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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 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. 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 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 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) 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 side Vertigo and nystagmus adaptation ECG Caloric test Others like X-ray, CT brain, MRI, autonomic functional test etc if indicated 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 Differential diagnosis Pseudovertigo: Drugs Anaemia Perimenopausal syndrome Postural hypotension Cardiac arrhythmias Complete partial seizure Brain secondary Psychosocial 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 May take 6 week or so to subside Nystagmus present because of involving the vestibular system DDx: Acute labyrinthitis Tx: Stemetil 1 tab tds or im if severe beware of extra-pyramidal side effects relieved by benadryl diphenhydramine 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) 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 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 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. What questions will you ask? For discussion Physical examination General appearance: Xanthoma/Xanthelasma/arcus senilis BMI Goitre Anxiety/depressed sweating, pallor CVS: BP pulse: rate, volume and regularity JVP heart murmurs, mid-systolic click carotid bruit Any signs of thyrotoxicosis Any signs of infection Further investigation For discussion Differential diagnosis Sinus tachycadia: fever anaemia perimenopausal Thyrotoxicosis Phaeochromocytoma Carcinoid syndrome Porphyria Anxiety/Depression (effort syndrome) Drugs, tea, coffee, alcohol, cigarette smoking Paroxysmal bradycardia: Sick sinus syndrome heart blocks Paroxysmal tachycardia: supraventricular (narrow QRS)— Atrial ectopics SVT Atrial flutter Atrial fibrillation Wolff-Parkinson-White syndrome Ventricular (wide QRS)— Ventricular ectopics Ventricular tachycardia Ventricular fibrillation Note: It is important to look for the underlying cause of each arrhythmia and the provoking factors 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 maneuver immersion face to water drink a glass of ice water Verapamil/Diltiazem (monitor BP) DC cardioversion (haemodynamically unstable) Wolff-Parkinson-White syndrome Risk of sudden death Congenital abnormality with bundle of Kent Can present with SVT or AF EPS and radiofrequency ablation of the abnormal pathway Atrial fibrillation Common causes of AF: IHD Thyrotoxicosis Valvular lesions like ASD, mitral valve disease Alcohol-related heart disease impaired ventricular function Idiopathic AF Acute or chronic? Sinus rhythm converted or ventricular rate control ? Chemically converted or DC cardioversion? Anticoagulant? Risks: disease itself and the treatment 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? 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/infarction back: dissecting aneurysm/PPU/acute pancreatitis dermatome: shingles Aggravating factors: supine– reflux oesopagitis exercise, emotion, large meal, sexual intercourseangina inspiration—acute pericarditis Relieving factors: rest, TNG —angina/oesophageal spasm leaning forward– acute pericarditis antacid, standing up, belching --GRED 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 Physical examination For discussion General appearance: P/E CVS: Chest: Abd: Others: Further investigation For discussion: Differential diagnosis Consider 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 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 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 Medical treatment: Streptokinase Symptoms control: Morphine, nitrates Aspirin Beta-blockers Risk factors modifications ? Primary PTCA CABG Cardiac rehabilitation Common skin problem in FM Diagnosis in dermatology mainly based on Clinical history Morphology Distribution Further investigation 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 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 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 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) 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 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) 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 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) Tinea capitis: scalp Tinea pedis: feet, toe web Tinea manuum: hand Tinea unguium: nail Tinea crutis: groin Tinea corporis: trunk Tinea faciale: face Treatment: Topical: Imidazole, Allylamine, Whitfield onitment, tolnaftate Systemic: Griseofulvin Imidazole (ketoconazole, miconazole) Triazole (itraconazole, fluconazole) Allylamine (terbinafine) Usually use for longer term and beware the LFT