Common Symptoms/Complaints in Family Medicine - PowerPoint PPT Presentation

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Common Symptoms/Complaints in Family Medicine

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Common Symptoms/Complaints in Family Medicine Medicine and Skin Dr Edmond CW Chan Medicine Dizziness A 69 yo woman who has no children and her husband has married ... – PowerPoint PPT presentation

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Title: Common Symptoms/Complaints in Family Medicine


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 AE 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(S20D10)
  • 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 Rinnes test and Webers test
  • Other systems to look for any primary tumor
  • ( probably brain secondary)

6
Further investigations
  • CBP
  • Na, K, Hstix, 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)
  • Menieres 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
Menieres 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 Menieres 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 gt28 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 appearanceXanthoma/Xanthelasma/arcus
    senilisBMIGoitreAnxiety/depressedsweating,
    pallor
  • CVSBPpulse 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 tachycadiafeveranaemiaperimenopausalThy
    rotoxicosisPhaeochromocytomaCarcinoid
    syndromePorphyriaAnxiety/Depression (effort
    syndrome)Drugs, tea, coffee, alcohol, cigarette
    smoking

20
  • Paroxysmal bradycardiaSick sinus syndromeheart
    blocks
  • Paroxysmal tachycardiasupraventricular (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
  • Treatmentcarotid sinus message (no carotid
    bruit)valsalva maneuverimmersion face to
    waterdrink a glass of ice waterVerapamil/Diltiaz
    em (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 AFIHDThyrotoxicosisValvular
    lesions like ASD, mitral valve diseaseAlcohol-rel
    ated heart diseaseimpaired ventricular
    functionIdiopathic

26
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27
AF
  • Acute or chronic?
  • Sinus rhythm converted or ventricular rate
    control ?
  • Chemically converted or DC cardioversion?
  • Anticoagulant?
  • Risks disease itself and the treatment

28
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?

29
What questions will you ask?
  • Site retrosternal, epigastric, superficial
  • Onset acute, progressive, crescendo, chronic
  • Quality crushing, tight, heavy
  • Duration Angina-few mins, Infaration gt30mins
  • Radiationjaw, shoulders angina/infarctionback
    dissecting aneurysm/PPU/acute pancreatitisdermat
    ome shingles

30
  • Aggravating factors supine reflux
    oesopagitisexercise, emotion, large meal, sexual
    intercourse- anginainspirationacute
    pericarditis
  • Relieving factorsrest, TNG angina/oesophageal
    spasmleaning forward acute pericarditisantacid,
    standing up, belching --GRED

31
  • Associated symptoms SOB, palpitation, headache,
    fatigue, sweating, ankle swelling, nausea and
    profound vomiting
  • Risk factorssmoking, alcohol, occupation,
    lifestyle, obesity
  • Family history lipid, Marfans
  • Medication TNG, Antacid, OCP
  • Life events and worries cardiac neurosis

32
Physical examination
  • For discussion
  • General appearance

33
P/E
  • CVS
  • Chest
  • Abd
  • Others

34
Further investigation
  • For discussion

35
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

36
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

37
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

38
  • Medical treatmentStreptokinaseSymptoms
    control Morphine, nitratesAspirinBeta-blockers
  • Risk factors modifications
  • ? Primary PTCA
  • CABG
  • Cardiac rehabilitation

39
Common skin problem in FM
  • Diagnosis in dermatology mainly based on
  • Clinical history
  • Morphology
  • Distribution
  • Further investigation

40
Dermatology terms
  • Macule skin colour change without elevation
  • Papule palpable elevation lt5mm
  • Nodule palpable mass gt5mm
  • Plaque palpable plateau-like elevation gt2cm
  • Vesicle small blister lt5mm of clear fluid within
    or below the epidermis
  • Bulla larger vesicle gt5mm
  • Pustule visible collection of free pus in a
    blister

41
  • 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

42
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

43
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)

44
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

45
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46
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)

47
  • 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

48
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,
    Woods lamp (tinea capitis)

49
  • Tinea capitis scalp
  • Tinea pedis feet, toe web
  • Tinea manuum hand
  • Tinea unguium nail
  • Tinea crutis groin
  • Tinea corporis trunk
  • Tinea faciale face

50
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52
  • Treatment
  • Topical Imidazole, Allylamine, Whitfield
    onitment, tolnaftate
  • Systemic GriseofulvinImidazole (ketoconazole,
    miconazole)Triazole (itraconazole,
    fluconazole)Allylamine (terbinafine)
  • Usually use for longer term and beware the LFT

53
Thank you
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