Common general practice consultations Notes for

OSCEs

Check up general, cardiac and female genital

Cardiac see CHF summary
Assessment of Cardiovascular Risk Factors

Previous IHD
Hypercholesterolaemia
Smoking
Hypertension
Family history of CAD
History of Diabetes
Renal failure

Female Genital PAP smears

Should be done every 2 years for women 18-70 for those without pathology s/s and for those
who have had sex

From sexual activity 70y.o.

- Begin at 18-20 or two years after sex, whichever is later
- Cease at 70 if have had normal smears for five years
- There are reminder registers

Hysterectomy
- PAP required if cervix not fully excised
- Vaginal vault smears needed if Hx of dysplasia

Grading of squamous abnormalities

- HPV = atypia
- CIN 1 3 = mild moderate severe dysplasia
- CIS = carcinoma in situ
- Invasive carcinoma
- ASCUS = atypical SC of undetermined significance
- LSIL = low grade squamous intraepithelial lesion
- HSIL = high grade SIL
- CIN = cervical intraepithelial neoplasia

When to refer
- If normal repeat at 2 years
- If possible or definite LSIL repeat at 12 months, if over 30 with no negative smears in
last 3 years refer to colposcopy or repeat in six months
- High grade lesions refer to colposcopy or gynaecologist

NOTE: if the patient has HPV smoking is a significant RF for developing a dysplasia advise
to quit

s/s of cc or other disorders

 - Vaginal bleeding especially postcoital
- Discharge
- Weakness

Prevention of cancer
- Intercourse with one partner
- Condoms if unsure of sexual Hx
- PAP smears
- Counseling for those at risk
- Use of beta carotene has protective effect eat lots of green leaf and orange veges
- NO smoking

Gardisil
- Females 18-26 at practice
School program

Test results
BSLs
BGL 4-6 mmol/L (fasting)
HbA1c < or equal to 7%

Cholesterol
LDL-C < 2.5 mmol/L
Total Cholesterol < 4.0 mmol/L
Triglycerides < 1.5 mmol/L

LFTs
Plasma bilirubin
Albumin indicates chronic liver disease if low
ALT specific to liver indicates hepatocyte damage
AST indicates hepatocytes damage
ALP indicates cholestasis
GGT - raised with cholestasis and drug and alcohol

Thyroid function tests

- First look for TSH
- Then look for T3, T4
- Hyperthryroidism = Increased HR, Sweating, tremor, anxiety, Increased appetite, Weight
loss, Intollerance to heat
- Hypothyroidism = Cretinism (if present at birth), Mental and physical slowness,
Sensitivity to cold, Decreased pulse, Weight gain, Thickening of skin myxoedema

Immunisation/vaccination (all ages)

See immunisation schedule

Throat complaint
With a sore throat you need to determine whether it is not deep neck pain, get them to point to
the area that is sore, enquire about other s/s e.g. fever, metallic taste

Usually viral treat symptomatically

- Soothing fluids including icy poles
 - Analgesia 2 paracetamol or soluble aspirin for adults, paracetamol elixir for kids
- Rest with adequate fluids
- Soothing gargles e.g. soluble aspirin
- Advice against overuse of OTC lozenges and topical sprays

DDx
1. Viral pharyngitis
2. Strep tonsillitis
3. Chronic sinusitis with postnasal drip

What not to miss

- CV angina, MI
- Neoplasia of oropharynx, tongue\
- Severe infections acute epiglottitis, peritonsillar abscess, pharyngeal abscess,
diphtheria, HIV

Pitfalls often missed

- Foreign body
- EBV
- Candida (infants and steroid inhalers)
- STIs (gonococcal, herpes, syphilis)
- Reflux oesophagitis pharyngitis
- Irritants e.g. cigarette
- Chronic mouth breathing
- Apthous ulceration
- Thyroiditis

Strep tonsillopharyngitis
1. Fever >38
2. Tender cervical lymph
3. Tonsillar exudates
4. NO cough

Dx with throat swab Tx with penicillin

Upper respiratory infection

Most common cause of a cough

History
- How would you describe it, how long present for?
- Do you cough up sputum, describe?
- Any blood in sputum and how much?
- Is there burning in your throat or chest?
- Any other s/s?
- Smoker?
- Chest pain or fever, shivers or sweats?
- Wheeze?
- Previous attacks of wheezing or hay fever?
- Hx of asthma?
- Lost weight?
- Anyone in family with TB or persistent cough?
 - Smoker? Exposure to smoke?
- Work? Work history? Exposure to asbestos?
- Do you keep birds?
- Foreign body?
- Recent operation?
- Swelling in legs?
- Timing of cough day or night?
- Associations posture, food, wheeze, breathlessness?

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

Investigations
- Hg, blood film and WCC
- Sputum for cytology
- ESR (high with bacterial infection, bronchiectasis, TB, lung abscess, bronchial cc)
- Respiratory function tests
- Radiology CXR
- Skin tests

What not to miss

- LV failure
- Carcinoma of lung
- TB, pneumonia, influenza, lung abscess, HIV
- Asthma
- Cystic fibrosis
- Foreign body or pneumothorax

Check for masquerades

- Depression, diabetes, drugs
- Anaemia, thyroid disorder, spinal dysfunction, UTI

Depression
Most depression is transient but 10% is significant

Major depression diagnostic criteria (at least five of these for more than two weeks)
1. Depressed mood
2. Loss of interest or pleasure
3. Significant appetite or weight loss or gain (usually poor appetite)
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive guilt
8. Impaired thinking or concentration; indecisiveness
9. Suicidal thoughts
Minor depression is where fluctuations occur due to environmental influences, Dx is based on
2-4 s/s of the above list including 1 & 2

Depression does occur in children and is characterized by feelings of worthlessness and despair

Management things to consider

- Is there a suicide risk
- Do they need inpatient assessment
- Is referral to a specialist psychiatrist indicated

Treatment
- Psychotherapy education, reassurance, support, CBT
- CBT: teaching pts new ways of positive thinking which have to be relevant and
achievable for the patient
- Pharmacological
- Electroconvulsive treatment

Drug therapy:
- First line: Selective serotonin reuptake inhibitors
- Second line: tricyclic antidepressants

About antidepressants
- There is not one ideal type
- TC can be given once daily
- Delay in onset of 1-2weeks
- Each drug should be trialed for 4-6 weeks before changing Tx
- Swapping from one agent to another may be beneficial
- Do not mix AD
- Consider referral if failed
- Full recovery may take 6 weeks or longer
- Continue Tx at maintenance levels for 6-9 months, relapse is common

Serotonin syndrome
Agitation, nausea, headache, tremor, tachycardia may happen when switching between AD
due to an inadequate without period 2 weeks for most

Abdominal pain
PAIN acronym for Abdominal Pain
P pancreatitis
P perforated viscous
P peritonitis
A acute cholecystitis
A appendicitis
A acute diverticulitis
I intestinal ischaemia
N number of others (volvulus, toxic megacolon)

Most cases need surgical referral, causes listed in Murtaghs include

- Inflammation, perforation, obstruction, haemorrhage, torsion (ischaemia)

Most common presentations in GP land include acute appendicitis, colic

General rules
Usually upper pain is upper GIT lesions and lower pain is lower GIT lesions
Colicky midline umbilical/abdominal pain vomiting distension small bowel
obstruction
Midline lower pain distension vomiting large bowel obstruction
Usually acute abdos with a surgical cause have pain followed by vomiting
Mesenteric aa occlusion to be considered in elderly with arteriosclerotic disease or AF

DDx
Most common causes of AA are
- Acute appendicitis, acute gastroenteritis, irritable bowel syndrome, various colics,
ovulation pain, mesenteric adenitis is common in kids

Things not to miss

- MI, ruptured AAA, dissecting aneurysm, mesenteric aa occlusion
- Neoplasia large or small bowel occlusions
- Infections salpingitis, peritonitis, pancreatitis
- Ectopic pregnancy
- SBO
- Volvulus
- Perforated viscous
- Duodenal ulcer
- Colonic diverticulum
- Colonic cancer

Pitfalls
- Appendicitis
- Pulmonary causes
- Faecal impaction (elderly)
- Herpes zoster

Red flag symptoms

- Collapsing at toilet (intra-abdo bleeding)
- Light headedness
- Progressive intractable vomiting
- Progressive abdo distension
- Progressive intensity of pains

Red flag signs

- Pallor and sweating
- Hypotension
- AF or tachycardia
- Fever
- Rebound tenderness/guarding
- Decreased urination

History
- What type of pain constant, waning
- How severe 1-10
- Any previous attacks anything else with the pain
 - Exacerbating/relieving factors
- Milk, food or antacid effect on pain
- Sweats or chills, burning urine
- Bowels behaving normally? Diarrhoea, blood in stool?
- Anything different about urine?
- Medications? Aspirin?
- Smoking? Heroin? Cocaine? Alcohol? Milk?
- Travel history
- Menstrual history mid cycle?
- Family Hx of abdo pain?
- Hernia? Operations on abdo? Appendix removed?

Examination
- Appearance
- Oral cavity
- Vital signs
- HR and lung check for upper abdo pain
- Abdo inspect, palpate, percuss, auscultation
- Inguinal region for hernia
- Rectal exam
- Vaginal exam
- Urine analysis WCC, RCC, glucose, ketones

Investigations
- Hb anaemia due to blood loss
- WCC infection and ESR (also high in cc and Crohns), CRP
- LFT
- Serum amylase and lipase for pancreatitis
- Pregnancy test
- Urine blood, WCC, bile, ketones
- Faecal blood interssusception (redcurrent jelly), Crohns disease, ulcerative colitis
- XR of abdo CXR for perforated ulcer (if air under diaphragm)

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

Diarrhoea
Acute DDx
- Gastroenteritis bacterial or viral
- Dietary indescretions
- AB reactions
Chronic DDx
- IBS
- Drug reaction
- Coeliac disease
- Chronic infections

History
How much, how often, nature of stool?
Associated with vomiting?
Travel history?
Daycare/work environment?
Associated with certain foods?
Abdominal pain or bloating?
Medication history?

Weakness/tiredness
Most common causes = psychological distress, depression

Other causes
- Psychiatric disorders anxiety, depression
- Lifestyle workaholic, lack of exercise, mental stress, bad diet, obesity
- Organic CHF, anaemia, malignancy, thyroid, respiratory
- Unknown chronic fatigue syndrome

DDx
Stress depression viral/post viral infection sleep disorders (sleep apnoea)
- Dont miss cancer, cardiac problems, anaemia, HCV
- Pitfalls = food intolerance, Coeliac disease, chronic infection, drugs, lack of fitness

History
- Sleep pattern
- Weight fluctuations
- Energy, performance, ability to cope
- Sexual activity
- Suicidal ideas
- Self medications
- Precipitating factors postpartum, postoperative, associated with chronic illness,
bereavement, pain, retirement, medication
- Work history and diet history

Investigations
- Hb
- ESR/CRP
- ECG
- Thyroid function tests
- LFT
- Kidney function tests
- BSL
- Iron
 - Tissue markers for malignancy
- Referral to a sleep disorder laboratory for sleep apnoea studies

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

History
- PHx - SOCRATES
- Did you have any injury even minor before pain started?
- Does the pain keep you awake?
- Is there pain or stiffness in your neck?
- Is there pain or restriction when touching your shoulder blades?
- Pain with sport?
- Explain the restriction i.e. how much could you lift without pain?

Examination
- Inspect, palpate, movements (resisted, active and passive)

Causes of pain aside from trauma, fracture and dislocation

- Dysfunction (cervical or AC joint), spondylosis, bursitis, RC disorders, tendinopathy,
tendonitis, rheumatoid inflammation, osteoarthritis

Foot/toe complaint
Common disorders of the feet and toes
- Fracture of toes
- Foot strains
- Ingrown toenails
- black nails
- Bony outgrowth of under the nail
- Calluses
- Athletes foot (Tinea pedis)
- Plantar warts

Tx specific to cause

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

Maintain within the following

BGL 4-6 mmol/L (fasting)
HbA1c < or equal to 7%
LDL-C < 2.5 mmol/L
 Total Cholesterol < 4.0 mmol/L
Triglycerides < 1.5 mmol/L
Blood Pressure < or equal to 130/80 mm Hg
BMI < 25
Urinary albumin excretion
o < 20g/min (overnight)
o <20mg/L (spot collection)
Cigarette consumption zero
Alcohol intake (per day)
o < 2 standard drinks per day
Physical Activity
o At least 30 minutes a day walking (or equivalent) 5 or more days per week

Management plans
The ABC of diabetic care
This is an effective management plan referred to by texts is the ABC of diabetic care (Murtagh
2008, p.1326), specifically this refers to:
A. HbAIc < 7%
B. BP < 130/80
C. Cholesterol < 4mmol/L

NEAT diabetic management plan

NEAT is a handy mnemonic that can be easily taught to patients in order for them to have a
better understanding of how to control their diabetes and other associated conditions such as
dyslipidaemia

N = Nutrition (a healthy diet)

E = Exercise (30 minutes per day five times per week)
A = Avoidance of toxins (alcohol, tobacco, sugar, salt)
T = Tranquility (stress relieving activities)

Other considerations
- Diabetic educator
- Nutritionist, exercise physiologist
- Refer to ophthalmologist, podiatrist if necessary
- Assess for peripheral neuropathies
- Assess vision
- Assess CV health
- Assess family Hx, social Hx (alcohol, smoking occupation, diet, psychosocial, living
arrangements), medications, current conditions, immunisations

Prevention
- Fluvax and pneumovax

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

Assess coordination, sensation of limbs; assess foot and toe health, look for ulcers or infection, ask about
footwear, look at quality of skin, assess for nail infections

Assess bladder and sexual function

Assess end organ damage LFTs, BP etc

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

Defining features
- OA is usually symmetrical
- Pain worse on initiating movement and loading
- Pain eased at rest
- Associated with stiffness especially after activity in contrast to RA
- Main joints involved = first CMC joint of thumb, first MTP joint of great toe, DIP joints of
hands
- Hips, knees and shoulders also involved

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

Signs
- Hard and bony swelling
- Crepitus
- Signs of inflammation
- Restricted mmts
- Joint deformity
Diagnosis
Clinical and radiological
- XR findings: joint space narrowing, sclerosis of subchondral bone
- Formation of osteophytes on the joint margins
- Cystic areas in subchondral bone
- Altered shape of bone ends

Management
- Explanation and reassurance including handouts
- Control pain and maintain function with appropriate drugs
- Suggest judicious activity, exercise and physical therapy
- Consider factors lowering the coping threshold (e.g. stress, depression, overactivity)
- Refer for surgical intervention for debilitating and intractable pain or disability

Treatment
1. Explanation not the crippling disease, information
2. Exercise graduated program to maintain joint function, aim for a good balance of
relative rest with sensible exercise, stop or modify any exercise or activity that increases
the pain systemic reviews show info + exercise help
3. Rest rest during an active bout of inflammatory activity only prolonged bed rest
contraindicated
4. Heat e.g. hot water bottle, warm bath, electric blanket to sooth. Advise against getting
too cold
5. Diet if fat get thin! Obesity increases risk of OA, no specific diet is shown to reduce or
cause OA suggest nutritious balanced diet
6. Correction of predisposing factors and aids the following may help: weight reduction,
walking stick, heel raise for leg length disparity, back brace, elastic or hinged joint
support
7. Physio referral for posture disparity, hydrotherapy program, heat therapy and advice
on simple home heat measures, exercises
8. OT for aids in the home and to achieve more efficient ADLs
9. Simple analgesics regularly for pain, take before activity: NSAIDs and simple anal
reduce pain but there is no good evidence that NSAIDs are any better

10. NSAIDs and aspirin F. line drugs for persistent pain, warn of risk of gastric bleed,
ulceration, kidney function, hepatotoxicitiy
11. COX 2 inhibitor
12. Intra articular corticosteroids
13. Viscosupplementation
14. Complimentary therapy glucosamine
15. Contraindicated drugs = immunosuppressants and oral CS

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

Management
1. Education consider acid suppression, neutralisation; stop smoking; reduce alcohol;
avoid fats; reduce caffeine especially at night; avoid gassy drinks; increase fibre; small
regular meals; avoid spicy food; use antacids
If no relief use antacid consider PPI

Contact dermatitis
Caused by allergens common in occupational situations often by
- Cosmetics
- Topical AB or anaesthetics
- Topical antihistamines
- Plants
- Dyes, perfumes
- Rubber, latex

Prednisolone, wash with water

Atopic dermatitis is associated with itch, family history of atopy, trigger factors, dry skin,
relapse

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

Ankle forced eversion causes most strains

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

Examination
- Note swelling, bruising
- Palpate over bony landmarks and ligaments
- Test joint laxity and ROM
- Do anterior draw sign

Look for underlying fracture- lateral malleolus or base of MT 5: can they walk without discomfort
straight after the injury

Indications for XR
- Inability to weight bear immediately after
- Marked swelling and bruising soon afer
- Marked tenderness over bony landmarks
- Marked pain on mmt
- Crepitus on palpation and mmt
- Special circumstances (litigation potential)
- Bone tenderness

OTAWA rules generally indicated XR if there is bony tenderness and an inability to weight bear
Management
1. Grade I (mild) = RICARS 48h, or until standing not painful (A = analgesics, R= review in
a week, S = strapping)
2. Grade II (moderate) = RICE for 48h, no weight bearing for 48h possibility of crutches, ice
packs over strapping
3. Grade III (severe) = appropriate referral if complete tesar, initial Mx = RICEAR and XR to
exclude fracture consider surgical repair, plaster immobilisation, strapping and
physiotherapy

Solar keratosis/sunburn
Reddened, adherent, scaly thickenings on light exposed areas with potential for malignant
change
- Usually on face, ears, scalp
- Dry rough adherent scale
- Discomfort on rubbing

Management
- Reduce exposure to sun
- May go spontaneously
- Liquid nitrogen if superficial or imiquimod
- Surgical excision
- Biopsy if doubtful

Oral contraception
Method of action = inhibition of hypothalamic and pituitary function leading to anovulation.
Efficacy pregnancy rate is 1-3/100 women per year.

When commencing take menstrual history and history of contraception can be taken
effectively until 50 y.o. and cover starts immediately if it is started on day one of the cycle.

Once over 50, stop and measure FSH and oestradiol levels to determine if menopause.

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

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

Acne
Commence with less androgenic progestogen e.g. Diane

Use high dose monophasics for breakthrough bleeding on low dose, to control menorrhagia, on low dose
pill failure

Contraindications for OCP absolute

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

Contraindications for OCP relative

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

Non contraceptive advantages of OCP

- Reduce menstrual cycle disorders
- Reduction in incidence of PID
- Reduction in ovarian and endometrial cc
- Reduced thyroid disorders

Side effects
- DVT, pulmonary embolism, kidney thrombosis
- MI, stroke
- Commonly seen s/e = amenorrhoea, breakthrough bleeding, breast fullness or
tenderness, depression, libido loss, headache, nausea vomiting, weight gain

Important advice
- Periods are shorter, regular and lighter, no break from pill is necessary
- Drugs interacting = vitamin C, Antibiotics, oral hypos
- Diarrhoea and vomiting may reduce its effectiveness
- Yearly return visits are needed to update Hx and repeat PAPs

Missed pills
- Keep going, take a pill ASAP and keep with the normal cycle
- If in week three omit the pill free interval
- Condoms or abstinence should be used for seven days in the following: 2 for 20 if two
or more 20micrograms are missed, 3 for 30: if three or more 30-35 mcg are missed

Seven day rule for the missed or late pill (>12 hours late)
- Take forgotten pill ASAP, even if it means taking two pills in one day
- Take next pill at usual time and finish course
- If you forget to take it for more than 12 hours use condoms for a week
- If the 7 days run beyond the last hormone pill then miss the inactive pills and start new packet
you may miss a period

Menstrual disorders: menorrhagia (heavy bleeding)/ dysmenorrhoea (painful)

Other forms of contraception

- Rhythm
- Withdrawal
- Spermicide
- IUD
- Vaginal ring
- OCP
- Implant
- Injections
 Gastroenteritis
Usually self limiting problem 1-3 days
- Abdo cramps
- May have constitutional symptoms (fever, malaise, nausea, vomiting)
- Other meal sharers affected food poisoning
- Consider dehydration
- Consider enteric fever

Diarrhoea after visiting less developed countries may have a protozoal infection if fever and
blood suspect amoebiasis.

Management of acute diarrhoea

- Hydration
- Antiemetic if severe vomiting
- Antidiarrhoeal agents
- Rest
- Diet dont eat but drink small amounts of clear fluids until it settles
- Eat low fat foods
- Avoid alcohol, caffeine, spicy food, raw fruit, smoking
- On day three add dairy and lean meat

Cough
Facts
Usually minor and self-limiting, but serious causes shouldnt be overlooked
Cough can be:
o Chronic bronchitis
o Asthma
o Psychogenic basis
o URTI
o Postnasal drip (most common), mainly from chronic sinusitis, tracking down the
larynx and trachea during sleep
o Others
Haemoptysis (coughing blood)
o URTI (24%)
o Acute/chronic bronchitis (17%)
o Bronchiectasis (13%)
o TB (10%)
o Unknown (22%)
o Carcinoma (4%)
Drugs can be a cause (cytotoxic drugs, ACE-inhibitors, beta-blockers, inhaled steroids)

Hx
Respiratory systems review if appropriate

Key questions about the cough: o Other symptoms

o Describe the cough o Chest pain, fever, shivers,
o How long sweats
o Sputum (presence, amount, o Wheeze
colour, blood) o Previous attacks
 o Presence of asthma in family o Keep birds at home, or birds
o Weight loss nesting nearby
o Presence of TB in family o Foreign body gone down the
o Presence of persistent cough in wrong way
family o Recent operation or being
o Smoking (how much) confined to the bed
o Smoke/fume exposure (plus o Swelling of legs
other occupational exposures)

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

Investigations (particularly if haemoptysis)

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

It is important to remember that all that is needed initially for investigating a chronic cough is a
plain chest X-ray.

DDx
Probability diagnosis (most common):

URTI

Postnasal drip

Smoking
 Acute bronchitis

Chronic bronchitis

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

Serious disorders not to be missed include:

Cardiovascular (LV failure)
Neoplasia (lung ca)
Severe infections (TB, pneumonia, influenza, lung abscess, HIV)
Asthma
Cystic fibrosis
Foreign body
Pneumothorax

Consideration for children

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

Common respiratory infections

Acute coryza Highly infections URTI, mistakenly referred to as the flu

(common Mild systemic upset, prominent nasal symptoms
cold) Headache, malaise, (fever), tender eyes, runny nose, sneezing, sore
throat, cough, (myalgia)
Possible complications: sinusitis, otitis media, bronchopneumonia
 Advise rest, analgesics (paracetamol or aspirin), steam inhalations (for blocked
nose), cough mixture (dry cough), gargling aspirin in water or lemon juice for
sore throat, vitamin C/echinacea/zinz (clinical trials inconclusive)
Influenza Relatively debilitating illness, do not confuse with the common cold
Abrupt commencement (1-3 days)
Fever >38C + 1 resp symptom + 1 systemic symptom
Dry cough, sore throa, coryza, prostration/weakness, myalgia,
headache, rigors/chills
Possible complications: secondary bacterial infection, S. aureus pneumonia
(20% mortality), depression, encephalomyelitis
Advise rest, analgesics (aspirin, codeine+aspirin, codeine+paracetamol), high
fluid intake
Rx: antivirals (neuraminidase inhibitors: zanamivir 10mg by inhalation AND
oseltamivir 75mg bd) must be commenced within 36 hrs of onset and given
for 5 days
Prophylaxis: immunisation
Acute Acute inflammation of the tracheobronchial tree, usually follows URTI
bronchitis Generally mild and self-limiting, may be serious in debilitated patients
Cough and sputum (main symptoms), wheeze and dyspnoea, usually
viral, scattered wheeze on auscultation, fever or haemoptysis
(uncommon)
Can complicate chronic bronchitis
Usually improves spontaneously in 4-8 days in healthy patients
Rx: symptomatic; inhaled bronchodilators for airflow limitation, antibiotics
usually not needed
If evidence of acute bacterial infection with fever, increased sputum
volume/purulence:
o Amoxicillin 500mg (8 hourly for 5 days) or
o Doxycycline 200mg statim, then 100mg daily for 5 days
Pneumonia Inflammation of lung tissue. Usually presents as acute illness
Cough, fever, purulent sputum, physical signs and X-ray changes if
consolidation
Initial presentation can be confusing if systemic without respiratory symptoms
Community acquired pneumonia (CAP):
People who have not been to hospital recently, not institutionalised or
immunocompromised
Usually S. pneumonia
Treatment usually empirical (5-10 days for most bacterial causes, 2
weeks for Mycoplasma or Chlamydia and 2-3 weeks for Legionella)
Often history of viral respiratory infection
Rapidly ill with high temperature, dry cough, pleuritic pain, can be
rusty-coloured sputum, rapid and shallow breathing, consolidation on
examination and X-ray
Atypical pneumonias:
Fever, malaise, headache, minimal respiratory symptoms, non-
productive cough, no consolidation, chest X-ray (diffuse infiltration)
incompatible with chest signs
Causes include
o Mycoplasma pneumonia (most common) (adolescents and young
adults), treat with roxithromycin or doxycycline
o Legionella pneumophilia prodromal influenza-like illness, dry
cough, confusion, diarrhoea, very high fever, lymphopenia with
moderate leucocytosis, hyponatraemia, treat with azithromycin
 IV, erythromycin (IV or o) plus ciprofloxacin or rifampicin (if
very severe)
o Chlamydia pneumoniae (similar to mycoplasma), Chlamydia psittaci
(psittacosis)
o Coxiella burnetti (Q fever)
Chronic Cough not associated with a viral respiratory infection that lasts more than 2
persistent weeks: persistent
cough Cough lasting 2 months or more: chronic cough
Divided into productive/non-productive (see table)
Can be a feature of GORD
Bronchial Features: 50-70yrs, only 10-25% have symptoms at time of diagnosis, if
carcinoma symptoms, then usually advanced and not resectable
Small cell lung carcinoma (poorer prognosis), non-small cell lung cancer
(SCLC, NSCLC)
Local: cough (42%), chest pain (22%), wheezing (15%), haemoptysis
(7%), dyspnoea (5%)
General: anorexia, malaise, unexplained weight loss
Other: unresolved chest infection, hoarseness
Symptoms from metastases
Investigations: chest X-ray, CT scan, fibre-optic bronchoscopy, PET scan,
fluorescence bronchoscopy, tissue diagnosis
Management: refer to respiratory physician; main aim is resection for NSCLC,
but that is not an option for SCLC because they metastasize so quickly.
Radiotherapy and chemotherapy.
Bronchiectasi Dilation of the bronchi when their walls become inflamed, thickened and
s irreversibly damaged, usually following obstruction followed by infection
Predisposing factors: whooping cough, measles, TB, inhaled foreign body,
bronchial carcinoma, cystic fibrosis, congenital ciliary dysfunction)
Left lower lobe and lingual are the most common sites
Chronic cough, worse on waking, mild cases: yellow/green sputum
after infection
Advanced: profuse purulent offensive sputum, persistent halitosis,
recurrent febrile episodes, malaise, weight loss
Episodes of pneumonia
Haemoptysis (amount is variable)
On examination: clubbing, coarse crackles over infected areas (usually lung
base), bronchial breath sounds, normal or decreased vocal fremitus, resonant
to dull percussion note
Investigations: chest x-ray, sputum examination (for resistant pathogens), CT,
Management: explanation, preventative advice, postural drainage (10-20
minutes x 3/day), antibiotics according to organism, bronchodilators if
evidence of bronchospasm
Tuberculosis Pulmonary TB may be symptomless and detected by mass X-ray screening
Respiratory: cough, sputum (mucoid, then purulent), haemoptysis,
dyspnoea, pleuritic pain
General: anorexia, fatigue, weight loss, low grade fever, night sweats
(all usually insidious)
Examination: clubbing, may be no respiratory signs, or sings of fibrosis,
consolidation or cavitation (amphoric breathing)
Investigations: chest X-ray, micro and culture sputum, ESR, tuberculin test
(unless BCG vaccination)
Management: notifiable disease; hospitalisation usually not necessary,
monthly follow-up is recommended (inc. sputum smear and culture), multiple
 drug therapy indicated to guard against resistant organisms (rifampicin +
ethambutol + isoniazid + pyrazinamide daily for 2+ months, followed by
rifampicin + isoniazid for 4 months if the organism is susceptible to these
drugs)

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

o General health? o Effect of long walk?

o Nature of the pain? o Hx of psoriasis, diarrhoea,
o Presence of injury? penile discharge, eye trouble
o Worse morning/night? or severe joint pain?
o How is sleep? o Medications, particularly
o Rests effect? anticoagulants?
o Activitys effect? o Extra stress at work/home?
o Worse sitting/standing? o Feel
o Worse when tense/depressed/irritable?
coughing/sneezing/straining?

Compare inflammatory and mechanical injury:

Feature Inflammatory Mechanical

History Insidious Precipitating
onset injury/previou
s episodes
Nature Aching, Deep dull ache,
throbbing sharp if root
compression
Stiffness Severe, Moderate,
prolonged transient
Morning
stiffness
Effect of Exacerbates Relieves
rest
Effect of Relieves Exacerbates
activity
Radiatio More Usually diffuse
n localised Unilateral
Bilateral or
alternating
Intensity Night, early End of day,
morning following
activity

Examination
1. Inspection (posture, movement, symmetry, wasting, deviation, scoliosis (usually away
from painful side), lordosis)
2. Active movements (to reproduce the patients symptoms)
 o Forward flexion
o Extension
o Lateral flexion
3. Provocative tests (to reproduce the patients symptoms)
o Slump test (positive: suggests disc disruption)
Get patient to sit and slump, chin on chest, lift affected leg, then unaffected
leg, then both
Positive if back or leg pain is reproduced
4. Palpation (to detect level of pain)
o Commence at spinous processes of L1, move to L5, over sacrum and coccyx
o Apply pressure to either side of spinous processes, with a rocking movement
three or four times, note pain
o Three sites at each spinal level: centrally, unilateral (right and left sides, 1.5cm
from midline), transverse pressure to the sides of the spinous processes
5. Neurological examination of lower limbs if symptoms extend below buttocks
o Quick tests: walking on heels (L5), walking on toes (S1)
o Specific nerve root tests (L4, L5, L6) for sensation, power, reflexes
o Doing knee jerk and ankle jerk reflex tests can test these quickly
6. Testing of related joints (hip, sacroiliac)
7. Assessment of pelvis and lower limbs for any deformity (e.g. leg shortening)
8. General medical examination, including rectal examination

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

Child considerations
Rule out psychogenic (problems at home, school, sport)
Rule out organic disease (osteomyelitis, TB, discitis)
Rule out tumours (benign osteoid osteoma, malignant osteogenic sarcoma, osteoid
osteoma)
In older children/adolescents, more likely to be inflammatory, congenital or from
developmental anomalies and trauma
Prolapsed intervertebral disc (with marked spasm, stiff spine and lateral deviation)
Ankylosing spondylitis (early onset)

Elderly considerations
Most common is traumatic
Disc prolapsed and facet joint very common
Degenerative joint disease also common, can present as spinal stenosis with claudication
and nerve root irritation
Consider malignant disease, degenerative spondylolisthesis, vertebral pathological
fractures and occlusive vascular disease
Possible diagnoses:
Syndrome A (surgical emergency) spinal cord or cauda equine compression (saddle +
distal anaesthesia, UMN or LMN lesion evidence, loss of sphincter control, weakness of
legs peripherally). Rare.
Syndrome B (probable surgical emergency) large disc protrusion, paralysing nerve root
(anaesthesia or paraesthesia of leg, foot drop, motor weakness, absence of reflexes).
Uncommon.
Syndrome C posterolateral disc protrusion on nerve root or disc disruption (distal pain
with/without paraesthesia, radicular pain (sciatica), positive dural stretch tests).
Common.
Syndrome D disc disruption or facet dysfunction or unknown (non-specific) causation
(lumbar pain (unilateral, central or bilateral), +/- buttock and posterior thigh pain). Very
common.
Spondylolisthesis
Lumbar spondylosis
Malignant disease
Non-organic back pain (e.g. psychogenic)

Treatment
Advice to stay active
Reassurance of likelihood of cure
Relative rest
Patient education
Heat (first 2-4 weeks of LBP)
Exercise (extension, flexion, isometric, swimming)
Pharmacological agents (paracetamol, codeine, NSAIDs (any))
Injection techniques (trigger point with local anaesthetic, chymopapain, facet joint
injection with corticosteroids, epidural injections)
Physical therapy
o Passive spinal stretching
o Spinal mobilisation (within the range of movement of the joint)
o Spinal manipulation: a high velocity thrust at the end range of the joint more
effective, produces faster response but requires accurate diagnosis and greater
skill; adverse effects can be serious

Management guidelines for lumbosacral disorders

The management of mechanical back pain depends on the cause. Since most of the problems
are mechanical and there is a tendency to natural resolution, conservative management is quite
appropriate. The rule is if patients with uncomplicated back pain receive no treatment, on-third
will get better within 1 week and by 3 weeks almost all the rest of the other two-thirds are
better.

Clinicians should have a clear-cut management plan with a firm, precise, reassuring and
conservative clinical approach.

The problems can be categorised into general conditions:

Acute pain = pain less than 4 weeks

Subacute pain = pain 4-12 weeks
Chronic pain = pain greater than 3 months

Acute low Common problem caused by facet joint dysfunction and/or limited disc
back pain disruption, usually responds well to treatment
Typical patient 20-55 years, well, no radiation of pain below the knee
 Management:
Back education program
Encouragement of normal daily activities according to degree of comfort
Regular non-opioid analgesics (e.g. paracetamol)
Physical therapy: stretching of affected segment, muscle energy therapy,
spinal mobilisation of manipulation (if no contraindication on first visit)
Prescribe exercises
Review in about 5 days (probably best time for physical therapy)
No investigation needed initially
Most patients can expect to be relatively pain free in 14 days and can return to
work early
Sciatica Sciatica is a more complex and protracted problem to treat, but most cases will
with or gradually ettle within 12 weeks
without Acute:
low back Back education program
pain Resume normal activities as soon as possible
Regular non-opioid analgesics with review as the patient mobilises
NSAIDs for 10-14 days, then cease and review
Walking and swimming
Weekly or 2-weekly follow-up
Consider a coarse of corticosteroids for severe pain, e.g. prednisolone
(tapered therapy)
Chronic:
Reassurance that problem will subside (Assuming no severe neurological
defects)
Consider epidural anaesthesia (if slow response)
Refer for surgical intervention if: bladder/bowel control disturbance, perineal
sensory change, progressive motor disturbance, severe prolonged pain or
disabling pain, failure of conservative treatment
Chronic Uncomplicated chronic back pain:
back pain Back education program and ongoing support
Encouragement of normal activity
Exercise program
Analgesics (e.g. paracetamol)
NSAIDs for 14 days (if inflammation, i.e. pain at rest, relieved by activity)
and review
Trial of mobilisation or manipulation (at least three treatments) if no
contraindications
Consider trigger point injection
Multidisciplinary team approach
Prevention of further back pain:
Education about back care, including a good laypersons reference
Golden rules to live by: how to lift, sit, bend, play sport and so on
Exercise program, tailor-made program for the patient
Posture and movement training

When to refer:

Myelopathy, especially acute cauda equina compression syndrome

Severe radiculopathy with progressive neurologic deficit
Spinal fractures
 Neoplasia or infection
Ungdiagnosed back pain
Pagets disease
Continuing pain of 3 months duration without a clearly definable cause

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

History of presenting complaint

Three basic questions:
1. Where is the rash and where did it start?
2. How long have you had the rash?
3. Is the rash itchy?
Is it mild, moderate, severe?
Questions to consider for yourself
1. Could this be a drug rash?
2. Has this rash been modified by treatment?
3. Do any contacts have a similar rash?
Further questions for the patient:
1. Do you have contact with a person with a similar eruption?
2. What medicine are you taking or have you taken recently?
3. Have you worn any new clothing recently?
4. Have you been exposed to anything different recently?
5. Do you have a past history of a similar rash or eczema or an allergic tendency (e.g.
asthma)?
6. Is there a family history of skin problems?

Then, of course, general history as appropriate.

Examination
There are two phases to the examination.
Characteristics of the individual lesion:
Must determine whether the lesion involves the dermis alone or whether the epidermis is
involved
o Epidermis: there will be scaling, crusting, weeping, vesiculation, or combination
of these
o Dermis: lump, papule or nodule
o No lesion ever involves the epidermis without involving the dermis as well
Colour, shape, size
Feel the lesion: firm or soft?
Does it have a clearing centre and an active edge?

Distribution of the lesions:

Must decide whether they are localised or widespread
o Widespread: are they distributed centrally, peripherally or both?
o A specific location can help the diagnosis
Are the lesions all at the same stage of eruption/evolution?

An examination of the whole body is appropriate, and in every case examine the mouth, scalp,
nails, hands and feel.
Diagnostic tests
Skin scrapings for dermatophyte diagnosis
Patch testing (to determine allergens in allergic contact dermatitis)
Biopsies (punch or shave)
Hair (for microscopy and root analysis)

Fever
Key facts:
Fever can have an important physiological role
Normal body temperature is 36-37.2
o Oral temperature is about 0.4 lower than core
o Axillary is 0.5 lower than core
o Rectal, vaginal and ear drum temperatures reflect core termperature
o There is a normal diurnal variation of 0.5-1
Fever is >37.8
A fever due to infections have an upper limit of 40.5-41.1, but hyperthermia and
hyperpyrexia have no upper limit
Infection is the most important cause
Symptoms associated with fever include sweats, chills, rigors and headache
General causes include:
o Infections, malignant disease, mechanical trauma, vascular accidents,
immunogenic disorders, acute metabolic disorders (e.g. gout), and haemopoetic
disorders
o Drugs (allopurinol, antihistamines, barbiturates, cephalosporins, cimetidine,
methyldopa, penicillins, esoniazid, quinidine, phenolphthalein, phenytoin,
procainamide, salicylates, sylphonamides), mainly because of hypersensitivity.
Drug fever should subside by 48 hours after discontinuation
50% of acute HIV infections present with fever and an associated infection like glandular
fever, so think of it

Clinical approach
Consider fever in three categories:

Less than 3 days duration:

o Often self-limiting viral infection of respiratory tract
o But, be vigilant for other infections (UTI, pneumonia, other infection etc.)
o Routine urine analysis (especially females)
o Majority of patients can be managed conservatively
Between 4 and 14 days duration:
o Less common infection should be suspected (since the viral infections should have
subsided)
o Checklist:
Influenza, sinusitis, Epstein-Barr mononucleosis, enteroviral infection,
infective endocarditis, dental infections, hepatobiliary infections, abscess,
pelvic inflammatory disease, cytomegalovirus infection, lyme disease,
travel-acquired infection (typhoid, dengue, hepatitis, malaria, amoebiasis),
zoonosis (brucellosis, Q fever, leptospirosis, psittacosis), drug fever
o Intermittent fever (a peak every four days):
Malaria, CMV, EBM, other pyogenic infections
o Remittent fever (temperature returns towards normal but is always elevated)
Collections of pus (abscesses, wound infection, empyema, carcinoma)
 o Undulant fever (several days of fever, several days of non-fever):
Brucellosis, lymphomas (Hodgkins)
o Continuous
Viral infections, e.g. influenza
o Quotidian fever (daily recurrence):
Pseudomonas, gonococcal endocarditis (for e.g.)
Fever of undetermined origin (>3 weeks, >38.3, undiagnosed after 1 week of intensive
study)
o Mainly unusual manifestations of common diseases
o The longer the duration, the less likely the cause is infection
o Common causes:
Infection (40%)
Malignancy (30%)
Immunogenic (20%)
Factitious (1-5%)
Unknown (5-9%)

Children with fever:

Dont treat low grade fevers

With high grade, treat the cause, increase fluids, paracetamol or ibuprofen

Elderly with fever:

Any fever is significant with the elderly

Viral infection a less common cause
Sepsis until proven otherwise (think lungs or urinary tract)

Diagnostic approach for fever of unknown origin

History:

Past history
Occupation
Travel history
Sexual history
Social history (IV drug use, animal contact)
Medication

Physical examination:

Needs to be done more than once, on separate occasions

Skin look for rashes, vesicles and nodules
Eyes ocular fundi
Temporal arteries
Abdomen organomegaly
Rectal and pelvic examination
Lymph nodes
Blood vessels (esp. legs, ?thrombosis)
Urine

Investigations:

Bloods (Hct, WBCs, ESR, CRP), blood chemistry and cultures

Chest X-ray and sinus films
Urine analysis and culture
 Further Ix if necessary:
o Stool (and sputum) microscopy and culture
o Screening (HIV, typhoid, EBM, Q fever, psittacosis, CMV, toxoplasmosis, syphilis,
rheumatic fever, others)
o Upper GIT series
o CT, US for neoplasia
o MRI for nervous system lesions
o Echocardiography (for suspected IE)
o Aspiration, needle biopsy
o Laparoscopy for suspected pelvic infection
o Tissue biopsies as indicated

Hypertension
History
History of hypertension
o Method/date of original diagnosis
o Known duration and levels of elevated BP
o Symptoms that may indicate the effect of hypertension on the body (headache,
dyspnoea, chest pain, claudication, ankle oedema and haematuria)
Presence of other diseases and risk factors
o History of CV disease or peripheral vascular disease, kidney disease, DM, recent
weight gain
o Obesity, hyperlipidaemia, smoking, salt intake, ETOH, exercise levels, analgesic
intake
o Asthma, psychiatric illness
Family history of any of the above
Medication history
Alcohol intake

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

Investigations
Routine: Recommended:

Plasma glucose Echocardiogram

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

Treatment
Aim is to get levels to 140/90 mmHg or less. Base treatment on assessment of all cardiovascular
risk factors.

Start with non-pharmacological treatment strategies:

Weight reduction
 Alcohol intake reduction
Sodium intake reduction
Icreased exercise
Reduction of stress
Other dietary factors (lactovegetarian diets and magnesium supplementation, high
calcium and low in fat and caffeine, avoid licorice)
Smoking cessation
Management of sleep apnoea

Pharmacological:

Useful drug combination:

o Diuretic PLUS beta-blocker OR ACE inhibitor OR AT-2 receptor antagonist
o Beta-blocker PLUS diuretic PLUS calcium antagonist (except verapamil and
diltiazem)
o Alpha-blocker PLUS diuretic PLUS beta-blocker
ACE inhibitor, AT-2 receptor antagonist and diuretic combinations should be used in
patients with congestive heart failure
Beta-blockers and calcium channel blocker combinations should be used in patients with
coronary heart disease
ACE inhibitor, AT-2 receptor antagonist and verapamil and diltiazem should be used in
patients with metabolic risk (diabetes, lipids)

Headache
History
SOCRATES
Can you describe your headaches?
How often do you get them?
Can you point to exactly where in the
head you get them?
Do you have any pain in the back of
your head or neck?
What time of day do you get the
pain?
Do you notice any other symptoms
when you feel the headache?
Do you feel nauseated and do you
vomit?
Do you experience any unusual
sensations in your eyes, such as
flashing lights?
Do you get dizzy, weak or have any
strange sensations?
Does light hurt your eyes?
Do you get blurred vision?
Do you notice watering or redness of
one or both of your eyes?
Do you get pain or tenderness on
combing your hair?
Are you under a lot of stress or
tension?
Does your nose run when you get the
headache?
What medications do you take?
Do you get a high temperature,
sweats or shivers?
Have you had a cold recently?
Have you ever had trouble with your
sinuses?
Have you had a knock on your head
recently?
What do you think causes the
headaches?

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

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

Dagnosis
Probability diagnosis:

Acute: respiratory infection

Chronic: tension-type headache, combination headache, migraine, transformed migraine

Serious disorders not to be missed:

Cardiovascular issues (SAH, ICH, carotid or vertebral artery dissection, temporal

arteritis, cerebral venous thrombosis)
Neoplasia (cerebral tumour, pituitary tumour)
Severe infections (meningitis, encephalitis, intracranial abscess)
Haematoma
Glaucoma
Benign intracranial hypertension
Often missed:

o Cervical dysfunction o Exertional headache

o Dental disorders o Post-traumatic headache
o Vision problems o Post-spinal procedure
o Sinusitis o Sleep apnoea
o Ophthalmic herpes zoster

Also keen in mind depression, diabetes, drugs, anaemia, thyroid disorder and
psychogenic causes

Diagnostic clue for migraine vs tension headache:

FHx, onset before 20 years, prodromata, unilateral, throbbing, less than 1/week, lasts
<24hrs, vomiting, aggravated by the pill and alcohol = MIGRAINE
Bilateral, constant, continuous daily, relieved by alcohol = TENSION HEADACHE

Types of headache
Some of the common types of headache

Tension Symmetrical, bilateral tightness

headache Last hours, recur each day
Associated with cervical dysfunction, stress, tension (although patients do not
realise)
75% females
Dull ache, or tightness
Aggravated by stress, overwork, skipping meals
 Relieved by alcohol
Associated with perfectionist personality, anxiety/depression
On examination: muscle tension, scalp tender to touch, invisible pillow sign
may be positive
Management: educate about tension, stress, stress management, mild
analgesics (paracetamol, aspirin)
Migraine The sick headache, has various types, affects 1 in 10, more common in
females, caused by vasospasm
Classic migraine (headache, vomiting and aura), Common migraine (no
aura) the best known
Most important trigger factor is stress
Can be unilateral or bilateral, last 4 to 72 hours, onset is paroxysmal, offset is
spontaneous
Aggrivated by tension and activity
Relieved by sleep and vomiting
Associated with vomiting (90%), visual or sensory aura
Exogenous causes include some foods (chocolate, oranges), alcohol, drugs
(vasodilators, oestrogens, nitrites etc.), glare, emotional stress, head trauma,
allergens, climatic change, excessive noise and perfume
Endogenous causes include tiredness, stress, exercise, hormonal changes,
hunger, FHx
Management:
Counselling and advice on what to do during attack and what to avoid
Acute attack: aspirin or paracetamol, rest in a quiet dark room with cold
packs on forehead or neck, do not watch television or move too much
Medication: aspirin/paracetamol + antiemetic (metoclopramide). Other
medications are used in emergency situations.
There are prophylactic options also
Cluster Paroxysmal clusters of unilateral headache, usually occurs nightly. Very
headache pronounced cyclical nature
6:1 males
Tip: retro-orbital headache + rhinorrhoea + lacrimation = cluster headache
Occurs over one eye, always same side, radiates to frontal and temporal
regions
Severe pain, 1-3 times a day, like clockwork, for 15 minutes to 2-3 hours,
spontaneous offset
Aggravated by alcohol
Relieved by drugs
Assocaited with FHx, rhinorrhoea on ipsilateral nose, lacrimation, flushing of
forehead
Management:
Consider 100% oxygen therapy (usually good response)
Sumatriptan IM or ergotamine medihaler or rectally
Metoclopramide IV + dihydroergotamine IV
Consider greater occipital nerve block with local anaesthetic
Intense drug prophylaxis is available for once a cluster starts.
Combination Combined/mixed headaches are common and often diagnosed as
headache psychogenic or typical migraine
Usually unilateral on whole half of head except below the eye anteriorly
Combination of varying degrees of: tension and/or depression, cervical
dysfunction, vasospasm, drugs
Can last for days, weeks or months, heavy deep ache at every waking moment
Often related to stress and adverse working conditions, sometimes follows an
 accident
Management:
Go through the possible causes and use a stepwise trial by elimination
process
Others Temporal arteritis (inflammation of the temporal artery)
Frontal sinusitis
Raised intracranial pressure
Intracerebral tumours
Subarachnoid haemorrhage
Meningitis
Drug rebound headache
Chronic paroxysmal hemicranias
Post-lumbar-puncture headache
Trigeminal neuralgia
Hypertension headache
Benign intracranial hypertension
Headaches related to specific activities: sex headache, cough and ewxertional
headache, gravitational headache, ice-cream headache

Knee complaint
History
SOCRATES
Can you explain in detail how the injury happened?
o Did you land awkwardly after a leap in the air?
o Did you get a direct blow? From what direction?
Did your leg twist during the injury?
Did you feel a pop or a snap?
Did your knee feel wobbly or unsteady?
Did the knee feel as if the bones separated momentarily?
How soon after the injury did the pain develop?
How soon after the injury did you notice swelling?
Have you had previous injury or surgery to the knee?
Were you able to walk after the injury or did you have to be carried off the ground or
court?
Does this involve work care compensation?
If there is no history of injury
o Does the pain come on after walking, jogging or other activity?
o How much kneeling do you do? Scrubbing floors, cleaning carpets?
o Could there be needles or pins in the carpet?
o Does your knee lock or catch?
o Does swelling develop in the knee?
o Does it grate when it moves?
o Does the pain come on at rest and is there morning stiffness?
o Do you feel pain when you walk on steps or stairs?

Significance:

Swelling: if sudden and painful, think haemoarthrosis, torn ligaments, torn synovium or
fractured bones; if intermediate rate and with stiffness, think of an effusion of synovial
fluid such as in meniscal tears and milder ligamentous injuries
Recurrent or chronic swelling: indicates intra-articular pathology (patellofemoral pain
syndrome, osteochondritis dissecans, degenerative joint disease, arthritides)
 Locking: torn meniscus, loose body, torn ACL, avulsed anterior tibial spine, dislocated
patella
Catching: loose bodies
Clicking: patellofemoral maltracking or subluxation, loose intra-articular body, or normal
Lateral knee pain: osteoarthritis of lateral compartment of knee, lesions of the lateral
meniscus, patellofemoral syndrome
Medial knee pain: osteoarthritis of medial compartment of knee, lesions of the medial
meniscus, patellofemoral syndrome

Examination
Inspection:

Walking, standing, erect and lying supine

Get the patient to squat, sit on the couch with legs hanging over the side, note
abnormalities of the patella, deformities, swelling, muscle wasting
Check for valgus and varus deformities

Palpation:

Concentrate on patella, patella tendon, joint lines, tibial tubercle, bursae and popliteal
fossa
Feel of fluid, warmth, swelling, synovial thickening, crepitus, clicking, tenderness,
Bakers cyst
o Fluid effusion by pressing the patella against the femur: positive if you feel it
clicking against it

Movements:

Extension, flexion, rotation (of the feet)

Ligament stability tests:

Anterior and posterior drawer tests for ACL and PCL

Adduction (varus) and abduction (valgus) for LCL and MCL

Also examine the lumbosacral spine and hip joint of the affected side.

Investigations
Select from:

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

Diagnosis
Probability diagnosis:

Ligamentous tears and strains (of varying degrees) (ACL, PCL, MCL, LCL)
+/- traumatic synovitis
Osteoarthritis
 Patellofemoral syndrome
Prepatellar bursitis

Serious disorders not to be missed:

Acute cruciate ligament tear

Vascular disorders: DVT, superfiucial thrombophlebitis
Neoplasia (primary, metastasis)
Severe infection (Septic arthritis, tuberculosis)
Rheumatoid arthritis
Juvenile chronic arthritis
Rheumatic fever

Often missed:

Referred pain from back or hip Factures around knee

Foreign bodies Pseudogout, gout
Intraarticular loose bodies Ruptured popliteal cyst
Osteochondritis dissecans Sarcoidosis
Osteonecrosis Pagets disease
Osgood-Schlatter disorder Spondyloarthropaty
Meniscal tears

Nasal congestion/sneezing

Anxiety
Anxiety is an uncomfortable inner feeling of fear or imminent disaster. Defined as generalised
and persistent anxiety or anxious mood, which cannot be associated with, or is
disproportionately large in response to a specific psychosocial stressor, stimulus or event.

Classification:
Generalised anxiety disorder
Panic disorder with/without agoraphobia
Specific phobia
Social phobia
Obsessive-compulsive disorder
Post-traumatic stress disorder
Acute stress disorder

Generalised Excessive anxiety and worry about various life circumstances and is not
anxiety disorder related to a specific activity/time/event such as trauma, obsessions or
phobias
Check: is it hyperthyroidism? Depression? Normal anxiety? Mild, or
phobia? Moderate, severe?
Management:
Non-pharmacological methods, explanation and reassurance
Stress management techniques, meditation, avoid drugs, use ongoing
psychotherapy
Drugs: diazepam or oxazepam for 4 weeks, tapering dose, for short
term. For long term, SSRI (venlafaxine, paroxetine etc.) or buspirone
Panic disorder Sudden, unexpected, short-lived episodes of intense anxiety
Most often in females. Recurrent. Follow DSM-IV for diagnosis
Management:
CBT: teach patients how to identify, evaluate and control episodes
Hyperventilating: breathe in and out of a paper bag
Pharmacological: acute: benzodiazepine (diazepam, oxazepam,
alprazolam) or SSRI (paroxetine); prophylaxis: benzodiazepine in
daily divided doses
Phobic disorders Anxiety is related to specific situations or objects. Three main: simple
phobias, agoraphobia, social phobias.
Ten most common (in order): spiders, people and social situations, flying,
open spaces, confined spaces, heights, cancer, thunderstorms, death, heart
disease
Management:
Psychotherapy (CBT)
Pharmacological: only if psychotherapy fails. Use as panic attacks for
all expect social phobia with performance anxiety, where propranolol
can be used. SSRI can be used for problematic social phobia
Obsessive- Management:
compulsive CBT (exposure-response therapy) and pharmacological treatment
disorder (any of the SSRIs or clomipramine)
PTSD Treatment is difficult, involves counselling where abreaction of the
experience is facilitated by individual or group therapy. Aim is for patients
to face up openly to memories.
No specific indication, but medication can be successful in treating
symptoms like panic attacks, anxiety or depression associated with PTSD.

Vertigo/dizziness
Dizziness is divided into vertigo and pseudovertigo.
Pseudovertigo is further subdivided into:
o Giddiness or lightheadedness a sensation of uncertainty or ill-defined
lightheadedness. Usually a psychoneurotic symptom
o Fainting or syncopal episodes sensation of impending fainting or loss of
consciousness. Many causes, including cardiogenic, postural hypotension, drug-
induced
o Equilibrium disorders (see below)
Vertigo is an episodic sudden sensation of circular motion of the body or its
surroundings

Equilibrium disorders:
Loss of balance or instability while walking, like standing on a rocking boat without
spinning
Causes include:
o Drugs: affecting the vestibular nerve; numerous drugs, including antibiotics,
anticonvulsants, cardiogenic, salicylates
o Cervical spine dysfunction: theoretically caused by inappropriate messages from
proprioceptors in damaged/repaired joints in the cervical spine
o Acute vestibulopathy: infection of the labyrinth or the vestibular nerve; nausea
and vomiting, no hearing loss.
Treatment: lie still in bed, staring at a comfortable spot, drugs to lessen
vertigo:
Prochlorperazine or dimenhydrinate (Dramamine) or diazepam
 o Benign paroxysmal positional vertigo (BPPV): common, induced by changing
head position, cause not entirely known
Treatment: reassurance that it will pass, no drugs
o Meniers syndrome: build up of endolymph; common 30-50, paroxysmal attacks
of vertigo, tinnitus, nausea/vomiting, sweating and pallor, deafness. Can be
abrupt, last 30min to several hours
Treatment: acute attack: procholorperazine suppository and 30g urea
crystals. Long term: reassurance that it is not malignant, avoid excess salt,
tobacco and coffee, alleviate abnormal anxiety (fluid builds up with stress),
refer for neurological treatment, diuretics (check electrolytes regularly)
o Vestibular migraine: vertigo can take place of the aura that precedes a migraine

History
Need to figure out the following questions:

Is it vertigo or pseudovertigo?
Symptom pattern:
o Paroxysmal or continuous?
o Effect of position and change of posture?
Any aural symptoms?
o Tinnitus?
o Deafness?
Any visual symptoms?
Any neurological symptoms?
Any nausea or vomiting?
Any symptoms of psychoneurosis?
Any recent colds?
Any recent head injury (even trivial)?
Any drugs being taken?
o Alcohol, marijuana, hypotensives, psychotropics, other drugs?

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

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

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

In children, vertigo is sinister and requires thorough investigation. In late teens, they are
common, and usually due to blood pressure fluctuations (so give reassurance that it settles with
age, and advise to reduce stress, get more sleep, exercise less if excessive). Also relatively
common in elderly (postural hypotension due to hypertension drugs), also other possibilities as
listed above.

Refer if uncertain diagnosis.

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

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

Analysed into usual characteristics: SOCRATES

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

Examination
Cardiovascular examination:
 General appearance: evidence of atheroscleross (thickened vessels), pale, sweaty,
hemiparesis (?aortic dissection)
Pulses (radial and femoral) check for nature and presence/absence
Blood pressure
Temperature
Palpation of chest wall, lower cervical spine and thoracic spine (look for evidence of
localised tenderness, pathological fracture, spinal dysfunction, herpes zoster)
Palpation of legs (evidence of DVT)
Examination of chest: check for evidence of pneumothorax
Auscultation of chest:
o Reduced breath sounds, hyperresonant percussion note and vocal fremitus
pneumothorax
o Friction rub pericarditis or pleurisy
o Basal crackles cardiac failure
o Apical systolic murmur mitral valve prolapse
o Aortic diastolic murmur proximal dissection (aortic regurgitation)

Investigations
ECG
Exercise stress test
Chest x-ray
Blood glucose
Haemoglobin and blood film (for anaemia)
Serum enzymes (troponins, creatine kinase, myoglobin)
Echocardiography (for abnormalities in heart wall motion)
Angiography
TOE
Spinal x-ray
Ambulatory Holter monitor, isotope scanning, oesophageal studies also

Treatment is long and complicated send to hospital!

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

Lipid disorders
Facts about dyslipidaemia:

Major risk factors coronary arterial disease include:

o Elevated LDL and low HDL cholesterol
o Ratio of LDL/HDL >4
Risk increases with increasing total cholesterol levels (90% if >7.8 mmol/L)
TV levels >10mmol/L increases risk of pancreatitis
Management should be correlated with risk factors
10% reduction in total cholesterol gives 20% reduction in CAD after 3 years

Investigations
Serum triglyceride
Serum cholesterol and HDL and LDL
Management
Appropriate treatment goals:

Total cholesterol <4.0 (especially if high risk)

LDL <2.5mmol/L
HDL >1.0mm/L
Triglycerides <1.5mmol/L

Treat all risk factors.

Non-pharmcological measures:

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

Pharmacological measures:

Hypercholesterolaemia: choose one of the following:

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

Acute bronchitis/bronchiolitis

Acute Acute inflammation of the tracheobronchial tree, usually follows URTI

bronchitis Generally mild and self-limiting, may be serious in debilitated patients
Cough and sputum (main symptoms), wheeze and dyspnoea, usually viral,
scattered wheeze on auscultation, fever or haemoptysis (uncommon)
Can complicate chronic bronchitis
Usually improves spontaneously in 4-8 days in healthy patients
Rx: symptomatic; inhaled bronchodilators for airflow limitation, antibiotics usually
not needed
If evidence of acute bacterial infection with fever, increased sputum
volume/purulence:
o Amoxicillin 500mg (8 hourly for 5 days) or
 o Doxycycline 200mg statim, then 100mg daily for 5 days

Asthma
Classical features of asthma:

Wheezing
Coughing (especially at night)
Tightness in the chest
Breathlessness

Asthma should be suspected in children with recurrent nocturnal cough and in people with
intermittent dyspnoea or chest tightness, especially after exercise.

Examination
Physical signs may be present if the patient has symptoms at the time of examination. The
absence of physical signs does not exclude a diagnosis of asthma.

Investigations
Measurement of peak expiratory flow rate (PEFR): demonstrates variation in values over
a period of time
Spirometry: a value of <75% for FEV1/FVC ratio indicates obstruction. It is the more
accurate test
Measurement of PEFR or spirometry before and after a bronchodilator (short acting beta-
agonist): positive if there is a characteristic improvement in FEV 1 and PEF
Exercise challenge may also be helpful
Chest x-ray not routine but useful if there are complications suspected or if symptoms
are not explained by asthma

Management
Pharmacological management:

Preventer drugs or anti-inflammatory agents

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

Maintenance plan example:

Inhaled SABA prn

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

Urinary tract infection

Risk factors for urinary infection:

Female sex
Sexual intercourse
Diabetes mellitus
Diaphragm contraception
Pregnancy
Immunosuppression
Menopause
Urinary tract obstruction/malformation
Instrumentation

History should include questions about the above, and a thorough sexual history.

Examination
Generally look for:
o Fever, chills, sweating, rigors, headache, nausea, vomiting, diarrhoea (indicate
kidney infection)
Check temperature, pulse, respiration, blood pressure
Examine abdomen for possible upper UTI (loan pain, abdominal pain)
Examine pelvis
Vaginal examination, rectal examination

Investigations
Urine collection
o Midstream specimen of urine (MSU)
o Catheter specimen of urine (CSU) for particularly obese women, the infirm and
the elderly (where getting an uncontaminated MSU is difficult)
o Suprapubic aspirate of urine (SAU) very reliable, should be done under
anaesthetic
Dipstick
o Finding urinary WBCs and/or nitrites are suggestive of UTI
Microscopic examination
Culture

Wait for results before treatment.

Sleep disturbance
About half of the population report a sleep-related problem in 12 months. Normal ideal sleep in
a fit young person is 7.5-8 hours with latency less than 30 mins.

Classification of sleep disorders (modified DSM-IV)

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

Management
Primary insomnia:

Exclude and treat other causes: drugs, anxiety/stress, depression, restless legs syndrome,
sleep apnoea, nightmares, physical disorders, bet-wetting, reflux disease
Give explanation and reassurance if cause is known
Try to recognise what helps the patient to settle best (e.g. warm bath, listening to music)
Establish a routine before retiring
Avoid alcohol and caffeine at night
Warm drink of milk before bed
Comfortable quiet sleep setting with the right temperature
Sex as the last thing before bed is helpful where appropriate
Remove pets from the bedroom
Try relaxation therapy, meditation, stress management, consider hypnosis
If all other measures fail, try zopiclone (imovane), zolpiderm tartrate (Stilnox) or
temazepam
Consider referral

Periodic limb movements:

Aka nocturnal myoclonus, leg jerks, tend to occur in the anterior tibialus muscles of the
leg
Mostly asymptomatic (diagnosis is often made during sleep studies)
If troublesome, refer to sleep specialist
Medication if symptomatic: levodopa + carbidopa, or clonazepam, or sodium valproate

Restless legs syndrome:

Exclude diabetes, uraemia, hypothyroidism, anaemia, various drugs

Mainly a functional disorder affecting the elderly
Eliminate caffeine, follow a healthy diet
 Gentle stretching of legs, particularly hamstrings and calf muscles, for at least 5 minutes
before bed
Medication: 1st paracetamol, 2nd diazepam +/- paracetamol, 3rd codeine or levodopa or
baclofen or propranolol

Narcolepsy:

Condition where periods of irresistible sleep occur in inappropriate circumstances and

consists of a tetrad of symptoms:
o Sudden brief sleep attacks (15-20 minutes)
o Cataplexy (sudden loss of muscle tone in the lower limbs), may slump to floor
o Sleep paralysis
o Hypnagogic (terrifying) hallucinations on falling asleep
Treat with methylphenidate (Ritalin) or amphetamines (dexamphetamine) and tricyclic
antidepressants (small doses) for cataplexy

Sleep apnoea:

Cyclical brief interruptions of ventilation resulting hypoxaemia and related biochemical

effects and terminating in sleep arousal, which is often not recognised by the patient
o Main type is obstructive sleep apnoea, which involves an intermittent narrowing
or occlusion of the pharyngeal area of the upper airway
o Effects include snoring and hypopnoea, sometimes apnoea
o Predisposing causes include:
Diminished airway size (e.g. obesity, tonsillar-adenoidal hypertrophy)
Upper airway muscle hypotonia (e.g. alcohol, neurological disorders)
Nasal obstruction
o Clinical effects include daytime somnolence and neuropsychiatric disturbances
(e.g. depression, personality change)
Refer to a sleep disorder centre is advisable. General principles:
o Lifestyle modification (weight loss, no smoking)
o Continuous positive airway pressure (CPAP) delivered by nasal/facial mask
o Corrective surgery (e.g. tonsillectomy, nasal obstruction)
o Oral appliance (e.g. the mandibular advancement splint)
o Medication (e.g. amitriptyline)

Parasomnias:

Dysfunctional episodes associated with sleep, sleep stages or partial arousal, more
common children
Nightmares (dream anxiety): occur later in the sleep period, accompanied by
unconscious body movements.
o Associated with traumatic stress disorders, drugs or drug withdrawal
o Psychological evaluation with CBT is appropriate
o Medications that may help include phenytoin, clonazepam or diazepam (6 week
trial)
Sleep terrors: a feature of these are sharp screams, violent thrashing movements and
autonomic overactivity
o The sufferers may or may not be awake and usually cannot recall the event
o They require psychological evaluation and therapy
o Similar medications for nightmares can be used
Sleep walking (somnoambulism): the person performs some repetitive motor activity in
bed or walks around freely
o No treatment is usually required but the sleeping environment should be
rendered safe if it is repetitive and problematic
 o Benzodiazepines can be used

Sinusitis (acute/chronic)
The maxillary sinus is the one most commonly infected. It is important to determine whether
the sinusitis is caused by stasis following a URTI or acute rhinitis, or due to dental root
infection. An examination of the respiratory system and the oral cavity is appropriate (plus
vitals).

Clinical features of acute sinusitis:

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

Palpate the non-sinus area and then the sinus area, then the non-sinus area again to determine
where the pain is coming from. Also illuminate the oral cavity in a dark room to see if one side
of a sinus is diminished in illumination this indicates unilateral sinusitis.

Management
Acute bacterial sinusitis:

Exclude dental root infection

Control predisposing factors
Use appropriate antibiotic therapy
Establish drainage by stimulation of mucociliary flow and relief of obstruction
Antibiotic therapy for severe cases
Surgical drainage may be necessary
Inhalation of vapor (friars balsam, Vicks Vaporub or menthol)

Chronic sinusitis:

May arise from chronic infection or allergy, nasal polyps, vasomotor rhinitis, also
structural abnormality of the upper airways
Treat as for acute attack, with longer period of antibiotic therapy

Viral disease
Vague category; assuming this refers to viral rhinitis, see Cough.
 Acute otitis media/myringitis
Otitis media in children:

Two peaks of incidence: 6-12mths of age, and school entry

Seasonal incidence coincides with URTIs
Two most common organisms are viruses: adenovirus and enterovirus, and the bacteria
S. pneumonia, H. influenzae and Moraxella catarrhalis
Fever, irritability, otalgia and otorrhoea may be present
The main symptoms in older children are increasing earache and hearing loss
Pulling at the ears is a common sign in infants
Viral cause indicated by reddening and dullness of tympanic membrane (without
mucopus) associated with URTI
Antibiotics obviously not warranted for viral causes, most improve within 48 hours
Bacterial OM is suggested by acute onset of ear pain/tugging, hearing loss, irritability
and fever. Suppurative OM has progressive erythema and bulging of OM with loss of
landmarks. Treat with antibiotics
Treatment:
o Rest patient in warm room with adequate humidity
o Paracetamol suspension for pain (high dosage)
o Decongestants only if nasal congestion
o Bacterial: amoxicillin, with clavulanic acid if resistance suspected
o Refer if no improvement in 72 hours, re-evaluate at 10 days

Otitis media in adults:

Analgesics to relieve pain

Adequate rest in a warm room
Nasal decongestants for nasal congestion
Antibiotics for evidence of bacterial infection
Treat associated conditions (e.g. adenoid hypertrophy)
Follow-up: review and test hearing audiometrically
Antibiotics: amoxicillin, or doxycycline for milder, or amoxicillin + clavulanic acid if
resistance suspected

Fracture
Huge array of possible fractures. Remember our joint examinations for fractures. Good history
and thorough examination essential. Consider x-ray of affected area, at different angles. Give
analgesia and sedation where appropriate. Classic signs of fracture are: pain, tenderness, loss of
function, deformity, swelling/bruising, crepitus.

Once nature of fracture is determined, consider what type of treatment: plaster, fibreglass,
padding, surgical referral etc.

Infectious conjunctivitis
Four types of infectious conjunctivitis: bacterial, viral, primary herpes simplex infection, and
chlamydial conjunctivitis.

Bacterial conjunctivitis:

Gritty red eye

Purulent, lids stuck in morning
Starts in one eye, spreads to the other
Usually bilateral purulent discharge
 Negative fluorescein staining
Swab for smear and culture for:
o Hyperacute or severe purulent conjunctivitis
o Prolonged infection
o Neonates
Management (mild):
o Limit spread by avoiding close contact with others, use of separate towels etc.
o May resolve with saline irrigation of the eyelids and conjunctiva
o Antiseptic eye drop (propamidine isethionate)
Management (severe):
o Chloramphenicol eye drops and eye ointment
o Pseudomonas and other coliforms: use topical gentamicin and tobramycin
o Neisseria gonorrhoeae: use appropriate systemic antibiotics
o Chlamydia trachomatis: oral azithromycin

Viral conjunctivitis:

Very contagious (examine with gloves)

Usually adenovirus
Tends to occur in epidemics (pink eye), 2-3 week course
Starts in one eye, spreads to other
Scant watery discharge
May have tiny pale lymphoid follicles
Preauricular lymphadenopathy
Can perform viral culture and serology to predict epidemics
Treatment:
o Limit cross infection with hygiene and patient education
o Symptomatic treatment only (cool compress, topical lubricants)
o Do not pad
o Watch for secondary bacterial infection
o Avoid corticosteroids (prolong the infection)

Primary herpes simplex infection:

A follicular conjunctivitis
50% have lid or corneal ulcers (diagnostic)
Dendritic ulceration with fluorescein in some
Treatment:
o Attend to eye hygiene
o Acyclovir ointment
o Atropine drops (to prevent reflex spasm of the pupil)
o Debridement by a consultant

Chlamydial conjunctivits:

Three common situations:

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

Excessive ear wax

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

Bursitis/tendonitis/synovitis
History, examination and investigations are for Knee complaint.

Treatment of tendonitis/bursitis of a small area:

Generally (apart from patella tendonitis), the treatment is an injection of local anaesthetic
and long-acting corticosteroids into and deep to the localised area of tenderness
In addition it is important to restrict the offending activity with relative rest and refer for
physiotherapy for stretching exercises
Attention to biomechanical factors and footwear is important
If conservative methods fail for iliotibial tract tendonitis, surgical excision of the affected
fibres may cure the problem
 Chronic heart failure
Signs and symptoms
Classic symptom = dyspnoea on exertion

Progression of dyspnoea
Exertional D D at rest Orthopnoea paroxysmal nocturnal dypnoea

Other symptoms
- Dypnoea
- Irritating cough
- Lethary/fatigue
- Weight change: gain or loss
- Dizzy spells/syncope
- Palpitations
- Ankle oedema

Physical examination
Left heart failure
- Tachycardia Right heart failure
- Low volume pulse - Elevated JVP
- Tachypnoea - Right ventricular heave
- Laterally displaced apex - Peripheral/ankle oedema
- Bilateral basal crackes - Hepatomegaly
- Heart rhythm - Ascites
- Pleural effusion
Look for peripheral oedema pitting
- Poor peripheral perfusion
oedema
Investigations
FBE and ESR
- Anaemia can occur with CHF
- Serum electrolytes for monitoring
- Kidney function tests to monitor drug therapy
- LFTs congestive hepatomegaly gives unusual LFTs
- Urinalysis
- Thyroid function tests (esp if in AF)
- Viral studies for suspectedviral myocarditis

Specialist examinations
- Coronary angiography for suspected and known ischaemia
- Haemodynamic testing
- Endomyocaridal biopsy

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

Prevention
- Dietary advice (weight nutrition)
- Emphasise dangers of smoking
- Control HT
- Control other RF (hypercholesterolaemia)
- Early detection of diabetes
- Early intervention of MI (thrombolytic therapy shunting)
- Secondary prevention after occurrence of MI (BB, ACEi and aspirin)
- Appropriate timing of surgery or angioplasty

Treatment of causes and precipitating factors

Precipitating factors to be Tx
- Arrhythmias
- Electrolyte imbalance (hypokalaemia)
- Anaemia
- Myocardial ischaemia esp MI
- Diactary factors
- Adverse drug reactions
- Infection
- Thyrotoxicosis
- Fluid overload
Management
Non pharm
- Educate and support
- Smoking
- Refer to rehab program
- Encourage exercise
- Rest if s/s severe
- Weght loss
- Salt restriction no added salt diet (<2g/day)water restriction 1.5L day or less
- Limit caffeine 1-2 coffees per day
- Limit alcohol 1 drink day
- Dayly weighing to see for fluctuations
- Optimise CV RF BP, lipids, HbAIc
- Vaccination fluvax, pneumococcus
- Echocardiography every two years

Drug therapy
1. ACE I start low aim high
2. Add a diuretic if congestion
3. BB
Add digoxin if indicated

Alcohol abuse
Excessive drinking
- > 4 std drinks per day for men
- > 2 std drinks per day for women

Problems associated with drinking

- Depression, sexual dysfunction
- HT, heart disease, liver disease, acute gastritis, gastric ulcers
- Gout obesity

Useful questions in history

- When did you last drink? Do you like alcohol?
- What type of alcohol do you drink?
- Do you drink in the morning? Do you feel off colour in the morning?

Questionnaires
CAGE two or more positives are suggestive of a problem
C- cut down
A annoyed by critism of your drinking
G guilty about your drinking
E eye openor

Lab investigations
- Raised GGT
- HDLs elevated
- LDLs elevated
Standard drink = 10g of alcohol middy of beer, two middies of light, 120mL of wine

Management
Early intervention and brief counseling
See if they are interested to change their behaviour

Stages of change: pre-contemplation (unconcerned, but may be effected by motivational

interviewing) contemplation action maintenance exit or relapse

Alcohol-sensitising drugs reserved for motivated patients who have someone at home
to supervise, make an unpleasant reaction when taken with alcohol (e.g. calcium
carbimide) vomiting, nauseas, flushing, dyspnoea
Anti craving drugs e.g. naltrexone reduces cravings

Management plan
This six-step plan works best if intervened early on. Based on giving feedback early on about
their level of alcohol consumption, presenting objective evidence about harmful effects and
setting realistic goals for reducing alcohol intake.

1. Feedback based on assessment and the degree of risk associated with their daily alcohol
intake emphasise damage has already occurred

2. Listen carefully to their reaction they may need to vent and may be defensive

3. Outline the benefits of reducing intake money, less family hassles, less depressed,
weight loss, better shape, lessen risks of HT, liver disease, brain disease, cancer, accidents

4. Set goals for consumption which you both agree are feasible (these are the upper limits)
- Men no more than 3-4 drinks, 3-4 times per week
- Women no more than 2-3 drinks, 2-3 times per week

5. Set strategies to keep below the limits

- Quench thirst with non alcoholic drinks
- Have first drink after starting to eat
- Switch to light beer
- Take care which parties you attend
- Think of a good explanation for cutting down
- Have a workout when bored or stressed
- Explore new interests

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

Restrictive lung disease