Common Symptoms/Complaints in Family Medicine

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Common Symptoms/Complaints in Family Medicine

• Medicine and Skin
• Dr Edmond CW Chan

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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.

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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

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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

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• 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)

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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

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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

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Differential diagnosis

• Pseudovertigo
• Drugs
• Anaemia
• Perimenopausal syndrome
• Postural hypotension
• Cardiac arrhythmias
• Complete partial seizure
• Brain secondary
• Psychosocial

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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

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• 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

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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)

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• 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

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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

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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.

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What questions will you ask?

• For discussion

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Physical examination

• General appearanceXanthoma/Xanthelasma/arcus
  senilisBMIGoitreAnxiety/depressedsweating,
  pallor
• CVSBPpulse rate, volume and regularityJVP

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

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Further investigation

• For discussion

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Differential diagnosis

• Sinus tachycadiafeveranaemiaperimenopausalThy
  rotoxicosisPhaeochromocytomaCarcinoid
  syndromePorphyriaAnxiety/Depression (effort
  syndrome)Drugs, tea, coffee, alcohol, cigarette
  smoking

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• Paroxysmal bradycardiaSick sinus syndromeheart
  blocks
• Paroxysmal tachycardiasupraventricular (narrow
  QRS)Atrial ectopicsSVTAtrial flutterAtrial
  fibrillationWolff-Parkinson-White syndrome

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

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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)

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Wolff-Parkinson-White syndrome
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• Risk of sudden death
• Congenital abnormality with bundle of Kent
• Can present with SVT or AF
• EPS and radiofrequency ablation of the abnormal
  pathway

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Atrial fibrillation

• Common causes of AFIHDThyrotoxicosisValvular
  lesions like ASD, mitral valve diseaseAlcohol-rel
  ated heart diseaseimpaired ventricular
  functionIdiopathic

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AF

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

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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?

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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

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• 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

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• 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

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Physical examination

• For discussion
• General appearance

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P/E

• CVS
• Chest
• Abd
• Others

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Further investigation

• For discussion

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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

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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

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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

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

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Common skin problem in FM

• Diagnosis in dermatology mainly based on
• Clinical history
• Morphology
• Distribution
• Further investigation

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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

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• 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

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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

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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)

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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

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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)

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• 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

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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)

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• 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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• 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

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Thank you