General Practice Notes

General Practice
General practice ................................................................................................................................................................................. 4

Cardiovascular .................................................................................................................................................................................... 6
Atrial Fibrillation ............................................................................................................................................................................ 7
Hypertension ............................................................................................................................................................................... 10
Coronary Artery Disease .............................................................................................................................................................. 11
Heart failure ................................................................................................................................................................................ 13
Fever................................................................................................................................................................................................. 16
Respiratory ....................................................................................................................................................................................... 18
Determinants for antibiotics ....................................................................................................................................................... 18
Sore Throat .................................................................................................................................................................................. 18
Group A Streptococcus (pharyngitis, tonsillitis)...................................................................................................................... 19
Cough........................................................................................................................................................................................... 21
Child with cough and SOB ........................................................................................................................................................... 24
Asthma ........................................................................................................................................................................................ 25
Chronic Obstructive Pulmonary Disease (COPD) ......................................................................................................................... 28
Acute Rhinitis............................................................................................................................................................................... 29
Acute bronchitis .......................................................................................................................................................................... 30
Sinusitis ........................................................................................................................................................................................ 31
Gastrointestinal ................................................................................................................................................................................ 32
Abdominal pain ........................................................................................................................................................................... 32
Diarrhoea ..................................................................................................................................................................................... 33
Constipation ................................................................................................................................................................................ 37
Simple Constipation ................................................................................................................................................................ 38
Faecal Impaction ..................................................................................................................................................................... 38
Colorectal cancer .................................................................................................................................................................... 38
Congenital Megacolon Hircschsprung disorder (aganglionsis) ............................................................................................... 39
Acquired Megacolon ............................................................................................................................................................... 39
Rectal Bleeding ............................................................................................................................................................................ 40
Pruritis Ani ................................................................................................................................................................................... 41
Gastroenteritis............................................................................................................................................................................. 42
GORD ........................................................................................................................................................................................... 43
Dyslipidaemia .............................................................................................................................................................................. 44
Vitamin B12 Deficiency ................................................................................................................................................................ 45
Thiamine Deficiency .................................................................................................................................................................... 46
Haematology .................................................................................................................................................................................... 48
Anaemia....................................................................................................................................................................................... 48
Iron Deficiency Anaemia.............................................................................................................................................................. 48
Bruising and bleeding .................................................................................................................................................................. 49
Haemophilia ................................................................................................................................................................................ 50
Disseminated intravascular coagulation (DIC) ............................................................................................................................. 50
Immune thrombocytopenic purpura (ITP) .................................................................................................................................. 50
Thrombotic thrombocytopenic purpura (TTP) ............................................................................................................................ 51
Leukaemia ................................................................................................................................................................................... 52
Acute leukaemia ..................................................................................................................................................................... 52
Chronic myeloid leukaemia (CML) .......................................................................................................................................... 52
Chronic lymphocytic leukaemia (CLL) .................................................................................................................................. 52
Lymphoma ................................................................................................................................................................................... 52
Hodgkin’s Lymphoma ............................................................................................................................................................. 52
Non-Hodgkin’s Lymphoma .................................................................................................................................................... 53
Multiple Myeloma ....................................................................................................................................................................... 53
Neurology ......................................................................................................................................................................................... 54
Headache ..................................................................................................................................................................................... 54
Dizziness and vertigo ................................................................................................................................................................... 56
Tiredness ..................................................................................................................................................................................... 58
Pain................................................................................................................................................................................................... 60
Chronic Pain ................................................................................................................................................................................. 60
Musculoskeletal ............................................................................................................................................................................... 66
Arthritis ........................................................................................................................................................................................ 66
Back pain ..................................................................................................................................................................................... 67
Low Back Pain .............................................................................................................................................................................. 70
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Neck pain ..................................................................................................................................................................................... 75
Knee pain ..................................................................................................................................................................................... 76
Foot Pain ...................................................................................................................................................................................... 79
Shoulder Pain............................................................................................................................................................................... 81
Osteoporosis................................................................................................................................................................................ 82
Fibromyalgia ................................................................................................................................................................................ 83
Polymyalgia Rheumatica ............................................................................................................................................................. 84
Obesity ............................................................................................................................................................................................. 85
Weight loss ....................................................................................................................................................................................... 86
Endocrine ......................................................................................................................................................................................... 87
Type 1 Diabetes ........................................................................................................................................................................... 87
Type 2 Diabetes ........................................................................................................................................................................... 88
Diabetes Chronic Disease Management Plan .............................................................................................................................. 93
Thyroid ........................................................................................................................................................................................ 93
Adrenal ........................................................................................................................................................................................ 94
Cushing’s Syndrome ............................................................................................................................................................... 94
Aetiology ................................................................................................................................................................................. 94
Phaeochromocytoma ............................................................................................................................................................. 95
Sleep Disturbance ............................................................................................................................................................................ 96
Chronic Fatigue Syndrome .......................................................................................................................................................... 98
Parasomnias ................................................................................................................................................................................ 99
ENT ................................................................................................................................................................................................. 100
Deafness and hearing loss ......................................................................................................................................................... 100
Otalgia/Ear Pain ......................................................................................................................................................................... 101
Otitis Media ............................................................................................................................................................................... 103
Otitis Externa ............................................................................................................................................................................. 104
Tympanic Membrane ................................................................................................................................................................ 105
Eye Pain and Red Eye................................................................................................................................................................. 106
Nasal disorders .......................................................................................................................................................................... 110
Neck lumps ................................................................................................................................................................................ 111
Dermatology................................................................................................................................................................................... 112
Rash ........................................................................................................................................................................................... 112
Contact Dermatitis .................................................................................................................................................................... 113
Atopic Dermatitis ....................................................................................................................................................................... 114
Infantile Seborrhoeic Dermatitis ............................................................................................................................................... 115
Psoriasis ..................................................................................................................................................................................... 115
Scabies ....................................................................................................................................................................................... 116
Skin Cancer ................................................................................................................................................................................ 117
Basal Cell Carcinoma ............................................................................................................................................................. 117
Squamous Cell Carcinoma .................................................................................................................................................... 118
Intraepidermal SCC/Bowen’s disease ................................................................................................................................... 118
Melanoma ............................................................................................................................................................................. 118
Genitourinary ................................................................................................................................................................................. 122
Dysuria ....................................................................................................................................................................................... 122
Haematuria ................................................................................................................................................................................ 122
Proteinuria ................................................................................................................................................................................. 122
Sexually Transmitted Infections ................................................................................................................................................ 123
Screening ................................................................................................................................................................................... 124
Urinary Tract Infections ............................................................................................................................................................. 125
Chronic kidney failure ................................................................................................................................................................ 126
Inguinoscrotal Lumps ................................................................................................................................................................ 127
Hernias .................................................................................................................................................................................. 127
Viruses ............................................................................................................................................................................................ 129
Epstein-Barr Mononucleosis...................................................................................................................................................... 129
Cytomegalovirus ........................................................................................................................................................................ 130
Ross River .................................................................................................................................................................................. 130
Travel medicine .............................................................................................................................................................................. 130
Immunisations ........................................................................................................................................................................... 130
Gastrointestinal infections ........................................................................................................................................................ 131
Dengue fever ........................................................................................................................................................................ 133
Malaria .................................................................................................................................................................................. 133
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Meliodosis............................................................................................................................................................................. 134
Leptospirosis ......................................................................................................................................................................... 134
Scrub typhus ...................................................................................................................................................................... 134
Schistosomiasis ..................................................................................................................................................................... 135
Pinworm/Threadworm ......................................................................................................................................................... 135
Palliative Care ................................................................................................................................................................................. 136
Complementary and Alternative Medicine .................................................................................................................................... 140
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General practice
- Cough
- Disturbance of bowel function
- Pain in abdomen
- Pain in back
- Pain in chest
- Pain in head
- Pain in neck
- Pain in ear
- Pain in throat
- Pain in joints/limbs
- Rashes
- Sleep problems
- Tiredness/fatigue
- Vaginal discomfort
7 Masquerades
- Depression
- Diabetes
- Drugs
- Anaemia
- Thyroid disorder
- Spinal dysfunction
- UTI
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Cardiovascular
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Atrial Fibrillation
History
- Palpitations
- PMHx - Age
o Hypertension - Alcohol
o Mitral valve disease - Family history
o Hyperthyroidism - Sleep aponea
o Previous MI
o Coronary heart disease
Aetiology à PIRATE SHIV

- Pulmonary disease - EtOH
- Infection/idiopathic/iatrogenic - Sick sinus syndrome
- Rheumatic heart disease - Hypertension*
- Anaemia - Ischemia/infarction*
- Thyroid: hyperthyroidism - Valvular disease*
*most common
Types
- Paroxysmal
o Tx: No drug or beta blocker +/- anticoagulation
- Persistent
o Want to restore sinus rhythm
§ DC cardioversion
§ Rate control
- Permanent
o Don’t restore sinus rhythm if
§ Unlikely to maintain SR
• Long duration of AF
• Older age
• LA enlargement
• Structural heart disease
• Cardiomegaly
§ Previously failed CV on AADs
§ Symptom free
§ Rate control strategy may be equivalent to rhythm control
o Other options: PPM and AV nodal ablation
§ Not a ‘cure’
- Secondary
o MI
o Surgery
o LRTI
o PE
o Pulmonary disease
§ NDHP CCB recommended
§ Cardioversion should be attempted in patients who become haemodynamically unstable with new-
onset AF
o Hyperthyroidism
§ Beta blockers recommended
§ Where beta blockers can’t be used a NDHP CCB is recommended
Clinical features
à The hallmark of AF is chaotic atrial impulses leading to irregularly irregular ventricular contraction, usually with incessant
tachycardia
- Palpitations
- Breathlessness
- Fatigue
- Dizziness/syncope
- Patient: Difficultly checking BP
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Elderly
- They are high risk but remember, the risk is that of the population and not of the individual
- Need to assess in context of patient
o Compliance
o Mobility / falls
o Polypharmacy
o Patient preference
o Age
Complications
- Increased mortality
- Systemic embolism, stroke
o CHADS-VASc score
- Impaired QOL
- Haemodynamic dysfunction
- Complications of drug therapy
Treatment
Aims
- Restore and maintain sinus rhythm whenever possible
- Prevent thromboembolic events
- Reduce symptoms and improve QoL
- Minimise impact of AF on cardiac performance
- Reduce risk of stroke
- Minimize cardiac remodelling
Rate control
à Beta blocker e.g. propranolol or non-DHP Ca2+ channel blockers e.g. verapamil
- For paroxysmal, persistent or permanent
- IV beta blocker or non-DHP CCBs recommended to slow ventricular HR in acute setting in patients without pre-
excitation
o A heart rate control (resting heart rate <80bpm) strategy is reasonable for symptomatic management of AF
(Class IIa)
- In haemodynamically unstable patients, electrical cardioversion is indicated (Class I)
- AV nodal ablation with permanent ventricular pacing is reasonable when pharmacological therapy is inadequate and
rhythm control is not achievable (Class IIa)
- Non-DHP CCBs should not be used in decompensated HF (Class III)
Others
- Digoxin
o Decreases conduction of electrical impulses through the AV node
o Commonly used antiarrhythmic agent in controlling heart rate during AF and atrial flutter
o An increase of force of contraction via inhibition of the Na+/K+ ATPase pump
- Amiodarone
o IV amiodarone can be useful for rate control in critically ill patients without pre-excitation
Rhythm control
- First line: Amiodarone
- Second line: AV node ablation, pacing
Anticoagulation à based on CHADS- VASc

- Aspirin
AF complicating ACS
- Urgent cardioversion of new-onset AF in the setting of ACS is recommended for patients with haemodynamic
compromise, ongoing ischemia, or inadequate rate control (Class I)
- IV beta blockers are recommended to slow RVR with ACS and no HF, hemodynamic instability, or bronchospasm (Class
I)
- With ACS and AF with CHA2DS2-VASc score ≥2, anticoagulation with warfarin is recommended unless contraindicated
(Class I)
- Amiodarone or digoxin may be considered to slow RVR with ACS and AF and severe LV dysfunction and HF or
hemodynamic instability (Class IIb)
- Non-DHP CCBs might be considered to slow RVR with ACS and AF only in the absence of significant HF or hemodynamic
instability (Class IIb)
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Hypertension
History
- Hyperlipidaemia
- MHx
o MI
o Renal disease
o Diabetes
o Peripheral artery disease
o Ischemic heart disease
o Phaeochromocytoma: headaches, sweating, palpitations
o Hypokalaemia: muscle weakness, cramps, arrhythmias
- Smoking, Alcohol consumption
- Previously high BP, Malignant HTN
- Family hx
- Age of onset
- Weight/BMI
- Lifestyle: impacts and improvements
- Current medication
- Recreational drug use
- Sleep apnoea: obesity, snoring, daytime sleepiness
Aetiology
- Primary/Essential hypertension
- Secondary hypertension
o Kidney
§ Glomerulonephritis
§ Renal artery stenosis
o Endocrine
§ Hyperaldosteronism
§ Phaeochromocytoma
§ PCOS
§ Conn syndrome
o Drug induced: alcohol, increase salt, oral recongestants, NSAIDS, OCP, SSRI/SNRI
o Sleep apnoea
o Hypokalaemia
Management
à Ambulatory blood pressure monitoring should be considered in people with first diagnosis of hypertension without end organ
damage. This is especially helpful in patients:
- To exclude ‘white coat’ hypertension in patients with newly discovered hypertension with no evidence of end-
organ damage
- In patients with borderline, labile or episodic hypertension
- To assist BP management in patients whose BP is apparently poorly controlled, despite using appropriate
antihypertensive therapy
- In patients with worsening end-organ damage, despite adequate BP control on office BP measurements
- To assess adequacy of BP control over 24 hours in patients at particularly high risk of cardiovascular events, in
whom rigorous control of BP is essential
(eg. diabetes, past stroke)
- In deciding on treatment for elderly patients with hypertension
st
1 line
- Diet and lifestyle modification
- ACE inhibitor
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o Captopril, lisinopril, ramipril
o Favouring use: LVH or dysfunction, post MI, heart failure, glucose intolerance, diabetic nephropathy,
microalbuminuria
o Contraindications: pregnancy, angioderma, hyperkalaemia, bilateral renal artery stenosis
- Angiotensin II receptor blocker (ARB)
o Eprosartan, losartan, candesartan
o Favouring use: LVH, heart failure, glucose intolerance, diabetic nephropathy, ACEi-induced cough
o Contraindications: pregnancy, hyperkalaemia, bilateral renal artery stenosis
- Calcium channel blocker
o Amlodipine, nifedipine
o Favouring use: stable angina, atherosclerosis, pregnancy (some in this class only), isolated systolic HTN in
elderly
o Contraindications: heart failure, tacharrhythmias, atrioventricular block
- Diuretics: thiazide and thiazide-like
o Indapamide, hydrochlorothiazide
o Favouring use: isolated systolic HTN, heart failure
o Contraindications: gout, glucose intolerance, pregnancy
Second line
- Beta blocker
o Atenolol, metoprolol
o Favouring use: stable angina, most MI, tachyarrhythmias, glaucoma, pregnancy
o Contraindications: asthma, AV block, athletes, COPD
Patients with Kidney Disease

à ACEi and ARB therapy is associated with a reduction in proteinuria and slowing of the rate of progression of kidney failure
- They are first-line therapy in people with CKD or diabetes. However,
- S/E
o Increased risk of hyperkalaemia
o May cause impairment of eGFR if significant renal artery stenosis is present. If greater than 25% of baseline,
need to stop treatment
- Avoid triple whammy
- Lower doses of ACEi needed as renally excreted
Hypertensive Emergency
- Reduce BP by <25% within first 2hrs
- Reduce to 160/100mmHg in 2-6hrs
- Allow adjusting for 24hrs before lowering further
- Lowering BP too rapidly can cause renal, coronary or cerebral ischemia
Coronary Artery Disease

History
- Dyslipidaemia
- Hypertension
- Smoking
- Diabetes
- Obesity
- Previous MI/stroke
- Family hx
Investigations
- Bedside: ECG
- Bloods: FBC, lipid profile, TFT, iron studies, vitamin B12, troponins
- Other: Echo, cardiac stress test, coronary angiography, cardiac disease risk calculator
Differential Diagnosis
- Collagen vascular disease: Kawasaki disease, polyarteritis nodosa, SLE, Ehlers-Danlos syndrome
- Septic emboli
- Syphilis
- Hyperthyroidism
- Anaemia
- Other arrhythmias: atrial flutter, other atrial tachy-arrhythmias
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Management
Rate control
- Choose one of the following:
o Beta blocker: Atenolol 25-100mg PO, Metoprolol 25-100mg PO
o CCB: Diltiazem 180-360mg PO, Verapamil 160-480mg PO
o Digoxin 62.5-250mcg PO, dosage according to eGFR and plasma digoxin concentration levels
- IV if urgent rate control is desired, choose one of:
o Metoprolol 5mg (1mg/min) IV at 5min intervals up to max 20mg
o Esmolol 500micrograms/kg IV over 1min
o Verapamil 1mg/min IV up to 15mg
Rhythm Control
- Flecanide 50-100mg PO BD
- Sotalol 40-160mg PO BD
- Amiodarone 200-400mg PO QRS for 7/7 then BD for 7/7 then daily
- Cardioversion
Anticoagulation
- The commencement of an anticoagulant should also occur to prevent complications such as stroke, PE, etc:
- Warfarin
- NOAC (new oral anticoagulant) such as: Dabigatran
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Heart failure
Clinical classification
- Course of the disease - Location
o Acute o Right heart
o Chronic o Left heart
- Cardiac output o Congestive
o Low output - Function impaired
o High output o Systolic
o Diastolic
Aetiology
- Coronary artery disease
o Most common cause
o Reversible: if you can get BF back, you can improve outcomes
o Revascularisation can markedly improve outcomes
- Idiopathic dilated cardiomyopathy
o Diagnosis of exclusion
- Alcohol/toxin induced cardiomyopathy
o Alcohol has a direct acute and chronic toxic effects on the myocardium
o Cocaine and other catecholaminergic drugs
o Chemotherapeutic drugs: anthracyclines
- Infection/inflammatory
o Coxsackie
o HIV, mycoplasma
o Lupus, RA, scleroderma
- Familial dilated cardiomyopathy
o Can be autosomal dominant or recessive, x-linked or mitochondria
o Some associated with muscular dystrophy
- Peripartum cardiomyopathy
o Development of clinical HF in the last month of pregnancy or the first 5 months of peripartum
- Stress-induced cardiomyopathy: Takotsubo
o Reversible cause of acute systolic dysfunction resembles a large anterior wall MI
o Associated with emotional, surgical or dramatic stresses and catecholamine surgery
o Improves over days to weeks, usually with complete resolution of LV function
- Endocrine/nutritional E.g. Hypothyroidism
- Iron overall cardiomyopathy
- Tachycardia mediated cardiomyopathy
NYHA
- 1: No limitation on physical activity
- II: Slight limitation
- III: marked limitation in physical activity, comfortable at rest but less than ordinary activity
- IV; unable to carry on any physical activity without symptoms, symptoms of HF at rest
Management
Symptoms
- Dyspnoea on exertion
- Orthopnoea
- PND
- Oedema
- Fatigue, weakness, dizziness, poor mentation, anorexia, nausea
Signs
- Fluid overload
o Raised JVP
o Peripheral oedema
o Pulmonary oedema
o Ascites
rd
o 3 HS
- Murmurs
- Hyperthyroidism
- Temperature
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Investigations
- CXR: pulmonary oedema – ABCDE
o Alveolar oedema
o Kerley B lines
o Cardiomegaly
o Dilated prominent upper lobe vessels
o Pleural effusion
- ECG: Poor R wave progression, W waves, LVH
o Ischaemia: ST elevation or depression
o Arrhythmias: AF, VT, SVT
- Bloods: infection, renal failure, thyroid function, anaemia
- BNP
o <100 high negative predictive value, >400 consistent with HF
o Works to release increased Na+ through kidneys (decreases renin, vasodilation) to try and lower BP
o AF, chronic HF, pulmonary hypertension, renal failure à Higher baseline, so use higher cut-off for dx
o Lower in obese at baseline so use lower cut-off for diagnosis of ADHF
o Released by heart when it is under stress
- Echo
- Angiogram
- Right heart catheterisation
- Cardiac MRI
Acute management
- Diuretics
o ACEi
o And a diuretic if congestion e.g. fruesemide
§ Loop diuretics preferred over thiazides if renal function impaired
o Gross oedema associated with reduced oral bioavailable à May require IV bolus
o No advantage IV infusion vs IV bolus
o No mortality advantage demonstrated
- Improve rate control: Digoxin
- Improve arterial haemodynamics
o Reduce preload: nitrates – GTN or infusion
o Reduce afterload: Hydralazine, alpha blockers
- Improve ventilation perfusion
o Positive airway pressure
- Improve cardiac output
o Inotropics
§ Dobutamine
§ Dopamine
o Mechanical supports
§ Intra-aortic balloon pumps
§ Ventricular assist devices
§ Extracorporeal membrane oxygenation (ECMO)
- Monitoring from improvement/deterioration
o Fluid chart: fluid restriction
o Urine output measurements: indwelling urinary catheter
o Daily weights
o Salt restriction
o Oxygenation
§ Saturations
§ Blood gasses
o Haemodynamics: BP – invasive or non-invasive
- Treat underlying disease
o Coronary revascularisation
o Control arrhythmias
o ?Endomyocardial biopsy/MRI
o Valvular/structural heart disease intervention
Drug MOA
ACE-I and ARB
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- Vasodilation: reduce cardiac preload and after load thereby improve systolic function & increase CO
- Facilitates salt and water excretion by complete effects on kidney
- ACEi and RB reduce LVH, myocardial fibrosis and stiffness
- ACEi
o Morality and morbidity advantage in HF
o Start at low dose and titrate 2 weekly following creatinine and K+ levels
o ACEi are first line but ARB may be used if symptoms
o Sudden deterioration Cr à ?RAS
Beta blockers
- Mortality and morbidity advantage in heart failure
- Start low and titrate slowly: Higher dose the better, as tolerated
- Beta blockers for heart failure to all patients with LV impairment
- Contraindications
o Elderly
o Erectile dysfunction
o DM
o Peripheral vascular disease
o COPD without reversibility
- Relative contraindications included reactive airway disease, asymptomatic bradycardia, resting limb ischaemia
Aldosterone antagonists e.g. Spironolactone

- Second line
- Potassium sparing diuretic
- Closely follow K and Cr
- Limited to patients to severe HF after they have already been on ACEi or ARB
Digoxin
- Symptomatic improvement with reduced hospitalisation in patients with mild-mod HF
- Very small therapeutic window: 0.6-0.9
- Less effective in women than men
- Verapamil and amiodarone interaction
Management
Non-pharmacologic
- Nutrition
- Weight
- Physical activity
- Education
Device therapy
- ICD
o 50% of patients with HF die suddenly from arrhythmias
o Implantation of and internal cardiac defibrillation improves survival
- Cardiac resynchronization therapy
o Used for patients with a conduction delay, meaning the walls of the ventricle contract at different times
o Allows contraction of the ventricle to be more efficient because it forces all walls of the heart to contract at
the same time
o Can be confirmed with ICD
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Fever
History
- Onset, Timing, Duration - Medication: SSRI/MAIO (serotonin syndrome)
- Associated features - CV risk for MI: HTN, obesity, smoking,
o Night sweats hyperlipidaemia
o Rigors - Recent surgery
o Weight loss - Previous carcinoma diagnosis
o Systemic symptoms - Immunisation history
- Immunocompromised - Travel: TB, parasite
- Diabetes - FHx: autoimmune diseases
Red Flags
- Rigors: uncontrolled paroxysm of shivering (followed by excessive sweating) implies a rapid rise in body temperature
- Signs of septicaemia: confusion, renal failure, neutrophilia, low plasma albumin, raised CRP
- Neonate (<3mths), Elderly
Investigations
à Strongly dependent on differentials
- Bedside: ECG, urinalysis, BSL
- Bloods: FBC, LFTs, arbovirus serology (ross river fever, dengue), blood culture
- Imaging: CXR
- Other: urine MCS, LP
- UTI - Kawasaki disease
- Pneumonia - Juvenile idiopathic arthritis
- Sinusitis - SLE
- Meningitis - Vaccine related fever
- Septic arthritis - Typhoid
- Osteomyelitis - Staph or strep toxic shock syndrome
- Cat-scratch disease - HSV
- Viral syndromes - HIV
- EBV - Leptospirosis
- Malaria - Encephalitis
- TB - Sarcoidosis
Fever in Specific Populations:

- Infants: under 3 months need to consider the infection may have come from the birth canal, sepsis
- Elderly: elderly people generally run colder than younger people. Therefore a large increase in temperature may
be more sinister. A raised temperature may also be the only indication of an infection (such an pneumonia or a
UTI).
- Child: arbovirus, URTI, otitis media, otitis externa, mumps, EBV, CMV
- Travellers: consider where they have travelled and what is endemic in those areas.
- Immunocompromised (includes diabetes and alcoholism): more at risk of developing opportunistic infections such
as candida.
- People in custody: increased risk of hepatitis and other blood-borne infections
- Polypharmacy: serotonin syndrome, neuroleptic malignant syndrome (fever, ALOC, ridgidity)
Pyrexia of Unknown Origin

There are 4 different types of PUO:
o
- Classic PUO: temperature above 38 C for more than 3 weeks
- Nosocomial PUO: >38.3°C, > 1wk of inpatient, or >3days of investigations.
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- Neutropenic PUO: >38.3°C and <1x 10 neutrophils.
- HIV associated PUO (there is neutropenic state): >38.3°C > 4wk outpatient / > 3days inpatient resulting in no
known causes.
Possible causes:
- Infective: abscess, TB, viral, URTI, parasitic, etc.
- Malignant: hodgkins or non-hodgkins lymphoma, others.
- Inflammatory (auto-immune causes): Giant cell arteritis, SLE, Rheumatic, ARF, sarcoidosis.
- Undetermined: MI, PE, drugs, endocrine, hepatic, allergic, CVA, etc.
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Management
Initial first presentation management of fever
- Infant: full sepsis screen and if under 1mth admit for empirical antibiotics
- Child with viral symptoms: maintain fluid intake, use anti-pyretics only if child is in distress due to fever, monitor,
return if not improving in 5/7
- Elderly: determine cause. Treat pneumonia, UTI, etc if present
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Respiratory
Determinants for antibiotics
- Illness factors: fever, lymphadenopathy, discoloured phlegm/sputum
- Patient factors: Age, social factors
- Patient expectations
- Doctor factors
o GP preference
o Time in GP
- Non-illness determinants
o Ab reduces work load
o Ab are non toxic and easy to prescribe
o Patients expect ab
o Social factors
o Triggers of patient visits
o Fear of ghosts: nephritis, ARF
Sore Throat
Viral sore throat ßà Sore throat caused by GAS ßà Life threatening
- Pharyngitis – inflammation of pharynx +/- tonsils
- Quinsy – a peritonsillar abscess
- Tonsilitis – inflammation of tonsils only
- As a general rule, antibiotics should not be prescribed to treat a sore throat, excluding evidence of group A beta-
haemolytic Streptoccocus (GABHS) infection
- Sore throats are common up to the age of 45, after which they decline considerably
Aetiology
- Viral vs Bacterial sore throat
o Viral - ~65%
§ EBV, herpangina, HPV, adenovirus, coronavirus, enterovirus, influenza virus, rhinovirus, varicella
o Bacterial
§ Stretococcus pyogenes - ~20%
§ GABHS, diphtheria (rare), gonococcal pharyngitis, Hib, Moraxella catarrhalis, staph aureus (rare),
syphilis (rare)
- As most are viral, usually Mx is symptomatic
- Unknown
- Other
o Spirochetes
o STI: Gonorrhoea, chlamydia, syphilis, HIV
o Corynebacterium influenza or diphtheria
o Streptococci of group C or G
o Haemophilius influenza
o TB
o Tonsillar cancer
What not to miss

Send to hospital
- Severe bacterial pneumonia
- Epiglottitis,
- Frontal sinusitis/Ethmoiditis,
- Quinsy
- Airway foreign body
- Severely affected general condition.
Quick follow up
- Uncomplicated bacterial pneumonia
- Otitis media à Give Abx
- Sore throat in patients at risk for ARF/RHD
Malignancies
- Long standing cough
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- Hoarseness
- Unilateral rhinosinusitis
- Tonsillitis in elderly
Immune system
- Allergic rhinitis
- Asthma
- HIV Seroconversion illness
Epidemiology
- Age groups
o Uncommon in children aged <3
o Max incidence 5-14 years
o Slow decrease in incidence after 14 years
- Annual incidence 1 - 13% of the population
Group A Streptococcus (pharyngitis, tonsillitis)

- Traditional signs indicating gas
o Intense redness
o Petechiae on the soft palate
o Tonsillar exudate if age >6 years
o Swollen tender anterior cervical lymph nodes
- GAS: Based on a centor criteria à Each of the following is worth 1 point (0 = unlikely – 4 likely)
à FAT NO
o Fever
o Anterior lymphadenopathy
o Tonsillar exudate
o No cough
- Alternative to centor = McIsaac criteria
o Same as centor but also age criteria
Sore throat: Ghosts

- Necrotising fasciitis
o Invasive GAS: the flesh eating bacteria
o Very rare
o Main symptom: often severe local pain
o Only 2-5% preceeded by a sore throat
- Retro/para-pharyngeal abscess
- Lemierres syndrome
o Very rare
o Linked to fusobaterium necrophorum
§ F necrophorum common between 15-35 years
o Unknown if treating sore throats prevels Lemierres syndrome
- Quinsy
o Usually unilateral
o Most common among teenagers and young adults
o Often without preceding sore throat
o Less likely to get quinsy if given Abx
o Many quinsy without a preceding sore throat
- Otitis media
o Less likely to get OM if given Abx
o AOM starts without a preceding sore throat
- Glomerulonephritis
- Rheumatic fever
History
- Determine if patient has – a sore throat, a deep pain in the throat, or neck pain
o Ask patient to point to exactly where pain is
- Relevant associated symptoms such as:
o Metallic taste in mouth
19
o Fever
o Upper respiratory infection
o Other pains – ear pain, nasal stuffiness or discharge and cough
- Immunisation history – particularly diphtheria
Investigations
- Diagnosis aim to establish aetiology, Clinical signs can’t establish aetiology
- Swab
o Rotate swab on one tonsil, the other tonsil then the posterior pharyngeal wall
o Seldom are helpful – isolation of GABHS often represents asymptomatic carriage
Treatment
- Soothing fluids, including icy poles
- Analgesia –
o Adults – aspirin
o Children – paracetamol elixir or ibuprofen
- Corticosteroids on top of Abx in adults
o Dexamethosone 10mg parenteral once or
o Prednisolone/prednisone 60mg orally once
- Identify complicated illnesses
o Usually referral to hospital
- Identify uncomplicated patients at risk
o Existing RHD
o Patient with scarlet fever
o Patient 2-25 years with sore throat in communities with a high incidence of ARF
o Treat these with Abx
Antibiotic therapy
- Severe tonsillitis with features of GABHS (generalised red, swollen appearance with exudate – nb! This is similar to EBV
sore throat)
- Existing rheumatic disease
- Scarlet fever
- Peritonsillar cellulitis or abscess
à First line treatment – phenoxymethyl penicillin
à Amoxicillin should be avoided: As it present similarly to EBV
- Amoxicillin and EBV results in reaction (rash)
Possible reasons for antibiotics to parents with an uncomplicated illness

- Symptom relief and shorten duration
- Prevent non-suppurative complications
o Rheumatic fever, not glomerulonephritis
- Prevent suppurative complications
o Quinsy, otitis media
- Reduce spreading of bacteria
Croup
- Parainfluenza viruses = no antibiotics
- Coryzal prodrome, hoarseness, inspiratory stridor and a barking
cough
- Standard treatment – oral steroids
o Dexamethosone 0.15mg/kg
- Red flags:
o Stridor at rest + fatigue à Send to hospital
o Difficultly swallowing à Epiglottitis
o Atypical cough à Airway foreign body
20
Cough
History
- How would you describe the cough?
- Duration of cough been present?
- Presence of wheeze?
- Sputum? Colour and blood?
o How much sputum do you produce? A teaspoon full? Cup?
- Is there any chest pain? (GORD, pneumonia)
- Associated symptoms – SOB, wheeze, constitutional symptoms (fever and weight loss)
- Do you have wheeze?
- Significant occupations: Bar tender, Mining, Aircraft manufacturing, Farming – farmer’s lung – allergic pneumonitis
from mouldy hay, Bird handling – allergic alveolitis, or psittacosis
- PMHx of – recurrent lung infections from childhood
o Suggestive of cystic fibrosis and bronchiectasis
- Is there a history of asthma in the family?
- Weight loss?
- Do you smoke?
- Sinus problems?
- Pets – particularly birds
- Recent illness
- Recent overseas travel
- Medications e.g. ACEi
Sputum
- Normal – clear white (mucoid)
- Yellow or green (purulent) – infections, asthma, bronchiectasis
- Rusty – lobar pneumonia – due to blood
- Thick and sticky – asthma
- Profuse, watery – alveolar cell carcinoma
- Thin, clear mucoid – viral infection
- Profuse and offensive – bronchiectasis; lung abscess
- Pink frothy – pulmonary oedema
Red Flags
- Age >50 - Unexplained weight loss
- Smoking history - Dyspnoea
- Asbestos history exposure - Hoarseness
- Persistent cough - Systemic features e.g. fever, night sweats
- Overseas travel - Abnormal respiratory exam or CXR
- Haemoptysis
Aetiology
- Postnasal drip is the commonest cause of a persistent or chronic cough, especially causing nocturnal cough due to
secretions
- Viral respiratory coughs should last no more than 2 months
Most likely
- Upper respiratory infection
- Postnasal drip
- Smoking
- Acute bronchitis
- Chronic bronchitis
Not to miss
- Cardiovascular – left ventricular failure
- Neoplasia – lung cancer Bovine cough – explosive power is loss due to laryngeal paralysis
21
- Severe infections – tuberculosis, pneumonia influenza, lung abscess
- Asthma
- Cystic fibrosis
- Foreign body
- Pneumothorax
Pitfalls
- Atypical pneumonias - Pertussis
- GORD (nocturnal) - ILD
- Bronchiectasis - Sarcoidosis
Investigations
- Bedside: spirometry, sputum examination, pulse oximetry
- Bloods: FBC, CRP, ESR
- Imaging: CXR, bronchoscopy
- Other: skin hypersensitivity test, lung function tests
Acute: <3wks
- URTI: common cold, sinusitis
- Pneumonia
- Bronchitis
- COPD exacerbation
- Irritation: smoke, fumes
- Inhaled foreign body
Chronic: >8wks
- COPD
- Asthma
- GORD
- Rhinitis
- Postnasal drip
- Sinus headache
- Bronchiectasis
- ACEi
- Lung Ca/laryngeal Ca
Management
- Rest
- Drink copious fluids
- Analgesics – paracetamol or aspirin
- Steam inhalation if blocked sinuses (acute coryza)
- Safety net: make sure that patient is aware of the red flags and to come back if cough is worsening or not improved
over expected timeline
- Cough suppressants: usually unhelpful, however may use codeine for limited duration to break cycle
- Return if not improving for CXR
Indigenous vs non-Indigenous
- Controversy regarding antibiotic therapy for GAS pharyngitis
- However, populations at high-risk (such as Indigenous) should always have antibiotic treatment and culture
confirmation if available
22
Cause Comments
Acute cough
Acute bronchitis Commonly follows viral upper respiratory tract infection; in patients without underlying airway
disease, sputum is not a good guide to the need for antibiotics.
Asthma and asthma-like Uncontrolled asthma is a common cause of cough, but it is unusual for cough to be the sole
syndromes symptom
Drug-induced cough Common precipitants include ACEIs and beta blockers; there is not always a close temporal
relationship between starting a drug and development of cough.
Inhaled foreign body Sudden onset of cough, particularly if cough started while eating or, in a child, while playing
with small objects.
Chronic cough
Post-infective cough Follows an acute viral respiratory tract infection; may last up to 8 weeks.
Persistent bacterial The most common diagnosis in a child with purulent sputum and cough lasting for more than 4
bronchitis weeks.
Pertussis Consider if cough is persistent and paroxysmal, and lasting for 2 to 6 weeks or more
Gastro-oesophageal Consider if patient has symptoms such as heartburn or water brash, or if cough is worse at
reflux or night or after eating specific foods; diagnosis often made clinically or following a response to
laryngopharyngeal reflux empirical treatment.
Upper airway cough May be associated with excessive mucus production or with increased perception of normal
syndrome (previously volumes of postnasal mucus.
called postnasal drip)
Upper airway May be triggered by any other cause of cough and worsened by irritants such as gastro-
dysfunction (vocal cord oesophageal reflux, exposure to smoke or fumes, or excessive use of the voice.
dysfunction)
Obstructive sleep Inflammation of the pharynx from snoring may contribute to cough.
apnoea
Psychogenic or habit Particularly in children; cough not present during the night.
cough
Inhaled foreign body Sudden onset of cough, particularly if cough started while eating or, in a child, while playing
with small objects.
Tuberculosis Can present with or without sputum, fever and/or weight loss; consider in patients who were
born in or have visited countries where tuberculosis is endemic, or in patients with impaired
immunity.
Lung or laryngeal cancer Consider in smokers older than 45 years with a new cough, altered cough, or cough with voice
disturbance.
Recurrent aspiration Aspiration-prone people include patients with Parkinson disease, stroke, dementia, COPD,
impaired consciousness, or neuromuscular disorders affecting bulbar muscles.
Chronic bronchitis Productive cough, occurring every day for at least 3 months, at least 2 years in a row; occurs in
the majority of heavy smokers (more than 20 pack years [NB5]).
Bronchiectasis Productive cough and frequent chest infections
Interstitial lung disease Dry cough, often associated with shortness of breath
Cystic fibrosis Productive cough associated with gastrointestinal symptoms or failure to thrive
Drug-induced cough Common precipitants include ACEIs and beta blockers; there is not always a close temporal
relationship between starting a drug and development of cough.
23
Child with cough and SOB
History
- SOCRATES - Medication
- Triggers - Obstetric history: premature?
- Recent illness - Smoking in the household
- Do they cough anything up? What? How much? - Day care/school
- Wheezing, stridor - Asthma/allergies
- Sinus problems? - Hear cough: this can help with diagnosis
- SOB? - Eating/drinking?
- Previous lung conditions?
Red Flags
- Dyspnoea
- Chronic, wet or productive cough
- Systemic symptoms: rigors, fevers, night sweats
- Feeding difficulties
- Stridor or other respiratory noise
- Recurrent pneumonia
- Abnormal respiratory examination or CXR
24
Investigations
- Bedside: spirometry, sputum examination, pulse oximetry
- Bloods: FBC, CRP, ESR, ABG
- Imaging: CXR, bronchoscopy
- Other: skin hypersensitivity test, lung function tests
- Croup: laryngotracheobronchitis - URTI: viral infection, sinusitis
- Asthma - Inhaled irritants
- Pneumonia - Inhaled foreign body
- Pertussis - Cystic fibrosis
- Acute pharyngitis - TB
- Streptococcal pharyngitis (strep throat) - Epiglottitis
- Tonsillitis
Management
Croup
- Common cause of cough in children: barking cough, intercostal indrawing, stridor
- Normally worse at night and peaking around day 3
- DO NOT EXAMINE THEM AS IT MAY CLOSE OFF THEIR AIRWAY
- Inhaled corticosteroids (budesonide or dexamethasone or prednisolone)
- If there is persisting respiratory distress, also use adrenaline 0.1% (1:1000, 1mg/kg) 5mL nebuliser repeated every
30mins
- Assessment of severity:
Pneumonia
- Birth – 1mth
o benzylpenicillin 50mg/kg IV
o gentamicin IV
- 1mth – 3mth: azithromycin 10mg/kg orally 5/7
- 3mth+: amoxicillin 25mg/kg orally 5/7
Asthma
History
- Previous diagnosis of asthma
- Features Asthma triggers:
o Chronic cough - Infection
o Intermittent dyspnoea - Smoke
o Cough - Fumes
o Wheeze - Stress
o SOB - Exercise
o Sputum production
Red Flags
- Increased work of breathing: tracheal tug, indrawing of intercostal muscles, tripoding
- Reduced consciousness or collapse
- Exhaustion
- Unable to talk
- Decreased O2 sats
- Arrhythmia
- RR <25 breaths/min
- Seizures/syncope
- Previous hospital admissions
Aetiology
à No single cause has been found, but a checklist of factors include:
- A – allergies – pollens, animal dander, dust mites, mould
- B – bronchial infection
- C – cold air, exercise
- D – drugs – aspirin, NSAIDs, beta-blockers
- E – emotion – stress, laughter
25
- F – food – sodium metabisulphite, seafood, nuts, monosodium glutamate
- G – gastro-oesophageal reflux
- Hormones – pregnancy, menstruation
- I – irritants – smoke, perfumes, smells
- J – job – wood dust, flour dust, isocyantes, animals
Note – asthma should be suspected in children with recurrent nocturnal cough and in people with intermittent dyspnoea or chest
tightness, especially after exercise
Investigations
Acute
- Treat immediately
Chronic
- Bedside: spirometry, ABG
- Bloods: FBC
- Imaging: CXR if differentials need to be excluded
- Anaphylaxis
- MI
- Foreign body inhalation
Management
Six step asthma management plan
- Assess severity of asthma
- Achieve best lung function
- Avoid trigger factors
- Maintain best lung function with optimal medication
- Develop an individualised written action plan
- Educate and review regularly
Acute
- Assess need for acute management: looking for red flags. Assessing ability to continue increased effort of breathing
- Assess for need for intubation
- Children will fight you if they’re sick. Minimal handling required
26
Chronic
- Short action beta 2 agonist
o Salbutamol
o Terbutaline
- Inhaled corticosteroid
o Beclomethasone
o Budesonide
o Fluticasone propionate
o Fluticasone furoate
Other drugs which may be used

- Cromones: mast cell stabalisers
- Montelukast: Leukotriene receptor antagonist
- Anti-immunoglobulin E therapy
- Allergen immunotherapy
Non-drug intervention
- Breathing exercises
- Education about treatment, adverse effects, worsening asthma recognition
- Inhaler technique education
- Written asthma action plan
27
Chronic Obstructive Pulmonary Disease (COPD)
à Progressive development of airflow limitation that is not fully reversible.
à COPD should be diagnosed on the basis of symptoms and confirmed with spirometry
Symptoms
- Chronic cough
- Chronic sputum
- Shortness of breath
- Expiratory airflow obstruction leads to hyperinflation, particularly during exercise
o Peripheral airway obstruction progressively traps air during expiration, resulting in hyperinflation
o Hyperinflation reduces inspiratory capacity such that functional residual capacity increases, particularly during
exercise (dynamic hyperinflation)
- These factors contribute to impairment of the intrinsic contractile properties of respiratory muscles
- Significant lung function deterioration in the early stages of COPD make early diagnosis and intervention essential for
avoiding serious breathlessness that impacts on productivity and wellbeing
Risk factors
- >40 years of age
- History of smoking
- Occupation
- Indoor/outdoor pollution
Mild Moderate Severe

Lung Function ~60-80% ~40-59% <40% predicted
(FEV1)
Typical symptoms - Few symptoms - Increasing dyspnoea - Dyspnoea on minimal
- Breathless on - Breathless walking on level exertion
moderate exertion ground - Daily activities
- Recurrent chest - Increasing limitation of severely curtailed
infections daily activities - Experiencing regular
- Little or no effect on - Cough and sputum sputum production
daily activities production - Chronic cough
- Infections requiring steroids
Complications - None - Exclude complications - Severe hypoxaemia

- Consider sleep apnoea of - Pulmonary
there is pulmonary hypertension
hypertension - Heart failure
- Polycythemia
GOLD COPD Staging
Treatment
Aims
- Slowing accelerated decline in Respiratory function
- Relieving symptoms- SOB, cough
- Improving daily lung function
- Decrease exacerbation
- Improving QOL
28
Bronchodilators
- The primary physiological impairment in COPD is airflow limitation resulting from inflammation and remodelling of
small airways1,2
- Bronchodilators reduce bronchoconstriction and air trapping
- SABA e.g. salbutamol
- LABA e.g. salmeterol
- Long-acting muscarinic receptor antagonists (LAMA): Ipratropium bromide (Spiriva), Tiotropium
Long term oxygen therapy (LTOT)

- Improves mortality
- Improves pulmonary hypertension
- Low FIO2 aiming Sats>88%
- Increase FIO2 with exercise
Treatment of acute COPD exacerbation

- Oxygen therapy
- Confirm exacerbation (symptoms & Investigations)
- Bronchodilators (SABA or SAMA)
- Systemic Steroid
- Antibiotics
- Chest Physiotherapy and Breathing exercise
Acute Rhinitis
à Acute rhinitis (common cold) is a viral UTRI with inflammation and is caused by many organisms. Most commonly:
- Rhinovirus: 35%
- Coronavirus
- Adenovirus
- RSV
- Influenza
- Parainfluenza
- Coxsackie virus
History
- SOCRATES - Sneezing
- Age - Sore throat
- Stress - Conjunctivitis
- Smoking - Cough
- Fatigue - Malaise
- Sick contacts - Headache
- Nasal congestion - Fever
Investigations
- Nil necessary for uncomplicated URTI
- Viral throat swab: ?influenza
- Allergic rhinitis
- Pharyngitis
- Laryngitis
- Croup
- Sinusitis
- Bacterial infection
Management
- Patient education: may peak at 1-3 days and subside after about a week, will have a cough that may persist. Nil
antibiotics necessary. Secondary bacterial infection can present 3-10 days after onset of viral illness
- Prevention: frequent hand washing, avoid mucous membrane contact, have influenza vaccination annually
- Symptomatic relief: rest, hydration, gargle warm salty water, steam, nasal irrigation, analgesics and anti-pyretics, cough
suppression if necessary, decongestants
- If patient has COPD/asthma: increased use of bronchodilators and inhaled steroids
29
Acute bronchitis
à Short-term inflammation of the bronchi. This is most commonly caused by a viral infection (90%).
Aetiology
- Viral
o Respiratory syncytial virus
o Rhinovirus
o Influenza
- Bacterial:
o Mycoplasma pneumonia
o Chlamydophilia pneumonia
o Streptococcal pneumonia
o Haemophilius influenzae
à May also be caused by irritation to the bronchi due to smoke and polluation.
History
- SOCRATES
- Getting worse or better?
- Viral illness
- Sputum production
- Wheeze
- Fever
- SOB
- Malaise
- Chest discomfort
- Smoking
- Air pollution
Investigations
- Bedside: sputum sample
- Bloods: FBC
- Imaging: CXR (exclude pneumonia)
- Asthma
- Pneumonia
- Bronchiolitis
- Bronchiectasis
- COPD
Management
- Conservative management with increasing fluids
- Smoking cessation
- Expect improvement in days to weeks.
- Should not last longer than a month.
30
Sinusitis
History
- Previous sinusitis - Allergies
- Recent URTI - Asthma
- Headaches - Smoking
- Ear pain - Cocaine use
- Nasal congestion - Rhinorrhoea
Clinical diagnosis
à Can be made with 2+ of:
- Congestion
- Nasal discharge
- Facial pain
- Hyposmia/anosmia
Bacterial sinusitis is suspected with:

- Symptoms of rhinosinusitis lasting >1 week
- Plus ANY of the following:
o High fever lasting >3 days
o Purulent nasal discharge
o Sinus tenderness or maxillary toothache (particularly unilateral)
o Severe symptoms or worsening symptoms post-initial improvement
Chronic sinusitis:
à 2+ symptoms are present for ≥ 12 weeks:
- Nasal blockage, obstruction, or congestion
- Nasal discharge (either anterior or posterior nasal drip)
- Facial pain or pressure or headache
- Reduction or loss of smell
- There may also be observation of nasal polyps, oedema or purulent mucus in the middle meatus or ethmoid region, or
radiographic documentation of paranasal sinus inflammation
Complications
- Orbital cellulitis: erythema around eye
- Osteomyelitis
- Abscess formation
- Venous sinus thrombosis: abnormal vision, weakness of face and limbs, seizures
- Bacterial meningitis: neck stiffness, confusion, headache
Investigations
- Bloods: ESR, CRP
- Imaging: CT of paranasal sinuses
- Other: Sinus aspirations for cultures, nasal endoscopy
Management
Acute
- Analgesic and anti-pyretic
- Intranasal corticosteroids
- Saline nasal sprays
- If antibiotics are indicated:
o Amoxicillin 500mg (15mg/kg up to 500mg in a child) PO, 8hrly, for 5/7
Chronic: Prednisolone 25mg PO for 5-10/7
31
Gastrointestinal
Abdominal pain
32
Diarrhoea
- An increase in frequency of bowel action
- An increase in softness, fluidity or volume of stools
Types of diarrhoea:
- Secretory: high volume and persists with fasting. Caused by E coli, Staph aureus, Vibrio cholera, hormone conditions,
carcinoid syndrome and villous adenoma
- Osmotic
- Exudative: contain blood, inflammation of the colon is IBD or colon cancer
- Malabsorption: steatorrhoea
- Upper GI – tend to be copious, watery or fatty, pale yellow or green

- Colonic disorders – stools that are small, of variable consistency, brown and may contain blood or mucus
- Acute gastroenteritis should be regarded as a diagnosis of exclusion
- A history of travel, especially to countries at risk of endemic bowel infections, is essential
- Certain antibiotics cause an overgrowth of Clostridium difficile – produces pseudomembranous colitis
- Coeliac disease can present at any age
History
- Nature of stools
o Consistency and colour
o Blood and mucus
- Frequency of diarrhoea
- Associated symptoms – abdo pain and constitutional symptoms (fever)
- Food intake in past 72 hours
- Recent travel history
Acute Diarrhoea
- What foods have you eaten? Chicken or seafood?
o Chicken – Salmonella or Campylobacter
o Seafood – vibrio parahaemolyticus
- Did any other people get the same problem?
- Have you noticed any blood or mucus in your stools?
- Noticed any fever, weakness or other symptoms?
33
Chronic Diarrhoea
- Any blood or mucus?
- Travelled overseas?
- Do you have any pain? Is it relieved by opening your bowels or
passing wind?
- Are you taking antibiotics?
- How much alcohol do you drink?
- Do you take laxatives?
- Have you had any weight loss?
- Trouble with pain in your joints, back pain, eye trouble or mouth ulceration?
- Are you under a lot of stress?
General questions
- Age - Immunosuppression: corticosteroids, HIV/AIDS,
- SOCRATES chemotherapy
- Stool form - PPI or H2 antagonist
- Abdominal pain - Cancer
- Diarrhoea loss - Cancer screening
- Travel - Previous colonoscopy and results
- Child: daycare, waterpark - Nausea or vomiting
- Sick contacts - Change in diet
- Food and food preparation - Worse after food
- Medications - EtOH
- Intolerance: lactose, gluten - Had to race to the bathroom
- Fevers, rigors, chills - Recent antibiotics
- Blood or pus in stool - Faecal incontinence
- Stools oily, greasy, smell and float
Red Flags
- Blood in stool - Nocturnal diarrhoea
- Elderly - Reduced urine output
- >4wks - Fever, rigors, night sweats
- Unintentional weight loss
Investigations
- Bedside: DRE
- Bloods: FBC, LFTs, U&E, iron studies, vitamin B12, folate, CRP, TFTs
- Imaging: abdo x-ray, CT
- Other: faecal antigen test
- Gastroenteritis: viral, bactieral, parasitic - Poor digestion from disease of the pancreas
- Colorectal cancer - Ischemic bowel disease
- Hyperthyroidism - Alcoholism
- Lactose intolerance - Laxative abuse
- Inflammatory bowel disease: ulcerative colitis, - Diabetes
crohn’s disease - Bile salt malabsorption
- Medications: opioids, NSAIDS - Pseudomembranous colitis: C. difficile
- Irritable bowel syndrome
Serious disorders not to be missed

- Neoplasia – colorectal cancer, ovarian cancer, peritoneal cancer
- HIV
- Infections – cholera, typhoid/ paratyphoid, amoebiasis, malaria
- IBD
- Intussusception
- Appendicitis – in onset of acute diarrhoea and vomiting
34
Pseudomembranous colitis
- Profuse, watery diarrhoea
- Abdominal cramping and tenesmus
- Maybe fever
- Within 2 days of taking antibiotics (can start up to 4 - 6 weeks after usage)
- Persists 2 weeks (up to 6) after ceasing antibiotics
Malabsorption
- Bulky, pale, offensive, frothy, greasy stools
o Difficult to flush down toilet
- Weight loss
- Prominent abdomen (distension)
- Failure to thrive (in infants)
- Signs of multiple vitamin deficiencies
- Glossitis
- Anaemia (possible)
Coeliac disease
- Gluten-sensitive enteropathy – can occur at any age
- Most patients present with non-GIT symptoms, such as tiredness
- Autoimmune disorder – has lots of associated autoimmune disorders
- Mx – avoid gluten
Acute Gastroenteritis
- Acute onset – lasts less than 10 days
- Associated with fever, diarrhoea and/or vomiting, where there is no other evident cause for the symptoms
- Note – dehydration from gastroenteritis is an important cause of death, particularly in infants
Traveller’s Diarrhoea
- Very severe diarrhoea
o May be associated with blood or mucus – may be a feature of a more serious bowel infection such as
amoebiasis
- Persistent Traveller’s Diarrhoea – may indicate a protozoal infection such as amoebiasis giardiasis
Management
- Maintenance of hydration
- Antiemetic for severe vomiting
- Antimicrobial drugs if the specific organism is identified
o Only treat if symptoms continue for more than 48 hours
- Eat low fat foods
Diverticular disorder
- Problem of the colon (90% descending colon)
- Related to lack of fibre in diet
- Mx
o Usually responds to a high-fibre diet
o Avoid constipation
Coeliac Disease
- Usually presents 9 – 18 months, but any age
- Previously thriving infant, now failure to thrive
- Anorexia, lethargy, irritability
- Malabsorption – abdo distension, offensive frequent stools
Management
- Treat the underlying cause of diarrhoea if it can be identified
- The management is determined by the nature of the pathogen and the severity of the illness
35
- However, in Australia most cases are viral
- Basic principle – achieve and maintain adequate hydration until the illness resolves
- Oral rehydration solution – sodium, potassium and glucose
o Should be considered for patients with mild to moderate dehydration
o If severe dehydration – IV fluids
- Antimotility drugs – should be not readily given – only should be for short-term control of symptoms during periods of
significant social inconvenience, such as travel
For gastro – if diarrhoea continues/ worsens (over about 3 days) à do stool M/C/S
+ BRAT diet – bananas, rice, apples, toast
36
Constipation
- Infrequent passage of stools <3/week
- Passage of hard stools
- Straining >25% of the time
- Incomplete evacuation and sensation of anorectal blockage
However, emphasis should be on consistency of stool rather than frequency of defaecation
Alarm Symptoms
- Recent constipation in >40 years of age
- Rectal bleeding
- Family history of cancer
History
- SOCRATES - Blood
- Age of patient - Abdominal pain
- Does it feel like there is a blockage? - Recent weight loss
- Do you never need to use your fingers to help pass - Do you ever have diarrhoea?
a stool? - Hx or family hx of colonic polyps or cancer
- Has your bowel habits changed recently? - Pregnancy
- Change in medications - Straining
- How often do you go to the toilet? - Is there any pain on opening your bowls?
- What are the bowel motions like? - Have you noticed any blood?
- Stool consistency – bulky, hard, like rabbit pellets - Have you noticed any lumps?
or soft?
Red Flags
- Acute constipation - Rectal bleeding
- Rectal blood loss - FMHx of bowel cancer
- Weight loss - Weight loss
- Fever - Tenesmus
- Rectal pain - Rectal bleeding
- Change in stool calibre - Weight loss
- Anorexia, nausea and vomiting - Altered blood PR
- Family hx of IBD or colorectal Ca - Change in bowel habit
- >50yo - Abdominal pain
- Nil passing stool or gas - Mucous passed PR
- New onset in elderly patient - Anorexia
- Unexplained anaemia
Pitfalls
- Impacted faeces - Depressive illness
- Local anal lesions - Acquired megacolon
- Drug/ purgative abuse - Diverticular disease
- Metabolic – hypothyroidism, hypercalcaemia,
hypokalaemia
Aetiology
Chronic
- Psychogenic
o Depression
37
o Anorexia nervosa
- Neurological disease
o CAN
o Autonomic neuropathy
o Parkinson disease
- Drugs
- Endocrine/metabolic
o Hypothyroidism
o Hyerpcalcaemia
- Idiopathic constipation
o Simple constipation
o Slow transit constipation
o Irritable bowel syndrome
- Organise disease of large bowel
o Carcinoma colon
o Diverticular disorder
o IBD
Serious diagnosis not to be missed
- Intrinsic Neoplasia – colon, rectum or anus, especially colon cancer
- Extrinsic malignancy (e.g. lymphoma, ovarian cancer)
- Hirschsprung (children)
Investigations
- Bedside: stool sample
- Bloods: FBC
- Imaging: abdo x-ray, standing CXR
- Other: colonoscopy
Simple Constipation
- Commonest idiopathic constipation
- Essentially related to a faulty diet and bad habit
o Neglect of the call to stool, unfavourable living and working conditions, lack of exercise, travel
Faecal Impaction
- Solid, immobile bulk of faeces that can develop in the rectum as a result of chronic constipation
- Symptoms include: malaise, nausea, confusion, headache, abdominal discomfort, tenesmus and frequent amounts of
small stool
- Patient may have spurious diarrhoea – overflow incontinence
- Confirm with rectal examination +/- AXR
- Mx – oral or osmotic laxatives
Colorectal cancer
- Clinical features
o Blood in stools
o Mucus discharge
o Recent change in bowel habits (constipation more common than diarrhoea)
o Alternating constipation with spurious diarrhoea
o Tenesmus
o Abdo pain (colicky) or discomfort (if obstructing)
o Rectal discomfort
o Symptoms of anaemia
- Screening recommendations:
38
o Low risk - FOBT every 2 years for everyone 50 – 80 years
o Moderate risk – colonoscopy every five years from 50 years or 10 years younger than when a family member
presented
o High risk – year or 2 yearly colonoscopies commencing at 25 years, and every 12 months from 10 – 15 years of
age if a strong family history of FAP
Congenital Megacolon Hircschsprung disorder (aganglionsis)

- Form of megacolon that occurs when part or all of large intestine have no ganglion cells and therefore cannot function
à results in constipation
- Clinical features:
o Congenital
o Constipation from infancy
o Abdominal distension from infancy
o Possible anorexia and vomiting
o Male to female ratio = 8:1
o Rectal exam – narrow or normal rectum
o Diagnosis – confirmed by full thickness biopsy, showing absence of ganglion cells
o Absent rectoanal reflex on anal manometry
Acquired Megacolon
- Megacolon – abnormal dilation of colon, often accompanied by paralysis of peristaltic movement
- Clinical features
o In older children and adults
o Mainly due to bad habit
o Can be caused by:
§ Chronic laxative abuse
§ Milder form of Hircschsprung disorder
§ Chagas disease
§ Hypothyroidism (cretinism)
§ Systemic sclerosis
Management
Lifestyle
- Adequate exercise, especially walking
- Develop good habit – answer the call to defecate as soon as possible
- Avoid laxatives and codeine compounds
- Take plenty of fluids, especially water and fruit juices (e.g. prune juice)
- Eat an optimal bulk diet – vegetables and salads, cereals, fresh and dried fruit, whole meal bread
Pharmacological
- First-line – general bulking agent
- Second-line – use an osmotic laxative or a fibre-based stimulant preparation
39
Rectal Bleeding
History
- Age
- Duration
- Pain
- Constipation
- Diarrhoea
- Colour
- Family hx of colorectal Ca
- Previous colonoscopy?
- Fever
- Night sweats
- Mucus?
- How much blood?
- Timing?
- Previous fissure or haemorrhoids
Investigations
- Bloods: FBC
- Imaging: Abdo x-ray – erect and supine, CT
- Other: endoscopy and colonoscopy, barium swallow
- Colorectal cancer
- Angiodysplasia
- Diverticular disease
- Anal fissure
- Haemorrhoids
- Polyp
- Inflammatory bowel disease
- Meckel’s diverticulum
- Small bowel disease: tumour diverticula, intussusception
- Haemophilia: bleeding from the gallbladder
Screening
- Colorectal cancer screening involves a FOBT is recommended
for asymptomatic people of average risk in the population
from 50 years old every two years until the age of 75 with
repeat negative findings.
- Increased risk screening involves a colonoscopy every five
years from 50 years old or at an age 10 years younger than the
age of the first people diagnosed in the family.
- High risk people are recommended genetic screening, referral to a bowel cancer specialist, flexible sigmoidoscopy or a
colonoscopy.
- FAP: every 12 months between 12-35yo and every 3 years after 35
Management
Colorectal cancer
- Colonoscopy
- Surgical intervention and adjunct therapy if appropriate
Angiodysplasia
- Small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding
and anaemia. Lesions are often multiple, and frequently involve the cecum or ascending colon.
- Diagnosis: endoscopy or colonoscopy
- Blood transfusion if blood loss is significant
- Cautery or argon plasma coagulation therapy through endoscopy
Anal fissure
- Avoid hard stools: increase fibre, use bulking agents
- Glyceryl trinitrate 0.2% ointments PR
40
- Local injection of botulism toxin
- Lateral sphincterotomy may be performed if the fissure in non-healing
Haemorrhoids
- Increase fibre intake
- Avoid straining at stool
- Respond to the urge to defecate and do not try to initiate defecation without this
- Rubber band ligation if repeated bleeding is occurring
Pruritis Ani
à Itching of the anus
- Often worse at night, during hot weather and exercise
Aetiology
- Psychological factors:
o Stress and anxiety
o Fear of cancer
- Generalised systemic or skin disorders:
o Seborrhoeic dermatitis
o Eczema
o Diabetes mellitus
o candidiasis
o Psoriasis (look for fissures in natal cleft)
o Antibiotic treatment
o Worms: pinworm (threadworm)
o Diarrhoea causing excoriation
- Local anorectal conditions:
o Piles
o Fissures
o Warts
- Zealous hygiene
- Contact dermatitis:
o Dyed or perfumed toilet tissue, soap, powder
o Clothing
- Excessive sweating (e.g. tight pantyhose in summer)
Diagnosis
- Urinalysis (?diabetes)
- Anorectal examination
- Scrapings and microscopy to detect organisms
- Stool examination for intestinal parasites
Treatment
- Treat the cause (if known).
- Avoid local anaesthetics, antiseptics.
- Advise aqueous cream to wash anus (instead of soap).
41
Gastroenteritis
à Inflammation of the gastrointestinal tract causing diarrhoea, vomiting and abdominal pain. It may be caused by viruses,
fungus, bacteria, parasites and non-infectious causes such as celiac and lactose. The most common cause of gastroenteritis is
viruses.
History
- SOCRATES - Intolerance: lactose, gluten
- Diarrhoea and vomiting loss - Fevers
- Stool form - Diarrhoea
- Travel - Vomiting
- Child: daycare, waterpark - Blood or pus in stool
- Sick contacts - Immunosuppression: corticosteroids, HIV/AIDS,
- Food and food preparation chemotherapy
- Medications - PPI or H2 antagonist
Red Flags
- Febrile - Severe abdominal pain
- Tachycardia - High-volume diarrhoea
- Leucocytosis - Hypovolaemia
- Abdominal tenderness - Blood in stool
Aetiology
- Children: rotavirus (60%), norovirus, adenovirus, E. coli, Salmonella, Shigella, protozoa (Giardia lamblia Entamoeba
histolytica, Cryptosporidium)
- Adults: Norovirus (cruise ships, hospitals, restaurants), Camptylobacter jejuni
- Elderly: Clostridium difficile often associated with antibiotic use
- Travel: Staph aureus
- Non-infectious: NSAIDS, lactose, celiac disease, Crohn’s disease
Management
- Fluid therapy
- Electrolyte replacement
- Empirical antibiotics
o Ciprofloxacin 500mg (child: 12.5mg/kg up to 500mg) orally once daily for 3/7
or
o Norfloxacin 400mg (child: 10mg/kg up to 400mg) orally daily for 3/7
- Giardia: Metronidazole 2g for 3/7
- Entamoeba histolytica: Paromomycin 500 mg (child: 10 mg/kg up to 500 mg) orally, 8-hourly for 7 days
- Clostridium difficile: Metronidazole 400mg for 10/7
à Empirical antibiotic therapy is generally indicated when bacterial infection is suspected in patients who have clinical features
suggesting severe disease (such as high fever, tachycardia, leucocytosis, abdominal tenderness or severe abdominal pain, high-
volume diarrhoea with hypovolaemia, blood in the stool).
à Antibiotic therapy is not recommended in children with bloody diarrhoea without fever, due to the potential for precipitating
haemolytic uraemic syndrome if the infection is caused by enterohaemorrhagic Escherichia coli.
42
GORD
History
- Heartburn - CNS depressants: opioids
- Regurgitation - Pregnancy
- Dysphagia - Worse after food
- Atypical chest pain - Better with alkaline food such as milk
- Alcohol - Worse with spicy food, carbonated food and
- Smoking caffeine
- Obesity - Worse on lying down
Red Flags
- Anaemia
- Dysphagia
- Haematemesis and/or malaena
- Vomiting
- Weight loss
Other indications for an endoscopy:

- New or changing symptoms
- New presentation in an old person
- Severe/frequent
- Inadequate response to treatment
- Diagnostic clarification
43
- Chemical, infectious, drug-induced or eosinophilic oesophagitis
- PUD, Barrett’s oesophagus
- MI, angina etc
- Achalasia
- Distal oesophageal spasm
Management
Non-pharmacological:
- Eating smaller meals
- Drinking fluids mostly between meals rather than with meals
- Avoiding lying down after eating
- Avoiding eating or drinking for 2 to 3 hours before bedtime or vigorous exercise
- Elevating the head of the bed (if symptoms occur at night)
- Stopping smoking
Pharmacological
1. Antacid
2. Alginate preparation 10-20mL PO PRN
3. Magnesium hydroxide plus aluminium hydroxide prep 10-20mL PO PRN
4. H2-receptor antagonist
o Ranitidine 150mg PO BD
o Famotidine 20mg PO BD
5. Proton pump inhibitor
o Esomeprazole 20mg PO
o Omeprazole 20mg
o Pantoprazole 40mg
6. Laparoscopic fundoplication
Dyslipidaemia
à Presence of an abnormal lipid/lipoprotein profile in the serum
- Classified as
o Predominant hypertriglyceridemia
o Predominant hypercholesterolemia
o Mixed pattern with elevated cholesterol and triglyceride
- Elevated plasma cholesterol causes pathological changes in the arterial wall -à CAD
- Major CAD risks
o Increased LDL and decreased HDL cholesterol
o Ratio LDLC/HDLC >4
History
- Aboriginal or Torres Strait Islander - Erectile dysfunction
- Smoking - Inflammatory disease
- Diabetes - HIV
- Hypertension - COPD
- Family history - Atherosclerosis
- CKD - Obesity
Screening Guidelines
- <45 or <35 for ATSI with fasting lipids tested every 5 years. Lipid levels should be interpreted in the context of an
absolute CVD risk assessment.
Investigations
- Bloods: Fasting lipids
o Serum triglyceride level
o Serum cholesterol level and HDL LDL levels
o TFT
- Imaging
- Other
44
Secondary causes of dyslipidaemia:
- Familial hypercholesterolemia
- Increased LDL
o Hypothyroidism
o Nephrotic syndrome
o Cholestasis
o Anorexia nervosa
- Increased triglycerides or decreased HDL
o T2DM
o Obesity
o Renal impairment
o Smoking
- Drug therapy
o Increased triglycerides and increased HDL
o Alcohol use
o Oestrogen use
Investigations
- Serum triglyceride level
- Serum cholesterol: HDLC, LDLC
- TFT
à Confirm an initial high result with a second test 6-8 weeks later
Management
Health behaviours
- Smoking cessation
- Dietary modification
- Physical activity
Pharmacological
- Statin e.g. Atorvastatin 10-80mg
- Ezetimibe
- Bile acid binding resins: not appropriate in moderate to severe hypertriglyceridaemia
- Nicotinic acid: poorly tolerated, with flushing, gastric irritation, gout and impaired glucose tolerance
- Fibrates: increased risk of myositis when combined with a statin
Vitamin B12 Deficiency

Aetiology
- Vegetarian/vegan
- Pernicious anaemia: intrinsic factor deficiency
- Malabsorption in ilium
- PPI use
- Malnutrition and alcoholism
- Eating disorder
45
Clinical features
- Anaemia symptoms o Depression
o Weakness o Irritability
o Fatigue o Peripheral neuropathy
o Palpitations o Mania
o SOB o Psychosis
o Pallor o Memory loss
- GIT symptoms o Ataxia
o Diarrhoea - Other
o Constipation o Tongue inflammation
o Loss of bladder or bowel control o Decreased taste
o Poor growth and development
o Easy bruising, bleeding
o Bleeding gums
- Neurological symptoms
Investigations
- Bloods: FBC, vitamin B12, iron studies
- Autoantibodies: Anti-parietal Cell Antibody, anti-intrinsic Abs
- Intrinsic factor test
- Iron deficiency
- Depression
- Dementia
- Diabetes
- Alcohol intoxication
- Schizophrenia
- Leukaemia
- Thiamine deficiency
Management
Acute
- Hydroxocobalamin 1mg IM, on alternate days for 2 weeks
- For severe anaemia or neurological symptoms, give supplementation immediately.
Maintenance therapy
à Generally life-long therapy is required
- hydroxocobalamin 1mg IM, once every 2 to 3 months
o or (if absorption is not impaired)
- Cyanocobalamin 50 to 200 micrograms orally, daily between meals
- Serum iron can fall after 1 to 2 days; iron supplementation may be required.
- Potassium supplementation may also be required.
à Haemoglobin usually increases by about 10 g/L per week. Neuropathy improves slowly with therapy; patients with a long
history of neurological symptoms may have residual defects
Thiamine Deficiency
History
- Age
- Alcoholism: alcohol history
- Diet/Malnourishment: eating disorder, dementia, elderly
- Previous Wernicke’s
- Bariatric surgery
Examination
- Neurological & gastrointestinal examinations
- Mini mental state examination
- Wernicke’s encephalitis classical triad:
46
o Ophthalmoplegia: later expanded to other eye movement abnormalities, most commonly affecting the lateral
rectus or any eye sign. Lateral nystagmus is most commonly seen although lateral rectus palsy, usually
bilateral, may be seen.
o Ataxia: later expanded to imbalance or any cerebellar signs
o Confusion: later expanded to include other mental changes
Investigations
- Bedside: vitals, ECG
- Bloods: Erythrocyte thiamine disphosphate level, ABGs looking at possible metabolic acidosis
- Imaging: Echo
- Other: mini mental state examination, alcohol withdrawal scale
- DKA
- Delirium
- Dementia
- Stroke
- Intoxication
- Psychosis
Management
- Thiamine 100 mg PO daily
o Higher dose to begin with
o Always give thiamine before administering glucose for hypoglycaemia to patients at high risk of thiamine
deficiency, because glucose may further deplete thiamine stores and precipitate Wernicke encephalopathy.
- Promote increase in dietary thiamine. Foods high is thiamine include:
o Whole grain cereals, rice, beans, chickpeas, lentils, peas, vegetables
Watch for complications:

- Wernickes encephalopathy
- Alcohol induced brain injury
- Cardiac complications: cardiomyopathy, cardiomegaly, heart failure
- Peripheral neuritis
- Untreated thiamine deficiency will lead to death
47
Haematology
Anaemia
Iron Deficiency Anaemia

Aetiology
- Deficiency: Vegetarian/vegan
- Malabsorption
o Coeliac disease
o Pernicious anaemia
o Gastrostomy
- Excess use/loss
o Pregnancy
o Breastfeeding
o Menstruation loss
o GIT loss
- Toddlers and adolescents periods of rapid growth
Red Flags
- Iron deficiency anaemia in someone over 65 is colorectal cancer until proven otherwise
o DO A DRE AND COLONOSCOPY.
Clinical features
- Fatigue
- SOB
- Pallor
- Palpitations
- Weakness
- Pica
Investigations
- Bedside: DRE, ECG
- Bloods: FBC, iron studies, vitamin B12
o Low serum ferritin
o Microcytic anaemia
48
- Other: colonoscopy, endoscopy
- Other anaemias: vitamin B12 deficiency, anaemia of chronic disease, alcoholic anaemia, thalassemia, sideroblastic,
chronic renal disease
- Hypothyroidism
- Diabetes
- Chronic fatigue
Management
- Oral supplementation
- Elemental iron 100-210mg (child 3-6mg of elemental iron/kg/day up to 210mg) PO daily
- Parenteral iron supplementation
Bruising and bleeding

Systemic bleeding disorders
- Vascular
o Inherited
§ Hereditary haemorrhagic telangiectasia
§ Marfan syndrome
o Acquired:
§ Infection (e.g. meningococcus, measles, dengue)
§ Purpura simplex
§ Senile purpura
§ Henoch–Schönlein purpura
§ Steroid purpura
§ Scurvy
- Coagulation factor deficiency or inhibitor
o Inherited
§ Haemophilia A
§ Haemophilia B
§ vWD
o Acquired:
§ Disseminated intravascular coagulation
§ liver disease
§ Vitamin K deficiency
§ Oral anticoagulant therapy or overdosage
- Thrombocytopenia
o Inherited:
§ Amegakaryocytic thrombocytopenia
o Acquired:
§ Immune
• Immune thrombocytopenic purpura
• Drug-induced thrombocytopenia (e.g. heparin)
• thrombotic thrombocytopenic purpura
• Post-transfusion purpura
§ Non-immune
• Disseminated intravascular coagulation
• Bone marrow replacement or failure
• Splenic pooling
- Functional platelet disorders
o Inherited
§ Bernard–Soulier syndrome
§ Storage pool deficiency
o Acquired
§ Drug-induced (e.g. aspirin, NSAIDs)
§ Uraemia
§ Myeloproliferative disorders
§ Dysproteinaemias
49
Haemophilia
à Impaired ability to form blood clots resulting in increased bleeding
- Usually mild but can lead to severe joint and internal bleeding
Types
- Haemophilia A: Deficiency clotting factor VIII
- Haemophilia B: Deficiency of factor IX
- Both are x linked recessive disorders
Clinical features
- Mild: increase in bleeding but typically minor
o Caution needed for surgery and serious trauma
- Internal bleeding
Diagnosis
- Normal BT, PT, TT
- Prolonged PTT
Treatment
- Factor VIII and IX replacement
Disseminated intravascular coagulation (DIC)

à Widespread activation of the clotting cascade that results in the formation of blood clots in the small BV
à As all the clotting factors and platelets are consumed which then results in severe bleeding
- Results in compromised blood flow à Widespread multiorgan damage
Aetiology
- Solid tumours and blood cancers
- Obstetric complications: abruptio placentae, pre-eclampsia, eclampsia, amniotic fluid embolism
- Massive tissue injury: severe trauma, burns, hyperthermia, rhabdomyolysis
- Sepsis
- Transfusion reactions
- Severe allergic/toxic reactions
Treatment
- Treat underlying condition
- If severe: platelet and FFP transfusion
Immune thrombocytopenic purpura (ITP)

à Type of thrombocytopenic purpura defined as isolated low platelet count with normal bone marrow and absence of other
causes of thrombocytopenia
à Autoimmune disease with antibodies detectable against several platelet surface antigens
Clinical features
- Purpuric rash, bruising, petechiae
o Most commonly extremities, gums, menorrhagia
- Increased tendency to bleed
- Severe cases
o SAH
o ICH
o Lower GIT bleed
Diagnosis
à Diagnosis of exclusion
- Low platelet count
- Bone marrow biopsy may also be required
- Bone marrow examination
- Need to ensure no blood abnormalities other than low platelet count or no physical sings other than bleeding
- Secondary causes should be excluded e.g. leukaemia, vWD, antiphospholipid syndrome
Types
- Acute condition: children
50
o Often follows an infection
o Spontaneous resolution within 2 months
- Chronic condition: Adults
o Persists longer than 6 months
o Specific cause unknown
Management
- Mild
o Careful observation
- Moderate-severe
o Corticosteroids
o Intravenous Ig: can decrease rate at which macrophages consume antibody-tagged platelets
o Anti-D Ig
o Immunosuppressive drugs
- Splenectomy: Those that are unresponsive to steroid treatment
Thrombotic thrombocytopenic purpura (TTP)

à Rare disorder resulting in extensive microscopic clots to form in the small blood vessels throughout the body resulting in low
platelet counts
- Thrombotic damage to kidneys, heart, brain and CNS can result
- Due to antibody activation of the immune system resulting in inhibition of ADAMSTS13 enzyme which suppresses the
immune system
- Idiopathic
Clinical features
- Fever
- Changes in mental status
- Thrombocytopenia
- Reduce kidney function
- Haemolytic anaemia
- Hypertension
Treatment
- Supportive
- Plasmapheresis: exchange transfusion – removal of the patient’s blood plasma and replacement with donor plasma
- Transfusion contraindicate: fuels coagulopathy
51
Leukaemia
Acute leukaemia
Clinical features
- General constitutional e.g. malaise
- Symptoms of anaemia
- Susceptibility to infection e.g. sore throat, mouth ulceration, chest infection
- Easy bruising and bleeding e.g. epistaxis, gingival bleeding
- Bone pain (notably in children with ALL) and joint pain
- Symptoms due to infiltration of tissues with blast cells (e.g. gingival
hypertrophy in AML)
- Variable enlargement of liver, spleen and lymph nodes
- Bone tenderness, especially sternum
Diagnosis
- FBE and film: normochromic/normocytic anaemia; pancytopenia with
circulatory blast cells; platelets: usually reduced
- Bone marrow examination
- PCR studies
- Cytogenetics
Chronic myeloid leukaemia (CML)
Clinical features
- A disorder of middle age, typically 40–60 years
- Insidious onset
- Constitutional symptoms: malaise, weight loss, fever, night sweats
- Symptoms of anaemia
- Splenomegaly (very large)
- Priapism
- Gout
Diagnosis
- Markedly elevated white cell count (granulocytes)
- Marked left shift in myeloid series
- Presence of Philadelphia chromosome
Chronic lymphocytic leukaemia (CLL)
- A disorder of late middle age and elderly

- Insidious onset
- Constitutional symptoms: malaise, weight loss, fever, night sweats
- Lymphadenopathy—neck, axilla, groin (80%)
- Moderately enlarged spleen and liver (about 50%)
- Mild anaemia
Diagnosis
9
- Lymphocytosis >15 × 10 /L
- ‘Mature’ appearance of lymphocytes, smudge cells
- Consider cytogenetics
Lymphoma
Hodgkin’s Lymphoma
- Painless (rubbery) lymphadenopathy, especially cervical nodes
o Alcohol-induced pain in any enlarged lymph nodes
- Constitutional symptoms (e.g. malaise, weakness, weight loss)
- Fever and drenching night sweats—undulant, Pel–Ebstein fever
52
- Pruritus
- Possible enlarged spleen and liver
Diagnosis
- Lymph node biopsy with histological confirmation.
- FBC
- CXR, CT/MRI (to stage)
- Bone marrow biopsy, functional isotopic scanning
Non-Hodgkin’s Lymphoma
à Heterogeneous group of cancers of lymphocytes derived from the malignant clones of B or T cells.
- Painless lymphadenopathy—localised or widespread
- Constitutional symptoms possible, especially sweating
- Extra nodal sites of disease
o e.g. CNS, bone, skin, GIT
- Possible enlarged liver and spleen
- Possible nodular infiltration of skin
Diagnosis
- Lymph node biopsy.
- CXR and CT abdomen to stage.
Multiple Myeloma
- Clonal malignancy of the differentiated β lymphocyte—the plasma cell
- Mean age of presentation being 65 years.
- The classic presenting triad in an older person is anaemia, back pain and elevated ESR which helps to differentiate it
from monoclonal gammopathy of uncertain significance (MGUS).
- Other investigations include serum protein electrophoresis and immunofixation, Sestamibi scan.
Clinical features
à Old CRAB IN
- Elderly
- Elevated Calcium
- Renal failure
- Anaemia
- Bone lesions
- Infection
- Neurological symptoms e.g. weakness, confusion, fatigue
Diagnosis
- Paraprotein in serum (on electrophoresis)
- Bence–Jones protein in urine
- bony lytic lesions on skeletal survey
Treatment
- Chemotherapy: 3–4 year median survival.
53
Neurology
Headache
History
- Pain – SOCRATES
- Do you notice any other symptoms when you get the headache?
o Nausea, vomiting
o Vision changes, blurriness
o Photophobia
o Dizziness, weakness
o Runny nose, watering eyes
- Recent high temperatures, fever, illnesses
- Recent sinusitis
- Recent trauma
Examination
- Inspect the head, temporal arteries and eyes
- Palpate the temporal arteries, facial and neck muscles, the cervical spine and sinuses, the teeth and
temporomandibular joints
- Particularly search for meningeal irritation and papilloedema
- Also do a mini mental state examination
- Neurological examination includes:
o Assessment of visual fields and acuity, reactions of the pupils and eye movements
o Sensation and motor power in the face, and limbs and reflexes
Aetiology
- Many headaches previously considered to be tension are
secondary to disorders of the neck, eyes, teeth,
temporomandibular joints or other structures
- Drug-induced headaches are common
- In children – triad of: dizziness, headache and vomiting à indicates
medulloblastoma of posterior fossa until proven otherwise
- Cerebral tumour of adult – typical triad: headache, vomiting and
convulsions
Common
- Acute : Respiratory infection
- Chronic : Tension-type headache, combination headache, migraine, transformed migraine
Not to miss
- Cardiovascular:
o Subarachnoid haemorrhage, intracranial haemorrhage, carotid or vertebral artery dissection, temporal
arteritis, cerebral venous thrombosis
- Neoplasia: Cerebral tumour, pituitary tumour
- Severe infections: Meningitis, encephalitis, intracranial abscess
- Haematoma – extradural/ subdural
- Glaucoma
- Increased ICP: Benign intracranial hypertension
Types/Causes of Headaches
Tension-Type Headache
- Typically a symmetrical tightness
- Tend to last for hours and recur each day
- Associated with cervical dysfunction and stress or tension
- Mx –
o Counselling and relaxant advice
o Advise and demonstrate massage of the affected area
o Medication – mild analgesics such as aspirin or paracetamol
54
Migraine
- Unilateral location, pulsating quality
- Aura
- Nausea and/or vomiting, photophobia and phonophobia
- Can have specific triggers – foods, alcohol, glare or bright light, emotional stress, head trauma, climatic change, strong
perfume, stress, exercise, hormonal changes, the pill may exacerbate migraines
- Mx –
o Reassure patient of benign nature of migraines
o Avoid known trigger factors – main way to treat
o Relaxation programs
- Acute attack – Mx
o Rest in a dark, quiet, cool room
o Place cold packs on forehead or neck
o Aspirin or paracetamol + antiemetic
Cluster Headache
- Occurs in paroxysmal clusters of unilateral headache that typically occur nightly
- Over or about one eye, always same side à can radiate frontal and temporal regions
- Quality – severe
- Offset – spontaneous
- Associated features – rhinorrhoea, lacrimation; flushing of forehead and cheek; redness of ipsilateral eye
- Mx
o Consider 100% oxygen – 20 minutes
o Metoclopramide (antiemetic)
o Avoid alcohol during cluster
Combination headache
- Relatively constant pain lasting for many days – have a mix of components such as:
o Tension, depression, cervical dysfunction, vascular headache and drug dependence
Acute ‘Thunderclap’ Headache

- Enlarging aneurysm
- SAH – pain is typically occipital, localised at first then generalised
- Meningitis – headache is generalised – especially in presence of fever, neck stiffness, and malaise
Chronic Headaches
- Space-occupying lesions including subdural haematomas
- Temporal arteritis
- Benign intracranial hypertension
Note – although some patients experience headache with TIAs, it is not a distinguishing feature
Vomiting is suggestive of a migraine over a cerebrovascular accident
Cervical Dysfunction/ Spondylosis

- Headache from neck disorders
- Can be caused by abnormalities in any structure innervated by the upper two cervical nerves C2, C3
- Pain usually occipital, with possible radiation to parietal region, vertex of skull and behind eye
TA – Temporal Arteritis
- Persistent, unilateral throbbing headache
- Treatment – oral corticosteroids – start immediately to prevent permanent blindness
- ESR doesn’t necessarily need to be raised
Frontal Sinusitis
- May not have an obvious URTI or vasomotor rhinitis
- Some patients don’t have signs of nasal obstruction or fever
55
- Typically, a frontal or retro-orbital headaches
Raised ICP
- Generalised headache, usually worse in morning
- Later associated with drowsiness and vomiting Tumour, Subdural, extradural haematomas
- Aggravated by – coughing, sneezing, straining at toilet
Benign intracranial hypertension

nd th
- Usually occurs in young obese women from their 2 – 5 decades
- Considered to be due to a disturbance in the CSF circulation
o LP shows increased CSF pressure
- Features – headache, blurring vision and obscurations
Management of headache if investigations are negative

- Definition – medication condition characterised by chronic widespread pain and heightened pain response to pressure
- Pain relief – NSAID, Paracetamol, Aspirin
o Also stress not to overuse – otherwise could cause headaches!
- Preventative treatment
- Other features
o Female to male ratio = 4:1
o Usual age onset 29 – 37 years
o Poor sleep pattern
o Dematographia
o Fatigue – similar to chronic fatigue syndrome
o Psychological disorders e.g. anxiety, depression, tension headache
- Very difficult to treat and usually unresponsive in the long term to passive physical therapy or injections
- Patients require considerable explanation, support and reassurance
- Attention to sleep disorders, stress factors and physical factors
- Relaxation program
- Rehabilitation exercise program (e.g. walking, swimming or cycling)
Dizziness and vertigo

- Need to define what dizziness means to the patient.
- Vertigo: sensation of circular motion of the body or the
surroundings.
- Giddiness: uncertainty or light-headedness, this is typical of a
psychoneurotic cause
- Syncopal episodes: dizziness or lightheadedness with the
sensation of impending fainting or LOC.
History
- Age
- Is it vertigo or pseudovertigo?
- Symptom pattern:
o Effect of position and change of posture?
o Continual or paroxysmal?
- Other symptoms
o Visual disturbances
o Neurological symptoms
o Nausea or vomiting
o Any aural symptoms?
o Tinnitus? Deafness?
- Head injury or trauma to ear
- Any symptoms of psychoneurosis?
- Recent colds
- Drug history including illicit drugs
56
Examination
- ENT examination
o ear disease:
§ auroscopic examination: ?wax ?drum
§ hearing tests
§ Weber and Rinne tests
o Eyes:
§ visual acuity
§ test movements for nystagmus
- Cardiovascular examination
o evidence of atherosclerosis
o blood pressure: supine, standing, sitting
o cardiac arrhythmias
- Neurological examination
o cranial nerves II, III, IV, VII and VIII most important
o the cerebellum or its connections:

§ gait
§ coordination
§ reflexes
§ Romberg test
§ finger nose test: ?past pointing
- Hallpike manoeuvre: head positional testing to induce vertigo or nystagmus
- Blood pressure sitting, standing and lying
Investigations
- Bedside: ECG/holter monitor, VBG
- Bloods: FBC, BGL
- Imaging: CT, MRI (acoustic neuroma)
- Other: audiometry, visual evoked potentials (MS)
à The most common causes are postural hypotension and hyperventilation.
- Anxiety hyperventilation - Neoplasia: acoustic neuroma, posterior fossa
- Postural hypotension tumour, other brain tumour
- Vasovagal - Intracerebral infection
- Vestibular neuronitis: acute vertigo, nausea, - Cardiovascular: arrhythmia, MI, aortic stenosis
vomiting - Cerebrovascular: vertebrobasilar insufficiency,
- Acute labyrinthitis: acute vertigo, nausea, brain stem infarct
vomiting, hearing loss and tinnitus - Multiple sclerosis
- Benign paroxysmal vertigo - Ear wax
- Motion sickness - Drugs
- Post head injury - Menieres disease: tinnitus, vertigo, hearing loss
- Cervical dysfunction/spondylosis (sensorineural
- Peripheral disorders
o Labyrinth
§ Labyrinthisis: viral or suppurative
§ Meniere syndrome
§ Benign paroxysmal positional vertigo (BPPV)
§ Drugs
§ Trauma
§ Chronic suppurative otitis media
o Eighth nerve
§ Vestibular neuronitis
§ Acoustic neuroma
§ Drugs
o Cervical vertigo
- Central disorders
o Brain stem (TIA or stroke)
§ Vertebrobasilar insufficiency
• Vertebrobasilar insufficiency
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• Infarction
§ Cerebellum
• Degeneration
• Tumours
§ Migraine
§ Multiple sclerosis
- A sudden attack of vertigo in a young person following a recent URTI is suggestive of vestibular neuronitis.
- Dizziness is a common symptom in menopausal women and is often associated with other features of vasomotor
instability.
- Phenytoin therapy can cause cerebellar dysfunction.
- Postural and exercise hypotension are relatively common in the older atherosclerotic patient.
- Acute otitis media does not cause vertigo but chronic otitis media can, particularly if the patient develops a
cholesteatoma, which then erodes into the internal ear causing a perilymphatic fistula.
Hallpike Manoeuvre
- Patient looks at about 45 degrees at you
- Then lower the patient down so they are supine, and the neck is
extended about 30 degrees
o Patient’s head should not be on the examination table
- Keep the patient’s head at 45 degrees
- Keep patient in this position for up to a minute
- See if there is any nystagmus
Management
- Symptomatic relief from acute vertigo:
- Anti-emetics: prochlorperazine, metoclopramide
- Anti-histamine: promethazine, bethhistine
- Benzodiazepines (short-term use): diazepam, lorazepam
Tiredness
History
- Length
- Timing
- Exacerbating factors
- Depression: screen for anhedonia, feeling down, depressed or hopeless, appetite, trouble concentrating and thoughts or
plans of suicide
- Recent blood loss
- Abdominal bleeding: frank rectal bleeding, black stools, stomach ulcers, Mallory-Weiss tears (alcohol consumption)
- Previous medical hx: hypothyroidism, anaemia
o Hypertension, obesity, diabetes (risk factors for chronic kidney disease)
- Social hx: diet including vegetarianism
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Red Flags
- Recent onset in previously well older patient
- Unintentional weight loss
- Abnormal bleeding
- SOB
- Unexplained lymphadenopathy
- Fever
Examination
- Thyroid examination
- Haematological examination
- Gastrointestinal examination
Investigations
- Bedside: DRE, beta HCG
- Bloods: FBC, iron studies, TFTs, vitamin B12, folate, coeliac serology
- Imaging:
- Other: colonoscopy, endoscopy (if colon Ca is suspected), K10
- Depression - Cancer: leukaemia and lymphoma
- Anaemia - Chronic renal disease
- Hypothyroidism - Coeliac disease
- Chronic heart failure - Chronic fatigue
- Diabetes: hyperglycaemia - CMV
- EBV infection - Hemochromatosis
- Medication side-effect - Sleep disorder
- HIV - SLE
- TB - COPD
- Sleep apnoea
Management
- Rule out underlying cause: FBC, TFT, U&E, LFTs, arbovirus serology if suspected with other symptoms present
- Sleep hygiene
- Discuss use of sleeping tablets (diazepam) for short-term use if patient is unable to maintain a good sleeping pattern
such as a shift worker. Need to make sure they know the side effects, that the medication is addictive and that they
should not be using them every night.
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Pain
- Allodynia: Pain due to a stimulus that does not normally provoke pain. Mechanical—light touch feels painful.
Temperature—hot/cold stimulus (normally not painful) is painful.
- Causalgia: A syndrome of sustained burning pain, allodynia and hyperpathia after a traumatic nerve lesion, often
combined with vasomotor and sudomotor dysfunction and later trophic changes
- Central pain: Pain associated with a lesion of the central nervous system.
- Dysaesthesia: An unpleasant abnormal sensation, whether spontaneous or evoked (e.g. formication—a feeling like ants
crawling on the skin).
- Hyperaesthesia: Increased sensitivity to stimulation, excluding the special senses.
- Hyperalgesia: An increased response to a stimulus that is normally painful (i.e. painful stimulus feels much more painful
than expected, such as firm finger pressure).
- Hyperpathia: A painful syndrome, characterised by an increased reaction to a stimulus, especially a repetitive stimulus, as
well as an increased threshold for sensory detection.
- Hypoaesthesia: Decreased sensitivity to stimulation, excluding the special senses.
- Hypoalgesia: Diminished pain in response to a normally painful stimulus.
- Neuralgia: Pain in the distribution of a nerve or nerves
- Neuritis: Inflammation of a nerve or nerves
- Neuropathy: A disturbance of function or pathological change in a nerve
- Nociceptive pain: Pain arising from stimulation of superficial or deep tissue pain receptors from tissue injury or
inflammation
- Paraesthesia: Abnormal sensation, whether spontaneous or evoked.
- Phantom pain: The sensation of the presence of a missing body part.
- Somatoform pain: Pain that has the qualities of pain arising from a physical (somatic) cause but not attributable to any
objectively demonstrable organic causation (i.e. the expression of psychological distress as physical symptoms)
History
- What is the cause of the pain?
- What is the dominant mechanism—somatic, visceral or neuropathic?
- Is there a treatable cause?
- Is there a significant incident factor?
Measurement of pain
- Pain is subjective in nature
- It is necessary to record some type of repeatable measurement, particularly for chronic pain
- Unidimensional scales
o Visual analogue scales (VAS) e.g. faces pain
- Multidimensional scales
o Consider several aspects of pain perception and assess functional effects and levels of disability
§ McGill Pain Questionnaire
§ Pain Disability Index
Chronic Pain
History
- Event/circumstances surrounding onset of pain: trauma
- SOCRATES
- Baseline measurement of the pain
- Previous pain comparisons
- Analgesic use, medications, illicit drug use
- Associated symptoms: fatigue, depression
- Ongoing pathology: cancer, rheumatoid arthritis
- Postural changes
- Sleep pattern
- Appetite
- Social situation
- Psychosocial issues
- Medical and surgical hx
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Investigations
- Restrict investigations to those useful for confirming clinical impressions and influencing management decisions.
- Avoid screening batteries
- Review previous investigations before ordering further tests.
- Fibromyalgia
- Cancer
- Arthritis: RA, OA
- Polymyalgia rheumatica
- Arbovirus: ross river virus
- Neuropathic pain: diabetes, vitamin B12 deficiency etc
- Psychogenic pain: depression, anxiety, loss
Management
Non-pharmacological
- Physical techniques - Acupuncture
- Thermotherapy - Biofeedback
- Acupuncture - Mirror therapy
- Yoga - Mind-based techniques
- Strengthening and aerobic exercises - CBT
- Stretch - Hypnosis
- Hydrotherapy - Meditation
- Massage - Occupational therapy
- Mind-body techniques
Pharmacological
- Need to use the analgesic ladder approach
- Paracetamol
- NSAIDS: low dose for a short amount of time
- Opioids: role in chronic non-malignant pain is limited. Should be ceased if there is nil improvement in QoL and pain scores.
Start low and go slow
Nociception vs pain
- Transduction: nociceptors detect potentially damaging (i.e. noxious) stimuli and convert them to electrical pain signals
- Transmission: neurons transmit these signals to pain- processing structures of the spinal cord and brain
- Modulation: the signals can be amplified or dampened at various points in the pathway to facilitate or inhibit transmission,
thereby enhancing or reducing the sensation of pain
- Perception: conscious perception of pain occurs when the signals are conveyed to the brain, in particular the
somatosensory region of the cerebral cortex
Modulating pathways (+) and (-)
Origins of pain
- Nociceptive: arises from stimulation of superficial or deep tissue pain receptors (nociceptors) from tissue injury or
inflammation
- Neurogenic pain: caused or initiated by a primary lesion or dysfunction. Subdivided into central or peripheral pain
- Psychogenic pain: Pain arising in the absence of any discernible injury and where predominant aetiology is psychological
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Neuropathic pain
à Pain associated with injury, disease or surgical section of the peripheral or central nervous system.
Examples
- Post-herpetic neuralgia
- Trigeminal neuralgia (‘tic douloureux’)
- Atypical facial pain
- Phantom limb pain
- Complex regional pain syndrome
Clinical features
- Burning, shooting, pulsating or stabbing pain
- Paroxysmal or spontaneous pain
- Pain in the absence of ongoing tissue damage
- Pain in an area of sensory loss
- Allodynia: pain on light touch
- Hyperpathia: nociceptive stimuli evoke exaggerated levels of pain
- ± Hyperalgesia
- ± Dysaesthesia e.g. ‘ants crawling on skin’
- ± Delay in onset of pain after nerve injury
- Radiating electric shock like pains in nerve distribution
o e.g. Tinel’s sign—tapping of neuroma or nerve
- Often refractory to simple analgesics and NSAIDs and poor response to opioids
- ± Autonomic nervous system instability
o e.g. pallor or cyanosis, excessive warmth or cold, sweating changes
Treatment
- Amitriptyline (SNRI)
- Carbamazepine
- Gabapenitin
- Anti-depressants: TCA’s, Venlafaxine, Duloxetine
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- Gabapentin, pregabalin
- Other AED’s best avoided
- Carbamazepine for trigeminal neuralgia
- Lignocaine>infusions, topical
Complex regional pain syndrome

- Neuropathic pain: continuous burning, aching, shooting, prickling pain; stress, movement; may spread proximally +/- other
limb
- Sensitisation: allodynia (1/3), hyperalgesia (all)
- Sensory deficit: regional: Crosses dermatomes and peripheral nerves
- Motor weakness, dystonia, co-ordination deficit
- Trophic changes: skin, hair, nails, bone
- Autonomic changes: colour, temperature, oedema, sweating
- With CRPS, pain is more than that expected from usual healing
- Brain changes are similar to those seen with phantom limb pain
- Rigorous and early multi-disciplinary rehab
- Medical treatments help some – not all
- Prognosis varies – some never get better
Management
Early therapy
- Analgesia: paracetamol, NSAIDS, anti- neuropathic agents (TCA, pregablin), opioids
- Corticosteroids: prednisolone 10mg tds
- N-acetylcysteine, dimethyl-sulphxide
- Explanation/patient education and appropriate reassurance.
- Attention to lifestyle—the NEAT approach:
o Nutrition—optimal diet, ideal weight, low fat, low sugar, etc.
o Exercise—a balanced lifestyle program
o Avoidance of toxins—avoid or limit alcohol, nicotine, other drugs
o Tranquillity—relaxation techniques
Medical therapy
- Sympathetic blocks
- Regional analgesic techniques (tunnelled epidural or regional nerve catheters)
- Intra-venous regional analgesia: guanethidine, local anaesthetics
- Neuromodulation: implanted dorsal column stimulators
- Amputation is un-successful (phantom limb pain and stump pain)
Physiology
- Graded exercise: passive, isometrics, stress loading, functional rehab
- Goal-directed
- Should not aggravate the pain
- Re-activation and de-sensitisation
- Graded motor imagery: laterality training, mirror box therapy
- Compression garments
Psychological
- Pain ßà mood
- Treat anxiety / depression
- Cognitive behavioural therapy
- Acceptance and commitment therapy
- Bio-feedback (inhibits sympathetic nervous system output)
‘simple’ analgesics
Paracetamol
Dose: 1g x 4 hourly (max 4g daily)
- Moderate analgesic and antipyretic effects
o Less effective than NSAIDs for pain relief
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- Minimal anti-inflammatory activity
- Its excellent safety in therapeutic doses makes it the first-line analgesic for mild-moderate pain
- Well tolerated in patients with GIT symptoms
- S/E: Dyspepsia, Nausea
- Administer with caution in patients with kidney and liver disease
Aspirin
Dose: 600mg x 4 hourly (max 4g daily)
- Analgesic and anti-inflammatory activity
- Very effective for mild-moderate acute pain
- S/E: GIT discomfort, ulceration, bleeding
Risk factors for NSAID-induced side effects

- Definite
o >65 years
o Previous ulcer disease or complication
o High dose, multiple NSAIDS
o Concomitant corticosteroid therapy
o Duration of therapy (>3 months)
- Relatively
o Conditions necessitating NSAID treatment e.g. RA
o Female
o Smoking
o Alcohol abuse
o H pylori
Opioids
à Normally reserved for the treatment of severe pain
- Commonly used agents are the weaker opioids: codeine, oxycodone, dextropropoxyphene, tramadol
- Stronger opioids include: morphine, pethidine, buprenorphine, methadone
- Other: Fentanyl, paraveretum
Codeine (methylmorphine)
Dosage: 30-60mg x 4 hourly
- Metabolised to morphine
- S/E: Nausea, Constipation
Oxycodone e.g. Endone, Oxycontin, OxyNorm

Dosage: 10mg x 4 hourly
- Synthetic opioid
- Very effective orally
- Used in moderate pain: bridges the gap between simple analgesia and strong opioids
- S/E
o Nausea
o Constipation
o Confusion
o Pruritis
Tramadol
Common dose: 50-100mg x 2-4 daily (oral)
- Atypical analgesia with opioid and non-opioid features
- Has minimal sedation or respiratory depression and low abuse/dependence potential
- S/E
o Dizziness
o Vertigo
o Nausea, Vomiting, constipation
o Headache
o Tremor
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o Confusion
Morphine
Common dose: 10mg x 4 daily (oral)
- Dose requirements vary considerably and patient response should be monitored frequently
- Should be titrated based on patient’s needs
Fentanyl
- Very potent drug
- Can be administered IV, IM, SC, transdermally
Other analgesics
- Antidepressants (amitriptyline)
- Membrane stabilisers (anticonvulsants, antiarrhythmics)
- NMDA blockers (ketamine)
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Musculoskeletal
Arthritis
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Back pain
à Acute back pain will generally settle in 6-12 weeks and recurrences are common. 50% may go on to intermittent pain.
- Superficial muscles
o Latissius dorsi
o Trapezius
o Rhomboid minor/major
o Levator scapulae
- Intermediate muscles
o Serratus posterior superior
o Serratus posterior inferior
- Deep muscles
o Splenus capatis
o Splenus cervicus
o Erector spinae muscles
§ Ileocostalis
§ Longalis
§ Spinalis
§ Note: each of these
muscles are broken into
lumborum, thoracis and
cervicis
Types of pain
- Mechanical or non specific low back pain - most common
- Nerve root impingement, spinal stenosis
- Other specific cause
History
- Present episode: time course, pain, trauma, resting pain, leg pain, treatment à SOCRATES
- Occupation: looking for a hx of heavy lifting
- PHx: recent infection, surgery, malignancy, emotional disturbance
- FHx: chronic back pain, spondarthritis, interstitial disease
- Fever, unplanned weight loss
- Menstrual and urinary symptoms
- Social Hx: smoking, alcohol (undernourishment, vitamin deficiency), recent travel, migrant (TB)
- Previous episodes: how often, long, what so you normally do about it, major injuries
Symptoms – usually after lifting/twisting

- Severity of the pain can range from mild to severe
- Typically, the pain is in one area of the lower back but sometimes it spreads to one or both buttocks or thighs
- The pain is usually eased by lying down flat
- It is often made worse if you move your back, cough, or sneeze
- Sacral and gluteal areas are common sites of referred pain from the lumbar spine, however in the absence of back pain
look for local causes
- Loin pain may be referred from the thoracic spine, but is less likely to be due to lumbar pathology. Exclude renal
problems in first instance
- Somatic referred pain is pain that arises from somatic tissue in the spine (muscles, ligaments, bones and joints) and
spreads distally into the buttocks and legs. It is analogous to arm pain arising from cardiac causes
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Six Dysfunctional D’s of chronic pain syndromes
- Emotional distress (e.g. anxiety, conflict, anger, hostility, resentment, alienation)
- Behavioural and cognitive deficits
- Varying degrees of disability related to work
- Depression
- Physical de-conditioning
- Disturbed sleep
Aetiology
Mechanical/non-specific pain
- Severity of the pain can range from mild to severe
- Typically the pain is in one area of the lower back sometimes it spreads to one or both buttocks or thighs
- The pain is usually eased by lying down flat, it is often made worse if you move your back, cough or sneeze.
Disc herniation
- Pain into lower leg
- ? Reflexes preserved
- Prognosis
o 50% settle 3 months
o More over 12 months
Spinal stenosis
- Narrowing from osteophyte formation, facet hypertrophy, bulging disks, and
hypertrophy of the ligamentum flavum
- Degenerative condition
- >50
Symptoms
- Pain both legs when walking
- Both legs feels weak
- Eases with rest
- Eases with bending forward
- May get peripheral neuropathy type symptoms
Red Flags
- Neurological symptoms and signs
- Significant trauma
- Recent infection, Fever
- Neoplasia
- Unexplained weight loss
- IVDU, Alcohol abuse
- Undernourished
- Corticosteroid use
- First episode > 50 and any episode after 65, or
pain in <20
- Night pain with no relief when supine
- Pregnancy
- Structural deformity
- Saddle anaesthesia
- Paralysis
- Sphincter disturbance
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Yellow Flags
- Belief that pain and activity and harmful
- Inappropriate sickness behaviour
- Low or negative mood
- Social withdrawal
- Treatment not fitting best practise over investigation
- Hx of time loss from back or neck pain
- Continuing compensation claims
- Work problems, poor job satisfaction repeated work absences
- Heavy work or unsociable hours
- Over or under protective family
Examination
- Vitals: temperature
- Check for lymphadenopathy
- Breast and pelvic examination
- Abdominal examination: masses, tenderness, femoral
pulses, renal angles,
- Neurological examination: essential particularly sensation
and tone around the anus
- Msk examination: general inspection, palpate spine,
extension, flexion, lateral flexion and extension, stress and
pelvis and see if there is generalised bony tenderness
o Inspection – ‘look’
§ Gait
§ Scoliosis
§ Pelvic tilt
o Palpate: generalised bony tenderness
§ Vertebra
§ Paravertebral muscles
o Movement
§ Quality of movement
- Leg extension test
Investigations
- 18-50 with no findings: no investigations required
- Simple blood tests and plain x-ray first
- CT should be considered if signs of red flags are present, there
is suspicion of a spinal cord compression, or nerve root compression or spinal canal stenosis
Lumbar spine x-ray
- Pick up rate very poor - mainly degenerative disease up to 48% normal in primary care
- Not recommended in absence of red flags
- Consider after 4-6 weeks
MRI
- MRI abnormal in 64% of normal (asymptomatic) people
- Knowing MRI report < patient “wellness”
15-30yrs
- Prolapsed disc
- Herniation
- Trauma
- Fractures
- Ankylosing spondylitis
- Pregnancy
- Musculoskeletal
- Spondylolisthesis
- Cauda equina syndrome
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30-50yrs
- Degenerative spinal disease
- Prolapsed disc
- Malignancy
- Metastasis
- Musculoskeletal
- Mechanical/non-specific
>50yrs
- Degenerative
- Osteoporosis with vertebral collapse
- Pagets
- Malignancy
- Myeloma
- Spinal stenosis
- Musculoskeletal
- Shingles
à The most common cause is non-specific. Structure in the spine such as the disc annulus, ligaments or zygopophyseal is
generally the cause.
Management
- 90% will get better on with own with short-term
bed rest and gradual mobilisation.
- Urgent neurosurgical referral if any neurological
deficit is present
- May need short-term: paracetamol, NSAIDS
(meloxicam/mobic, etc), codeine, low dose
amitriptyline (TCA) àWeak opiates, strong opiates,
benzodiazepines, tricyclics
- Address psychosocial issues
Physical therapies
- Physiotherapy, osteopathy etc.
- Bed rest not recommended
Disc herniation management

- Conservative treatment for the first 6-8wks
- Referral to a specialist should be considered if unresponsive to conservative treatment or uncertain about the
diagnosis
- Surgery if severe or progressive neurological deficit or if all four of the following symptoms are present:
1. Leg pain is equal or worse than back pain
2. Positive straight leg raise test
3. No response to conservative treatment after 4-6wks
4. Imaging shows a lesion corresponding to symptoms
Low Back Pain

Acute – pain <6 weeks
Subacute – pain 6 – 12 weeks
Chronic – pain greater than 12 weeks
- Most common age groups 30-50s – the average age is 45 years
- Mechanical back pain aka vertebral dysfunction – the main presentation of back pain in the doctors
o Vertebral dysfunction – dysfunction of the mobile segment – e.g. facet joint, the intervertebral joint (with its
disc) and the ligamentous and muscular attachments
- An intervertebral disc prolapse has been proven in only 6 – 8% of cases of back pain
- Bilateral back pain – more typical of systemic diseases, while unilateral pain – typifies mechanical causes
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Pathophysiology of Back pain
- In theory, any structure with a nociceptive nerve supply may be a source of pain
- Such structures include: the ligaments, fascia and muscles of lumbosacral spine, intervertebral joints, facet joints, dura
mater and sacroiliac joint
- Muscular pain commonly with back pain – disc injury causes a reflex of protective muscle spasm
History
- Can you describe the nature of your back pain?
- Was your pain brought on by a back injury?
- What is your general health like?
- How do you sleep during the night?
- What effect does rest have on the pain?
- What effect does activity have on the pain?
- Is the pain worse when sitting or standing?
- What effect does coughing or sneezing or straining at the toilet have?
- What happens to the pain in your back or leg if you go for a long walk? – claudication
- Do you have a history of psoriasis, diarrhoea, penile discharge, eye trouble or severe pain in your joints?
- Do you have any urinary symptoms?
- What medications are you on? Anticoagulants?
- Are you under any extra stress at work or home?
- Do you feel tense or depressed or irritable?
Physical examination
- Objectives –
o Reproduce the patient’s symptoms
o Detect the level of the lesion
o If possible, determine the cause by provocation of the affected joints or tissues
1. Inspection
2. Palpation – bony deformities, tenderness, paraspinal muscle bulk, trigger points
3. Active movements – ROM:
a. Forwards flexion
b. Extension
c. Lateral flexion
4. Provocative tests – to reproduce the patient’s symptoms – e.g. straight leg raise, slump test
5. Neurological testing of lower limbs
6. Testing of related joints (hip, sacroiliac)
7. General medical examination, including rectal examination
Types
- Local, radicular, referred, or related to a psychiatric illness
- Radicular pain – pain that radiates along a dermatome of a nerve due to inflammation or other irritation of the nerve
root
Aetiology
- 98% are due to mechanical causes
o Pain is worse with movement, better with rest
o Sprain (ligament), strain (muscle), facet joint degeneration, disc degeneration/ herniation, spinal stenosis (e.g.
spondylosis), spondylolisthesis, compression fracture, pregnancy
- 2% are non-mechanical causes
o Most concerning when pain is worse at rest and does not change with position
o Surgical emergencies:
§ Cauda equina syndrome
§ AAA (pulsatile abdominal mass)
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o Medical conditions
§ Neoplastic (primary, metastatic, multiple myeloma)
§ Infectious (osteomyelitis, TB)
§ Metabolic (osteoporosis, osteomalacia, Paget’s disease)
§ Rheumatologic (ankylosing spondylitis, polymyalgia rheumatica)
§ Referred pain (perforated ulcer, pancreatitis, pyelonephritis, ectopic pregnancy, HVV
Common causes
- Vertebral dysfunction – especially facet joint and disc
- Musculoligamentous strain/ sprain
- Spondylosis (degenerative OA): broad term meaning degeneration of the spinal column from any cause
- Can present as spinal stenosis with claudication and nerve root irritation due to narrowed intervertebral foraminae
Do not miss
- Cardiovascular
o Ruptured aortic aneurysm
o Retroperitoneal haemorrhage (anticoagulants)
- Neoplasia
o Myeloma
o Metastases
- Severe infections
o Vertebral osteomyelitis
o Epidural abscess
o Septic discitis (inflammation of intervertebral discs)
o Tuberculosis
o Pelvic abscess/ PID
- Cauda equina compression
Pitfalls
- Masquerades – UTIs, Depression, Spinal dysfunction
- Spondyloarthropathies – ankylosing spondylitis, reactive arthritis, psoriasis, bowel inflammation
- Sacroiliac dysfunction
- Claudication – vascular, neurogenic
- Paget disease
- Prostatitis
- Endometriosis
Investigations
- Plain films not recommended in initial investigations
- If infection/ cancer suspected: FBC, ESR
- If neurological deficits worsening or infection/ cancer suspected: CT or MRI
Acute
- Back education program
- Resume normal activities as soon as possible
- Regular non-opioid analgesics
- NSAIDs for 10 – 14 days, then cease and review
- If severe pain unrelieved – add tramadol or oxycodone
- Walking and swimming
- Weekly or 20 weekly follow up
- Consider oral steroids (prednisolone) for severe pain
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Chronic
- Reassurance that problem will subside (assuming no severe neurological defects)
- Consider epidural anaesthesia
- Consider amitriptyline
- Consider trigger point injection
Most cases settle within 12 weeks
Vertebral dysfunction with non-radicular pain

- Outstandingly common cause of low back pain
- Considered to be due mainly to dysfunction on pain-sensitive facet joint
- Typical profile
o Hx of injury – lifting or twisting
o Site and radiation – unilateral or central lumbar - Refers over sacrum, SIJ areas, buttocks
o Type of pain – deep aching pain, episodic
o Relief – rest and warmth
o Examination – localised tenderness – unilateral or central L4, L5 or S1 levels
Radiculopathy
- Radicular pain – caused by nerve root compression from a disc protrusion or tumours or a narrowed intervertebral
foramen
- Typically produces pain in the leg related to the dermatome and myotome innervated by that nerve root
- Leg pain may occur alone without back pain and vary considerably with intensity
- Most settle with time – 6 – 12 weeks
General guidelines for surgical intervention for radiculopathy
- Absolute
o Bladder/ bowel control disturbance
o Progressive motor disturbance – e.g. significant foot drop, weakness in quadriceps
- Relative
o Severe prolonged pain or disabling pain
o Failure of conservative treatment with persistent pain
o If all 4 of the following criteria are met:
§ Leg pain equal to or worse than back pain
§ Positive straight leg raise test
§ No response to conservative therapy after 4 – 6 weeks
§ Imaging shows a lesion corresponding to symptoms
Spondylolisthesis
- Pain caused by extreme stretching of interspinous ligaments or of the nerve roots
- Onset of back pain in many patients due to concurrent disc degeneration rather than a mechanical problem
- Pain that is worse on standing and walking, but relieved by sitting – probably spondylolisthesis
Lumbar Spondylosis
- Aka degenerative osteoarthritis or osteoarthrosis – a common problem of wear and tear that may follow vertebral
dysfunction
Spondyloarthropathies
- Seronegative spondyloarthropathies – characterised by involvement of sacroiliac joints with an ascending spondylitis
and extraspinal manifestations, such as oligoarthritis and enthesopathies
- Main disorders include – ankylosing spondylitis, psoriatic arthritis, reactive spondyloarthropathies and inflammatory
bowel diseases
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Malignant Disease
- Important to identify malignant disorders and other space-occupying lesions
- Neurological features – more than one nerve root may be involved
o Major neurological signs may be present with severe root pain
o Neurological signs will be progressive
Non-Organic back pain

- Back pain can be a symptom of an underlying functional, organic or psychological disorder
- Pain distribution is often atypical of any dermatome and reflexes are almost always hyperactive
- Important to remember – patients with psychogenic back pain (depression, conversion disorders) do certainly
experience back pain
- If suspected, consider a trial of antidepressants
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Neck pain
75
Knee pain
History
- SOCRATES
- Chronic or acute
- Trauma to knee: direct blow from what angle, twist
- Hear pop or snap
- Feel unsteady
- Knee catch or lock, grating
- Able to walk
- Swelling timeframe
- How soon after injury did the pain develop
- Does pain start after exercise
- Come on at rest
- Pain when walking on stairs
- Previous injury or surgery
- Morning stiffness
- Red Flags
o Acute swelling with or without trauma
o Acute or acute on chronic erythema
o Systemic features such as a fever in the absence of
trauma
o Unexplained chronic, persistent pain
Examination
- General Inspection
o Vital Signs
- Inspection
o Swelling, deformity
- Palpation
o Warmth: compare sides
o Patella-femoral joint movement (move knee feeling for
creps)
o Patella ligament
o Tibial tuberosity
o Medial collateral ligament
o Anserine bursa
o Posterio-medial joint line
o Patella
o Quadriceps tendon
o Lateral collateral ligament and iliotibial band
o Ballottement of fibula head
- Movement and Measure
o Standing
§ Flexion (partial squat): patello-femoral joint (PFJ) function, patellar tracking
§ Flexion (full squat)
o Lying
§ Push legs right down into the bed: muscle bulk and tone
§ Knee flexion and extension movements (heels to bottom and back)
- Special Tests
o Lachman Test: Anterior cruciate ligament tears
§ With the patient supine, the examiner places a small bolster or their knee under the knee of the
patient being examined so as the knee is flexed 20-30 degrees. Stabilise distal femur and proximal
end of tibia. Then push and pull knee anterior and posteriorly to determine the degree of movement
§ Negative test when the degree of movement is the same as for the unaffected knee.
o Anterior Draw Test: Anterior cruciate ligament tears (less sensitive in non-anesthetised patient)
§ The patient is placed in the supine position and their affected knee is flexed to approximately 90°. The
foot of the flexed knee is stabilised by the examiner gently sitting on the foot so as to prevent it
moving. The examiner then grasps firmly the proximal tibia and applies several firm anterior
posterior movements to determine degree of movement when compared to the unaffected knee.
o Thessaly Test: meniscal pathology
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§ With the patient standing with feet shoulder width apart, the examiner supports the patient by gently
holding their two hands. The patient is then asked to flex their unaffected knee so as the foot is off
the ground.
§ The affected knee is then flexed approximately 5° and locked in that position. The patient is then
instructed to rotate the knee joint about it axis so as to grind the joint. If the patient experiences pain
they are asked to point to the location.
§ The patient is then requested to flex the affected knee to approximately 20°, lock it in that position
and repeat the rotational movement. The patient should then point to the location of any pain in the
joint generated by this movement.
o Valgus Stress Test: medial collateral ligament
§ Hold leg up with hand under knee and then with other hand placed medially just above the ankle
apply pressure with both hands in opposite directions.
o Varus Stress Test: lateral collateral ligament
§ Hold leg up with hand under knee and then with other hand placed laterally just above the ankle
apply pressure with both hands in opposite directions.
Investigations
- Bedside: urinalysis, vitals
- Bloods: FBC, chlamydia serology, inflammatory markers, arthritis markers (RA: ANA, HLAB27) ESR, blood cultures
- Imaging: x-ray if Ottawa rules are met, MRI may be needed for ligamental tears, bone scan
- Knee aspiration: if suspecting septic arthritis or gout
Ottawa Knee Rules

- Main purpose is to rule out patients presenting with ankle injuries who had a lower risk of a fracture and therefore
avoid unnecessary medical imaging
1. Patient must have sustained the injury in the previous seven days
2. Be aged 18-55yo
- Outside these inclusion criteria the rule cannot be applied
X-ray required if:
- Aged >55
- Tenderness at the head of the fibula
- Isolated tenderness of the patella
- Inability to flex the knee to 90 degrees
- Inability to bear weight for at least four steps at both the time of the injury and the time of the examination
à Clinical judgement should always prevail and if the patient is intoxicated, uncooperative or have altered LoC, significant
distracting injuries, there is diminished sensation, gross swelling preventing useful palpation an x-ray may also be required in
these situations.
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- Musculoskeletal
o Ligament strains and sprains
o Acute cruciate ligament tear
o Meniscal tears
o Fracture
o Unhappy triad: Damage to ACL, medial meniscus, medial
collateral ligament
o Patellofemoral syndrome
- Infective
o Septic arthritis
o Tuberculosis
- Rheumatic
o Osteoarthritis
o Rheumatoid arthritis
o Juvenile chronic arthritis
o Rheumatic fever
o Pseudogout
o Reactive arthritis
- Inflammatory
o Traumatic synovitis
o Prepatellar bursitis
- Vascular
o DVT
o Superficial thrombophlebitis
- Neoplastic: primary in bone or mets
- Other
o Referred pain form back or hip
o Foreign body
o Intra-articular loose bodies
o Osgood-Schlatter disorder: children with traction apophysitis from repetitive stress to the intersection of the
patellar tendon. This is self limiting
Location
- Anterior pain - Medial pain
o OA o OA
o Patellofermoral syndrome o MCL
o Prepatella syndrome o Meniscus
o Prepatella bursitis o Bursitis
o Quadriceps abnormalities - Diffuse pain
- Lateral pain o OA
o OA o Infectious arthritis
o LCL o Gout, pseudogout
o Meniscus o RA
o ITB syndrome
Management
- RICE: Rest, ice, compression, elevation
- Lose weight if overweight
- Adequate support for ligamental sprains
- Paracetamol
- NSAIDS and corticosteroid injections
- Physiotherapy
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Foot Pain
History
- SOCRATES
- Trauma to the foot
- Nature of the pain
- Localised or generalised disease
- Ability to walk
- Unsuitable footwear
- Weight bearing
- Previous injury
- Pain also in other joints
- Injury to knee
- History of arthritis, psoriasis, chronic diarrhoea or colitis, urethritis or iritis
Red Flags
- Pain in the forefoot disturbing sleep
- Fever and systemic illness with bone pain
- Localised tenderness away from the heel in a child
- Burning feet
- Musculoskeletal - Infection
o Bone fracture o Septic arthritis
o Ligament injury - Vascular:
o Tarsal tunnel syndrome o Arteriosclerosis
o Stress fractures o Hemiplegia
o Morton’s neuroma o Raynaud’s
o Trauma - Tumour
- Inflammation o Osteoid osteoma
o Tendonitis o Osteosarcoma
o Achilles tendonitis o Ewing tumour
o Plantar fasciitis - Other
- Rheumatological o Cellulitis
o Rheumatoid arthritis o Diabetes
o Osteoarthritis o Peripheral neuropathy
o Psoriatic arthritis o Foreign body
o Gout o Warts
o Pseudogout
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Investigations
- Bedside: BSL
- Bloods: rheumatoid factor, CRP, ESR, serum uric acid, HLA-B27
- Imaging: Foot x-ray, CT/MRI, USS
- Other: nerve conduction studies
Ottawa Criteria: Ankle and Foot Rules

- Patient must have sustained the injury in the previous seven days
- Be aged 18-55yo
- X-ray required if
o Pain in the malleolar zone and fulfil one or more of the following criteria:
§ Bone tenderness at the posterior edge of the distal 6cm of the tibia
§ Bone tenderness at the posterior edge of the distal 6cm of the fibula
§ Inability to bear weight for at least four steps both at the time of the injury and the time of
examination
o Pain in the mid-foot and fulfil one or more of the following criteria:
§ Bone tenderness at the navicular
th
§ Bone tenderness at the base of the 5 metatarsal
§ Inability to bear weight for at least four steps both at the time of the injury and the time of
examination
- Clinical judgement should always prevail and if the patient is intoxicated, uncooperative or have altered LoC, significant
distracting injuries, there is diminished sensation, gross swelling preventing useful palpation an x-ray may also be
require in these situations.
Gout mx
Acute
- NSAID
- Colchicine 500micrograms PO until attack has ceased. Max 6mg over 4/7
- Prednisolone 15-20mg PO for 5/7
Chronic
- Allopurinol 50mg PO daily for the first month
- Increasing allopurinol by 50mg every 2-4wks (renal function and plasma urate level dependent)
Plantar fasciitis
Pain when first getting up in the morning that is relieved after walking and then increases again at the end of the day.
Will heal spontaneously in 12-24 months.
- NSAIDS
- Long acting corticosteroid injection into heel
- Plantar fascia stretching exercise
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Shoulder Pain
à The shoulder is innervated by C5. Pain may be coming from cervical spine, brachial plexus, glenohumeral joint, rotator cuff,
biceps tendon, soft tissue or viscera innervated by the phrenic nerve (C3, C4, C5)
History
- SOCRATES
- Recent trauma
- Associated fever
- Does the pain keep you awake at night?
- Pain or stiffness in neck
- Trouble combing hair (external rotation)
- Doing up bra (internal rotation)
- Both shoulders or hips
- Pain associated with activity
- Lift arm over head
- Lift weight
Red Flags
- Hot swollen joint
- Entry wound
- Trauma
Shoulder Examination
- General Inspection
o Vital signs
- Inspection
o Symmetry
o Balance
- Palpation
o Steronclavicular joint
o Clavicle
o Acromioclavicular joint
o Coracoid
o Long head of biceps tendon
o Insertion of supraspinatus
o Insertion of infraspinatus and teres minor
o Lateral border of scapulothoracic joint
o Medical border of scapulothoracic joint including
rhomboids
o Cervical spine
Movements and Measuring

Hand by yours sides thumbs facing forwards raise arms forwards to
above your head
- Forward flexion
- Extension
Hands by your sides, thumbs out raise your hands out to the sides and up above your head
- Abduction
- Adduction
Bent elbows and lock into your side. Move hands out
- External rotation
Repeat movements from the back
- Right thumbs up the middle of the spine
- Internal rotation
à If any of these movements cannot be performed, need to repeat with passive movement.
Special Tests
- Hawkins Kennedy Test: impingement
- Apprehension and Relocation Test: glenohumeral joint anterior instability
- Drop Arm: supraspinatus (more reliable in acute condition)
- Empty Can Test: supraspinatus (more reliable in acute condition)
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- Septic arthritis
- Osteomyelitits
- Pancoast tumour
- Polymyalgia rheumatic
- Trauma
- Fractures
- Dislocation
- Cervical dysfunction or spondylosis
- Osteoarthritis
- Subacromial bursitis
- Supraspinatus, infraspinitus or subscapularis tendonopathy
- Adhesive capsulitis
- Rheumatoid arthritis
- Psoriatic arthropathy
- Avascular necrosis
- Winged scapula
- Swimmer’s shoulder: most common in teenagers who swim
- Referred pain: cardiac, gall bladder or respiratory
Investigations
- Bedside: urinalysis
- Bloods: acute phase reactants: ESR, CRP, ferritin, albumin,
fibrinogen, complement (C3, C4), serology including ANA, anti-
dsDNA, anti-La, RhF, anti-CCP
- Imaging: X-ray, CT, bone density, bone scan
- Other: synovial fluid analysis with culture, Gram stain, cell count and microscopy
Management
- RICE
- Analgesia: NSAIDS, codeine, paracetamol
- Corticosteroid injections
- Physiotherapy
Osteoporosis
- May occur due to ageing or secondarily due to nutrient deficiency, metabolic disorders or medication side effects.
- The T-score compares the patient’s bone density to the peak bone density of young adults.
- The Z-score compares the patient’s bone density to that of adults of the same age. Z-score is a useful indicator of
possible secondary osteoporosis. A Z-score of -2.0 or below should trigger investigations for underlying disease to
exclude other causes of bone mineral loss.
- Osteopenia: low normal bone density with a T score between -1 to -2.5
- Osteoporosis: fragility fracture or a T score below -2.5
History
- Fracture, recent imaging showing vertebral - Endocrine disorders
fractures - Cancer
- Back pain - HIV
- Postural change - Family hx
- Dyspnoea - Alcohol
- Constipation - Diet: low calcium, anorexia, vegan
- Abdominal pain, distension - Vitamin D deficiency: nil sun exposure
- Reduced appetite - Smoking
- Medications: anticoagulation, hormonal - Physical activity
therapies, corticosteroids, - Menopausal
Examination
- Height loss
- Hyperthyroidism
- Kyphosis
- Testicular atrophy
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Classification
Primary
- Type 1: Postmenopausal (vertebral or distal forearm fractures between the ages of 51 and 75). Due to increased
osteoclast activity. It is six times more common in women than men.
- Type 2: Involutional or senile osteoporosis (fracture of proximal femur and other bones). It affects patients over 60
years and is twice as common in women as in men.
- Idiopathic osteoporosis: Occurs in children and young adults of both sexes with normal gonadal function.
Secondary
- Secondary to various endocrine disorders, malabsorption and malignancies
Investigations
- Bloods: FBC, vitamin D, calcium, TFT
- Imaging: bone density scan
Screening
Bone density scan is recommended when:
- Age >70 - Diet lacking calcium
- Age >60 for men and >50 for women plus and of: - Low body weight
- Family history of minimal trauma fractures - Recurrent falls
- Smoking - Sedentary lifestyle over many years
- High alcohol intake
Management
- Weight bearing exercise
- Smoking cessation and appropriate EtOH consumption
- Calcium and vitamin D supplements
- Bisphosphonates e.g. aldendronate
- Denosumab: Reversibly inhibits bone resorption by reducing osteoclast formation and differentiation and increasing
osteoclast apoptosis
- In post-menopausal women you can also use:
o Raloxifene: selective oestrogen receptor modulator that decreases bone loss, however also causes hot flushes
as a side effect. Decreases breast cancer risk.
o Strontium ranelate: unknown MoA
Fibromyalgia
à Chronic widespread non-inflammatory musculoskeletal pain accompanied by a variety of typical symptoms including fatigue,
sleep disturbance and cognitive clouding.
- Main diagnostic features are –
o History of widespread pain (neck to low back)
o Pain in 11 of 18 tender points on digital palpation (these points must be painful not tender)
History
- SOCRATES, severity and fluctuating severity
- Fatigue
- Cognitive clouding
- Concentration
- Sleep
- Depression
- GIT symptoms
- Urogenital symptoms
- Smoking
- Functional impact: inability to work, participate in everyday life or relationships
- Occupational activates that aggravate fibromyalgia: prolonged repetitive movements, sustained 1 position, high stress
jobs
Investigations
- Bloods: FBC, ESR, CRP, creatine kinase, TFT, ANA, rheumatoid factor, iron studies, vitamin D
- Imaging: x-ray of specific joints if arthritis may be suspected
- Other: mini-mental state
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Differential diagnosis
- Arbovirus - Neurologic disorders: MS, myasthenia gravis
- Arthritis - Chronic fatigue
- SLE - Anxiety and depression
- Ankylosing spondylitis - Sleep disorders
- Polymyalgia rheumatica - Hepatitis, HIV
- Sjogren syndrome - Statin induced muscle pain
- Spinal stenosis - Opioid induced hyperalgesia
- Endocrine disorders: hypothyroidism
Management
- Graded aerobic exercises
- CBT
- Sleep hygiene
Pharmacological treatment
- TCA
- Amitriptyline (SNRI)
- Gabapentin 100-300mg PO nocte, increasing to TDS dosing, max = 2400mg per day
- Pregabalin 25-75mg PO nocte, increasing to BD. Max = 450mg per day divided dosing
- Duloxetine 30mg PO, daily. Max = 60mg daily
Specialist Referral
- Referral should be considered if the patient has an atypical presentation or refractory symptoms.
- When abnormal mood or adjustment disorders are a feature, psychological or psychiatric assessment may be advisable.
Polymyalgia Rheumatica
à Syndrome of pain or stiffness typically in neck, shoulders, upper arms and hips
Clinical features
- Pain can be very sudden or occur gradually over time
- Typically pain is most severe upon waking
o Inhibits activity
- Associated with temporal arteritis
- Fatigue, weakness
- Lack of appetite
- Anaemia
- Low grade fever
Diagnosis
- No specific test
- ESR and CRP typically raised
- Arterial biopsy for temporal arteritis
Treatment
- Prednisolone
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Obesity
Factors
- Food: western diet - Disability
- Sedentary lifestyle - Occupation, technology
- Stress - Screen time
- ETOH - Medical conditions
- Genetics - Mental health
o Overweight mother - Pharmaceuticals e.g. antipsychotics, steroids
- Prematurity
Barriers to losing health

- Job: sedentary, long hours, convenience
- Lack of motivation to change lifestyle
- Money/expenses
- Advertising, availability of junk food, reward
- Medical comorbidities: Physical health barriers, pain etc.
- Lack of education
- Failure: previous attempt to lose weight
What to do?
- Population
o Sugar tax
o Plain packaging of increased fat, sugar foods
o Subsidies of fruit and veg
o Decreased advertising for fast foods
o Health food in schools
o Access ++
- Community
o Access to exercise facilities e.g. bike paths, hikes
o School eduation programs
o Events with healthy foods
- Family
o Education
o Breast feeding
o Subsidies
- Individual
o Lifestyle changes
o Counselling
o Medication
o Surgery
o Education
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Weight loss
à Loss of >5% of body weight is significant
History
- Exactly how much weight have you lost and over how long?
- Have you changed your diet in any way?
- Has your appetite changed? Do you feel like eating?
- Have your clothes become looser?
- What is your general health like?
- How do you feel in yourself?
- Do you feel uptight (tense), worried or anxious?
- Do you get very irritable or tremulous?
- Do you feel depressed?
- Do you ever force yourself to vomit?
- Are you thirsty?
- Do you pass a lot of urine?
- Do you have excessive sweating?
- Do you experience a lot of night sweats?
- What are your motions like?
- Are they difficult to flush down the toilet?
- Do you have a cough or bring up sputum?
- Do you get short of breath?
- Do you have any abdominal pain?
Investigations
- FBC, Hb, WCC, ESR/CRP, TFT, BGL
- Chest X-ray
- Urine analysis
- Others to consider: Upper GIT (endoscopy or barium meal)
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Endocrine
Type 1 Diabetes
History
- Age - Abdominal pain
- Polyuria - Tachypnoea
- Polydipsia - Lethargy
- Weight loss - Coma
- Blurred vision - Family hx
- Nausea - Infectious agent: rubella, human
- Vomiting enteroviruses
Red Flags
- Decreased GCS
- Gradual drowsiness
- Unexplained vomiting
- Anorexia
- Ketotic breath
- Kussmaul breathing
Investigations
Acute
- Bedside: ECG, urinalysis, BSL
- Bloods: ABG (acidosis) U&E, FBC, blood culture, glucose, ketones
- Imaging: CXR
Chronic
- Bedside: BSL, ECG (baseline)
- Bloods: HbA1c, FBC
- Other: monitoring for complications with a multidisciplinary approach
ABC of diabetes control

- HbA1c (<7%)
- BP (<130/80)
- Cholesterol (<4 mmol/L)
- Cerebellar tumour
- Trauma
- Seizures
- Mature onset diabetes of youth (MODY)
- Type 2 diabetes
Management
1. Strict glycaemic control
2. Blood pressure control (≤130/80, supine)
3. Control of blood cholesterol
Management Principles
- Provide patient education, support and reassurance
- Emphasis the importance of the diet: good nutrition, adequate complex carbohydrates, protein, restricted fats and sugars
- Promptly diagnose and treat urinary tract infections
- Treat and prevent hypoglycaemia in those taken insulin and oral hypoglycaemic agents
- Organise self-testing techniques, preferably blood glucose monitoring
- Detect and treat complications of diabetes
o Neuropathy, nephropathy, retinopathy, vascular disease
Insulin
- Basal insulin e.g. lantus: approx. 40% of daily insulin requirement, once a day at the same time each day
87
- Bolus insulin e.g. actrapid: approx. 60% of daily insulin requirement, given in divided doses immediately before meals
according to meal content
Diabetic Ketoacidosis
- If systolic BP <90mmHg
o Give N saline 1L IV over 60mins
o Then 1L over 2hrs
o Then 1L over 4hrs
- 0.1units/kg/hr insulin infusion
- 10% glucose at 125mL/hr
- Ensure serum K+ is >3.5mmol/L
- Potassium: dose dependent on current potassium level
o K+ <3.5 give 40mmol/hr under specialist advice in a critical care environment
o K+ 3.5-4.5 give 20mmol/hr
o K+ 4.5-5.5 give 10mmol/hr
o K+ >5.5 cease K+ infusion
Type 2 Diabetes
à Onset of T2DM can be subtle and it takes ~7-9 years for a patient to be diagnosed on average
History
- Age
- Weight – obesity, physical activity, nutrition
- Comorbidities
o Hx of PCOS
o HTN
o Dyslipidaemia
o CVD
- Family hx of T2DM
- Medications, substance use, obstetric history (where applicable)
Previously diagnosed:
- Age at diagnosis
- Did you require insulin from the start?
- Current medications
- Hypoglycaemia/hypergycaemia understanding of management
- DKA ever occurred
- Complications?
Secondary causes
- Endocrine
o Cushing’s syndrome
o Acromegaly
o Phaeochromocytoma
o PCOS
- Pancreatic
o Haemochromatosis
o Chronic pancreatitis
- Drug induced
o Thiazide diuretics
o Oestrogen therapy e.g. HRT
o Corticosteroids
- Transient causes
o Gestational diabetes
o Medical or surgical stress
Clinical features
- Polyuria, Polydipsia, Thirst
- Weight loss
- Tiredness, fatigue
- Propensity for infections: Particularly of skin and genitals (e.g. vaginal thrush)
- Blurred vision, vision changes
88
- Weakness
- Groin itch, vulvovaginitis
- Rash (pruritis vulvae, balaitis), Coarse skin
- Nocturnal enuresis (mostly Type 1 DM)
- Hypercarotenaemia
- Impotence
- Arterial disease: MI, PVD
Examination
- Initial screening
o general inspection including skin
o BMI (weight/height)
o waist circumference
o visual acuity
o blood pressure—lying and standing
o test for peripheral neuropathy: tendon reflexes, sensation (e.g. cotton wool, 10 g monofilament, Neurotips)
o urinalysis: glucose, albumin, ketones, nitrites

- Diabetic examination
- Respiratory examination
- Eye examination
- Cardiovascular examination
Diagnosis
Investigations
- Bedside: BSL, urinalysis, ECG
- Bloods: FBC, lipase, lipid profile, HbA1c, fasting and random blood glucose, 2-hr post-load glucose after 75g over
glucose, eGFR
- Other: oral glucose tolerance test, dilated retinal examination, ankle-brachial index, urine ketones (looking for
HHS), urine albumin
Risk factors
- Age >40 years
- Family history
- Overweight/obesity
- Sedentary lifestyle
- Positive obstetric history
- Women with polycystic ovarian syndrome (PCOS)
- Hypertension/ischaemic heart disease
- Medication causing hyperglycaemia
89
Screening
- People with impaired fasting glucose/ impaired glucose tolerance
- Age ≥55 years
- Age >45 years with: family history (1° relative with type 2), obesity (BMI >30), hypertension
- Age ≥35 years from high prevalence ethnic groups: e.g. Aboriginal and Torres Strait Islanders
- Previous gestational diabetes; history of large babies
- People on long-term steroids or atypical antipsychotics
- Polycystic ovarian syndrome, especially if overweight
- Cardiovascular disease and other risk factors
- Hypothyroidism
- Cushing’s disease
- Gestational diabetes
- PCOS
- Type 1 diabetes
- Pre-diabetes
- Mature-onset diabetes of youth: monogenetic aetiology with onset often in
childhood or adolescence. Insulin treatment is usually required
Blood Glucose Monitoring at home

How often and when:
- Type 1 diabetes
o Four times a day (before meals and before bedtime) at first and for problems
o Twice a day (at least once)
o May settle for 1-2 times a week (if good control)
- Type 2 diabetes
o Twice a day (fasting and 2-3 hours post-prandial)
o If good control – once a week or every 2 weeks
Prediabetes
à VPG (venous plasma glucose) is elevated above the normal range (i.e. 6.1–6.9) but does not satisfy the type 2 diagnostic
criteria. It includes two states:
- Impaired fasting glucose (IFG)
- Impaired glucose tolerance (IGT)
- Urinalysis is unreliable in diagnosis since glycosuria occurs at different plasma glucose values in patients with different
kidney thresholds.
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Complications
Macrovascular
- Ischaemia/coronary heart disease
- Cerebrovascular disease
- PVD
Microvascular
- Retinopathy, maculopathy
- Nephropathy
- Neuropathy
o Sensory
o Mononeuropathy
§ Isolated peripheral nerve lesions
§ Amyotrophy
§ Cranial nerve palsies (III, VI)
o Autonomic neuropathy
§ Erectile dysfunction
§ Postural hypotension, syncope
§ Impaired gastric emptying
§ Delayed/incomplete bladder
emptying
§ Diarrhoea
§ Loss of cardiac pain: ‘silent’
ischaemia
Infections
- Skin
o Mucocutaneous candidiasis
o Staphylococcal infections
- Urinary
o Cystitis, UTI
o Pyelonephritis
- Lungs: Pneumonia
- Vaginal thrush
Metabolic
- Hypoglycaemia
- DKA
- Hyperosmolar hyperglycaemia
- Lactic acidosis
Hypoglycaemia
- Blood glucose falls to <3.0mmol/L
- Clinical signs
o Sweating, tremor, palpitations, hunger, peri-oral paraesthesia
o Rapid loss of consciousness, usually without warning
o Coma or ‘strange’ behaviour
Diabetic Ketoacidosis
- Life-threatening emergency – requires intensive management
- Usually occurs during an illness (e.g. gastroenteritis) when insulin is omitted
- Clinical features
o Develops over a few days, but may occur in a few hours
o Preceding polyuria, polydipsia, drowsiness
o Vomiting and abdominal pain
o Hyperventilation – acidotic breathing
o Ketonuria
Hyperosmolar hyperglycaemia
- May present with ALOC varying from stupor to coma with marked dehydration
- Onset may be insidious over a period of weeks with fatigue, polyuria and polydipsia
- Key features – hyperglycaemia and dehydration without ketoacidosis
- High mortality – even higher than ketoacidosis
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Lactic Acidosis
- Present with marked hyperventilation ‘air hunger’ and confusion
- Consider in the very ill diabetic patient taking metformin
Management
- 1st line: Metformin - ↓ hepatic glucose output, and ↓ peripheral Type and peak onset
insulin resistance. Rapid, 1 hour (Novarapid)
o Contraindications: Renal disease - Metformin affects renal Short, 2-5 hours (Actrapid)
function, so contraindicated if EGFR < 30. Intermediate, 12-24 hours (Humulin)
- 2nd line: Long, 1x day, Basal (lantus)
o Sulfonylureas: ↑ insulin secretion (requires some Beta-cell function)
st
Eg: 1 generation: acetohexamide, carbutamide, chlorpropamide
nd
2 generation: glibenclamide, glibomuride
o Thiazolidinedione/glitazones: PPAR-gamma agonists. Bind to DNA and prevent gene transcription leading to a
decrease in the amount of fatty acids present in circulation.
o DPP4 inhibitor/gliptins: Prevent the breakdown of endogenous GLP1 and GIP by inhibiting the DPP4 enzyme.
Reduce glucagon and blood glucose levels.
o Acarbose inhibitors: prevent the absorption of carbohydrates - flatulence is an issue
o SGLT2 inhibitors: Prevents renal resorption of glucose in the renal tubule. Has risk UTI (especially in elderly)
o GLP1 agonist: inhibitglucagon-like peptide 1, work on the same pathway at DPP4 inhibitors, reducing glucagon
and blood glucose levels.
o Insulin
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Diabetes Chronic Disease Management Plan
Communication
There are five basic elements in the communication process:
- the communicator
- the message
- the method of communicating
- the recipient
- the response
Questions
- Open-ended questions: determine underlying agenda or significant psychosocial problems
- Direct questions: help to define the current problem
- Closed questions
- Leading questions
- Reflective questions
Listening and silence

- Means of encouraging communication
- Appear interested, attentive and relaxed
- Important when the patient has stopped speaking as they are overwhelmed with emotion
Support and reassurance

- Encourages patient communication as they feel that they are being understood
- Restores patient’s sense of well-being, worthiness or confidence
Summarising
- Keeps patient on track
- Helps check accuracy of understanding
- Allows patient to correct information
Shared decision making

- Shared decision making enables a clinician and patient to participate jointly in making a health decision, having
discussed the options and their benefits and harms, and having considered the patient's values, preferences and
circumstances. It is not a single step to be added into a consultation, but a process that can be used to guide decisions
about screening, investigations and treatments.
- The benefits of shared decision making include enabling evidence and patients' preferences to be incorporated into a
consultation; improving patient knowledge, risk perception accuracy and patient–clinician communication; and
reducing decisional conflict, feeling uninformed and inappropriate use of tests and treatments.
Thyroid
Investigations
- Thyroid function tests
o TSH, T4, T3
- Thyroid autoantibodies
o TSI
o TPO
o Thyroglobulin Ab
- Fine needle aspiration

- Thyroid isotope scan: nodules – malignant vs benign
- Thyroid US: nodules
- CT scan: compression on the neck by large goitre
93
Adrenal
Cushing’s Syndrome
Aetiology
- Iatrogenic—chronic corticosteroid administration
- Pituitary ACTH excess (Cushing disease)
- Bilateral adrenal hyperplasia
- Adrenal tumour (adenoma, adenocarcinoma)
- Ectopic ACTH or (rarely) corticotrophin-releasing hormone (CRH) from nonendocrine tumours (e.g. oat cell carcinoma
of lung)
Clinical features
- Proximal muscle wasting and weakness
- Central obesity, buffalo hump on neck
- Cushing facies: plethora, moon face, acne
- Weakness
- Hirsutism
- Abdominal striae
- Thin skin, easy bruising
- Hypertension
- Hyperglycaemia (30%)
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- Menstrual changes (e.g. amenorrhoea)
- Osteoporosis
- Psychiatric changes, especially depression
- Backache
Diagnosis
- Cortisol excess (plasma or 24-hour urinary cortisol)
- Dexamethasone suppression test
- Serum ACTH
- Radiological localisation: MRI for ACTH-producing pituitary tumours or CT for adrenal tumours
Phaeochromocytoma
A dangerous tumour of the adrenal medulla
Clinical features
Paroxysms or spells of:
- hypertension
- headache (throbbing)
- sweating
- palpitations
- pallor/skin blanching
- rising sensation of tightness in upper chest and throat (angina can occur)
Investigations
- Series of three 24 hour free catecholamines ↑ VMA
- Abdominal CT or MRI scan
Treatment
- Excise tumour, cover with α and β blockers
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Sleep Disturbance
- Normal sleep – in a fit young person the idea is 7.5 – 8 hours; latency <30 minutes; wakefulness within sleep usually
<5% of time
- Sleep disorders in children, including snoring – should be taken seriously and investigated
o Can result in learning difficulties, hyperactivity, behavioural disorders, failure to thrive and short stature
- Drugs that can disturb sleep include – alcohol, nicotine, antihistamines, SSRIs, caffeine, hypnotics, venlafaxine, beta-
blockers, corticosteroids, theophylline
- It is illegal for a drive with a commercial driver’s license to continue driving with untreated OSA
History
- Obesity - Thyroid disease
- Snoring - Family history of sleep apnoea
- Waking with choking sensation - EtOH
- Nocturia - Smoking
- Daytime sleepiness and irritability - Recreational drugs
- Poor concentration or attention span - Marfan’s syndrome
- Morning headache - Depresion hx and screen: depressed, down or
- GORD worthless, decreased enjoyment in things
- Erectile dysfunction - Anxious worrying about things before sleep
- AF - Restless legs
- Heart failure - Wake up unable to breathe
- DM
Investigations
- Bloods: FBC, TFT, fasting blood glucose, U&E
- Other: sleep study (overnight polysomngram), K10
- Sleep apnoea - Problem drug use: alcohol, caffeine, nicotine,
- Depression recreational drugs
- Anxiety - Hypothyroidism
- Restless legs - Diabetes
- GORD - Chronic fatigue syndrome
- Dyspnoea: heart failure - CKD
Insomnia
- Defined as inability to function well with the amount
and quality of sleep experienced
- Patient may complain of difficulty getting to sleep or
staying asleep, of frequent intermittent nocturnal
arousals, early morning awakening or combination of
these
- When taking Hx – explore lifestyle factors (esp.
psychological reasons), painful conditions, drug use and
abuse, appetite, energy, sexual issues and physical
factors
o Check for hyperthyroidism
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Sleep Apnoea
- Cyclical brief interruptions of ventilation, terminating in an arousal from sleep (often not recognised by the patient)
- Broadly classified into:
o Obstructive
§ Diminished airway size (e.g. obesity, tonsillar-adenoidal hypertrophy)
§ Upper airway muscle hypotonia (e.g. alcohol hypnotics, neurological disorders)
§ Nasal obstruction
o Central
- Clinical effects
o Excessive daytime sleepiness – ‘I’m just tired all the time’
o Nocturnal problems – e.g. loud snoring, thrashing, choking
o Morning headache
o Occupational and driving problems
Narcolepsy
- A permanent neurological disorder characterised by brief spells of irresistible sleep during daytime hours in
inappropriate circumstances
o Even during activities
o Uncommon – incidence of 2-5/ 100 000
- Tetrad of symptoms
o Daytime hypersomnolence – sudden brief sleep attacks (15 – 20 minutes)
o Cataplexy – sudden decrease or loss of muscle tone in lower limbs – may cause person to slump to floor.
Usually triggered by surprise or emotional upset
o Sleep paralysis – frightening feeling of inability to move while drowsy (between sleep and waking)
o Hypnagogic (terrifying) hallucinations on falling asleep or waking up
Several attacks per day are possible
Idiopathic hypersomnia
- Type of excessive daytime sleepiness – presents similarly to narcolepsy without cataplexy
- Diagnosed despite adequate sleep and exclusion of other causes
o Usually have non-refreshing deep nocturnal sleep, but unlike narcolepsy, naps are not refreshing
Periodic limb movements (nocturnal myoclonus)

- Periodic limb movements (PLMs) and restless legs syndrome may coexist in the same patient
- Periodic limb movements – referred to as nocturnal myoclonus (leg jerks)
- Medication
o Levodopa plus carbidopa or
o Clonazepam or
o Sodium valproate
Restless Legs Syndrome (RLS)

- Aka Ekbom syndrome
- Common movement disorder of the nervous system – the legs feel as though they want to exercise or move when the
body is trying to rest
o Sensations that may be experienced – ‘twitching’, ‘prickling’ and ‘creeping’
- Major complaint of most sufferers – disruption both to sleep and relaxing activities (reading a book, watching television
ect.)
o Prolonged car rides or airplane travel can be difficult
- Symptoms
o Urge to move legs upon resting, due to unpleasant sensation in legs (especially calves)
o Sensations – crawling, creeping, prickly, tingling, itching, contractions, burning, pulling or tugging, electric
shock-like
- Secondary (medical) causes include:
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o Anaemia (common) o Hypothyroidism
o Iron deficiency o Pregnancy
o Uraemia o Drugs
- Can run in families
Management
- Perform activities that can reduce symptoms – e.g. modest amount of walking before bed, massage or prescribed
exercises
- Good sleep hygiene
- Diet – healthy diet and avoid caffeine, smoking and alcohol
- Try keeping the legs cooler than the body for sleep
- Exercises – stretching of legs 5 minutes before sleep
- Pharmacological
o Paracetamol or clonazepam or diazepam or levodopa
Bruxism (teeth grinding)
- The habit of grinding, clenching or tapping teeth, which may occur while awake
- Usually doesn’t affect patient’s sleep
- May result in headaches and TMJ dysfunction during the day
- Aggravated by stress and more common in heavy alcohol drinkers
Management
- Sleep hygiene advice
o Try to recognise what helps patient to settle best (e.g. warm bath, music)
o Establish a routine before going to bed
o Regular daytime exercise
o Regular time of arising
o Avoiding daytime naps
o Avoiding strenuous exercise close to bed
o Avoiding alcohol and caffeine
o Avoiding a heavy evening meal
o Avoid smoking
o Avoiding Lights
- Sleep-promoting adjuvants
o Warm milk before retiring
o Warm bath before bed
o Sex as the last thing at night where appropriate
- Non-Pharmacological treatment
o Meditation, CBT
o Relaxation therapy
- Pharmacological Treatment: Sleep Hygiene + Sleep Journal first
o Shorting acting benzo – temazepam (on PBS)
o If also depressed – tricyclic antidepressants (e.g. amitriptyline)
o Quetiapine can also be used
Chronic Fatigue Syndrome

Presence of unexplained persistent or relapsing fatigue for 6 months or more that is not attributable to exertion, not improved
by rest and causes substantial functional impairment.
Fatigue must be accompanied by at least 4 of 8 additional symptoms:
1. Postexertional malaise lasting more than 24 hours
2. Unrefreshing sleep
3. Impaired memory or concentration
4. Muscle pain
5. Joint pain without swelling or erythema
6. Headache of a new type or severity
7. Tender cervical or axillary lymph nodes
8. Sore throat
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Parasomnias
Nightmares (dream anxiety)
- Occurs during REM (night terrors occur in NREM)
- Usually occur later in sleep period and are accompanied by unconscious body movements, which usually cause the
person to awaken
- Associations – traumatic stress disorders, drug withdrawal
- Violent behaviour can occur during these dreams
- Psychological evaluation with CBT is appropriate
- Medications that may help – phenytoin, clonazepam or diazepam
Night terrors
- Characteristics include – sharp screams, violent thrashing movements and autonomic overactivity, including sweating
and tachycardia
o Universal feature – inconsolability
- Sufferers may or may not awake and usually cannot recall the event
- Require psychological evaluation and therapy
- Similar medication as used for nightmares may help
o E.g. 6-week trial of phenytoin, diazepam or lonazepam
Somnambulism (sleepwalking)
- Person performs some repetitive activity in bed or walks around freely
- No treatment usually required – but if dangerous than the sleeping environment should be rendered safe
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ENT
Deafness and hearing loss
- Degrees of hearing impairment:
o mild = loss of 20–40 dB (20 dB is soft-spoken voice)
o moderate = loss of 40–70 dB (40 dB is normal- spoken voice)
o severe = loss of 70–90 dB (shout)
o profound = loss of over 90 dB
History
- Onset and progression
- Recent/past generalised infection + presence of associated aureal symptoms e.g. ear pain, discharge, tinnitus, vertigo
- Vertigo
- Noise exposure
- Drug history
- History of swimming, diving, air travel, head injury
- Family history
Aetiology
Presbyacusis = natural aging of the auditory system
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Otalgia/Ear Pain
History
- SOCRATES - Sore throat
- Deafness - Swimming
- Discharge - Other symptoms
- Vertigo - Hit over ear
- Tinnitus - Allergies?
- Irritation - Aeroplane recently
Relevant features
- Site of pain and radiation
- Details of the onset of pain
- Nature of pain
- Aggravating or relieving factors, especially swimming
- Associated features – deafness, discharge, vertigo, tinnitus, irritation of external ear, and sore throat
Key Questions
- Where is the pain – in the ear, behind or below it?
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- Is it in one or both ears?
- Any other symptoms such as a sore throat, fever or vomiting?
- Has anyone hit you over the ear?
- Any discharge from the ear?
- Have you noticed any decreased hearing?
- Have you been swimming?
- Have you been in an airplane?
Physical Examination
- If the diagnosis is still doubtful, look for causes of referred pain – inspect the:
o TMJ and parotid glands
o Cervical spine
o Nose and postnasal space
o Mouth, including the teeth, pharynx and larynx
- ENT examination
o Start with ear examination before moving onto nose and throat
o Otoscope: looking at the external auditory canal and tympanic membrane. Normal is pearly grey, ovoid in
shape and semi-transparent. Look at colour, transparency, dilated blood vessels, bludging or retraction of
membrane or perforation. Light reflex, short process of the malleus, handle of the malleus, umbo, incus, pars
flaccida, pars tensa.
o Hearing tests should also be performed: whisper, weber, rinne tests
Red Flags
- Offensive discharge for >9 days
- Downward displacement of the pinna
- Swelling behind the ear
- Neurological symptoms: headache, drowsiness
- Older person: unexplained, intractable ear pain
- Persistent fever
- Patients with otalgia – 77% acute otitis media, 12% otitis externa
- Outer ear
o Cholesteatoma: growth of stratified squamous epithelium that starts in the middle ear that can perforate the
tympanic membrane
o Ear wax
o Otitis externa: acute localised, acute diffuse, chronic, malignant
§ Candidia albicans, Aspergillus nigra, Pseudomonas, Staph aureus
o Furnunculosis
o Trauma: foreign body
o Neoplasia
o Herpes zoster
- Middle ear
o Infection
o Otosclerosis
o Middle ear tumour
o Otitis media
o Eustachian tube dysfunction
o Bartotrauma
o Cholesteatoma
o Acute mastoiditis
- Other
o Dental disorders
o Upper cervical spinal dysfunction
o TMJ arthralgia
o Parotitis
o Temporal arteritis
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o Lymph node inflammation
o Pharyngeal disorders
o Tonsillitis
Investigations
- Seldom needed
- Weber/Rinne
- Audiometry
- Swab if the tympanic membrane is perforated
Perichondritis
- Infection of the cartilage of the ear characterised by severe pain of the pinna
o Pinna becomes red, swollen and exquisitely tender
Otic barotrauma
- Damaged caused by undergoing rapid changes in atmospheric pressure in the presence of an occluded Eustachian tube
- Symptoms – temporary or persisting pain, deafness, vertigo, tinnitus and perhaps discharge
- Mx – most cases resolve spontaneously, so treat with analgesics and reassurance
Cholesteatoma
- Sac of keratinising squamous epithelium arising from a perforation involving the periphery of the TM
- Associated with chronic otitis media
- Clinical features
o Hearing loss
o Discharge – purulent
o Less common symptoms – pain, tinnitus, balance disruptions
Otitis Media
Clinical Features
- Organisms – Streptococcus pneumoniae, Haemophilus influenza and Moraxella catarrhalis
o But can be caused by viruses
- Fever, irritability, otalgia and otorrhoea (discharge) may be present
- Main symptoms in older children – increasing earache and hearing loss
- Pulling at ears is a common sign in infants
Complications
- Otitis media with effusion (aka serous otitis media or glue ear) – 70% of children will have
present 2 weeks after presentation
- Chronic otitis media (Chronic suppuratives otitis media) - >2 weeks with episodes of
discharge from the ear
- Acute mastoiditis
- Meningitis (document absence of neck stiffness)
Perforated TM
- Can be safe or unsafe
o Safe – perforation not involving the drum margin
o Unsafe – perforation between the lateral process of the malleus and the roof of
the external auditory canal immediately above
Management
- Check hearing
- Simple analgesics – paracetamol
- Antipyretic treatment – controversial – unless fever is high grade (<38.5 degrees), it may actually prolong the course of
some viral illnesses
- Instruct not to let water enter ear
- Review in 2 days
- Check hearing 2 months after injury
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Antibiotics
- Antibiotics should be prescribed if:
o Aboriginal or Torres Strait Islander child
o Systemic features
o <6 months
o Sick child with fever
o Vomiting
o Red-yellow bulging TM
o Loss of TM landmarks
o Persistent fever and pain after 3 days conservative approach
- Antibiotic therapy: Amoxicillin 8rhly for 5 days
- Most children have mild reddening or dullness of the eardrum – antibiotics are not warranted
Otitis Externa
Aetiology
- Bacteria – Pseudomonas sp. E. coli, S. aureus, Kelbsiella sp.
- Fungal – Candida albicans, Aspergillus sp.
Clinical Features
- Itching at first
- Pain (mild to intense)
- Fullness in ear canal
- Scant discharge
- Hearing loss
- TM – granular or dull red
Management
- Antibacterial, antifungal and corticosteroid – Sofradex, Kenacomb drops
o 2 – 3 drops tds
- Analgesics
- Lidocaine with glycerol eardrops
- Recommendations – keep ear dry
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Tympanic Membrane
- Translucency – middle ear structures are clearly visible through the drum
- Colour – normal TM is a shiny pale-grey to brown
o Yellow is suggestive of an effusion
Otitis media TM – reddened and inflamed with engorged vessels. Bulging of the drum is a late sign
Normal TM Perforated TM
Healed TM with perforation Otitis media
Cholesteatoma Middle ear effusion
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Eye Pain and Red Eye
à Eye innervation: 3 SO4 LR6
History
- Patient demographics
- SOCRATES
- Trauma
- Daytime changes
- Eye pain
- Substance use hx
- Immunisation hx
- Medications
- Anxiety, drowsiness, muscle stiffness, nausea, cold/hot waves: caffeine withdrawal
- CVD
Red Flags
- Retinal detachment
o Curtain being pulled across the field of vision
o Floaters
o Flashes of light
o Gradual reduction in visual fields
- Closed angle glaucoma
o Halos around lights
o Nausea, headache
o Fixed dilated pupil
o Corneal oedema (cloudy)
o Conjunctival ejection
o Increased intraocular pressure
- Systemic symptoms
o Fever
o Anticoagulation
o Pregnancy
- Neurological signs
o Impaired mental status
o Neck stiffness
o Seizures
o Focal neurological deficits
- Onset
o Sudden and severe
o New after 50
- Other associated condition
o Following head trauma
o Awakens patient from sleep
o Jaw claudication
o Scalp tenderness
o Worse with exercise, sex or valsalva
- Prior headache history
o Different pattern
o Rapidly progressing in severity or frequency
- Bacterial conjunctivitis: central sparing, bilateral
- Episcleritis: segmental, cornea unilateral
- Acute iritis: ciliary flush, unilateral, small irregular pupil with may not respond to light
- Glaucoma: around cornea, unilateral, dull corneal surface with mod-oval shape pupil with no light response
- Corneal ulcer: around cornea, unilateral, fluorescein dye stains the ulcer
- Subconjunctival haemorrhage: localised haemorrhage
- Conjunctival haemorrhage: localised haemorrhage with posterior limit
Examination
- General Appearance
o Visual aids
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o Glasses, eye patch
o Patient looks generally unwell
o Signs of systemic disease: diabetes, skin rash, CT disorders
- Vitals
o Pulse: AF may be associated with episodes of visual loss
o BP: HTN may lead to increased intracranial pressure, diabetic and hypertensive changes
o Temperature: cellulitis, abscess
o BMI
o BSL: diabetic changes
- Visual Acuity: Snellen chart
o Best corrected (wearing their glasses if they have them) each eye separately and then eyes together
o Pin-hole: want to see if you are able to correct refractive error
o If unable to read chart
§ Move closer to chart
§ Counting fingers close to face
§ Hand movements
§ Perception of light
o Notation of visual acuity: 6/5-1
§ 6: using a 6m chart or equal (3m chart at 3m, still notate as 6). If you use a 6m chart at 3m, you need
to change the numerator to 3
§ 5: line that they got up to
§ -1: on line 5 they got 1 letter wrong
Inspection
- Eyeball
o Exophthalmos/proptosis
o Ptosis: dropping of the eyelid
o Lid retraction
- Lids: erythema, oedema, lumps, lesions, lashes, lower lid position (normal: half way between the limbus and the cornea
for the top lid and at the lower limbus for the bottom lid)
o Chalazion: nodule on eyelid
o Stye: infection of eyelid
o Skin tumours
o Zoster vesicles
o Ectropion: drooping of the lower lid
o Entropion: scarring or thickening of the lower lid causing inversion. This can lead to corneal abrasion by the
eyelashes
o Orbital cellulitis may affect the eyelid
- Conjunctiva: pallor, redness, subconjunctival haemorrhage, discharge

o Palpebral and peripheral redness: conjunctivitis
o Central redness: iritis, scleritis, corneal ulcer
o Segmental redness: episcleritis
- Sclera
o Icterus: jaundice
o Blue sclera: osteogenesis imperfect, connective tissue disorders
o Cornea: clear/cloudy, ulceration, foreign body
- Anterior chamber
o Hyphaema: blood
o Hypopyon: pus
Palpate
- Orbits: grossly assess intraocular pressure
- Pre-auricular lymph nodes
Pupils
- PERLA: Pupils equal and reactive to light and accommodation
- Size: Normally 2.5-3.5mm
- This is non-pathological pupil asymmetry in 20% of the population
- Light reflexes
o Direct
o Consensual
o Accommodation
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o Convergence
- Relative afferent pupillary defect (Marcus Gunn Pupil)
Visual Fields, Blind spot

- A scotoma (blind spot) will be detected 15-20 degrees temporal to the point of fixation.
- Papilloedema will cause disc swelling and will increased the size of the blind spot.
Extra Ocular Movements à 3 SO4 LR6

- Diplopia
- Nystagmus
Colour Vision
Test using an Ishihara chart
Red desaturation can occur with optic nerve disease
Fundoscopy
Other Examinations
- Neurological examination
- Vasculitis, sclerosis, diabetes, thyroid disease
o Choose system depending on differential diagnosis
Investigations
- Bloods: FBC, BGL
- Imaging: head CT
- Others: measure intraocular pressure, fluorescein stain
Acute conjunctivitis
- Episode of conjunctival inflammation lasting <3 weeks
- Two major causes
o Infection: bacterial/viral
o Acute allergic or toxic reaction
- Clinical features
o Diffuse hyperaemia of tarsal or bulbar conjunctivae
o Absence of ocular pain
o Good vision, clear cornea
o Can be unilateral or bilateral
Bacterial conjunctivitis
- Can be primary or secondary to viral infection or blepharitis (eyelid inflammation)
- Clinical features
o Purulent discharge with sticking together of eyelashes in morning
o Typically begins in one eye and spreads to the other
o Gritty red eye
o Clear cornea
Management
Manage underlying cause
Foreign body removal
- Flip up upper eyelid
- Look for presence of foreign body
- Remove with cotton tip if possible
- Fluorescein stain looking for any corneal damage
- Headache
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109
Nasal disorders
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Neck lumps
Aetiology
Cervical lymphadenopathy
- Acute cervical lymphadenitis
o Acute viral lymphadenitis
o Acute bacterial lymphadenitis—coccal infection
- Chronic lymph node infection
o MAIS lymphadenitis (atypical tuberculosis)
§ Mycobacterium avium-intacellularescrofulaceum
o Tuberculosis
o Viral infection, for example, EBV, rubella, cytomegalovirus, HIV
o Toxoplasma gondii infection
o Cat scratch disease—Bartonella henselae infection
- Neoplastic lymphadenopathy
o Lymphomas, esp. Hodgkin lymphoma
o Leukaemia
- Metastatic
Neck lumps not due to lymph node swelling

- Widespread
o Sebaceous cysts
o Lipomas
- Midline
o Thyroid nodule (moves upon swallowing)
o Thyroglossal cysts (moves upwards on tongue protrusion)
o Dermoid cyst (beneath chin)
- Anterior triangle
o Branchial cyst (in upper part): — usually adulthood (20–25 years)
o Carotid body tumour:
§ Opposite thyroid cartilage
§ Smooth and pulsatile
§ Can be moved laterally but not vertically
§ Usually 40–60 years
§ Requires excision (with care)
o Carotid aneurysm
o Lateral thyroid tumours
- Posterior triangle
o Developmental remnants
— Cystic hygroma
— Bronchial sinuses and cysts
o Pancoast tumour (from apex lung)
o Submandibular swellings
o Submandibular salivary gland
o Cervicofacial actinomycosis (lumpy jaw syndrome):
o Pharyngeal pouch
§ A soft, squelchy, indefinite mass
§ Base of left neck
§ History of difficulty in swallowing Thyroid nodule
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Dermatology
Rash
History
Three basic questions
1. Where is the rash and where did it start?
2. How long have you had it?
3. Is it itchy? Severity of itchiness
- Do you have contact with a person with a similar eruption?

- Have you worn any new clothing recently?
- Have you been exposed to anything different recently?
- Pain or burning
- Symmetry of lesions
- Systemic symptoms: Fever
- Past history of skin disease: psoriasis, BCCs, previous dermatitis.
- Past medical history: diabetes, treatment with cytotoxic agents, asthma, hay fever
- Family history of skin disease
- Social and occupational history: travel, sex, EtOH, occupation
- Treatments to date
- Current medications
Rash form
- Erythema: cellulitis
- Macule: lentigo simplex
- Papule: molluscum contagiosum, dermatofibroma, viral wart
- Nodule: keloid scar
- Plaque, scale: psoriasis
- Vesicle: varicella
- Bullae: impetigo
- Pustule: varicella
- Petechiae: meningococcal, viral
Red Flags
- Signs of meningism: stiff neck (nuchal rigidity), photophobia, headache
- Non-blanching petechial rash: meningococcal
- Fever: viral, septicaemia, toxic shock
- Very young or old
- Immunocompromised
- Lymphadenopathy
- Diffuse erythroderma: staph scalded skin syndrome, toxic shock syndrome, strep toxic shock syndrome, necrotising
fasciitis
- Mucosal/oral lesions: erythema multiforme major, toxic epidermal necrolysis
- Hypotension
- Severe localised pain or tenderness
- Recent new drug use: cutaneous drug reaction, photosensitivity, erythema multiforme, toxic epidermal necrolysis,
hypersensitivity reaction
- Arthralgia: viral illness, arbovirus, drug reaction
Examination à Top to toe examination

- Vital signs
- Mucosal membrane involvement
- Check for blanching of the rash
- Nikolsky’s sign: sloughing of the skin when rubbed, which may indicate toxic epidermal necrolysis
- Signs of anaphylaxis
- Lymphadenopathy: drug reactions such as serum sickness, hypersensitivity syndrome, infections
Investigations
- Bedside: ECG
- Bloods: FBC, serology for arboviruses, syphilis testing, LFTs, blood cultures
- Imaging: CXR
- Others: punch biopsy
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- Meningococcal meningitis
- Viral examthem: rubella, roseola, EBV, enterovirus
- Arboviruses: ross river fever, malaria, JE
- Cutaneous drug reaction
- Secondary syphilis
- Hand-foot-and-mouth
- Eythema multiforme: hypersensitivity reaction that may be triggered by infections. Most commonly HSV, varicella
zoster, HIV and CMV
- Dermatitis
- Rosacea
- Acne
- Tinea
Management
- Rule out red flags
- Symptomatic management of rash if viral examthem suspected/diagnosed
Contact Dermatitis
à Inflammation of the skin due to contact with irritants or allergens.
History
- SOCRATES
- Pruritic
- Where had they been and what they had been in contact with when the rash appeared
- Change in soaps, detergents, oils etc used on skin
- Other allergies and asthma
- Blistering/break in skin
- Pus: possible secondary infection
Examination
- Examine top-to-toe looking as vesicles and ruling out other causes of a rash.
- Check for infected vesicles/rash as this may need treatment with antibiotics
Investigations
- Allergy testing if unknown causative agent
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Management
1. High potency topical corticosteroids with plastic cling wrap to increase penetration
2. Intralesional triamcinolone injection
3. Oral prednisolone in severe cases
4. Oral antibiotics for secondary infection: S aureus most commonly
Atopic Dermatitis
àType of eczema
à A common, genetically determined skin disease – endogenous
- Most common skin condition in children
Clinical features
- Itching may be severe, waking the patient several times at night
- A patchy, erythematous, poorly defined rash characteristically in the popliteal
and cubital foassae and face, but can occur anywhere on the skin and
generalise in several cases
- Dryness of the skin
- Excoriation (loss of skin surface) due to itching and scratching
- Lichenification (thickening of skin with accentuated skin lines)
- Crusting (scabbing) and weeping due to 2' bacterial infection
Investigation
M/C/S swab if flare up and suspecting infection
Management
1. Modification of lifestyle to avoid exacerbating factors
- Avoid wool and synthetics
- Avoid soaps and shampoos ect – use substitutes
- Avoid HOT baths
- Cold windy weather exacerbates
2. Use of topical anti-inflammatory agents
- Mainstay of treating atopic dermatitis involves use of topical anti-inflammatory agents
- Topical corticosteroids are used most often
3. Use of moisturisers and bath additives
- Use of emollients and bath oils (so that their skin doesn’t dry after the bath)
4. Use of wet dressings
- Wet dressings – damp bandage that is applied over topical emollients and anti-inflammatory agents – may be left on all
day and night
- Are very useful to quickly settle acute exacerbations
5. Investigation and treatment of infection
- Need for M/C/S if flare ups
- Treatment appropriate antibiotics
6. Education - chronicity and overall good prognosis
- Prognosis is good as most resolve but aren’t curable
- Needs long term plan not reactive
- Need to treat flare ups
7. Discussion, possible investigation and treatment of allergy
- IgE elevated due to impaired barrier not allergy
- Allergy is part of disease, not the cause and not a major part usually
- Allergy testing best for severe cases with reactions to food
- Difficult to reduce airborne allergens
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Infantile Seborrhoeic Dermatitis
- Condition arises in newborn babies up to the age of six months
o Though you can’t be certain this isn’t just atopic dermatitis
- Possibly has to do with overactive sebaceous glands in skin of newborn babies
o Due to mother’s hormones still in the baby
- Glands release a greasy substance that makes old skin cells attach to the scalp as they try to dry and fall off
- About a third of cases are self-limiting and resolve within a few weeks
- Usually presents as a cradle cap: patchy, greasy, scaly and crusty skin rash
o May also affect skin creases such as armpits and groin (when it presents as napkin dermatitis)
- Non-itchy salmon pink flaky patches may appear on the face, trunk and limbs in severe cases
Psoriasis
à Common, chronic, strongly familial, non-infectious inflammatory disorder characterised by well-defined salmon-pink plaques
bearing large adherent silvery centrally located scale
- Is very controllable but not curable
- Fluctuates in severity over time, often in response to physical and psychological stress
- Severity of disease – ranges from trivial nuisance to severely disabling
Clinical features
- Well defined plaques with a red base and white scale found most
commonly on the elbows and knees, lower back and scalp
- Often symmetrical
- It is usually very minor, but it can affect any area of skin and it may be
severe or atypical
o Causing a few dry patches on the backs of elbows and knees
o Can manifest in umbilicus, natal cleft or scaling in the scalp
- Abnormalities of the nails: pitting or onycholysis is the most common,
but virtually any nail abnormality may be a sign of psoriasis
- May or may not be itchy
- ~5 - 20% will develop psoriatic arthritis
Treatment
- Wide range of treatments available for psoriasis – no one treatment will work for everyone
- There is no cure for psoriasis but several new medications have recently been introduced and ongoing research looks
promising
Lifestyle Modification: Modification of lifestyle to avoid exacerbating factors
Medical:
- Use of topical anti-inflammatory agents
- Use of topical tar containing creams and shampoo
- Use of dithranol
- Investigation and treatment of infection
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Scabies
à Infection with mite Sarcoptes scabiei
Clinical features
- Variable presentation:
o May be virtually no signs except itching more severe
at night
o A vesicular or pustule eruption on the palms and
soles is characteristic in babies, but a non-specific
excoriated rash on the trunk or scattered nodules
may also be present
- Can be:
o Hands, feet, wrists
o Penis, nipples, sacrum
o Spares head and neck - except in babies and immunosuppressed
- Prevalent in Indigenous Australians - these racial groups also more prone to secondary streptococcal skin infections,
which can lead to glomerulonephritis or rheumatic fever
Diagnosis
- Burrow where mite lives and lays eggs - gently scraped off with scalpel and smeared on glass side for microscopy
o Usually found between fingers or on wrists
Treatment
- Topical permethrin
o Use on 2 occasions a week apart
- 2nd line - benzyl benzoate, 10% sulfur cream and 10% crotamiton cream
- Oral ivermectin can be used in resistant cases
- Itch may not resolve immediately after treatment, and topical corticosteroids can be applied
- Clothes, towels and bedding should be washed with hot water
- Contact tracing
116
Skin Cancer
History
- Have you ever had a skin cancer before?
- Any family history of melanoma, or has any relative ever died from a
- Past & present occupation
- Outdoor interests
- > 5 blistering sunburns?
- PMHx (esp. past skin conditions), medications (esp. immunosuppression ), allergies
- Any current skin lesions of concern; esp. new or changing moles? Specific history of lesion(s).
- Exposure to other sources UV, ionizing radiation, chemicals (e.g. coal, petroleum products, dyes, arsenic), chronic
irritation, hyperthermia, tobacco, HPV
Melanoma
- Last skin check
- Changing spots: change in colour, thickness or shape
- Crusty non-healing sores
- New spots
Sun related changes

- Acitinic changes: sun-related changes to the skin
- Solar keratosis: abnormal skin cell development leading to thickened, scaly or warty coloured skin, red lesions
o
- Solar lentigos: brown macules
o
- Cutaneous fagility and easy bruising
- Guttate hypomelanosis: white patches
Basal Cell Carcinoma

- Most common skin cancers
- Arise from otherwise normal appearing skin
- Raised pearly edge
There are several different morphologies:
- Nodular BCC: most common on the face. Small shiny skin coloured or pink nodule. May have central ulcer and bleed
spontaneously. Pearly papule
o
- Superficial BCC: often multiple and present on the upper trunk. Pink or red scaly plaques that bleed and ulcerate easily
o
- Morphoeic BCC: scar-like plaque that may infiltrate cutaneous nerves
o
117
- Ulcerative BCC: ulcer with pearly or indurated edge. Crusted or haemorrhagic.
- Pigmented BCC: papules, nodules or plaques with a foci of pigment that is often brown, blue or grey
Squamous Cell Carcinoma

- Well differentiated
- Chronically sun damaged skin
- Indurated nodules with a keratotic surface
- Firm papule, crusted surface, rolled edge, ulceration, recurrent bleeding
- May be painful, particular with touch
- Causes: sun damage, HPV infection malignant change in warts of
immunosuppressed
Intraepidermal SCC/Bowen’s disease

- Irregular, flat, red and scaly patches
- Often on sun exposed areas
Melanoma
à Most commonly a pigmented lesion with the possibility of early metastasis
Types:
- Superficial spreading: 70% of all melanomas, linked to sunburn and present as a flat, pigmented asymmetric macule
that is changing in shape, size or colour
o
- Lentigo maligna: mainly in elderly with a large dose of sun. Unpigmented asymmetric facial freckle that is changing
o
- Acral lentiginous: affects the soles of the feet, palms of hands, toes, fingers and the nail apparatus. Not sun related and
occurs equally in all skin pigments.
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- Nodular: aggressive, appears as a pigmented nodule. Has a vertical growth phase and will cause dissemination
o
- Non-pigmented
Risk factors
- Multiple common melanocytic naevi
- Dysplastic naevus syndrome
- Family history of melanoma
- Blistering sunburns as a child or adolescent
- Fair complexion and tendency to sunburn
- Marked solar skin damage
- Immunodeficiency
Examination
Skin examination
- Persons skin type and risks (multiple moles, fair skin)
- Examine all skin surfaces including scalp, palms, soles, nails and mucosae
- A=Asymmetry
- B=Border – usually irregular, resembling coastline with promontories. Often well defined
- C=Colour – variation in colours
- D=Diameter – superficial spreading often > 6mm on diagnosis
- E= Elevation or evolution
Histological
Clark level
1 In-situ – confined to epidermis
2 dermis
3 Infiltrating papillary dermis
4 Infiltrating reticular dermis
5 Infiltrating fat
Nodes and metastasis

- N0 no nodes l
- N1 1 node l
- N2 2-3 nodes l
- N3 4 or more nodes
- M0 no mets l
- M1a distant skin or s/c mets l
- M1b lung mets l
- M1c all other visceral mets
Stage grouping for melanoma

- Stage 1T1-2, N0M0 l
- Stage 2T3-4 N0M0 l
- Stage 3 any T N1-3, M0 l
- Stage 4 any T any N M1
- Stage 1 and 2 – no investigations unless symptomatic

- Stage 3 – Detailed history and physical examination – investigate if symptomatic – CT chest/abd/pelvis or whole body
PET
- If symptomatic – LDH, CT , MRI, PET
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- Dermal naevus
- Solar ketatosis
- Psoriasis: superficical BCC
- Seborrhoeic keratosis: begin as slightly raised, skin coloured or light brown spots, gradually they thicken and take on a
rough, warty surface. They slowly darken and may turn black.
- Dysplastic naevi
- Common acquired melanocytic naevi (moles): even in colour, regular in shape and symmetrical
Management
Skin biopsy
- Incisional biopsy l
- Excisional biopsy l
- Shave biopsy
- Punch biopsy
o 3mm or greater
o Avoid crushing tissue
- Include accurate history on request form & tag or score specimen to orientate
Excision
SCC BCC Pre cancer AK/IEC
Surgery 4mm margin 3mm margin
Cryotherapy No Superficial only AK: 5-10 sec
IEC: 30 sec
3mm margin
Curettage No Superficial or nodular No
Imiquimod No Superficial, biopsy proven Yes, biopsy proven IEC
Efudix (5-fluorouracil) No No Yes, biopsy provden IEC
Basal Cell Carcinoma

st
1 line
- Excision: 3-4mm clearance margin
nd
2 line
- Superficial BCC’s on the trunk may be treated with liquid nitrogen cryotherapy. It should be used for primary lesions
only.
- Imiquimod 5% topically at night for 6/52
- C&C for superficial well-demarcated BCC’s on the trunk
Squamous Cell Carcinoma

st
1 line
- Excision: 3-5mm clearance
- Adjuvant radiotherapy if histopathology shows perineural spread, lymphoid invasion, or tissue invasion more than
4mm, lesions recur or the lesions have positive margins
nd
2 line
- Refer for expert advice if radiotherapy is appropriate: tumour surgery is likely to produce severe scarring or is
unsuitable
Review patient every 6 months for at least 2 years after excision
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Melanoma
Excision margins:
- In situ: 5mm
- Thinner than 1mm: 1cm
- 1-4mm thick: 1-2cm
- >4mm: 2cm
à If melanoma is confirmed and some of the lesion
was left behind, wide local excision should be
performed as soon as possible.
- Excision depth should be the same of
the lateral margin when possible, but no
further than the deep fascia.
- Adjunct therapies include
immunotherapies and chemotherapies
Follow up
- 6 monthly for 5 years
- Total skin surveillance, examine local area and draining lymph nodes
- Often risk of second primary lesion higher than risk of recurrence primary
- Full body examination for new melanomas

- Examine excision site for local recurrence
- Careful examination of lymph nodes
- Metastasis to nodes uncommon for melanomas < 1.0 tumour thickness
- 60% melanomas > 4.0mm – nodal involvement – usually not clinically apparent at time of diagnosis
- Fine needle aspiration of any suspicious node (open biopsy may increase tumour spillage)
- Sentinel node biopsy – contentious – if positive – lymph node dissection – opportunity if >1mm
- Therapeutic lymph node dissection offered if nodes positive
- Melanomas > 4.0mm – consider referral – adjuvant therapy
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Genitourinary
Dysuria
Haematuria
Proteinuria
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Sexually Transmitted Infections
History
Why are you here and what are your concerns?
How to broach the subject:
- “Now that you’re here for the repeat script for the pill why don’t we talk about STIs”
- “Have you heard about the HPV vaccine”
- “I’m bringing this this up is because we know people under 29 are at high risk and most STIs are asymptomatic”
- Make sure that they know that everything is kept private and confidential.
You want active screening for anyone under the age of 29
6P’s
1. Partners
o Number: last 12 months and last 3 months how many sexual partners have you had?
o Gender: men, women or both? Never assume someone’s sexuality
This is important for what screening tests that you perform
o Length of relationship
o Partners risk of infection: past/current sexual partners, drug use
2. Practices
o “I want to be more explicit about the kind of sex that you’ve had over the last 12 months to better understand
if you’re at risk of STIs”
o What kind of sexual contact: vaginal, anal, oral
o Have you ever been paid for sex?
3. Past history of STIs
o Ever been diagnosed with an STI? When? How were you treated?
o Recurring symptoms or diagnosis?
o Ever been tested for HIV or other STIs?
o Would you like to be tested? Contact testing if the test becomes positive
4. Protection from STI/
o Use any protection?
o What?
o How often?
5. Prevention of pregnancy
o Trying to conceive?
o Contraception or birth control?
o Has she had any previous pregnancies or has the male fathered children
6. Problems
o Performance
o Pain on ejaculation
o Pain on intercourse
- Local symptoms such as burning, itching, pain discharge, sores, vesicles testicular pain, dysuria and abdominal pain.
- Systemic symptoms such as fever, lymphadenopathy and arthralgia.
Investigations
- Bloods: serology for HIV, syphilis, hepatitis A and hepatitis B
- Imaging: liver USS if hepatitis present
- Other: first catch urine for chlamydia and gonorrhoea, trichamonas, rectal and throat swap for gonorrhoea
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Screening
Management
Syphilis
Chronic venereal infection caused by Treponema pallidum.
1. Benzathine penicillin 1.8g stat dose
2. Biicillin injection (it’s two injections)
3. Advise no sex for sexual contact for 7 days
Empirical antibiotics
- Adults with neurosyphilis: IV benzylpenicillin
- Congenital syphilis: IV benzylpenicillin or IM benzylpenicillin
Gonorrhoea
à Neisseria gonorrhoeae
- Dual antibiotic therapy: ceftriaxone (gonorrhoea) and azithromycin (chlamydia)
Chlamydia
- Antibiotics: azithromycin or doxycycline
- Azithromycin 1g stat dose
Genital Herpes
- IV acyclovir: used when they have pneumonitits, hepatitis, or CNS involvement
- Genital disease: oral acyclovir and symptomatic treatment
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Urinary Tract Infections
Risk factors
- Female: Short urethra
- Urinary catheter
- Pregnancy
- Previous UTI
- Sexual history
Clinical features
- Can be regarded as a masquerade when it presents with a constitutional problem or general symptoms, without symptoms
suggestive of a urinary infection such as frequency, dysuria and loin pain.
o This applies particularly to infants and young children and the elderly but is not uncommon in adult women and in
pregnancy. Acute UTI may occasionally present as acute abdominal pain.
- Fever
- LUTS
o Dysuria
o Frequency
o Urgency
o Flank pain
Classification
- Sterile pyuria: Pus cells but sterile urine
- Asymptomatic bacteriuria
- Symptomatic bacteriuria
- Acute cystitis
- Acute phyelonephritis
- Uncomplicated UTI
- Urethral syndrome
- Interstitial cystitis
Investigations
- Bedside: urinalysis with leuks, nitrates
- Bloods: FBC (leucocytosis, neutrophilia)
- Others: Urine M/C/S with midstream catch urine
Management
- Non-pregnant woman or man
o Trimethoprim 300mg PO for 3/7
o Cephalexin 500mg PO 12-hrly for 5/7
- Pregnant Women
o Cephalexin 500mg PO 12hrly for 5/7
- Children
o Trimethoprim and Sulfamethoxazole 4+20 mg/kg up to 160+800mg PO 12-hrly
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Chronic kidney failure
Aetiology
- Diabetes
- Glomerulonephritis e.g. IgA nephropathy
- Hypertension
- Vascular: atherosclerosis
- Polycystic kidneys
- Obstructive nephropathy/reflux
- Drugs including analgesic nephropathy
- SLE
- Gout
- Amyloidosis
- Hypercalcamia
Clinical features
- Generally non-specific and referable to the
GIT, presumably due to the formation of
ammonia in the upper GIT.
- However, anaemia is the main cause of
symptoms.
- Anorexia
- Nausea
- Vomiting
- Tiredness
- Lethargy
126
Management
- regular review
- good blood pressure control (the most effective way to slow progression)
- keeping plasma phosphate levels in normal range
- maintaining effective fluid and electrolyte balance
- prompt treatment of intercurrent illness
- judicious use of drugs
- avoiding treatment errors, especially with drugs
o Avoid potassium-sparing diuretics
o avoid nephrotoxic medications
o other drugs that may cause problems include digoxin, tetracyclines, gentamicin, NSAIDs, nitrofurantoin and ACE
inhibitors (ACEIs)
o Triple whammy: ACEi, NSAID and diuretic
- Rapid treatment of complications, especially salt and water depletion and acute urinary tract infection
Inguinoscrotal Lumps
Differential Diagnoses of a Groin Mass
- Hernia – femoral, inguinal
- Malgaigne bulgings
- Lipoma
- Undescended testis
- Spermatic cord swelling – encysted hydrocele, lipoma
- Lymph node – localised, generalised
- Haematoma (post femoral artery puncture)
- Neoplasm – lipoma, others
- Psoas abscess
- Vascular anomalies – saphenous varix, femoral aneurysm
Hernias
- Commonest types of hernias in the groin are inguinal, femoral and a combination of the two
Inguinal Hernias – Direct or Indirect

- Direct – occurs medial to inferior epigastric artery – only goes through deep inguinal ring
- Indirect – occurs laterally to inferior epigastric artery – gores through both deep and superficial inguinal ring
o Can transverse the entire length of the inguinal canal through the spermatic cord
o When it enters the scrotum – inguinoscrotal hernia
o Such hernias are often irreducible and prone to lead to strangulation of entrapped bowel
- Femoral – herniates through the femoral ring (femoral canal)
o Femoral canal = the medial part of the femoral sheath
o Femoral hernias are often small, usually occur in females and may be unnoticed
o Are particularly liable to produce bowel obstruction of strangulation
127
Complications
- Intestinal obstruction
- Incarceration – hernias that are irreducible – a hernia so occluded that it cannot be returned by manipulation; may become
strangulated
- Strangulation – basically an incarcerated hernia, but which has loss blood supply
Symptoms and Signs of hernia obstruction

- Colicky abdominal pain
- Nausea and vomiting
- Constipation and failure to pass flatus
- Abdominal distension
- High-pitched tinkling bowel sounds
- Local tenderness and swelling of the hernia
- No expansive cough impulse
Clinical Features
- Lump
- Discomfort or pain –
o A dragging pain
o Worse after standing or walking
o Referred to testicle (indirect hernia)
- Expansile impulse on coughing
- Always attempt reduction in the recumbent position
Risk of Strangulation
- Femoral hernia – greatest risk
- Indirect – moderate risk
- Direct – least risk
Treatment
- Surgery
o Symptomatic hernias require repair and all femoral hernias should be repaired
o Obstructed and strangulated hernias require urgent surgery
- Conservative
o If hernias are asymptomatic, or a significant operative risk is posed
o Can use a truss
128
Viruses
Epstein-Barr Mononucleosis
à Type of herpes virus
- Can mimic disease e.g. HIV primary infection, streptococcal tonsillitis, viral hepatitis and ALL
- Most common 15-25 years
Clinical features
- Slow onset malasise: 1-6 weeks
- Fever
- Myalgia
- Headaches, anorexia
- Nasal quality to voice
- Blocked nose
- Sore throat
- Nausea and vomiting
- Rash
- Dyspepsia
- Clinical findings
o Exudative pharyngitis
o Petichiae of palate
o Lymphadenopathy
o Rash: maculopapular
o Splenomegaly
o Jaundice +/- hepatomegaly
Complications
- Antibiotic induced skin rash (amoxicillin)
- Prolonged weakness
- Hepatitis
- Depression
- Cardiac: myocarditis, pericarditis
- Haematological: agranulocytosis, haemolytic anaemia, thrombocytopenia
- Respiratory: Upper airway obstruction (lymphoid hypertrophy)
Diagnosis
- WCC shows absolute lymphocytosis.
- Blood film shows atypical lymphocytes.
- Paul–Bunnell or Monospot test for heterophil antibody is positive (although positivity can be delayed or absent in 10% of
cases).
- Diagnosis confirmed (if necessary) by EBV-specific antibodies, viral capsule antigen (VCA) antibodies— IgM, IgG and EB
nuclear antigen (EBN-A).
129
Differential
- HIV
- CMV
- Toxoplasmosis
- Acute streptococcal pharyngitis
- Adenovirus infection
- Hepatitis A-E
Cytomegalovirus
Clinical features
Three important clinical manifestations are described.
- Perinatal disease Intrauterine infection may cause serious abnormalities in the fetus
o Including CNS involvement (microcephaly, hearing defects, motor disturbances), jaundice, hepatosplenomegaly,
haemolytic anaemia and thrombocytopenia.
- Acquired CMV infection In healthy adults, CMV produces an illness similar to EBM with fever, malaise, arthralgia and
myalgia, generalised lymphadenopathy and hepatomegaly.
o However, cervical lymphadenopathy and exudative pharyngitis are rare.
o The fever often manifests as quotidian intermittent fever spiking to a maximum in the mid-afternoon and falling to
normal each day
o There is often a relative lymphocytosis with atypical lymphocytes but the heterophil antibody test is negative.
Liver function tests are often abnormal.
o Diagnosis: Specific diagnosis can be made by demonstrating rising antibody titres from acute and convalescent (2
weeks) sera. A four-fold increase indicates recent infection. PCR testing can be used. The virus can be isolated
from the urine and blood.
- CMV disease in the immunocompromised host Disseminated CMV infection
o Opportunistic severe pneumonia, retinitis (a feature of AIDS), encephalitis and diffuse involvement of the
gastrointestinal tract.
Treatment
- In the patient with normal immunity no treatment apart from supportive measures is required, as the infection is usually
self-limiting
Ross River
- Arbovirus
- Clinical features
o Polyarthritis (75% of patients)—mainly fingers, wrists, feet, ankles and knees
o Maculopapular rash—widespread, often ‘subtle’, mainly trunk and limbs
o Myalgia
o Pyrexia (mild)
o Headache
o Nausea
o Fatigue with exercise
Travel medicine
Pre-travel health care
- Advise the patient to plan early—at least 8 weeks beforehand.
- Advise a dental check.
- Allow adequate time for consultation (e.g. 30–45 minutes).
- Individualise advice.
- Provide current information.
- Provide written as well as verbal advice.
- Provide a letter concerning existing medical illness and treatment.
- Encourage personal responsibility.
Immunisations
- All travellers, all destinations
o Tetanus toxoid and diphtheria booster if >10 years since last dose
o Yellow fever
§ 1 injection is valid for 10 years
130
- All travellers to developing countries free of malaria
o Tetanus toxoid booster
o Polio immunisation
§ If >10 years Measles immunisation (consider MMR)
o Influenza
o Pneumococcus
- Travellers to developing and other countries at high risk of infection
o Malaria prophylaxis
o Hepatitis A, Hepatitis B
o Typhoid
o Tuberculosis (BCG if Mantoux –ve)
o Other vaccinations—consider:
§ Meningococcus (required in some countries)
§ Japanese B encephalitis
§ Rabies
§ Typhus
§ Plague
§ Anthrax
§ Cholera
Gastrointestinal infections
Traveller’s diarrhoea
- Occurs about 6-12 hours after taking infected food or water
- Usually mild and lasts 2-3 days: unusual to last >5 days
- Most commonly due to E Coli, campylobacter, Shigella, salmonella
- Clinical features
o Abdominal cramps
o Frequent diarrhoea with loose, watery bowel movements
o +/- vomiting
o Very severe diarrhoea with passing of blood or mucus: Shigella or campylobacter
Treatment
- Mild diarrhoea
o Maintain fluid intake—Gastrolyte.
o Antimotility agents: e.g.

Loperamide
§ Note avoid in children
- Moderate diarrhoea
o Attend to hydration.
o Antibiotic—e.g. norfloxacin or
azithromycin
- Severe diarrhoea (patient toxic and febrile)
o ? Admit to hospital.
o Attend to hydration—use an oral
hydrate solution (e.g.
Gastrolyte).
o Antibiotic—e.g. norfloxacin or
azithromycin
Prevention
- Only drink purified water
- Do not use ice
- Avoid fresh salads and raw vegetables
- Be wary of dairy products
- Avoid eating raw seafood
- Use disposable moist towels for hand washing
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Returned traveller
- Mild diarrhoea
o Stool microscopy and culture
o Look for and treat associated helminthic infestation
- Moderate or prolonged (>3 weeks) diarrhoea
o Usually due to Giardia lamblia, Entamoeba histolytica, Campylobacter jejuni, Salmonella, Yersinia enterocolitica or
Cryptosporidium.2
o Stool examination (three fresh specimens):
§ Microscopy
§ Wet preparation
§ Culture
o Treat pathogen
- Non-pathogens such as E. coli and Endolimax nana are often reported but do not treat specifically.
132
Infectious Diseases
Dengue fever
- Also known as ‘breakbone’ fever, it is widespread in the south-east Pacific and endemic in Queensland.
- A returned traveller with myalgia and fever <39°C is more likely to have dengue than malaria.
- Mosquito-borne (Aedes aegyptii) viral infection
Clinical features
- Incubation period 5–6 days
- Abrupt onset fever, malaise, headache, nausea, pain behind eyes, severe backache, prostration
- Sore throat
- Severe aching of muscles and joints
- Fever subsides for about 2 days, then returns
- Maculopapular rubelliform rash on limbs → trunk
- Petechial rash common (even in absence of thrombocytopenia)
- Generalised erythema with ‘islands of sparing’
- ± Diarrhoea
- The rare haemorrhagic form is very severe; may present with shock which is usually fatal
- Later severe fatigue and depression (prone to suicide)
Diagnosis
- Dengue-specific IgM serology
- FBE: leukopenia; thrombocytopenia in haemorrhagic form
Treatment
- Symptomatic with rest, fluids and analgesics
Prevention
- Avoid mosquito bites—no vaccine available
Malaria
- Types
o Plasmodium vivax and P. ovale—tertian malaria
o P. falciparum—malignant tertian malaria
o P. malariae—quartian malaria
o P. knowlesi—presents like vivax and falciparum
- Malaria is either benign (vivax, ovale) or malignant
(falciparum).
- Resistance to many drugs is increasing:
Clinical features
- High fever, chills, rigor, sweating, headache
- Usually abrupt onset
- Can have atypical presentations (e.g. diarrhoea, abdominal
pain, cough)
Prevention
- Avoid mosquito bites
- Take antimalarial medicines regularly (see table below)
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Meliodosis
à Gram-negative bacillus, Burkholderia psuedomallei
- Infects humans mainly by penetrating through skin wounds, especially abrasions.
o It is mostly acquired while wading in rice paddies.
- May manifest as a focal infection or as septicaemia with abscesses in the lung, kidney, skin, liver or spleen
Clinical features
- Fever, headache, cough, pleuritic pain and generalised myalgia
Diagnosis
- Blood culture, swabs from focal lesions, haemagglutination test
Treatment
- Meropenem 1 g IV, 6 hourly
or
- Imipenem 1 g IV, 6 hourly all for at least 14 days
- Followed by oral cotrimoxazole ± doxycycline bd + folic acid for 3 months
Leptospirosis
- Leptospirosis follows contamination of cut skin or mucous membranes with Leptospira-infected urine of many animals
Clinical features
- Fever, chills, myalgia
- Severe headache
- Macular rash
- Light-sensitive conjunctivitis (marked suffusion)
- Some may develop the immune phase (after an asymptomatic period of 1–3 days) with aseptic meningitis or jaundice and
nephritis (icterohaemorrhagic fever, Weil syndrome) with a significant mortality.
Diagnosis
- High/rising titre of Ab
Treatment
- Doxycycline or benyzlpenicillin
Scrub typhus
à Rickettsia tsutsugamushi, which is transmitted by mites.
Clinical features
- Abrupt onset febrile illness with headache and myalgia
- A black eschar at the site of the bite with regional and generalised lymphadenopathy
134
- Short-lived macular rash
- Can develop severe complications (e.g. pneumonitis, encephalitis)
Diagnosis
- Serological assays
Schistosomiasis
à The infestation is caused by parasite organisms (chistosomes) whose eggs are passed in human excreta, which contaminates
watercourses
Clinical features
- The first clinical sign is a local skin reaction at the site of penetration of the parasite (it then invades liver, bowel and
bladder). This site is known as ‘swimmer’s itch’.
- Within a week or so there is a generalised allergic response, usually with fever, malaise, myalgia and urticaria
- A gastroenteritis-like syndrome can occur (nausea, vomiting, diarrhoea) and respiratory symptoms, particularly cough.
- Lymphadenopathy and hepatosplenomegaly
Diagnosis
- Serology
- Detecting eggs in the stools, the urine or in a rectal biopsy
Treatment: Praziquantel (may need retreatment)
Prevention
- Travellers should be warned against drinking from, or swimming and wading in, dams, watercourses or irrigation channels,
especially in Egypt and other parts of Africa.
Pinworm/Threadworm
- Ubiquitous parasite: Tiny white worms about 1 cm long that multiply profusely and are spread readily between individuals
by close contact
- Virtually all children have been infected by the time they reach high school but at any one time approximately 50% of the
5–10 years age group will harbour pinworms.
Clinical features
- Usually asymptomatic
- Pruritus ani (in about 30% of cases)
- Diarrhoea (occasionally)
Diagnosis
Treatment
- Troublesome cases
o Scrupulous hygiene by family
o Hands should be washed thoroughly after toileting and before handling food
o Clip fingernails short (eggs lodge under nails)
o Bed linen, nightwear and underwear changed and washed in very hot water daily for several days
o Vacuum room of affected person daily
- Medication
o Pyrantel, albendazole or mebendazole—as single dose orally
§ Repeat in 2–3 weeks—both patient and household contacts
135
Palliative Care
Symptom control and QOL
- Palliative care aims to maximise QOL
- Symptom control improves QOL
- Studies show high symptom prevalence but low levels of treatment
- 2/3 of cancer patients suffer pain, however pain is only one of many symptoms and may not be the main problem
- Pain is genergally treatable, but often under-treated
Symptom assessment
à Diagnosis of what is causing the symptom is key to therapy
- Reversible causes
o Biological e.g. infection, anaemia
o Psychological e.g. fear, depression
o Iatrogenic e.g. drug or treatment adverse effects
- Anatomic changes due to disease progression
o E.g. new mets
- Biochemical abnormalities
- Co-morbidities
Symptom management
- Some symptoms e.g. pain, nausea, vomiting, constipation are easier to control than others e.g. dry mouth, anorexia,
fatigue
- Consider burden of treatment vs benefit
- Medications
o Right drug: right dose, right route of administration
- Non-drug approaches
o Nursing care, wound care, physiotherapy, occupational therapy
o Surgery, radiotherapy, chemotherapy
- Approach to care
o Explain and discuss treatment options
o Individualize treatment
o Review often – things change
§ Attend to detail, monitor progress
Appropriate routes of administration

- Gastroenteric
o Oral: preferred, Gastric or jejunal tube, Rectal
- Parenteral
o IV, IM, SC
- Topical
o Skin, Buccal, Nasal
- Inhaled
When to refer to specialist palliative care

- Most patients are cared for at home, by family members and the primary care team
- Specialist palliatve care has a supportive role
- Patients with complex symptoms benefit most from specialist palliative care
Nausea and vomiting

- Prevalence 20-25% in palliative care patients
- 50% multifactorial or cause unknown
Causes
- Gastrointestinal
o Gastric stasis
o Hyperacidity
o Constipation
o Bowel obstruction
- Psychological causes
o Anticipatory vomiting
- Intracranial causes
o Mass
136
o Infection
- CTZ causes
o Medications
o Biochemical
o Toxins
Drug therapy
- Choice of medications based on cause
o Metoclopramide (maxalon)
o Prochlorperazine (stemetil)
o Haloperidol
o Domperidone
o Levomepromazine, olanzapine
o Cyclizine
o Ondansetron
- Appropriate rout of administration e.g. SC
Constipation
- Symptoms
o Abdo pain
o Bloating
o Nausea
o Vomiting
- Outcomes
o Faecal impaction
o Urinary retention
o Bowel obstruction
o Colonic perforation
- Assessment
o History
§ Usual bowel habit, differences
§ Udnerlying illness
§ Constipating drugs
o Examination: abdomen and PR
o Investigations: plain xray, biochemistry
- Remember
o Most patients taking opioids will become constipated without laxatives
o Sick people find it difficult to eat well, drink enough and exercise
Incontinence
- Can be embarrassing and social isolating
- Difficult for patients to discuss
- Medical options few, surgical options sometimes unacceptable
- Big role for counselling and support
Agitation and delirium

- Agitation
o Treat reversible causes
§ Pain
§ Anxiety
§ Fear
§ Urinary retention
§ Full rectum
o Benzodiazepines e.g. diazepam, midazolam
- Delirium
o Treat reversible causes
§ Drug toxicities
§ Cerebral irritability
§ Biochemical imbalance
§ Space occupying lesion
§ Alcohol or drug withdrawal
o Explanation and support to patient’s family
137
o Reduce stimulation
o Antipsychotics e.g. haloperidol
Managing breathlessness
- Reversible cause?
o E.g. PE, pneumonia, pleural effusion, HF, COPD
o Consider patient’s goals, balance of benefit and burden
- Dyspnoea management techniques
o Information and education
o Ventilation e.g. fan
o Management of panic attacks
- Pharmacological treatment
o Opioids e.g. ordine 2.5-5mg po prn
o Benzodiazepines
- Oxygen therapy??
o Does not improve subjective sensation of dyspnoea
Cough
- Reversible? Treat only if benefit > burden
o Antibiotics
o Physiotherapy
o Drainage
o Radiotherapy
- Treat symptomatically
o Wheeze: salbutamol
o Loosen secretions: steams inhalations, saline nebs
o Suppress: opioids or codeine linctus
Fatigue
- Reversible causes
o Anaemia
o Malnutrition
o Deconditions
o Medication effects
o Hypoxemia
o Infection
- Management
o Education, listening, support
o Stress reduction techniques
o Exercise management
o Assistance with ADLs
Insomnia
- Contributing factors
o Pain
o Depression
o Fear
o Anxiety
o Medications
o Institutional factors
- Approach
o Discussion and education
o ‘sleep hygiene’
o Sedatives
o Melatonin for disturbed sleep cycle
Lymphoedema
- Pressure garments and bandaging
- Massage
- Elevation
- Laser
- Drainage
138
Wounds
- Infection control
- Odour control
o Charcoal dressings
o Topical antibiotics
o Aromatherapy
- Pain management
- Hyperbaric oxygen
- Radiotherapy
- Surgery/grafting
Symptoms in the last 48 hours of life

- Dying people suffer similar symptoms regardless of the cause of death
o Pain, nausea, dyspnoea, excess secretions, restlessness, delirium
- Symptoms change quickly so you need an anticipatory approach to care
- Patients often cannot swallow and need parental medications
- Give explanation and reassurance to patients and families
139
Complementary and Alternative Medicine
Complementary alternative medicines are medical products and practices that are not traditionally practiced by health professionals
and not part of standard medical care. They include acupuncture, special diets etc.
Integrative medicine is an approach to health care that combines both standard medicines with complementary alternative
medicine. They propose to treat the patients mind, body and spirit.
Meditation Transforming the mind to a state of deep peace (calm and silent). Some evidence that it reduces blood
pressure as well as symptoms of irritable bowel, ulcerative colitis, anxiety and depression and
insomnia.
A small 2016 study found that mindfulness meditation does help to control pain and doesn’t use the
brain’s naturally occurring opiates to do so. This suggests that combining mindfulness with pain
medications and other approaches that rely on the brain’s opioid activity may be particularly effective
for reducing pain.
A 2014 literature review of 47 trials in 3,515 participants suggests that mindfulness meditation
programs show moderate evidence of improving anxiety and depression. But the researchers found no
evidence that meditation changed health-related behaviors affected by stress, such as substance abuse
and sleep.
Homeopathy First developed in Germany – remedies that are derived from substances that come from plants,
minerals or animals. Treatments are individualised to tailor each person.
Little evidence to support homeopathy as an effective treatment – some products can contain
substantial amounts of active ingredients that could cause side effects and drug interactions. 2015
assessment by Australian government conclude that there are no health conditions for which there is
reliable evidence that homeopathy is effective.
Acupuncture Involves the stimulation of points on the body by inserting thin needles through the skin.
Some studies to suggest that acupuncture may help ease types of chronic pain (lower back, neck and
osteoarthritis) and also the frequency of tension headaches.
Clinical practice guidelines issued by the American Pain Society and the American College of Physicians
in 2007 recommend acupuncture as one of several nondrug approaches physicians should consider
when patients with chronic low-back pain do not respond to self-care (practices that people can do by
themselves, such as remaining active, applying heat, and taking pain-relieving medications).
A 2009 systematic review found that adding acupuncture to basic care for migraines helped to reduce
migraine frequency. However, in studies that compared actual acupuncture with simulated
acupuncture, researchers found that the differences between the two treatments may have been due
to chance.
Osteopathy Alternative medicine that emphasizes massage and other physical manipulation of muscle tissues and
bones. In Australia, osteopaths are registered and regulated by law as therapists and may not practice
medicine. 5 years training in anatomy, physiology, pathology and general medical diagnosis.
Good evidence as a treatment for lower back pain and limited evidence to suggest its effectiveness in
neck, shoulder and lower limb pain. Not effective as a treatment for conditions “unrelated” to the
bones and muscles – headaches, migraines, period. Acknowledged in the GP Care Plan.
140

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General Practice

General practice ................................................................................................................................................................................. 4

Aetiology à PIRATE SHIV

Anticoagulation à based on CHADS- VASc

Patients with Kidney Disease

Coronary Artery Disease

Aldosterone antagonists e.g. Spironolactone

Fever in Specific Populations:

Pyrexia of Unknown Origin

What not to miss

Group A Streptococcus (pharyngitis, tonsillitis)

Sore throat: Ghosts

Possible reasons for antibiotics to parents with an uncomplicated illness

Bronchiectasis Productive cough and frequent chest infections

Other drugs which may be used

Mild Moderate Severe

Complications - None - Exclude complications - Severe hypoxaemia

GOLD COPD Staging

Long term oxygen therapy (LTOT)

Treatment of acute COPD exacerbation

Bacterial sinusitis is suspected with:

- Upper GI – tend to be copious, watery or fatty, pale yellow or green

Serious disorders not to be missed

Congenital Megacolon Hircschsprung disorder (aganglionsis)

Other indications for an endoscopy:

Vitamin B12 Deficiency

Watch for complications:

Iron Deficiency Anaemia

Bruising and bleeding

Disseminated intravascular coagulation (DIC)

Immune thrombocytopenic purpura (ITP)

Thrombotic thrombocytopenic purpura (TTP)

Chronic myeloid leukaemia (CML)

Chronic lymphocytic leukaemia (CLL)

- A disorder of late middle age and elderly

Acute ‘Thunderclap’ Headache

Cervical Dysfunction/ Spondylosis

Benign intracranial hypertension

Management of headache if investigations are negative

Dizziness and vertigo

o the cerebellum or its connections:

Modulating pathways (+) and (-)

Complex regional pain syndrome

Risk factors for NSAID-induced side effects

Oxycodone e.g. Endone, Oxycontin, OxyNorm

Symptoms – usually after lifting/twisting

Disc herniation management

Low Back Pain

Vertebral dysfunction with non-radicular pain

Non-Organic back pain

Ottawa Knee Rules

Ottawa Criteria: Ankle and Foot Rules

Movements and Measuring

Barriers to losing health

ABC of diabetes control

o urinalysis: glucose, albumin, ketones, nitrites

Blood Glucose Monitoring at home

Listening and silence

Support and reassurance

Shared decision making

- Fine needle aspiration

Periodic limb movements (nocturnal myoclonus)

Restless Legs Syndrome (RLS)