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Common Symptoms/Complaints in Family Medicine

Common Symptoms/Complaints in Family Medicine. Medicine and Skin Dr Edmond CW Chan. Medicine. Dizziness

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Common Symptoms/Complaints in Family Medicine

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  1. Common Symptoms/Complaints in Family Medicine Medicine and Skin Dr Edmond CW Chan

  2. Medicine • Dizziness • A 69 yo woman who has no children and her husband has married again 2 years ago and he has migrated to USA. She has 5 years history of NIDDM and HT and now on Diamrion 80mg BD and Natrilix 2.5mg om • She complained severe dizziness for few days. Reviewed the has history, she has repeatedly attended to A&E for dizziness in recent 2 years.

  3. What questions will you ask? • Definitioin of dizziness • Vertigo • Posture: • Tinnitus: which ear? • Balance • Severity: • Associated symptoms: N, Vomiting, pallor, sweating chest pain, palpitation, neurological symtoms • Drugs hx • psychosocial

  4. Physical examination • Cardiovascular system: BP: supine and erect(S:20;D:10) both arms Pulse: regular or irregular heart murmur, carotid bruit CNS: muscle power and tone, gait eyes movement, Nystagmus cranial nerves V, VIII ( corneal reflex) cerebellar signs

  5. Features of cervical spondolysis • Otoscope: ear wax chronic otitis media • Hearing test: Rinne’s test and Weber’s test • Other systems to look for any primary tumor ( probably brain secondary)

  6. Further investigations • CBP • Na, K, H’stix, glucose and HbA1c • Head tilt test: starting from sitting position to hyperextend the neck when lying supine and turned the head to one sideVertigo and nystagmusadaptation • ECG • Caloric test • Others like X-ray, CT brain, MRI, autonomic functional test etc if indicated

  7. Differential diagnosis • Vertigo: • Benign positional vertigo • Vestibular neuronitis (without tinnitus or deafness) • Acute labyrinthitis (hearing loss) • Meniere’s syndrome (vertigo, tinnitus, sensorineural deafness, recurrent episodes) • Acoustic neuroma • Brain stem migraine • Multiple sclerosis

  8. Differential diagnosis • Pseudovertigo: • Drugs • Anaemia • Perimenopausal syndrome • Postural hypotension • Cardiac arrhythmias • Complete partial seizure • Brain secondary • Psychosocial

  9. Vestibular neuronitis • Usually a viral infection of vestibular nerve causing a prolonged attack of vertigo lasting for several days • Can be severe enough for asking admission • Precedes with some URI symptoms (viral infection) • Without tinnitus or hearing loss • Abrupt onset with nausea, vomiting, dizziness and vertigo

  10. May take 6 week or so to subside • Nystagmus present because of involving the vestibular system • DDx: Acute labyrinthitisTx: Stemetil 1 tab tds or im if severe beware of extra-pyramidal side effects relieved by benadryl diphenhydramine

  11. Meniere’s syndrome • Usually over diagnosed • 30-50 aged group • Paroxysmal attacks of vertigo, tinnitus, nausea and vomiting, sweating and pallor, sensorineural deafness • Abrupt onset • Lasts 30 mins to several hours • Variable interval between attacks, recurrent episodes • Nystagmus (usually opposite to the affect ear)

  12. Treatment: • explanation and advice on stress management • Avoid coffee and smoking • Low salt diet • Drug: cyclizine 50mg tds Betahistine (Serc 8-16mg tds) • Refer to ENT for persistent Meniere’s syndrome for any surgical treatment such as operative decompression of the saccus endolymphaticus or labyrinthectimy

  13. Benign positional vertigo • All age group • Recurs periodically for several days • Brief and subsides rapidly (changing position or adaptation) • Not associated with nausea, vomiting or deafness • Treatment: explanation and reassurance avoidance measures

  14. Palpitation • A 46 yo woman, single, working as accounting manager, chronic smoker with BMI >28 has history of thyrotoxicosis 20 yrs ago and has been put on Carbimazole but stopped for more than 5 yrs because of normal TFT. She has complained occasional palpitation for recent few months. Previously she has experienced chest discomfort but did not seek for any medical help.

  15. What questions will you ask? • For discussion

  16. Physical examination • General appearance:Xanthoma/Xanthelasma/arcus senilisBMIGoitreAnxiety/depressedsweating, pallor • CVS:BPpulse: rate, volume and regularityJVP

  17. heart murmurs, mid-systolic click carotid bruit Any signs of thyrotoxicosis Any signs of infection

  18. Further investigation • For discussion

  19. Differential diagnosis • Sinus tachycadia:feveranaemiaperimenopausalThyrotoxicosisPhaeochromocytomaCarcinoid syndromePorphyriaAnxiety/Depression (effort syndrome)Drugs, tea, coffee, alcohol, cigarette smoking

  20. Paroxysmal bradycardia:Sick sinus syndromeheart blocks • Paroxysmal tachycardia:supraventricular (narrow QRS)—Atrial ectopicsSVTAtrial flutterAtrial fibrillationWolff-Parkinson-White syndrome

  21. Ventricular (wide QRS)—Ventricular ectopicsVentricular tachycardiaVentricular fibrillation Note: It is important to look for the underlying cause of each arrhythmia and the provoking factors

  22. Supraventricular tachycardia: • Rate: 150-220/min • Sudden onset • Passing copious urine after an attack (ANP) • Predisposing factors: thyrotoxicosis, WPW • Treatment:carotid sinus message (no carotid bruit)valsalva maneuverimmersion face to waterdrink a glass of ice waterVerapamil/Diltiazem (monitor BP)DC cardioversion (haemodynamically unstable)

  23. Wolff-Parkinson-White syndrome

  24. Risk of sudden death • Congenital abnormality with bundle of Kent • Can present with SVT or AF • EPS and radiofrequency ablation of the abnormal pathway

  25. Atrial fibrillation • Common causes of AF:IHDThyrotoxicosisValvular lesions like ASD, mitral valve diseaseAlcohol-related heart diseaseimpaired ventricular functionIdiopathic

  26. AF • Acute or chronic? • Sinus rhythm converted or ventricular rate control ? • Chemically converted or DC cardioversion? • Anticoagulant? • Risks: disease itself and the treatment

  27. Chest Pain • A 40 yo man, chronic smoker and social drinker who is working in the construction site. He has history of epigastric pain with PPU and patch repair done 5 years ago. Incidentally AXR found a small radio-opaque asymptomatic gallstone. He complained sudden onset of chest discomfort for few hours during duty and then run to your clinic for medical help. • DDX and immediate treatment?

  28. What questions will you ask? • Site: retrosternal, epigastric, superficial • Onset: acute, progressive, crescendo, chronic • Quality: crushing, tight, heavy • Duration: Angina-few mins, Infaration >30mins • Radiation:jaw, shoulders: angina/infarctionback: dissecting aneurysm/PPU/acute pancreatitisdermatome: shingles

  29. Aggravating factors: supine– reflux oesopagitisexercise, emotion, large meal, sexual intercourse- anginainspiration—acute pericarditis • Relieving factors:rest, TNG —angina/oesophageal spasmleaning forward– acute pericarditisantacid, standing up, belching --GRED

  30. Associated symptoms: SOB, palpitation, headache, fatigue, sweating, ankle swelling, nausea and profound vomiting • Risk factors:smoking, alcohol, occupation, lifestyle, obesity • Family history: lipid, Marfan’s • Medication: TNG, Antacid, OCP • Life events and worries: cardiac neurosis

  31. Physical examination • For discussion • General appearance:

  32. P/E • CVS: • Chest: • Abd: • Others:

  33. Further investigation • For discussion:

  34. Differential diagnosisConsider anatomically from the skin to deep inside and the referral pain • Skin infection or inflammation • Costochondritis/ Ribs fracture • IHD (Angina/MI) • Acute pericarditis • Dissecting thoracic aorta • Pneumothorax • Reflux oesophagitis/oesophageal spasm • Peptic ulcers • Gallstones diseases, pancreatits, shingles • Cardiac neurosis/Effort syndrome

  35. Pectoris angina • Sudden onset of retrosternal chest pain radiating to the jaw or left shoulder lasting 3-5mins only and relieving by rest and TNG, aggravated by exertion. • Risk factors found • P/E unremarkable • ECG: no change at rest • Further investigation like TMT and echo • TNG and risk factors modification

  36. Myocardial infaraction • Sudden onset of restrosternal chest pain at rest lasting more than 15 mins associated with distress and not relieved by TNG • Beware the painless presentation in DM • ECG: ST elevation, T wave inverted and pathological Q-wave • Elevated CE: CK, AST, LDH CK-MB, Troponin I/T • Echo: EF, akinesia, valvular lesions

  37. Medical treatment:StreptokinaseSymptoms control: Morphine, nitratesAspirinBeta-blockers • Risk factors modifications • ? Primary PTCA • CABG • Cardiac rehabilitation

  38. Common skin problem in FM • Diagnosis in dermatology mainly based on • Clinical history • Morphology • Distribution • Further investigation

  39. Dermatology terms • Macule: skin colour change without elevation • Papule: palpable elevation <5mm • Nodule: palpable mass >5mm • Plaque: palpable plateau-like elevation >2cm • Vesicle: small blister <5mm of clear fluid within or below the epidermis • Bulla: larger vesicle >5mm • Pustule: visible collection of free pus in a blister

  40. Wheal: an area of dermal odema • Crust: dried serum and exudate • Excoriations: lesions caused by scratching that results in loss of the epidermis • Erosion: superficial break in the epidermis not extending into the dermis • Ulcer: extending into the dermis • Lichenification: chronic thickening of the skin with increased skin markings

  41. Eczema/Dermatitis • 3 hallmarks: • 1) pruritus • 2) ill defined border of the lesions • 3) epidermal elements: Acute, subacute– papules, vesicles, weeping Chronic– lichenification, xerosis, scaling • Endogenous vs exogenous

  42. Atopic eczema • Chronic, relapsing, pruritic disorder • 10% population, Strong genetic predisposition: • Associated with asthma, hay fever, allergic rhinitis • Elevated serum IgE in 80% • Infantile type: • 1-6 months • Itchy scaly weeping lesions over the face, trunk, extensor of elbows and knees • Remit between 2-5 yo (50 % by 5 yo)

  43. Actopic eczema: • Childhood type : • Lichenification at antecubital, popliteal fossa, nape of neck around adolescence (80% by 10 yo) • Adult type: • Poor prognosis • Bad prognostic factors: strong family hx, onset after 2yo, social & maternal deprivation, discoid type, extensor area, associated with ichthyosis

  44. Treatment: • General: • Explanation and reasuurance • Avoid soap or detergents • Avoid irritating woolen clothing • Avoid sudden temperature & humidity change • Removal of common allergens (house dust mite)

  45. Emollients: (use adequately and frequently) • Aqueous cream, emulsifying ointment • Urea cream (also as humectant) • Topical steroids: • Avoid potent one • Oral antihistamines: piriton, clarityn • Topical /systemic antibiotics: aureomycin, fucidin, bactroban, cloxacillin, macrolides, quinolones • Tar onitment or bath

  46. Tinea • Common superficial fungal infection • Incidence high in summer • Individual susceptibility • Chronic itchy erythematous scaly lesions with active margin • Cause agents: trichophyton, microsporum, epidermatphyton • Diagnosis: clinical picture, skin scarping, Wood’s lamp (tinea capitis)

  47. Tinea capitis: scalp • Tinea pedis: feet, toe web • Tinea manuum: hand • Tinea unguium: nail • Tinea crutis: groin • Tinea corporis: trunk • Tinea faciale: face

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