GP Flashcards
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
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