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Common general practice consultations – Notes for

OSCEs

Check up – general, cardiac and female genital


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
 advise to quit

s/s of cc or other disorders…


– 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

Test results
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

Immunisation/vaccination (all ages)


See immunisation schedule

Throat complaint
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

DDx
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

Upper respiratory infection


Most common cause of a cough

History
– 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?

Physical examination
– General inspection
– Lymphadenopathy
– Lungs and CV system
– Inspect sputum

Investigations
– 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

Depression
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. Fatigue or loss of energy
7. Feelings of worthlessness or excessive guilt
8. Impaired thinking or concentration; indecisiveness
9. 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
Management – things to consider
– Is there a suicide risk
– Do they need inpatient assessment
– Is referral to a specialist psychiatrist indicated

Treatment
– 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

Abdominal pain
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

DDx
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

History
– 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?

Examination
– 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

Investigations
– 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)

Elderly considerations
– Vascular problems
– Ruptured ulcer
– Biliary disorders
– Volvulus
– Carcinoma

Diarrhoea
Acute DDx
– Gastroenteritis – bacterial or viral
– Dietary indescretions
– AB reactions

Chronic DDx
– IBS
– Drug reaction
– Coeliac disease
– Chronic infections

History
• 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?

Weakness/tiredness
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

DDx
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

History
– 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

Investigations
– 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

Shoulder complaint
Common problems include instability, stiffness, impingement, RC tear, AC joint pain
and arthritis

History
– 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?

Examination
– 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

Foot/toe complaint
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

Diabetes
Signs and symptoms of diabetes
– Polyuria
– Polydipsia
– Weight loss
– Tired and fatigued
– Characteristic breath
– Propensity for infections

Maintain within the following


• 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)
○ <20mg/L (spot collection)
• Cigarette consumption zero
• Alcohol intake (per day)
○ < 2 standard drinks per day
• Physical Activity
○ At least 30 minutes a day walking (or equivalent) 5 or more days per
week

Management plans
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 = Nutrition (a healthy diet)


E = Exercise (30 minutes per day five times per week)
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

Prevention
– Fluvax and pneumovax

Examination
• General inspection
○ Weight
○ Hydration
○ Endocrine facies
○ Pigmentation
○ Legs
• Inspection:
○ Inspection of the skin for hair loss, infection, atrophy, ulceration,
injection sites, pigmented scars, or cracking
○ Muscle wasting
• Palpation:
○ Temperature of the feet and hands for vessel pathology
○ Peripheral pulses (femoral, Popliteal, posterior tibial, Dorsalis pedis)
• Arms
• Inspection:
○ Injection sites
○ Skin lesions
• Palpation:
○ Pulse
• Eyes
○ Fundi for cataracts or retinal disease
• Mouth
○ Any signs of infection
• Neck
○ Carotid arteries palpated and auscultated
• Chest
○ Signs of infection
• Other
○ 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

Osteoarthritis
Most common type or arthritis, degenerative disease of cartilage may be primary or
secondary to trauma, mechanical problems or inflammatory disorders

Defining features
– 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

Clinical features
– Pain – worse at end of day, aggravated by use, relief by rest, worse in cold
and damp
– Variable morning stiffness, and variable disability

Signs
– Hard and bony swelling
– Crepitus
– Signs of inflammation
– Restricted mmts
– Joint deformity

Diagnosis
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

Management
– 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

Treatment
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 cause OA  suggest nutritious balanced diet
6. Correction of 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

Oesophageal disease
Features
– Heartburn
– Acid regurgitation
– Water brash
– Dx usually on Hx
– Ix usually not needed

Management
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

Contact dermatitis
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
Sprain/strain
History
– Mechanism of injury
– SOCRATES
– What have they taken?
– Done this before?
– Affecting their life?
– Done at work? Occupation?

Ankle – forced eversion causes most strains

Clinical features
– Ankle gives way
– Difficulty weight bearing
– Discomfort mild to severe
– Bruising, may take 12-24h may have functional instability

Examination
– 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

Indications for XR
– Inability to weight bear immediately after
– Marked swelling and 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

Solar keratosis/sunburn
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
Management
– Reduce exposure to sun
– May go spontaneously
– Liquid nitrogen if superficial or imiquimod
– Surgical excision
– Biopsy if doubtful

Oral contraception
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.

Adolescents
Can start once menstruation has commenced
– Monophasic low dosed combined preparation is best

Women over 35
Low dose monophasic COC (combined oral contraception)

Acne
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

Contraindications for OCP – absolute


– Pregnancy
– First 2 weeks post partum
– Hx of thromboembolic disease
– Cerebrovascular disease
– Focal migraine
– CAD
– Recent impaired liver function

Contraindications for OCP – relative


– Heavy smoker
– Undiagnosed abnormal bleeding
– Breast feeding
– Four weeks prior to surgery or 2 weeks after
– Hypertension
– Diabetes
– Severe depression

Non contraceptive advantages of OCP


– Reduce menstrual cycle disorders
– Reduction in incidence of PID
– Reduction in ovarian and endometrial cc
– Reduced thyroid disorders
Side effects
– 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

Important advice
– 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

Missed pills
– 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

Gastroenteritis
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.

Management of acute diarrhoea


– 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

Cough
Facts
• Usually minor and self-limiting, but serious causes shouldn’t be overlooked
• Cough can be:
○ Chronic bronchitis
○ Asthma
○ Psychogenic basis
○ URTI
○ Postnasal drip (most common), mainly from chronic sinusitis, tracking
down the larynx and trachea during sleep
○ Others
• Haemoptysis (coughing blood)
○ URTI (24%)
○ Acute/chronic bronchitis (17%)
○ Bronchiectasis (13%)
○ TB (10%)
○ Unknown (22%)
○ Carcinoma (4%)
• Drugs can be a cause (cytotoxic drugs, ACE-inhibitors, beta-blockers, inhaled
steroids)

Hx
• Respiratory systems review if appropriate

• Key questions about the cough:
○ Describe the cough
○ 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
○ 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

Examination
• Lung exam
○ Fine crackles: pulmonary oedema of heart failure, interstitial pulmonary
fibrosis, early lobar pneumonia
○ Coarse crackles: resolving pneumonia, bronchiectasis, TB
• Cardiovascular exam
• Inspect sputum
○ Clear white: normal, uninfected
○ Yellow/green (purulent): cellular material, +/- infection, asthma
(eosinophils), bronchiectasis
○ Rusty: lobar pneumonia (blood)
○ Thick and sticky: asthma
○ Profuse, watery: alveolar cell carcinoma
○ Thin, clear mucoid: viral infection
○ Redcurrant jelly: bronchial carcinoma
○ Profuse and offensive: bronchiectasis, lung abscess
○ Pink frothy sputum: pulmonary oedema

Investigations (particularly if haemoptysis)


• Blood tests (general)
• Sputum cytology and culture
• ESR (elevated with bact. infection, bronchiectasis, TB, lung abscess and
bronchial carcinoma)
• Respiratory function tests
• Radiology
○ Plain chest X-ray
○ Tomography (more precise, can show cavitation)
○ Bronchiography (shows bronchiectasis, very unpleasant)
○ CT scanning
○ V/Q isotope scan (for pulmonary infarction)
• Skin tests
• Lung biopsy
• Bronchoscopy

It is important to remember that all that is needed initially for investigating a


chronic cough is a plain chest X-ray.

DDx
Probability diagnosis (most common):
• URTI
• Postnasal drip
• Smoking
• Acute bronchitis
• Chronic bronchitis

Dry vs productive: ○ Interstitial lung disorders


• Dry cough (pneumoconiosis,
○ URTI, LRTI (viral, sarcoidosis)
mycoplasma) ○ TB
○ Inhaled irritants (smoke, ○ LV failure
dust, fumes) ○ GORD, hiatus hernia
○ Inhaled foreign body (early
response)
○ Bronchial neoplasm
○ Pleurisy
○ Postnasal drip ○ Foreign body (later
• Productive cough response)
○ Chronic bronchitis ○ Bronchial carcinoma
○ Bronchiectasis ○ Lung abscess
○ Pneumonia ○ TB (when cavitating)
○ Asthma

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

Consideration for children



• Early months of life:
○ Milk inhalation/reflux
○ Asthma
• Toddler/preschool child
○ Asthma
○ Bronchitis
○ Whooping cough
○ Cystic fibrosis
○ Croup
○ Foreign body inhalation
○ TB
○ Bronchiectasis
• Early school years
○ Asthma
○ Bronchiits
○ Mycoplasma pneumonia
• Adolescence
○ Asthma
○ Psycholenic
○ Smoking

Common respiratory infections

Acute Highly infections URTI, mistakenly referred to as ‘the flu’


coryza Mild systemic upset, prominent nasal symptoms
• Headache, malaise, (fever), tender eyes, runny nose, sneezing,
(common sore throat, cough, (myalgia)
cold)
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)
Influenza 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 Acute inflammation of the tracheobronchial tree, usually follows URTI
bronchitis 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:
○ Amoxicillin 500mg (8 hourly for 5 days) or
○ Doxycycline 200mg statim, then 100mg daily for 5 days

Pneumonia 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, non-
productive cough, no consolidation, chest X-ray (diffuse
infiltration) incompatible with chest signs
• Causes include
○ Mycoplasma pneumonia (most common) (adolescents
and young adults), treat with roxithromycin or
doxycycline
○ 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)
○ Chlamydia pneumoniae (similar to mycoplasma),
Chlamydia psittaci (psittacosis)
○ Coxiella burnetti (Q fever)

Chronic Cough not associated with a viral respiratory infection that lasts
persistent more than 2 weeks: persistent
cough Cough lasting 2 months or more: chronic cough
Divided into productive/non-productive (see table)
Can be a feature of GORD
Bronchial Features: 50-70yrs, only 10-25% have symptoms at time of
carcinoma diagnosis, if symptoms, then usually advanced and not resectable
Small cell lung carcinoma (poorer prognosis), 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.
Bronchiect Dilation of the bronchi when their walls become inflamed, thickened
asis 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
Tuberculosi Pulmonary TB may be symptomless and detected by mass X-ray
s 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)

Back complaint
Hx
• HPx, PHx, FHx, SHx
• Key questions:

○ General health?
○ Nature of the pain?
○ Presence of injury?
○ Worse morning/night?
○ How is sleep?
○ Rest’s effect?
○ Activity’s effect?
○ Worse sitting/standing?
○ Worse when coughing/sneezing/straining?
○ 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 Inflammat Mechanical


ory

History Insidious Precipitating


onset injury/previou
s episodes

Nature Aching, Deep dull


throbbing ache, sharp if
root
compression

Stiffnes Severe, Moderate,


s prolonged transient

Morning
stiffness

Effect Exacerbates Relieves


of rest

Effect Relieves Exacerbates


of
activity

Radiati More Usually


on localised diffuse

Bilateral or Unilateral
alternating

Intensit Night, early End of day,


y morning following
activity

Examination
1. Inspection (posture, movement, symmetry, wasting, deviation, scoliosis
(usually away from painful side), lordosis)
2. Active movements (to reproduce the patient’s symptoms)
○ Forward flexion
○ Extension
○ Lateral flexion
3. Provocative tests (to reproduce the patient’s symptoms)
○ 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
○ 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
5. Neurological examination of lower limbs if symptoms extend below buttocks
○ Quick tests: walking on heels (L5), walking on toes (S1)
○ Specific nerve root tests (L4, L5, L6) for sensation, power, reflexes
○ Doing knee jerk and ankle jerk reflex tests can test these quickly
6. Testing of related joints (hip, sacroiliac)
7. Assessment of pelvis and lower limbs for any deformity (e.g. leg shortening)
8. General medical examination, including rectal examination

Investigations
• Screening tests:
○ Plain X-ray
○ Urine examination
○ ESR-CRP
○ Serum alkaline phasphatase
○ Prostatic specific antigen
• Specific disease Ix
• Procedural and preprocedural diagnostic tests (reserved for chronic
undiagnosed/unabated disorders), e.g. CT, myelography, radiculography,
discography, MRI
Child considerations
• 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)

Elderly considerations
• 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

Possible diagnoses:
• 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 – disc disruption or facet dysfunction or unknown (non-specific)
causation (lumbar pain (unilateral, central or bilateral), +/- buttock and
posterior thigh pain). Very common.
• Spondylolisthesis
• Lumbar spondylosis
• Malignant disease
• Non-organic back pain (e.g. psychogenic)

Treatment
• 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
○ Passive spinal stretching
○ Spinal mobilisation (within the range of movement of the joint)
○ Spinal manipulation: a high velocity thrust at the end range of the joint
– more effective, produces faster response but requires accurate
diagnosis and greater skill; adverse effects can be serious

Management guidelines for lumbosacral disorders


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 Common problem caused by facet joint dysfunction and/or limited disc
low back disruption, usually responds well to treatment
pain
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 Sciatica is a more complex and protracted problem to treat, but most
with or cases will gradually ettle within 12 weeks
without
low back Acute:
pain • 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

Chronic Uncomplicated chronic back pain:


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

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

Rash/skin complaint
• Diagnosis based on systematic history, examination and experience; refer if in
doubt

History of presenting complaint


• 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.

Examination
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
○ Epidermis: there will be scaling, crusting, weeping, vesiculation, or
combination of these
○ Dermis: lump, papule or nodule
○ No lesion ever involves the epidermis without involving the dermis as
well
• 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
○ Widespread: are they distributed centrally, peripherally or both?
○ 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.

Diagnostic tests
• Skin scrapings for dermatophyte diagnosis
• Patch testing (to determine allergens in allergic contact dermatitis)
• Biopsies (punch or shave)
• Hair (for microscopy and root analysis)

Fever
Key facts:
• Fever can have an important physiological role
• Normal body temperature is 36-37.2
○ Oral temperature is about 0.4 lower than core
○ Axillary is 0.5 lower than core
○ Rectal, vaginal and ear drum temperatures reflect core termperature
○ 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:
○ Infections, malignant disease, mechanical trauma, vascular accidents,
immunogenic disorders, acute metabolic disorders (e.g. gout), and
haemopoetic disorders
○ 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

Clinical approach
Consider fever in three categories:

• Less than 3 days duration:


○ Often self-limiting viral infection of respiratory tract
○ But, be vigilant for other infections (UTI, pneumonia, other infection
etc.)
○ Routine urine analysis (especially females)
○ Majority of patients can be managed conservatively
• Between 4 and 14 days duration:
○ Less common infection should be suspected (since the viral infections
should have subsided)
○ 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):
 Malaria, CMV, EBM, other pyogenic infections
○ 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):
 Brucellosis, lymphomas (Hodgkin’s)
○ Continuous
 Viral infections, e.g. influenza
○ Quotidian fever (daily recurrence):
 Pseudomonas, gonococcal endocarditis (for e.g.)
• Fever of undetermined origin (>3 weeks, >38.3, undiagnosed after 1 week of
intensive study)
○ Mainly unusual manifestations of common diseases
○ The longer the duration, the less likely the cause is infection
○ 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)
Diagnostic approach for fever of unknown origin
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 arteries
• Abdomen – 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
○ Screening (HIV, typhoid, EBM, Q fever, psittacosis, CMV, toxoplasmosis,
syphilis, 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

Hypertension
History
• History of hypertension
○ Method/date of original diagnosis
○ Known duration and levels of elevated BP
○ 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
○ History of CV disease or peripheral vascular disease, kidney disease,
DM, recent weight gain
○ Obesity, hyperlipidaemia, smoking, salt intake, ETOH, exercise levels,
analgesic intake
○ Asthma, psychiatric illness
• Family history of any of the above
• Medication history
• Alcohol intake

Examination
• Cardiovascular examination
○ Volume and timing of radial and femoral pulses
○ BP in arm and leg, comparison of BP in both arms
• Remember fundoscopy to check for hypertensive retinopathy

Investigations

Routine: Recommended:

• Plasma glucose • Echocardiogram


• Serum total and HDL cholesterol, • Carotid, femoral ultrasound
fasting serum TGs • CRP, microalbuminuria,
• Serum creatinine/eGFR quantitative proteinuria
• Serum uric acid, K, Na+, Hct,
haemoglobin
• Urinalysis, ECG

Treatment
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:


○ Diuretic PLUS beta-blocker OR ACE inhibitor OR AT-2 receptor
antagonist
○ Beta-blocker PLUS diuretic PLUS calcium antagonist (except verapamil
and diltiazem)
○ 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)

Headache
History

• 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?

Examination
• Inspect the head, temporal arteries and eyes (ophthalmoscope)
• Take vitals (BP, temp etc.)
• Palpate temporal arteries, facial and neck muscles, cervical spine and sinuses
• Mental state examination: mood, anxiety-tension-depression, mental changes
• Special signs:
○ Palpate over C2 and C3 areas of the cervical spine, if tender it indicates
spinal origin of headache

Investigations
• Bloods (?anaemia, ?leucocytosis with bacterial infection, ?temporal arteritis
indicated by ESR)
• Radiography:
○ Chest (cerebral malignancy), skull (brain tumour, Paget’s disease with
deposits in skull), cervical spine X-ray
○ CT scan (brain tumour, cerebrovascular accidents, subarachnoid
haemorrhage)
○ Radioisotope scan for specific tumours and haematoma
○ MRI if necessary
• Lumbar puncture: for diagnosis of meningitis or suspected SAH if CT is normal

Dagnosis
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:

○ Cervical dysfunction
○ Dental disorders
○ Vision problems
○ Sinusitis
○ Ophthalmic herpes zoster
○ Exertional headache
○ Post-traumatic headache
○ Post-spinal procedure
○ Sleep apnoea

• 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

Types of headache
Some of the common types of headache

Tension Symmetrical, bilateral tightness


headache
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)

Migraine 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

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

Cluster Paroxysmal clusters of unilateral headache, usually occurs nightly.


headache 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.

Combinatio ‘Combined’/’mixed’ headaches are common and often diagnosed as


n headache 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

Others 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

Knee complaint
History
• SOCRATES
• Can you explain in detail how the injury happened?
○ Did you land awkwardly after a leap in the air?
○ 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?
○ How much kneeling do you do? Scrubbing floors, cleaning carpets?
○ Could there be needles or pins in the carpet?
○ Does your knee lock or catch?
○ Does swelling develop in the knee?
○ Does it ‘grate’ when it moves?
○ Does the pain come on at rest and is there morning stiffness?
○ 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

Examination
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
○ 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.

Investigations
Select from:

• Blood tests (RA factor tests: ANA, HLA B27; ESR, culture if suspected septic
arthritis)
• Radiology:
○ Plain X-ray
○ Special views: intercondylar, tangential, oblique, weight-bearing
○ Bone scan (tumour, stress fracture, osteonecrosis, osteochondritis
dissecans)
○ MRI (good for cartilage, menisci disorders and ligament damage)
○ Ultrasound (soft tissue mass, fluid collection)
• CT (for complex fractures)
• Special: examination under anaesthesia, arthroscopy, knee aspiration (for
culture or crystal examination)

Diagnosis
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
Nasal congestion/sneezing

Anxiety
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 Excessive anxiety and worry about various life circumstances and
anxiety is not related to a specific activity/time/event such as trauma,
disorder 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

Panic Sudden, unexpected, short-lived episodes of intense anxiety


disorder
Most often in females. Recurrent. Follow DSM-IV for diagnosis

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

Phobic Anxiety is related to specific situations or objects. Three main:


disorders 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

Obsessive- Management:
compulsive
disorder • CBT (exposure-response therapy) and pharmacological
treatment (any of the SSRIs or clomipramine)

PTSD 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.

Vertigo/dizziness
‘Dizziness’ is divided into vertigo and pseudovertigo.
• Pseudovertigo is further subdivided into:
○ Giddiness or lightheadedness – a sensation of uncertainty or ill-defined
lightheadedness. Usually a psychoneurotic symptom
○ Fainting or syncopal episodes – sensation of impending fainting or loss
of consciousness. Many causes, including cardiogenic, postural
hypotension, drug-induced
○ Equilibrium disorders (see below)
• 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, anticonvulsants, cardiogenic, salicylates
○ 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 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
○ 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

History
Need to figure out the following questions:

• Is it vertigo or pseudovertigo?
• Symptom pattern:
○ Paroxysmal or continuous?
○ Effect of position and change of posture?
• Any aural symptoms?
○ Tinnitus?
○ Deafness?
• 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?
○ Alcohol, marijuana, hypotensives, psychotropics, other drugs?

Examination
Full general examination is appropriate, pay particular attention to cardiovascular
and CNS, and auditory and vestibular mechanism.

• Ear disease:
○ Wax? Drum?
○ Hearing tests
• The eyes:
○ Visual acuity
○ Test movements for nystagmys
• Cardiovascular system:
○ Evidence of atherosclerosis
○ Blood pressure: supine, standing, sitting
○ Cardiac arrhythmias
• Cranial nerves:
○ II, III, IV, VI, VII
○ Corneal response for V
○ VIII (auditory nerve)
• Cerebellum or its connections:
○ Gait
○ Coordination
○ Reflexes
○ Finger-to-nose test
• The neck, including cervical spine
• General search for evidence of anaemia, polycythaemia, alcohol dependence

Investigations
• Haemoglobin, glucose
• ECG
• Radiology: chest x-ray, cervical spine x-ray, CT scan, MRI (for neural tumours)
• EEG, audiometry
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.

Chest pain
Determine quickly whether oxygen and an aspirin are necessary immediately.

History
Meticulous history of the behaviour of the pain is the key to diagnosis.

• Analysed into usual characteristics: SOCRATES


• Keep in mind diabetes, Marfan syndrome, anaemia and SLE
• Associated symptoms to query:
○ Syncope (consider MI, PE, dissecting aneurysm)
○ Pain on inspiration (consider pleurisy, pericarditis, pneumothorax and
chest wall musculoskeletal pain)
○ Thoracic back pain (consider spinal dysfunction, MI, angina, aortic
dissection, pericarditis and gastrointestinal disorders such as peptic
ulcer, cholesystitis and oesophageal spasm)
• Key questions:
○ Where exactly do you get the pain?
○ Does it travel anywhere?
○ Can you give me a careful description of the pain?
○ How long does the pain last and could you do anything to relieve it?
○ Is the pain brought on by exertion and relieved by rest?
○ Do cold conditions bring it on?
○ Do you have any other symptoms, such as breathlessness, faintness,
sweating, back pain?
○ 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?
○ Is your pain associated with what you eat and drink? Or with a bitter
taste in your mouth?
○ Do you get the pain on stooping over and after lying in bed at night?
○ Do antacids relieve your pain?
○ Have you noticed a rash where you get the pain?
○ Have you had a blow to your chest or an injury to your back?

Examination
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  pneumothorax
○ Friction rub  pericarditis or pleurisy
○ Basal crackles  cardiac failure
○ Apical systolic murmur  mitral valve prolapse
○ Aortic diastolic murmur  proximal dissection (aortic regurgitation)

Investigations
• 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!

Leg/thigh complaint
Similar to knee above. History of injury, then examination, investigations.

Lipid disorders
Facts about dyslipidaemia:

• Major risk factors coronary arterial disease include:


○ Elevated LDL and low HDL cholesterol
○ 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

Investigations
• Serum triglyceride
• Serum cholesterol and HDL and LDL

Management
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
○ Reduce fat intake, especially dairy products and meat
○ Avoid ‘fast foods’ and deep-fried food
○ Replace saturated fats with mono- or polyunsaturated fats
○ Always trim fat off meat, remove skin from chicken
○ Avoid biscuits and cakes between meals
○ Eat fish at least twice a week
○ Ensure a high-fibre diet, especially fruit and vegetables
○ Keep alcohol intake to 0-2 standard drinks/day
○ Drink more water
○ Use approved cooking methods, e.g. steaming, grilling
• Regular exercise
• Cessation of smoking
• Cooperation of family is essential
• Exclude secondary causes (e.g. hypothyroidism, obesity, alcohol excess,
specific diuretics)

Pharmacological measures:

• Hypercholesterolaemia: choose one of the following:


○ Statins (first line) – simvastatin/pravastatin/atorvastatin (monitor LFTs)
○ Bile-binding resins – cholestyramine
○ Other – nicotinic acid, procubol, fish oils, ezetimibe
• Resistant LDL elevation:
○ Combine statin and cholestyramine
• Isolated TG elevation:
○ Fibrate – gemfibrozil/fenofibrate (reduce alcohol intake)

Acute bronchitis/bronchiolitis

Acute Acute inflammation of the tracheobronchial tree, usually follows URTI


bronchit Generally mild and self-limiting, may be serious in debilitated patients
is • 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:
○ Amoxicillin 500mg (8 hourly for 5 days) or
○ Doxycycline 200mg statim, then 100mg daily for 5 days

Asthma
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.
Examination
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.

Investigations
• 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 beta-agonist): positive if there is a characteristic improvement in FEV1
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

Management
Pharmacological management:

• ‘Preventer’ drugs or anti-inflammatory agents


○ Corticosteroids: beclomethasone, budesonide, ciclesonide, fluticasone
(all inhaled), prednisolone (oral)
○ Sodium cromoglycate
○ Nedocromil sodium
○ Leukotriene antagonists (new): montelukast, zafirlucast
• ‘Reliever’ drugs or bronchodilators
○ β 2 receptor antagonists (inhaled)
 SABAs – salbutamol, terbutaline
 LABAs – eformoterol, salmeterol
○ Methylxanthines (theophylline derivatives)
○ Anticholinergics

Maintenance plan example:

• Inhaled SABA – prn


• Inhaled steroid (dose according to severity)
• If more severe, add stepwise:
○ Longer acting steroid bd (if using shorter acting steroid, it should be
stopped)
○ LABA separate or combined with steroid
○ Theophylline (o) controlled release
○ Inhaled ipratropium
○ Leukotriene agonist
○ Oral prednisolone prn
• For attack: high dose inhaled bronchodilators (spacer preferred)
○ <25kg up to 6 puffs
○ 25-35kg 8 puffs
○ >35kg 10 puffs

Urinary tract infection


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.

Examination
• Generally look for:
○ 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

Investigations
• Urine collection
○ Midstream specimen of urine (MSU)
○ 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
• Microscopic examination
• Culture

Wait for results before treatment.

Sleep disturbance
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
○ Primary insomnia
○ Other disorders initiating or maintaining sleep
 Periodic limb movements (nocturnal myoclonus)
 Restless legs syndrome
○ Excessive somnolence
 Primary hypersomnia
 Narcolepsy
○ Breathing-related sleep disorders
 Obstructive sleep apnoea
 Central sleep apnoea
 Central alveolar hypoventilation syndrome
○ Circadian rhythm sleep disorder
 Jet lag type
 Shift work type
 Delayed sleep phase type
• Parasomnias
○ Nightmare (dream anxiety) disorder
○ Sleep terror disorder
○ Sleepwalking disorder
• Secondary sleep disorder
○ Medical condition disorder
○ Mental disorder
○ Substance abuse

Management
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 quiet sleep setting with the right temperature
• Sex as the last thing before bed is 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:
○ Sudden brief sleep attacks (15-20 minutes)
○ Cataplexy (sudden loss of muscle tone in the lower limbs), may slump
to floor
○ Sleep paralysis
○ 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
○ 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
○ Predisposing causes include:
 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 (e.g. depression, personality change)
• Refer to a sleep disorder centre is advisable. General principles:
○ Lifestyle modification (weight loss, no smoking)
○ Continuous positive airway pressure (CPAP) delivered by nasal/facial
mask
○ Corrective surgery (e.g. tonsillectomy, nasal obstruction)
○ Oral appliance (e.g. the mandibular advancement splint)
○ Medication (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
○ 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
○ The sufferers may or may not be awake and usually cannot recall the
event
○ They require psychological evaluation and therapy
○ Similar medications for nightmares can be used
• Sleep walking (somnoambulism): the person performs some repetitive
motor activity in bed or walks around freely
○ No treatment is usually required but the sleeping environment should
be rendered safe if it is repetitive and problematic
○ Benzodiazepines can be used

Sinusitis (acute/chronic)
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:


○ Facial pain and tenderness over sinuses
○ Toothache
○ Headache
○ Purulent postnasal drip
○ Nasal discharge
○ Nasal obstruction
○ Rhinorrhoea
○ Cough (worse at night)
○ Prolonged fever
○ Epistaxis
○ Suspect a bacterial fause if high fever and purulent nasal discharge
• Clinical features of chronic sinusitis:
○ Vague facial pain
○ Offensive postnasal drip
○ Nasal obstruction
○ Toothache
○ Malaise
○ Halitosis

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.

Management
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

Viral disease
Vague category; assuming this refers to viral rhinitis, see ‘Cough’.

Acute otitis media/myringitis


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 OM is suggested by acute onset of ear pain/tugging, hearing loss,
irritability and fever. Suppurative OM has progressive erythema and bulging
of OM with loss of landmarks. Treat with antibiotics
• Treatment:
○ Rest patient in warm room with adequate humidity
○ Paracetamol suspension for pain (high dosage)
○ Decongestants only if nasal congestion
○ Bacterial: amoxicillin, with clavulanic acid if resistance suspected
○ 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

Fracture
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.

Infectious conjunctivitis
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
○ Prolonged infection
○ Neonates
• Management (mild):
○ Limit spread by avoiding close contact with others, use of separate
towels etc.
○ May resolve with saline irrigation of the eyelids and conjunctiva
○ Antiseptic eye drop (propamidine isethionate)
• Management (severe):
○ Chloramphenicol eye drops and eye ointment
○ Pseudomonas and other coliforms: use topical gentamicin and
tobramycin
○ 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
○ 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
○ Acyclovir ointment
○ Atropine drops (to prevent reflex spasm of the pupil)
○ Debridement by a consultant

Chlamydial conjunctivits:

• Three common situations:


○ Neonatal infection (first 1-2 weeks)
○ Young patient with associated venereal disease
○ Isolated Aboriginal people with trachoma
• Acute infection resembles acute bacterial conjunctivitis. Take swabs for
culture and PCR testing
• Systemic antibiotic treatment:
○ Neonates: erythromycin 3 weeks
○ Adults and children: azithromycin as single dose (partner must be
treated in cases of STI)

Excessive ear wax


Check the ear with an otoscope, disimpact with a syringe with saline/water until it
comes out. May take a long time.

Bursitis/tendonitis/synovitis
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
Chronic heart failure
Signs and symptoms
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

Physical examination

Left heart failure Right heart failure


– Tachycardia – Elevated JVP
– Low volume pulse – Right ventricular heave
– Tachypnoea – Peripheral/ankle oedema
– Laterally displaced apex – Hepatomegaly
– Bilateral basal crackes – Ascites
– Heart rhythm
– Pleural effusion Look for peripheral oedema  ‘pitting
– Poor peripheral perfusion oedema’

Investigations
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

Treatment
1. Determination and treatment of cause
2. Removal of precipitating factors
3. Appropriate patient education
4. Non pharmaceutical measures
5. Drug Tx

Prevention
– 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

Treatment of causes and precipitating factors


Precipitating factors to be Tx
– Arrhythmias
– Electrolyte imbalance (hypokalaemia)
– Anaemia
– Myocardial ischaemia esp MI
– Diactary factors
– Adverse drug reactions
– Infection
– Thyrotoxicosis
– Fluid overload

Management
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

Alcohol abuse
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

Useful questions in history


– 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

Lab investigations
– Raised GGT
– HDLs elevated
– LDLs elevated

Standard drink = 10g of alcohol  middy of beer, two middies of light, 120mL of
wine

Management
 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

1. 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

1. Evaluate – monitor drinking with diary, check that FBE are returning to
normal, make follow up appointment
Obstructive lung disease

Restrictive lung disease