General Presentations Flashcards
What are red flag signs or symptoms in lower back pain?
(9)
History of cancer
Age > 50 or < 15
Known Osteoporosis or high fracture risk
Fevers > 38/night sweats
Use of IV drugs
urinary retention
urinary incontinence/bowel incontinence/saddle anaesthesia
Lower limb weakness/paralysis
prolonged morning stiffness (Ank spond) + <40yo + 3months of sx
Management for mechanical lower back pain.
Ibuprofen
Referral to physio for active treatment program
Advise not to have prolonged bed rest
Return to work as soon as possible
Can use massage therapy
Advise to trial Yoga or Taichi or Pilates
Long term 5-10% weight loss
Treatment for PMR - dosing.
prednis(ol)one 15 mg orally, daily for 4 weeks; then reduce daily dose by 2.5 mg every 4 weeks to 10 mg daily; then reduce daily dose by 1 mg every 4 to 8 weeks to stop
For GCA, without evolving visual loss, list two steps of management. dosing if required.
- Urgent referral to ophthalmologist for treatment to prevent visual loss
- Start prednisolone 40-60mg, orally, for a minimum of 4 weeks
(3. Can start aspirin 100mg to prevent vascular thrombus)
If having visual loss will need IV glucocorticoids in hospital
Up to one third of abdominal pain presenting to GPractice has no cause.
Apart from surgical causes, what are non-abdominal causes of abdominal pain?
(6)
PE
MI
Pneumonia
Anxiety/depression
Lumbar spine pathology
Pelvic Pathology: ectopics ,ovarian torsion, fibroids, PID
In the elderly person with abdominal pain, what two things should you consider as serious diagnoses?
Mesenteric Artery occlusion
Leaking AAA
What Imaging can you use to investigate Abdominal pain?
Right Upper Quadrant–> U/S
Right lower quadrant –> CT with IV contrast
Left Lower quadrant–> CT with oral and IV contrast
Suprapubic–> U/S
Right or Left lower quadrant pain in child bearing age females or pregnancy related concerns –> Abdominal U/S for LLQ or TVU/S for suspected ectopics or other pelvic pathology
In a frail elderly person with abdominal pain, who appears unwell, what is the appropriate management?
Consider sepsis, perforation, ischemic bowel.
answer: CT and hospitalisation
In a 56 year old patient with flank pain and haematuria
1 What is the most likely diagnosis
- What is the diagnosis not to be missed
- What should you do
- Renal stone
- Ruptured AAA
A ruptured AAA can tamponade and cause a normotensive BP. So you might not pick it up.
Secondly the AAA can irritate the ureter and cause haematuria - A new presumed diagnosis of “kidney stones,” in someone aged over 50 should prompt imaging of the Aorta.
Aside from imaging, what investigations may you consider for abdominal pain?
- EUC
- FBC for infection
- CRP for inflammation
- LFTs- liver
- Lipase- pancreatitis (can be falsely elevated with mesenteric ischemia)
- urine MCS
- Urinanalysis
- Pregnancy test
- (ECG) if suspecting cardiac
- Fasting BGL or any BGL - ?DKA
- Venous Blood gas for lactate. ?ischemic bowel
Explain the appropriateness of imaging for different types of LBP?
- non specific LBP. unless red flags. do not image. If > 6 weeks then consider XRAY first line. If red flags MRI is preferrable
- Symptomatic Lumbar disc herniation. This is when a disc causes pain, usually radicular sharp and shooting. Radicular pain alone is not a red flag, but if combined with weakness, numbness or parasthesia then yes it is. If > 6 weeks then consider MRI.
- Symptomatic spinal canal stenosis. Usually bilateral pain from back (or not) to hips. Usually aggravating by walking (psuedoclaudication). This case definitely IMAGE. with MRI.
What is the most common cause for chest pain?
Musculoskeletal causes
Isolated MSK issues (costochondritis, lower rib pain syndrome)
Rheumatological Diseases: fibromyalgia, RA
Non-rheumatological systemic disease: Cancer/mets, Osteoporotic fracture, Sickle Cell disease (Rare)
What to ask regarding sleep patterns specifically?
Usual Bed time
Shift work
Time taken to fall asleep when lights out
Rough duration and amount of wakenings
Time patient gets out of bed
Any triggers that wake the patient
What can impact a patient’s sleep?
Too much Caffiene
Alcohol
Nicotine
Exercise before bed
Period of stress/anxiety/depression
Television in the room
Pets/kids interrupting
When would you order a PSN (polysomnograph) for sleep?
Suspicious of Sleep Apnoea, treatment resistant insomnia, sleep related movement disorder and parasomnias
What are the components of CBT used for insomnia?
(4)
- Stimulus Control
(removing all wakening triggers; phones, TVs, computers, light sources. And excluding sleep from living room) - Sleep Restriction
- Relaxation techniques (imagery, biofeedback, mediation, hyponosis)
- Sleep hygiene
- Cognitive therapy
Medications that can be used for insomnia?
Melatonin- helps more with sleep onset time and delayed sleep phase disorder
2 mg orally, 60 to 120 minutes before bedtime for an initial period of 3 weeks then review. Melatonin may be continued for an additional 10 weeks.
Temazepam 10 to 20 mg orally, 30 minutes before bedtime for the shortest possible duration; preferably not on consecutive nights and for less than 2 weeks.
Zolpidem MR 5 to 10 mg orally, at bedtime for the shortest possible duration; preferably not on consecutive nights and for less than 2 weeks
What points do you raise with a person when discussing sun protection?
Use sun protection when UV is > 3
Use of shade
Wide brimmed, legionnaire or bucket style hats
Protective clothing
Sunglasses
Use sunscreen with SPF > 30
Avoid the sun at peak times of the day
Is there a screening for skin damage?
No specific recommendation
Ask patients to be self aware and familiar with their skin as well as be alert of new lesions
Anyone at high risk should have 3-6 monthly checks.
High risk: past/family history, sun damage, solarium use, fair skin/red hair, easily burnt, extensive sun exposure
Advise anyone over 10 to be sunsmart (not screening)
Risk factors for hip and knee Osteoarthritis? (3)
age
joint injury
obesity and overweight
How can you can clinically diagnose knee Osteoarthritis?
(6)
If patient is >45 years
Activity related pain
Stiffness < 30 minutes in the morning
Crepitus on active ROM
Bony enlargement
No detectable warmth
What is the role of imaging with regards to Hip and Knee OA?
The diagnosis is clinical and imaging is not needed.
If other pathology is suspected then order imaging or if diagnosis is vague
Imaging for OA follow-up is recommended only if there are unexpected rapid progression of symptoms or change
in clinical characteristics that need to be confirmed (eg increasing severity of OA)
In management of hip or knee OA, what has strong recommendations?
only 2
- Land based exercises: walking and muscle strengthening exercise
- Weight management for BMI < 25
what are some conditional recommendations for management of hip and knee OA?
(up to 11)
- CBT best combined with exercise
- Stationery cycling or hatha yoga can be offered to some persons
- Aquatic exercises. can be offered. Can refer to an exercise physiologist
- Massage therapies
- Adjunctive stretching therapies
- Topical heat application
- Assisted walking devices to help with mobility
- TENS
- NSAIDs short courses
- Duloxetine (no TGA approval)
- Corticosteroid injection
What not to do (in terms of treatment) for hip/knee OA?
evidence base: strongly not recommended.
(5)
- opioids of any form
- doxycycline
- Strontium ranelate
- IL inhibitors
- Arthroscopic lavage
What are red flag features for neck pain and why?
(5)
- Significant trauma: MVA - disruption of the cervical spine
- History of RA (atlanto-axial disruption)
- Infective symptoms: meningism, fever, history of drug use
- abscess, meningitis, mycotic aneurysms - Neurology (of upper motor neuron problems) :
- Cervical cord compression, demyelinating process - Ripping/tearing neck pain sensation - arterial (carotid/vertebral dissection)
- Concurrent chest pain/cardiac features - MI
Acute neck pain is classified as _______ _____ ______. (Length of time)
The prognosis is generally _______.
under 6 weeks,
Good
What are the sub-acute and chronic definitions for neck pain?
Acute < 6 weeks
Sub acute 6 weeks to 6 months
Chronic > 6 months
What are two important predictors of chronic neck pain prognosis in whiplash injuries?
- Initial severity of the pain
- If there is a compensation claim simultaneously
Somatic neck pain can be superficial or deep.
Superficial pain from the skin is usually sharp and well defined.
Deep somatic pain is usually dull and achy, and more generalised.
Neither of these are ‘radicular pain’
what are causes of deep somatic neck pain?
- Spondylosis (though this can be difficult to diagnose at the cause as XRAY findings and level of pain don’t correlate well)
- Discogenic. prolapse of the nucleus pulposus
- Facet joint pain
- Myofascial pain
What is radicular pain?
pain that radiates along a sensory distribution.
Usually sharp and cutting and has parasthesia or dysathesia.
Causes of radicular neck (or even lower back) pain?
(2 main groups)
spondylotic myelopathy - degenerative changes that narrow the spinal canal, resulting in neurological compromise.
Cervical radiculopathy- causes are predominantly degenerative and include foraminal stenosis, such as those imparted by osteophyte encroachment from spondylosis. Another common cause includes posterolateral cervical disc herniation, compromising abutting exiting nerve roots
What are yellow flags?
yellow flags are psychosocial factors that are predictive of chronicity and disability with regard to any disease.
What are they yellow flags with regard to neck pain?
(4)
- Attitude that the spinal pain is potentially severely disabling
- Social or financial problems
- Reduced activity levels
- Presence of a compensation claim
Addressing some of these yellow flags may help to reduce the risk of acute neck pain progressing to sub-acute and even a chronic temporal pattern
What to note on examination of the neck in neck pain?
(3 main points)
Inspection - posture, scars, muscle bulk, symmetry
Palpation - midline tenderness (could be sinister)
Neurological exam- movement and sensation of the upper limbs
What are indications for imaging (with an MRI) for neck pain?
(6)
- Age > 50 with new symptoms
- Systemic features: weight loss, fevers/night sweats, anorexia
- Infection risk (IVDU, immnosuppressed)
- Moderate to severe pain lastin g> 6 weeks
- neurological findings
- History of malignancy
With neck pain, if there is associated extremity pain (due to nerves involved) that is worse than the neck pain itself, other than an MRI, what else could you consider?
A nerve conduction study
Management for non-critical causes for neck pain?
(3)
- Poor evidence but essentially manual therapy/physio for the neck
- Non opioid analgesics in the short term
- Addressing yellow flags (psychological barriers) in regards to the neck pain
When can a GP refer for MRI with regards to neck pain?
when patient is > 16 y.o and concerned about cervical radiculopathy
also 16+ and for cervical trauma however, CT is better and recognising fractures- but if worried about ligaments or spinal cord this can be done.
what is the chronological classification of a cough?
(3)
acute < 3 weeks
Sub acute 3-8 weeks
Chronic > 8 weeks
What are the red flags with regards to a cough?
(up to 7)
- Haemoptysis
- Smoker
a. 20 pack year history with a new cough
b. > 45 yo with new cough or altered voice - Prominent dysponoea at night
- Hoarseness
- Systemic features (weight loss, appetite loss, fever, oedema, vomiting)
- GORD with associated weight loss, haematemesis or melena, dysphagia or odophygia
- GORD not responding to treatment
- LRTI - recurrent
- Abnormal respiratory exam or CXR
When do you suspect pertussis with regards to a chronic cough?
Cough longer than 3 months
Paroxysms of coughing (coughing fit)
No fevers
Coughing to the point of needing to vomit
Inspiratory Whoop
What are the most common causes of a chronic cough?
-Post viral cough
-GORD
-Asthma
-Upper airway cough syndrome (post nasal drip or perceived post nasal discharge)
The bottom three make up 90% of the causes for chronic cough.
what is acute bronchitis?
Acute cough of less than 14 days duration and at least 1 other symptom of a respiratory infection:
such as symptoms of URTI, sore throat,
sputum production, dyspnoea, wheeze, chest
pain, for which there is no other explanation.
What management is recommended/ not recommended for acute bronchitis?
- Do not prescribe antibiotics
- Does not need a CXR on suspicion of acute bronchitis alone
- Reassure that it is self limiting
- Educate that it can take 8 weeks to settle / set realistic expectation of time frame
- Set a review in 3 weeks if no improvement at all, or worseninng
- CAN use inhaled fluticasone propionate in those who DO NOT smoke. Only this steroid was studied.
What are some general management options including medications (no dosing required) in dealing with a chronic cough?
(4)
- Avoid triggers: exposure to cold dry air, smoking and air pollution
- Vocal hygiene- helps reduce laryngeal irritation.
- Use an active cycle of breathing for sputum clearance
- Inhaled steroids - only really useful if the person has asthma.
After initiating therapy for weight loss, when should you first plan a follow up?
2 weeks ideally
what is the most recent statistics on overweight and obesity in Australia?
25% of children in Australia are either overweight or obese (17% overweight + 8 % obese)
67% of adults are either overweight or obese (1/3 of all adults were overweight, 1/3 were obese and 1/9 of all adults are severely obese).
What is the 5 A’s framework?
Ask
Assess
Advice
Agree
Assist
If a patient is unlikely to adhere to a 10 day course of antibiotics for a sore throat what can be done?
IM Benzathine penicillin as a single dose
What and when is treatment for this indicated?
This is Shingles. Reactivation of herpes Zoster virus.
treatment is indicated if
adults and adolescents who present within 72 hours of onset of rash,
And for all
immunocompromised adults and adolescents (including those with HIV infection) regardless of duration of rash.
Describe three things you are seeing on examination that support venous insufficiency?
Varicose veins in the feet
Venous stasis ulcer
Haemosiderin deposition
For this condition , what antibiotic would you use?
No systemic features, no ulcers or penetrating lesions.
What about if delayed non severe reaction to penicillin?
Or if severe penicillin reaction?
Phenoxymethylpenicillin 500mg, oral, 6 hourly, 5 days.
Or
Cephalexin 500mg, oral, 6 hourly, 5 days
If severe reaction
Clindamycin 450mg oral, 8 hourly, 5 days
What dietary advice should be given to those with raised cholesterol?
- Replace transfats altogether in the diet
- Reduce intake of saturated fat
- Increase soluble fibre intake
- Introducing plant sterol-enriched milk, margarine or cheese (this is the most effective measure at reducing LDL)
What structure/algorithm can you use to help assess a pigmented skin lesion when using a dermatoscope?
When might this structure/algorithm not be useful?
“Chaos and Clues”
This begins by looking at symmetry, however some symmetrical lesions can still be malignant. So don’t always rely on this.
What are the 8 “clues” when assessing a pigmented lesion?
- Eccentric structureless area
- Thick reticular lines or branches
- Grey or blue structures
- Black dots or clods, peripherally
- Radial lines, psuedopods or segmental lines
- White lines
- Polymorphous vessels
- Acral ridge lesions or chaotic nails
Which “clues” are these showing?
- eccentric structureless
- Blue clods
5a and b. Radial central lines
- White lines
- Polymorphous vessels
Is this a suspicious pigmented lesion?
Yes.
It is “chaotic” i.e. not symmetrical.
What are important points to elicit on history of haemoptysis?
(9)
- Associated SOB
- Associated weight loss
- Associated fevers
- Work exposure e.g. asbestos, wood dusts, silica
- Environmental exposure to high air pollutants.
- Chest or shoulder pain
- Hoarseness of voice.
- Active or passive smoking
- family history of lung cancer
What are the grades of haemorrhoids, and their treatments?
Grade 1. Bleeding, with no prolapse
Grade 2. Bleeding and prolapse that reduces after defecation
Grade 3. Bleeding and prolapse that has to be manually reduced. Painful if large .
Grade 4. irreducible prolapse. Usually thrombosed.
Treatment on flowchart
What are the two main aspects of symptomatic management for this?
- Avoiding constipation: fibre, stool softeners
- Local anaesthetic topical application
- Local GTN Application- advise not to get onto normal skin and expect a headache. Alternatively a topical calcium channel antagonist (diltiazem can be used)
