Duane Allman is a 54-year-old man. “Doctor, I’ve been putting this off but I think that with my family history I need to get my heart checked.”
CVD risk
Priorities
- Quantify CVD risk
- Minimise CVD risk by targeting modifiable risk factors
History
- HoPC: any history of vasculopathy? DM?
- PMHx: HC, HTN, DM, CKD, vasculopathy
- FHx: parents, siblings
- meds, allergies
- SHx: SNAP, stress, depression, support
Exam: BP, BMI and waist circumference, vasculopathy, DM
Investigations
- Online risk factor calculation
- ECG, HC, HTN, DM, CKD
- As per history
Management
- Non-pharm: SNAP
- Pharm: ?statin, ?ACEi, ?OHG
- Other screening: CRC, skin, PSA, depression
- F/U
Hypertension
Priorities
- Assess severity of hypertension and possible consequences
- Rule out secondary causes (cancer sx, haematuria, nocturia, Cushing syndrome)
- Assess CVD and CKD risk
- Treat HTN with lifestyle and pharm measures if necessary
Assessment
History: headaches, vision changes, vasculopathy, OSA, past treatment, ddx sx; PMHx and FHx of CVD/CKD, meds and allergies, SHx of SNAP and ADLs
Exam: BP (both arms), fundoscopy, stroke and CCF exam, abdo masses, renal bruits, pulses, urinalysis
Investigations: 24hr ambulatory BP; other CVD RF, LFTs, UECs; urine ACR
Management
- lifestyle measures
- firstline: ACEi/CCB/thiazide
- F/U in 4-6 weeks to gauge response, then every 3 months
Screen for other CVD risk factors, cancer (CRC, skin, PSA), psych
James Page is a 58-year-old man. He has recently undergone a coronary artery bypass graft. He has a number of questions concerning cardiac risk factors, cardiac medications and lifestyle issues following surgery.
Issues
- Wound care
- CVD risk reduction
- Cardiac meds: dual antiplatelets, beta blocker, statin, nitrates, ACEi (DABS? NA)
- Lifestyle changes: SNAP (incl via cardiac rehab)
- Psychosocial issues
- Other lifestyle issues eg sex
- Opportunistic screening - CRC, skin, psych
Stephen Raymond Vaughan is a 72-year-old man who presents saying “Doc, I’ve been feeling a bit dizzy. I think my heart is beating a little fast.” He is otherwise well.
Palpitations
DDx: cardiac - non-arrhythmic (sinus rhythm/tachy/ectopics) OR arrhythmia (AF, flutter, SVT), endo - arrhythmia (hyperthyroid, anaemia), psych - anxiety disorders, drugs/meds/alcohol
Assessment
- red flags: syncope/pre-syncope/chest pain/dyspnoea; onset during exercise; known structural heart disease
- associated with endo symptoms, drugs or anxiety?
- look for reasons for a sinus tachy (infection, inflammation)
- examine for sickness, heart disease, lung disease, endo disease
- Ix: ECG, FBC, CRP, EUC, CMP, TFTs
Management: as per cause
- treat underlying cause
- arrhythmias need to be treated
- ectopics are usually benign, if frequent may reflect cardiac disease (=referral)
- opportunistic screening
- F/U
Duane Allman is a 54-year-old man. “Doctor, I want to quit smoking.” How would you assess and manage this patient?
5As + motivational interviewing
- Assess use, dependence, consequences and stage of change
- Assist: education; Quitline
- –BIO: educate about potential side effects of quitting - weight gain, depression, irritability; NRT, varenicline/buproprion (contraindications: seizures; depression for varenicline, bipolar for bupropion)
- –PSYCHO: diary of use, identify reasons for past failure, underlying psychological issues
- –SOCIAL: social triggers and coping strategies
Diane Krall is a 30-year-old lady who presents saying “Doctor, I’ve been really tired over the last couple of months. I just want to lie down all the time.”
Fatigue DDx
- anaemia
- hypothyroidism
- psych incl sleep
- inflammation
- infection
- cancer
- meds
- BETA-HCG
Assessment
- History: ?anaemia symptoms, diet and menstrual history, ?hypothyroid sx, ?depression, systems review (incl cancer), past history incl psych, meds and allergies, SHx
- Exam: haem exam and as per history, vitals, urinalysis (incl b-hCG)
- Ix: FBC, Fe studies, B12 and folate, CRP, EUC, LFTs, BSL, TFTs as firstline
Management
- menorrhagia: contraception/tranexamic acid
- dietary: Fe supplementation, dietitian referral
- hypothyroidism: thyroxine
- opportunistic screening (pap, psych)
- F/U
James Hendrix is a 50-year-old overweight man. He states “Doc, I am feeling full and gassy all the time. I get a little regurgitation when I lie down.”
PDx: GORD
DDx: oesophagitis, PUD (rule out dangerous chest pain causes if chest pain part of the presentation)
Assessment
- Hx: gastro sx (incl bleeding) and any treatment, cv/resp sx; meds (NSAIDs, alcohol) and allergies, PMHx, FHx, SHx - diet, behaviours, SNAP
- RED FLAGS: odyno/dysphagia, weight loss, bleeding
- Exam: anaemia, tenderness
- Ix: urea breath test (<50yo with dyspepsia); if ?PUD or malignancy, no response to PPI: gastroscopy w biopsy urease test, FBC, Fe studies, CRP
Management
- lifestyle: SNAP and behaviour modification
- PPI until remission, then wean (secondline: H2 antagonists, antacids)
- triple therapy if H pylori confirmed:
- lap fundoplication is
- opportunistic screening + CVD risk
- F/U
James Beam is a 52-year-old accountant. He states “You know Doc, I was looking in the mirror and I swear my eyes are light yellow.”
Jaundice
DDx
- prehepatic: haemolytic anaemia (sickle cell, G6PD)
- intrahepatic: acute/chronic liver disease (alcohol, NASH, hepatitis, metabolic, autoimmune)
- posthepatic: biliary obstruction (stones, tumours, autoimmune)
Assessment
- History: time course, other anaemia/liver disease/cancer/biliary colic sx; PMHx/FHx: anaemic conditions, hepatitis conditions, biliary colic, autoimmune disease; meds and allergies, SHx esp SNAP, support, travel, IVDU
- Exam: haem, liver (incl biliary tract)
- Ix: FBC, haemolytic screen (haptoglobin, reticulocyte count, LDH, coombs test), LFTs (incl conjugated and unconjugated bilirubin), coags, hep serology, abdo U/S if indicated by hx and obstructive picture on LFTs
Management: as per cause
- Haemolytic anaemia: transfusion, referral
- Liver disease: treat cause, optimise underlying risk factors (alcohol, metabolic syndrome)
- Biliary obstruction: consider ERCP, cholecystectomy if stones, resection/palliation if cancer
- opportunistic screening
- F/U
Richard Derringer is a 65-year-old man who has noted bright red blood on the toilet paper over the past two weeks.
PR bleeding
PDx: CRC until proven otherwise
DDx: haemorrhoids, anal fissure/fistula, diverticulitis
Assessment
- History: bleeding - colour, amount, relation to stool, association with pain, CRC/cancer/infection sx; hx of constipation/FOBT/colonoscopies; PMHx of any of the above conditions, IBD, CRC, diverticular disease; FHx: CRC or other cancers (Lynch syndrome); meds (esp antithrombotics) and allergies, SHx of SNAP and support
- Exam: anaemia, vitals (esp HR, BP, t), GI and PR
- Investigations: colonoscopy; FBC, Fe studies, CRP
Management
- Haemorrhoids: behavioural change, cream, +/- banding/haemorrhoidectomy
- Anal fissure: avoid constipation (diet, stool softener), topical rectogesic +/- botox to reduce muscle spasm
- Anal fistula: fistulotomy
- CRC: resection and rtx or palliation
- Opportunistic screening
- F/U
James Taylor is a 42-year-old man. He states “My wife wanted you to look at this spot on my back. I can’t really see it and she was concerned.”
Skin cancer
PDx: melanoma
DDx: SCC, BCC, seborrhoeic keratosis, melanocytic naevus, dysplastic naevus, actinic keratosis, keratoacanthoma
Assessment
- Skin cancer risk: sun exposure from work and leisure (/radiation/ chemo/ immunosuppression) and protection
- Check for symptoms of metastatic spread
- Examine lesion, whole body and lymph nodes (dermatoscope if possible)
- Biopsy lesion if concerning (ABCDE)
Management
- Skin cancer: referral to gen surg, oncologist -> excision +/- radiotherapy; ongoing F/U
- Opportunistic screening
- F/U
Jeffrey Beck is a 10-year-old boy. He is brought in by his mother who says “He was playing soccer and fell onto his right arm. He says it’s really sore and won’t let anyone touch his right wrist.”
PDx: fracture eg supracondylar (worried about brachial artery and AIN of median nerve)
DDx: soft tissue injury, NAI, osteomyelitis, haemarthrosis
Assessment
- trauma = ABCDE (don’t forget tetanus!)
- History: MIST, PMHx (incl paeds, any ct/bone/metabolic disease), FHx, meds and allergies, SHx (support, assess parenteral capability)
- red flags: toxic (osteomyelitis), strange story (NAI), irretractable pain (compartment syndrome)
- Exam: look feel move for both arms, look for localised tenderness, deformity, limited ROM, neurovascularly intact distally (test nerves with minimal distal movement: OK sign, thumbs up sign, keeping paper between middle and ring finger; test sensation on dorsal web space, ring and little fingers)
- Ix: xray AP/lat/oblique hand/wrist/forearm/elbow
Management
- analgesia
- fixation - cast/ortho referral => present to ED
- screening
- F/U
Peggy Lee is a 58-year-old lady with peripheral joint pain [wrist and hands] and neck pain. She is on no medication. She states “Doctor, my neck and hands are so sore. I need something for pain relief.”
PDx: OA
DDx: RA, SLE, psoriatic, IBD
Assessment: what are her issues, what is causing her issues
- History: mech vs inflammatory sx, assoc sx; PMHx + FHx of inflammatory arthritis, meds and allergies, SHx - SNAP, ADLs - functional effect
- Exam: hands, neck, other joints if on history, as per history
- Investigations (if diagnosis not clear): xray joints, if inflammatory - FBC, ESR, RF, anti-CCP, ANAs, anti-dsDNA, ENAs (incl anti-Sm), C3, C4
Management
- MDT: PT/OT involvement, social worker for service linkage if necessary
- Non-pharm: weight loss, SNAP, heat packs
- Analgesia: paracetamol + NSAID short-term; consider steroid injections
- Treat underlying cause: DMARDs +/- pred as required
- Opportunistic screening
- F/U
Osteoporosis
Concerns
- Bone density
- Fractures
- Falls
- ?Underlying cause:
- – endo: Cushings(/steroids), hyperthyroidism, hyperparathyroidism, POF
- – drugs
- – reduced intake: diet, malabsorption, chronic diseases (incl CKD)
Assessment
- history: sx of fractures, sx of PMHx of causes, history of falls or causes; meds and allergies, SHx - SNAP, ADLs, support
- exam: spine (?vertebral fractures), as per history
- investigations: vit D, Ca (CMP), UEC, FBC, LFTs; DEXA; xray spine; as per history
Management OP - non-pharm: exercise (load bearing), sunlight and diet, cease smoking and limit alcohol - pharm: bisphosphonates/denosumab (raloxifene and teriparatide are secondline) - review BMD at 2 years - vit D and Ca too FALLS RISK - PT/OT involvement - age-related impairment treated - medication review - treatment of any medical comorbidities
- Opportunistic screening
- F/U
Elizabeth Finn is a 60-year-old lady with a two month history of dizziness. She states “Doctor, whenever I get up from lying down I feel like everything is spinning”.
Vertigo
PDx: BPPV
DDx: peripheral (Meniere’s, vestibular neuritis) or central (vestibular migraine, brainstem/cerebellar TIA/stroke)
Assessment
- History: confirm it’s vertigo, onset incl viral prodrome, timing, associated symptoms (Meniere’s, brainstem, cerebellar, migraine); PMHx/FHx of stroke risk factors; meds and allergies, SHx - SNAP, ADLs and impact, support
- Exam: CN incl Dix-Hallpike and hearing (formal testing if concerns), cerebellar, long tract signs, cardioresp, head impulse; vitals; general UL LL neuro exams
- Ix: MRI brain if stroke suspected, otherwise none
Management
- prochlorperazine (stemetil) + benzo if very unwell
- education
- BPPV: Epley manoeuvres (Cawthorne-Cooksey at home)
- Meniere’s: HCT (+salt restricted diet)
- Migraine: triptan (and prevention with amitriptylline)
- Stroke: modify risk factors
- Opportunistic screening
- F/U
Tinnitus
.
Tremor
PDx: physiological tremor
DDx: essential, PD, cerebellar, hyperthyroid, toxic (alcohol, meds, withdrawal)
Assessment
- history: precipitating/aggravating/relieving factors; screen for other causes (eg AUDIT)
- exam: is it resting/postural/action/intention; neuro exam
- ix: TFTs, wilson’s in <40yo
Management
- physiological: remove precipitant
- essential: propanolol
- orthostatic: benzo
- PD: treat PD
- cerebellar: non-pharm…
Insomnia
DDx
- poor sleep hygiene
- psych/personal issues
- medication/withdrawal
- physical symptoms: (CV) orthopnoea, palpitations, (resp) noctural asthma symptoms, OSA, pain
Assessment
- history: reasons they might be awake, any symptoms at night, screen for psych issues and social stressors, sleep hygiene, PMHx, FHx, meds and allergies, SHx very important
- exam: per history
- ix: per history
Management
- good sleep hygiene
- behavioural interventions: sleep restriction, stimulus control therapy, relaxation therapy, paradoxical intention, CBT
- treat underlying cause if found
- pharm: melatonin
Hair Loss
Alopecia DDx
- stress - psych, pregnancy, illness
- androgenic
- trauma: chemo/ radiotherapy/ surgery/ injury
- localised skin disease: alopecia areata, tinea capitis, psoriasis, atopic dermatitis, infection
- systemic disease with skin affected: Fe deficiency, hypothyroidism, SLE, syphilis
Assessment
- history: onset, hx of physical or psychological stress, local skin condition, systemic disease, skin trauma to the area
- exam: pattern, what kind of hair; systemic disease
- ix: TFTs, Fe studies, FBC
Management
- treat cause (androgenic has medical - topical minoxidil - and surg; areata has steroids)
- be nice to hair
- referral to dermatologist if unclear
Joan Jett is a 30-year-old woman with irritative voiding symptoms.
PDx: UTI
DDx: STI, diabetes, neurogenic bladder (painful bladder syndrome is a diagnosis of exclusion)
History
- history: HoPC - dysuria or just frequency and urgency, any obstructive symptoms, any STI sx, any polydipsia/polyphagia, any neuro sx, urinary practices, sexual practices; PMHx and FHx; meds and allergies, SHx - SNAP, support
- exam: palpate abdo, urinalysis, STI screen/pap smear if indicated by history
- ix: as above - cystoscopy and urodynamic tests if MSU MCS clear
Management
- abx
- drink lots of water and frequent voiding
- consider prophylactic abx if recurrent
- opportunistic screening
- F/U
John Baldy is a 54-year-old man with type 2 diabetes. He presents for yearly review.
Priorities: to review his
- diabetes control: hyper/hypos
- complications: eyes, kidneys, peripheral neuropathy, strokes, MI, PAD, erectile dysfunction, infections
- quality of life
Ix:
- HbA1c
- urinalysis, UEC, urine ACR
- ophthal referral if any vision concerns
- fasting lipids, BP etc
- as per history
Mx
- adjust meds
- lifestyle counselling
- adjust GPMP: diabetes counsellor, dietitian, ophthal, podiatrist
- other referrals as per history
William Wyman is a 60-year-old man with a 50 pack year smoking history. He states “Doc, I feel lousy. I am short of breath and my cough has got a lot worse.”
PDx: COPD
DDx: lung cancer, pneumonia, CCF
Assessment
- history: SOB and cough sx, ?cancer sx, ?infection sx; exercise tolerance, orthopnoea, PND
- exam: resp exam esp ?barrel chest, increased expansion, hyperresonant; signs of pneumonia, obstruction or pleural effusion; CCF signs
- ix: spirometry; CT chest if worried about cancer; CXR if infectious sx; echo if ?CCF
Management
- severity stratify
- nonpharm: risk reduction (smoking, vax), optimise function, treat comorbidities, consider pulmonary rehab
- reliever SABA/SAMA
- then add regular LAMA/LABA
- ICS+LABA combination when mod-severe
- theophylline, O2, surg, ACD when very severe
Molly Hatcher is a 36-year-old lady. “Doctor, I got home from work on Monday and I had this terrible headache.” On further questioning, she notes a bilateral frontal headache. She notes nausea without vomiting. She notes mild photophobia.
DDx:
- headache syndromes: migraine, tension, cluster
- organic path: SAH, meningitis, SOL, drugs/withdrawal
Assessment
- History: character of pain, associated sx (migrainey, red eye/lacrimation/sweating, meningism, neuro sx, raised ICP), onset; PMHx + FHx, meds and allergies, SHx incl SNAP, support
- Exam: vitals, neuro, meningism
- Investigations: as per history - consider CT brain if ?SAH/SOL, infection workup if ?meningitis
Management
- headache diary, massage, stretching, heating, CBT
- Migraine: psychological; simple analgesia initially, consider triptan and then amitriptyline for prevention
- Tension: psychological/behavioural; simple analgesia initially, then amitriptyline for prevention
- Cluster: psych/behavioural; O2 during attack, verapamil to prevent and pred to bridge
HAEMOCHROMATOSIS
Haemochromatosis:
- Liver
- Endo
- Heart
- Skin
- Joints
Assessment
- hx of symptoms, evidence of end organ damage, family history
- rule out liver disease as cause of iron overload (or ineffective erythropoiesis)
- examine for end-organ damage
- Fe studies, FBC, LFTs, liver MRI/biopsy, genetic testing
Management - genetic counselling - phlebotomy: weekly/fortnightly until ferritin 50-100; then 2-4monthly keeping ferritin in that range (if anaemic, can chelate) - dietary restriction - monitor for HCC - family genetic testing - opportunistic screening - F/U
Molly Malone is a 70-year-old lady. She is brought in by a daughter who notes an ulcer on the lower leg.
DDx
- arterial ulcer
- venous ulcer
- diabetic ulcer
- others: malignant ulcer
Issues
- ulcer
- infection
- vascular supply
Assessment
- history: development of ulcer, pain, trauma, sx of vasculopathy/venous insufficiency/diabetes incl peripheral neuropathy; PMHx and FHx, meds and allergies, SHx - SNAP, ADLs, support
- exam: ulcer incl pin; lower limb incl vascular, neuro, LN exam if ?malignant; CV exam
- investigations: as per history, but surely
- -ABI, angiography if reduced, venous Dopplers, fasting BSL, —FBC, CRP, ulcer swab MCS
Management
- wound care incl emollient, dressing
- elevation, exercise, compression stockings if venous
- treat infection, underlying vascular insufficiency/DM, other factors compromising healing (drugs, smoking)
- opportunistic screening
- F/U
