made worse by breathing or coughing, or by movement or pressing on the area? Is there any blood or sputum you bring up? o Is your pain associated with what you eat and drink? Or with a bitter taste in your o mouth? o Do you get the pain on stooping over and after lying in bed at night? o Do antacids relieve your pain? o Have you noticed a rash where you get the pain? Have you had a blow to your chest or an injury to your back? o
Cardiovascular examination:
General appearance: evidence of atheroscleross (thickened vessels), pale, sweaty, hemiparesis (?aortic dissection) Pulses (radial and femoral) – check for nature and presence/absence Blood pressure Temperature Palpation of chest wall, lower cervical spine and thoracic spine (look for evidence of localised tenderness, pathological fracture, spinal dysfunction, herpes zoster) Palpation of legs (evidence of DVT) Examination of chest: check for evidence of pneumothorax Auscultation of chest: Reduced breath sounds, hyperresonant percussion note and vocal fremitus o pneumothorax o Friction rub pericarditis or pleurisy o Basal crackles cardiac failure o Apical systolic murmur mitral valve prolapse Aortic diastolic murmur proximal dissection (aortic regurgitation) o
ECG Exercise stress test Chest x-ray Blood glucose Haemoglobin and blood film (for anaemia)
Serum enzymes (troponins, creatine kinase, myoglobin) Echocardiography (for abnormalities in heart wall motion) Angiography TOE Spinal x-ray Ambulatory Holter monitor, isotope scanning, oesophageal studies also
Treatment is long and complicated – send to hospital!
Similar to knee above. History of injury, then examination, investigations.
Facts about dyslipidaemia:
Major risk factors coronary arterial disease include: Elevated LDL and low HDL cholesterol o o Ratio of LDL/HDL >4 Risk increases with increasing total cholesterol levels (90% if >7.8 mmol/L) TV levels >10mmol/L increases risk of pancreatitis Management should be correlated with risk factors 10% reduction in total cholesterol gives 20% reduction in CAD after 3 years
Serum triglyceride Serum cholesterol and HDL and LDL
Appropriate treatment goals:
Total cholesterol <4.0 (especially if high risk) LDL <2.5mmol/L HDL >1.0mm/L Triglycerides <1.5mmol/L
Treat all risk factors. Non-pharmcological measures:
Dietary: Keep to ideal weight o o Reduce fat intake, especially dairy products and meat o Avoid ‘fast foods’ and deep-fried food Replace saturated fats with mono- or polyunsaturated fats o Always trim fat off meat, remove skin from chicken o o Avoid biscuits and cakes between meals o Eat fish at least twice a week o Ensure a high-fibre diet, especially fruit and vegetables Keep alcohol intake to 0-2 standard drinks/day o o Drink more water
approved cooking methods, e.g. steaming, grilling RegularUse exercise Cessation of smoking Cooperation of family is essential Exclude secondary causes (e.g. hypothyroidism, obesity, alcohol excess, specific diuretics)
o
Pharmacological measures:
Hypercholesterolaemia: choose one of the following: o Statins (first line) – simvastatin/pravastatin/atorvastatin (monitor LFTs) o Bile-binding resins – cholestyramine o Other – nicotinic acid, procubol, fish oils, ezetimibe Resistant LDL elevation: o Combine statin and cholestyramine Isolated TG elevation : o Fibrate – gemfibrozil/fenofibrate (reduce alcohol intake)
Acute bronchitis
Acute inflammation of the tracheobronchial tree, usually follows URTI Generally mild and self-limiting, may be serious in debilitated patients Cough and sputum (main symptoms), wheeze and dyspnoea, usually viral, scattered wheeze on auscultation, fever or haemoptysis (uncommon) Can complicate chronic bronchitis Usually improves spontaneously in 4-8 days in healthy patients
Rx: symptomatic; inhaled bronchodilators for airflow limitation, antibiotics usually not needed If evidence of acute bacterial infection with fever, increased sputum volume/purulence: o Amoxicillin 500mg (8 hourly for 5 days) or o Doxycycline 200mg statim, then 100mg daily for 5 days
Classical features of asthma:
Wheezing
Coughing (especially at night) Tightness in the chest Breathlessness
Asthma should be suspected in children with recurrent nocturnal cough and in people with intermittent dyspnoea or chest tightness, especially after exercise.
Physical signs may be present if the patient has symptoms at the time of examination. The absence of physical signs does not exclude a diagnosis of asthma.
Measurement of peak expiratory flow rate (PEFR): demonstrates variation in values over a period of time Spirometry: a value of <75% for FEV1/FVC ratio indicates obstruction. It is the more accurate test Measurement of PEFR or spirometry before and after a bronchodilator (short acting betaagonist): positive if there is a characteristic improvement in FEV 1 and PEF Exercise challenge may also be helpful Chest x-ray not routine but useful if there are complications suspected or if symptoms are not explained by asthma
Pharmacological management:
‘Preventer’ drugs or anti-inflammatory agents o Corticosteroids: beclomethasone, budesonide, ciclesonide, inhaled), prednisolone (oral) o Sodium cromoglycate o Nedocromil sodium o Leukotriene antagonists (new): montelukast, zafirlucast ‘Reliever’ drugs or bronchodilators 2 receptor antagonists (inhaled) o SABAs – salbutamol, terbutaline LABAs – eformoterol, salmeterol Methylxanthines (theophylline derivatives) o o Anticholinergics
Maintenance plan example:
Inhaled SABA – prn
fluticasone
(all
Inhaled steroid (dose according to severity) If more severe, add stepwise: o Longer acting steroid bd (if using shorter acting steroid, it should be stopped) o LABA separate or combined with steroid o Theophylline (o) controlled release Inhaled ipratropium o Leukotriene agonist o o Oral prednisolone prn For attack: high dose inhaled bronchodilators (spacer preferred) <25kg up to 6 puffs o o 25-35kg 8 puffs o >35kg 10 puffs
Risk factors for urinary infection:
Female sex Sexual intercourse Diabetes mellitus Diaphragm contraception Pregnancy Immunosuppression Menopause Urinary tract obstruction/malformation Instrumentation
History should include questions about the above, and a thorough sexual history.
Generally look for: o Fever, chills, sweating, rigors, headache, nausea, vomiting, diarrhoea (indicate kidney infection) Check temperature, pulse, respiration, blood pressure Examine abdomen for possible upper UTI (loan pain, abdominal pain) Examine pelvis Vaginal examination, rectal examination
Urine collection Midstream specimen of urine (MSU) o o Catheter specimen of urine (CSU) for particularly obese women, the infirm and the elderly (where getting an uncontaminated MSU is difficult) Suprapubic aspirate of urine (SAU) very reliable, should be done under anaesthetic Dipstick Finding urinary WBCs and/or nitrites are suggestive of UTI o Microscopic examination Culture o
Wait for results before treatment.
About half of the population report a sleep-related problem in 12 months. Normal ideal sleep in a fit young person is 7.5-8 hours with latency less than 30 mins. Classification of sleep disorders (modified DSM-IV)
Dyssomnias o Primary insomnia o Other disorders initiating or maintaining sleep Periodic limb movements (nocturnal myoclonus) Restless legs syndrome o Excessive somnolence
Primary hypersomnia Narcolepsy Breathing-related sleep disorders Obstructive sleep apnoea Central sleep apnoea Central alveolar hypoventilation syndrome o Circadian rhythm sleep disorder Jet lag type Shift work type Delayed sleep phase type Parasomnias Nightmare (dream anxiety) disorder o o Sleep terror disorder o Sleepwalking disorder Secondary sleep disorder o Medical condition disorder o Mental disorder o Substance abuse o
Primary insomnia:
Exclude and treat other causes: drugs, anxiety/stress, depression, restless legs syndrome, sleep apnoea, nightmares, physical disorders, bet-wetting, reflux disease Give explanation and reassurance if cause is known Try to recognise what helps the patient to settle best (e.g. warm bath, listening to music) Establish a routine before retiring Avoid alcohol and caffeine at night Warm drink of milk before bed Comfortable setting the right temperature Sex as the lastquiet thingsleep before bed iswith helpful where appropriate Remove pets from the bedroom Try relaxation therapy, meditation, stress management, consider hypnosis If all other measures fail, try zopiclone (imovane), zolpiderm tartrate (Stilnox) or temazepam Consider referral
Periodic limb movements:
Aka nocturnal myoclonus, ‘leg jerks’, tend to occur in the anterior tibialus muscles of the leg
Mostly asymptomatic (diagnosis is often made during sleep studies) If troublesome, refer to sleep specialist Medication if symptomatic: levodopa + carbidopa, or clonazepam, or sodium valproate
Restless legs syndrome:
Exclude diabetes, uraemia, hypothyroidism, anaemia, various drugs Mainly a functional disorder affecting the elderly Eliminate caffeine, follow a healthy diet Gentle stretching of legs, particularly hamstrings and calf muscles, for at least 5 minutes before bed Medication: 1st paracetamol, 2nd diazepam +/- paracetamol, 3rd codeine or levodopa or
baclofen or propranolol Narcolepsy:
Condition where periods of irresistible sleep occur in inappropriate circumstances and consists of a tetrad of symptoms: o Sudden brief sleep attacks (15-20 minutes) Cataplexy (sudden loss of muscle tone in the lower limbs), may slump to floor o Sleep paralysis o o Hypnagogic (terrifying) hallucinations on falling asleep Treat with methylphenidate (Ritalin) or amphetamines (dexamphetamine) and tricyclic antidepressants (small doses) for cataplexy
Sleep apnoea:
Cyclical brief interruptions of ventilation resulting hypoxaemia and related biochemical effects and terminating in sleep arousal, which is often not recognised by the patient o Main type is obstructive sleep apnoea, which involves an intermittent narrowing or occlusion of the pharyngeal area of the upper airway Effects include snoring and hypopnoea, sometimes apnoea o Predisposing causes include: o Diminished airway size (e.g. obesity, tonsillar-adenoidal hypertrophy) Upper airway muscle hypotonia (e.g. alcohol, neurological disorders) Nasal obstruction Clinical effects include daytime somnolence and neuropsychiatric disturbances o (e.g. depression, personality change) Refer to a sleep disorder centre is advisable. General principles: Lifestyle modification (weight loss, no smoking) o Continuous positive airway pressure (CPAP) delivered by nasal/facial mask o o Corrective surgery (e.g. tonsillectomy, nasal obstruction) o o
Oral appliance the mandibular advancement splint) Medication (e.g.(e.g. amitriptyline)
Parasomnias:
Dysfunctional episodes associated with sleep, sleep stages or partial arousal, more common children Nightmares (dream anxiety): occur later in the sleep period, accompanied by unconscious body movements. Associated with traumatic stress disorders, drugs or drug withdrawal o o Psychological evaluation with CBT is appropriate
Medications that may help include phenytoin, clonazepam or diazepam (6 week trial) Sleep terrors: a feature of these are sharp screams, violent thrashing movements and autonomic overactivity o The sufferers may or may not be awake and usually cannot recall the event o They require psychological evaluation and therapy o Similar medications for nightmares can be used Sleep walking (somnoambulism): the person performs some repetitive motor activity in bed or walks around freely o No treatment is usually required but the sleeping environment should be rendered safe if it is repetitive and problematic Benzodiazepines can be used o o
The maxillary sinus is the one most commonly infected. It is important to determine whether the sinusitis is caused by stasis following a URTI or acute rhinitis, or due to dental root infection. An examination of the respiratory system and the oral cavity is appropriate (plus vitals).
Clinical features of acute sinusitis: o Facial pain and tenderness over sinuses Toothache o Headache o o Purulent postnasal drip o Nasal discharge o
Nasal obstruction Rhinorrhoea Cough (worse at night) o o Prolonged fever o Epistaxis o Suspect a bacterial fause if high fever and purulent nasal discharge Clinical features of chronic sinusitis: o Vague facial pain Offensive postnasal drip o Nasal obstruction o o Toothache o Malaise o Halitosis o
Palpate the non-sinus area and then the sinus area, then the non-sinus area again to determine where the pain is coming from. Also illuminate the oral cavity in a dark room to see if one side of a sinus is diminished in illumination – this indicates unilateral sinusitis.
Acute bacterial sinusitis:
Exclude dental root infection Control predisposing factors Use appropriate antibiotic therapy Establish drainage by stimulation of mucociliary flow and relief of obstruction Antibiotic therapy for severe cases
Surgical drainage may be necessary Inhalation of vapor (friar’s balsam, Vicks Vaporub or menthol)
Chronic sinusitis:
May arise from chronic infection or allergy, nasal polyps, vasomotor rhinitis, also structural abnormality of the upper airways Treat as for acute attack, with longer period of antibiotic therapy
Vague category; assuming this refers to viral rhinitis, see ‘Cough’.
Otitis media in children:
Two peaks of incidence: 6-12mths of age, and school entry Seasonal incidence coincides with URTIs Two most common organisms are viruses: adenovirus and enterovirus, and the bacteria S. pneumonia, H. influenzae and Moraxella catarrhalis Fever, irritability, otalgia and otorrhoea may be present The main symptoms in older children are increasing earache and hearing loss Pulling at the ears is a common sign in infants Viral cause indicated by reddening and dullness of tympanic membrane (without mucopus) associated with URTI Antibiotics obviously not warranted for viral causes, most improve within 48 hours Bacterial is suggested acute onset of erythema ear pain/tugging, hearing loss, irritability and fever.OM Suppurative OMbyhas progressive and bulging of OM with loss of landmarks. Treat with antibiotics Treatment: o Rest patient in warm room with adequate humidity Paracetamol suspension for pain (high dosage) o Decongestants only if nasal congestion o o Bacterial: amoxicillin, with clavulanic acid if resistance suspected o Refer if no improvement in 72 hours, re-evaluate at 10 days
Otitis media in adults:
Analgesics to relieve pain Adequate rest in a warm room Nasal decongestants for nasal congestion
Antibiotics for evidence of bacterial infection Treat associated conditions (e.g. adenoid hypertrophy) Follow-up: review and test hearing audiometrically Antibiotics: amoxicillin, or doxycycline for milder, or amoxicillin + clavulanic acid if resistance suspected
Huge array of possible fractures. Remember our joint examinations for fractures. Good history and thorough examination essential. Consider x-ray of affected area, at different angles. Give analgesia and sedation where appropriate. Classic signs of fracture are: pain, tenderness, loss of function, deformity, swelling/bruising, crepitus.
Once nature of fracture is determined, consider what type of treatment: plaster, fibreglass, padding, surgical referral etc.
Four types of infectious conjunctivitis: bacterial, viral, primary herpes simplex infection, and chlamydial conjunctivitis. Bacterial conjunctivitis:
Gritty red eye Purulent, lids stuck in morning
Starts in one eye, spreads to the other Usually bilateral purulent discharge Negative fluorescein staining Swab for smear and culture for: Hyperacute or severe purulent conjunctivitis o Prolonged infection o o Neonates Management (mild): o Limit spread by avoiding close contact with others, use of separate towels etc. o May resolve with saline irrigation of the eyelids and conjunctiva o Antiseptic eye drop (propamidine isethionate) Management (severe): o Chloramphenicol eye drops and eye ointment o Pseudomonas and other coliforms: use topical gentamicin and tobramycin
o o
Neisseria gonorrhoeae: use appropriate systemic antibiotics Chlamydia trachomatis: oral azithromycin
Viral conjunctivitis:
Very contagious (examine with gloves) Usually adenovirus Tends to occur in epidemics (pink eye), 2-3 week course Starts in one eye, spreads to other Scant watery discharge May have tiny pale lymphoid follicles Preauricular lymphadenopathy Can perform viral culture and serology to predict epidemics Treatment: Limit cross infection with hygiene and patient education o o o o o
Symptomatic treatment only (cool compress, topical lubricants) Do not pad Watch for secondary bacterial infection Avoid corticosteroids (prolong the infection)
Primary herpes simplex infection:
A follicular conjunctivitis 50% have lid or corneal ulcers (diagnostic) Dendritic ulceration with fluorescein in some Treatment: Attend to eye hygiene o
o o o
Acyclovir ointment Atropine drops (to prevent reflex spasm of the pupil) Debridement by a consultant
Chlamydial conjunctivits:
Three common situations: o Neonatal infection (first 1-2 weeks) o Young patient with associated venereal disease Isolated Absrcinal people with trachoma o Acute infection resembles acute bacterial conjunctivitis. Take swabs for culture and PCR testing Systemic antibiotic treatment: o Neonates: erythromycin 3 weeks Adults and children: azithromycin as single dose (partner must be treated in cases o of STI)
Check the ear with an otoscope, disimpact with a syringe with saline/water until it comes out. May take a long time.
History, examination and investigations are for ‘Knee complaint’. Treatment of tendonitis/bursitis of a small area:
Generally (apart from patella tendonitis), the treatment is an injection of local anaesthetic and long-acting corticosteroids into and deep to the localised area of tenderness In addition it is important to restrict the offending activity with relative rest and refer for physiotherapy for stretching exercises Attention to biomechanical factors and footwear is important If conservative methods fail for iliotibial tract tendonitis, surgical excision of the affected fibres may cure the problem
Classic symptom = dyspnoea on exertion Progression of dyspnoea Exertional D D at rest Orthopnoea paroxysmal nocturnal dypnoea Other symptoms - Dypnoea - Irritating cough - Lethary/fatigue - Weight change: gain or loss - Dizzy spells/syncope - Palpitations - Ankle oedema
Left heart failure - Tachycardia - Low volume pulse - Tachypnoea - Laterally displaced apex - Bilateral basal crackes - Heart rhythm - Pleural effusion - Poor peripheral perfusion
Right heart failure - Elevated JVP - Right ventricular heave - Peripheral/ankle oedema - Hepatomegaly - Ascites Look for peripheral oedema oedema’
FBE and ESR - Anaemia can occur with CHF - Serum electrolytes for monitoring - Kidney function tests to monitor drug therapy - LFTs congestive hepatomegaly gives unusual LFTs - Urinalysis - Thyroid function tests (esp if in AF) Viral studies for suspectedviral myocarditis Specialist examinations - Coronary angiography for suspected and known ischaemia - Haemodynamic testing - Endomyocaridal biopsy
1. Determination and treatment of cause 2. Removal of precipitating factors
‘pitting
3. Appropriate patient education 4. Non pharmaceutical measures 5. Drug Tx
-
Dietary advice (weight nutrition) Emphasise dangers of smoking Control HT Control other RF (hypercholesterolaemia) Early detection of diabetes
-
Early intervention of MI (thrombolytic therapy shunting) Secondary prevention after occurrence of MI (BB, ACEi and aspirin) Appropriate timing of surgery or angioplasty
Precipitating factors to be Tx - Arrhythmias - Electrolyte imbalance (hypokalaemia) - Anaemia - Myocardial ischaemia esp MI - Diactary factors - Adverse drug reactions -
Infection Thyrotoxicosis Fluid overload
Non pharm - Educate and support - Smoking - Refer to rehab program - Encourage exercise - Rest if s/s severe - Weght loss -
Salt restriction – no added salt diet (<2g/day)water restriction 1.5L day or less Limit caffeine 1-2 coffees per day Limit alcohol 1 drink day Dayly weighing to see for fluctuations Optimise CV RF – BP, lipids, HbAIc Vaccination – fluvax, pneumococcus Echocardiography every two years
Drug therapy 1. ACE I start low aim high
2. Add a diuretic if congestion 3. BB Add digoxin if indicated
Excessive drinking - > 4 std drinks per day for men - > 2 std drinks per day for women Problems associated with drinking - Depression, sexual dysfunction HT, heart disease, liver disease, acute gastritis, gastric ulcers - Gout obesity
-
When did you last drink? Do you like alcohol? What type of alcohol do you drink? Do you drink in the morning? Do you feel off colour in the morning?
Questionnaires CAGE – two or more positives are suggestive of a problem C- cut down A – annoyed by critism of your drinking G – guilty about your drinking E – eye openor
-
Raised GGT HDLs elevated LDLs elevated
Standard drink = 10g of alcohol middy of beer, two middies of light, 120mL of wine
Early intervention and brief counseling See if they are interested to change their behaviour
Stages of change: pre-contemplation (unconcerned, but may be effected by motivational interviewing) contemplation action maintenance exit or relapse
Alcohol-sensitising drugs – reserved for motivated patients who have someone at home to supervise, make an unpleasant reaction when taken with alcohol (e.g. calcium carbimide) vomiting, nauseas, flushing, dyspnoea Anti craving drugs – e.g. naltrexone reduces cravings
Management plan
This six-step plan works best if intervened early on. Based on giving feedback early on about their level of alcohol consumption, presenting objective evidence about harmful effects and setting realistic goals for reducing alcohol intake. 1. Feedback – based on assessment and the degree of risk associated with their daily alcohol intake emphasise damage has already occurred 2. Listen carefully to their reaction – they may need to vent and may be defensive 3. Outline the benefits of reducing intake – money, less family hassles, less depressed, weight loss, better shape, lessen risks of HT, liver disease, brain disease, cancer, accidents 4. Set goals for consumption which you both agree are feasible (these are the upper limits) - Men – no more than 3-4 drinks, 3-4 times per week - Women – no more than 2-3 drinks, 2-3 times per week 5. -
Set strategies to keep below the limits Quench thirst with non alcoholic drinks Have first drink after starting to eat Switch to light beer Take care which parties you attend Think of a good explanation for cutting down Have a workout when bored or stressed Explore new interests
6. Evaluate – monitor drinking with diary, check that FBE are returning to normal, make follow up appointment
Obstructive lung disease
Restrictive lung disease
