GP- Common presentations Flashcards
What signs are specific for Graves’ disease when assessing hyperthyroidism?
- Thyroid acropatchy
- Exophthalmos
- Opthalmoplegia
- Pretibial myxoedema
What Ix are required for suspected hypothyroidism?
- TFTs
- Anti-TPO and thyroglobin Abs
- US
What Ix are required for suspected hyperthyroidism?
- TFTs
- TSH-R antibodies
- Nuclear scan
Signs and symptoms of hypothyroidism?
- Fatigue
- Sleepiness
- Cold intolerance
- Weight gain
- Muscle aches
- Bradycardia
- Constipation
- Menstrual irregularities
- Dry skin
- Coarse or brittle hair
- Oedema, especially periorbital
- Xanthelasma
- Difficulty with concentration and memory
- Onycholysis
- Myxoedema coma: profound hypothermia, bradycardia, skin and facial changes
Signs and symptoms of hyperthyroidism?
- Fatigue
- Insomnia
- Heat intolerance, excessive sweating
- Weight loss
- Weakness, proximal myopathy
- Palpitations, tachycardia/AF
- Diarrhoea
- Oligomenorrhoea
- Warm and moist skin
- Hair loss
- Nervousness, emotional lability
- Poor concentration
- Dyspnoea
- Hyper-reflexia (brisk) and muscle spasm
- Lid lag, retraction, thyroid stare and exophthalmos
- Goitre
- Onycholysis
What is a “cold” thyroid nodule?
Either cancer or cyst
What is a “hot” thyroid nodule?
Nodule that secretes T3/T4
What pathogens commonly cause UTIs?
- E. Coli
- Proteus
- Enterococcus
What pathogens commonly cause typical CAP?
- S. pneumoniae
- Hib
What pathogens commonly cause atypical CAP?
- Mycoplasma
- Chlamydia
- Legionella
- S. aureus
What pathogens commonly cause meningitis (adults and children >2mo)?
- N. meningitidis
- S. pneumoniae
- Hib
What pathogens commonly cause meningitis in children?
- S. pneumoniae
- GBS
- Listeria monocytogenes
Who do you screen for T2DM?
Every 3 years from
- 40yo and above
- Or 18yo if Aboriginal
Presentations of T2DM
- On screening
- Polyuria, polydipsia, weight loss (uncommon)
- Blurred vision
- Paraesthesias
- Fatigue
- Skin and candidal infections
Risk factors for T2DM
- FHx of DM
- Hx of GDM
- CVD risk factors: BMI, HTN
Diagnostic Ix for T2DM
- OGTT >11.1mmol/L (2hr)
- Fasting BG >7mmol/L
- HbA1c >6.5%
What monitoring is required every 6 months in T2DM?
SNAP, BMI, BP, HbA1c
What monitoring is required every 12 months in T2DM?
Eye and foot exams, kidney assessment
What monitoring is required every 24 months in T2DM?
Retinal screening, lipid assessment
What are the Mx options for T2DM?
- Screen for and manage complications and CVD risk
- Lifestyle changes: weight loss, diet/exercise, smoking and alcohol
- Monotherapy: metformin (sulphonylurea 2nd)
- Dual therapy: metformin + sulphonyluyrea (2nd = DPPIV inhibitor or GLP-1 agonist)
- Triple therapy: metformin + sulphonylurea + DPPIVi/GLP-1
- Insulin (± metformin): basal then bolus
Complications of T2DM
- Microvascular: nephropathy, retinopathy, delayed wound healing, erectile dysfunction
- Macrovascular: IHD, HTN, PVD, CVA
- Cellular: neutrophil dysfunction, peripheral neuropathy, NASH
- Autonomic: labile BP and postural hypotension, incontinence, gastroparesis, N+V
What symptoms should prompt urgent colorectal referral?
> 40 yo with unexplained wt loss + abdo pain
50 yo with unexplained rectal bleeding
60 yo with FeD anaemia or change in bowel habit
Positive faecal occult blood test
What are the abnormal blood results (PTH, ALP, Vit D, Ca, P) in osteoporosis
Normal PTH, normal Ca & P +/- low Vit D, tend to have high ALP (increased with increase # risk)
What is Rx for chlamydia? What are screening guidelines?
High dose azithromycin or doxycycline
All sexually active people b/w 15 - 29 should be screened with urine PCR annually
Also screen if any current UTI, partner with symptoms or > 2 partner in a year
What is Rx for gonorrhoea?
High dose azithromycin and cephalosporin
What are the clinical features of OA?
Joint pain with movement - usually improves with rest (may not in severe disease)
Crepitus on joint movement
Bony swelling
Bony tenderness on palpation (esp. joint line)
Bony enlargement or deformity
Reduced range of movement
Morning stiffness or ‘gelling’ after prolonged inactivity - time is less than in inflammatory arthritis (
What are red flags of joint pain?
Inflammatory symptoms (swelling, warmth, redness) Constitutional symptoms Sudden onset Nocturnal pain Pain which does not improve with rest Recent trauma Morning stiffness > 30 minutes Loss of function
What are risk factors/possible causes of OA?
Hx of injury/trauma to joint
Significant physical activity - overuse, high impact
Genetic - esp. when affecting small joints of hands
Overweight/obesity
Increasing age
Female gender
Muscle weakness - muscles contributing to joint stability & function
Proprioceptive defects
What is the pattern of joint involvement in OA?
Small joints of hands - DIP & PIP involvement (spaces MCP)
1st MCP and IP joints (thumb) & 1st MTP (toe)
Weight bearing joints - knees, hips, spine
Usually doesn’t affect elbow, wrist or ankle
What are XRAY features of OA?
Loss of joint space (asymmetrical)
Osteophytes
Subchondrial sclerosis
Subchondrial cysts
How should you diagnose OA?
Clinical diagnosis which generally doesn’t require other Ix
Do not need to routinely XRAY - perform if red flags, severe impairment, to grade/identify severity of disease or initial diagnosis of HIP
XRAY features have poor correlation with symptoms (except in advanced disease)
If need to exclude inflammatory cause - ESR, CRP, Anti-CCP (ACPA), RF
What are important lifestyle factors to assess in initial diagnosis of OA?
Impact on function (occupational, ADLs, leisure), mood, sleep
Psychosocial/Yellow flags contributing to chronic pain - i.e. attitudes to recovery
Level of physical activity
Treatments previously tried and their effectiveness
What is the treatment for OA?
- Lifestyle measures
- Weight loss, exercise programs, psychological strategies to manage pain (i.e. CBT), consider physio referral, education on self-management & support groups - Simple analgesia +/- adjuvant topical treatments in short term (NSAIDs, capaicin - may provide some short term relief ~10days)
- Consider short term NSAID use (must consider risks, if increased GIT risk co-prescribe PPI)
- Consider intra-articular corticosteroid injection for short term benefit i.e. if travelling, particular event/task (can provide benefit for 4-12 weeks, should not be done >4/year)
- Consider adjuvant complementary non-pharm techniques (may have some minimal evidence, but don’t harm) i.e. accupuncture, TENS
Glucosamine and chondriton don’t have consistent evidence for benefit so should not be recommended
What are the normal and diagnostic values for T2DM?
Optimal 4 - 6.1
Impaired GT 6.1 - 6.9
Diagnostic
Random fasting >7
Random non-fasting >11
OGTT > 11.1 at 2 hours
Clinical features and risk factors of cataracts
Opacity/clouding of lens
Myopic shift - vision improves with pin hole
Loss of red reflex
Normal pupil response
May have halos around vision (more so at night)
Glare sensitivity, difficulty driving at night
Colours less bright
Usually bilateral
Risk factors - increasing age, steroids, myopia, diabetes, FHx, intra-ocular infection or trauma, HTN, increased alcohol
Clinical features & risk factors of open-angle glaucoma
gradual, painless vision loss Peripheral vision effected - visual field defect - often bump into things Raised IOP > 21mmHg Usually asymmetrical (can be bilateral) Increased cup-disc ratio
Risk factors - diabetes, steroids, increasing age, HTN, graves disease, FHX
Clinical features & risk factors of macular degeneration
Most common cause of blindness
Bilateral - one eye usually more effected
Gradual loss of central vision
Central scotoma - bits missing i.e. when reading
Lines appear bent or wavy - distortion on amsla grid
Can be wet or dry
- Wet 10%, worse prognosis, choroidal neovascularisation, good treatment if early
- Dry 90%, no specific/good treatment, drusen (yellow) spots +/- pigmentation changes
Risk factors - increasing age, HTN, female, caucasian, smoking
What ECG leads correspond to anterior, inferior & lateral infarction and their corresponding arterial supply
- Anterior
V1 - V4
LAD - Lateral
aVL, Lead I, V5 - V6
Circumflex - Inferior
aVF, Lead II - III
RCA
What increases the probability of a diagnosis of asthma in children?
Hx recurrent or persistent wheeze Difficulty breathing tight chest cough Hx or FHx allergies FHx asthma Consistent clinical response to inhaled bronchodilator Symptoms worse at night or early morning Associated with triggers
What investigations can be performed to support diagnosis of asthma in young children?
Spirometry - if able to, usually older than 4-5 yrs
Allergy testing - can help with trigger avoidance and prognostics
Bronchial provocation test if diagnosis unclear
CXR not routinely recommended
What are the different patterns of asthma in children 0-5 yrs vs. 6+ yrs?
- infrequent intermittent - flareups >6 weeks apart (no symptoms between)
- persistent, intermittent - symptoms more than once every 6 weeks but no symptoms between
3a. Mild persistent - one of daytime symptoms >once/week or night time symptoms >2 month
* FEV1 >=80%
3b. moderate persistent - any of daily daytime symptoms, night time symptoms >once/week or symptoms sometimes restrict activity/sleep
* FEV1
What are the indications for preventer medication in children
Consider in frequent intermittent or any persistent asthma patterns
Trial medication and review in 2-4 weeks 1st line = sodium cromoglycate (1-2), montelukast (2+) 2nd line (if no response) = low dose ICS
What should an asthma management plan for children include?
- Written and tailored to the child
- Medication and instructions for preventer/maintenance therapy
- Triggers to avoid, what to do before exercise
- Signs that help parent determine the severity of the symptoms and instructions on Rx for each case (i.e. how to adjust Rx)
- Signs for when to seek medical advice
- Danger signs to seek urgent medical advice and appropriate action to take
How are severity of acute asthma symptoms defined in children?
Mild/moderate - can walk and talk in full sentences
Severe - can’t talk in full sentences, visible breathlessness and increased work of breathing, sats 90 - 94%
Life-threatening - altered conscious state/collapsed, cyanotic, poor respiratory effort, sats
What is the acute Rx of asthma in children?
- commence salbutamol therapy with spacer (use mask if very young or O2 driven nebuliser if can’t breath with spacer or life-threatening asthma only)
- can give every 20-30 minutes in mild-severe
- continuous in life-threatening - Titrate O2 to maintain sats at least 95%
- Arrange ICU transfer if life-threatening
- Add ipratropium bromide every 20 mins if still no effect
- Systemic steroids in first hour (oral or IV) - avoid if
What is the CHA2DS2-VASc score?
Age: 65-74yo = 1, >75yo = 2 Stroke/TIA Hx = 2 DM = 1 Prior MI/vascular disease = 1 HTN = 1 CHF/LV dysfunction = 1 Female = 1
What is the HASBLED score?
All worth 1: Age >65yo Abnormal renal function (dialysis/transplant) Abnormal LFTs (cirrhosis, 3x ULN) Hx of major bleeding History of labile INR Alcohol use (>8 per week) Currently taking NSAID or antiplatelet
Adverse effects and contraindications of metformin?
C/I = renal impairment (GFR
What are the abnormal blood results (PTH, ALP, Vit D, Ca, P) in osteomalacia
Low Vit D, low Ca and P, normal PTH, high ALP
What are the abnormal blood results (PTH, ALP, Vit D, Ca, P) in hyperparathyroidism
High PTH, increased Ca, low P, increased ALP
What are the abnormal blood results (PTH, ALP, Vit D, Ca, P) in Paget’s disease
Normal PTH, normal Ca and P, markedly increased ALP
MOA and adverse effects of sulphonylureas
MOA = increase insulin secretion
A/E: Weight gain Hypoglycaemia Anorexia, nausea, diarrhoea Rashes Blood dyscrasias
MOA and A/E of acarbose
MOA = inhibit digestion of CHO
A/E:
Flatulence, bloating
Rare liver abnormalities
MOA, C/Is and A/E of glitazones
MOA = sensitive liver and peripheral tissues to insulin
C/Is = mod-sev HF, risk of bladder cancer
A/E: Increased subcutaneous fat Anaemia Increased # risk Increased LDL
MOA and A/E of DPP4 inhibitors
MOA = increase levels of incretins
A/E:
Nasopharyngitis
Headache
URTI Sx
MOA and A/E of GLP-1 agonists
MOA = activate GLP-1 receptor
A/E:
N+V
Pancreatitis (rare)
Weight loss
MOA, C/I and A/E of SGLT2 inhibitors
MOA = prevent renal absorption of glucose
C/I = renal impairment
A/E:
Weight loss
Increased UTIs
Aggravate dehydration
Salbutamol, Terbutaline
- Class
- Mechanism of action
- Available routes of delivery
- Side effects
- Short acting B2 adrenoreceptor agonist
- Induces bronchial smooth muscle relaxation - limited systemic effect
- Inhaler +/- spacer, nebuliser, oral
- Tachycardia, tremor, hypokalaemia (very high doses)
Ipratropium
- Class
- Mechanism of action
- Available routes of delivery
- Side effects
- Short-acting muscarinic receptor antagonist
- Reduces parasympathic nerve activation (via ACh-MR path), thus reducing bronchoconstriction
- Inhaler, nebuliser
- Dry mouth, throat irritation
Salmeterol, eformoterol
- Class
- Mechanism of action
- Available routes of delivery
- Side effects
- Long-acting B2-adrenoreceptor
- Persistent low level activation of ARs, reducing constrictor binding, thus net resting bronchodilator tone
- combination with ICS or turbuhaler & accuhaler individually
- Tolerance can occur, tremor, palpitations, headache
Improves QOL, symptoms and reduces frequency & severity of exacerbations in COPD
Fluticasone, Budesonide
- Class
- Mechanism of action
- Available routes of delivery
- Side effects
- Inhaled corticosteroids
- Decreased recruitment of inflammatory mediators and SMC - reduces remodelling (longer term) and inflammation and hyper-responsiveness (short-medium term)
- Combined with LABA or indivudally
- Dysphonia, oral thrush
Use of SAMA vs. SABA in COPD and Asthma
SABA 1st line to SAMA
SAMA ? increased risk CVD
Can be used in combination
Tiotropium
- Class
- Mechanism of action
- Available routes of delivery
- Side effects
- Long-acting muscarinic antagonist (LAMA)
- persistent reduction of parasympathic nerve activation - reduced bronchoconstriction
- Individually (spiriva inhalers) for COPD
- Dry mouth, throat irritation
Largely used for COPD, can be used to control asthma if on hgih dose ICS+LABA
Improves QOL, symptoms and reduces frequency & severity of exacerbations in COPD
Use of LAMA vs. LABA in COPD
Both same benefits in improving QOL, symptoms & reducing frequency & severity of exacerbations
Response is individual
Can be used in combination
Hypoglycaemia Mx in DM
Rule of 15s:
15 grams of a quick acting CHO
Wait 15 minutes and repeat BGL check
If not rising, add another quick acting CHO
If patient’s next meal is >15 minutes away, provide a longer acting CHO
Test glucose again during the next 2-4 hours
GORD red flags
Dysphagia, odynophagia Unexplained weight loss Persistent vomiting Haematemesis, malaena Signs of anaemia
REFER TO ENDOSCOPY IF PRESENT
GORD lifestyle Mx
Weight loss
Avoid exacerbating foods, eg/ spicy foods, citrus, fatty foods, caffeine, chocolate
Avoid lying down after meals or late evening meals
Reduce tobacco and alcohol consumption
Avoid exacerbating medications, eg/ anticholinergics, b-blockers, benzos, NSAIDs, opioids
What DDx need to be excluded in order to Dx fatty liver disease?
Excess alcohol consumption
Chronic viral hepatitis, autoimmune hepatitis, haemochromatosis
Thyroid and coeliac disease
Headache red flags
Sudden onset, awoken from sleep Thunderclap nature Confusion, with drowsiness and/or vomiting Fever or neck stiffness Seizures or personality changes Morning vomiting Associated cerebral Sx Persistent neurological Sx Provoked by Valsalva (eg/ coughing) Aggravated by posture change
Mx of cluster headache
Subcutaneous sumatriptan or O2
Prevention = verapamil
Mx of migraine
Analgesics
Anti-emetic if severe nausea or vomiting
If above fails, use triptan or an ergot alkaloid
PMR Mx
Oral corticosteroids with response in 24-72 hours
Back pain red flags
Age 50yo Progressive symptoms (>12w) despite treatment Cancer Unexplained weight loss Immunosuppression Prolonged use of steroids Intravenous drug use Urinary tract infection Pain that is increased or unrelieved by rest Tearing nature of pain, associated with pulsatile abdominal mass Fever Significant trauma related to age Bladder or bowel incontinence or pain Urinary retention (with overflow incontinence) Night pain Worsening pain
Back pain yellow flags
Belief that pain is harmful or potentially severely disabling
Fear-avoidance behaviours and reduced activity levels
Tendency to low mood and withdrawal from social interactions
Drug seeking behaviours
Clinical features of malaria
Cyclical and persistent fever (>2w)
Jaundice, hepatosplenomegaly
Viral Sx: headache, nausea, malaise, diarrhoea
LONG to INT IP
Clinical features of dengue fever
Maculopapular rash (after fever) Splenomegaly, thrombocytopaenia Viral Sx: headache, joint/muscle aches, anorexia, abdominal pain, N+V, malaise
SHORT IP
Clinical features of typhoid fever
Maculopapular rash (chest and stomach) Hepatosplenomegaly Viral Sx: cough, sore throat, abdominal pain, constipation/diarrhoea
INT IP
Ix for fever in a returned traveller
FBE, UEC, LFTs
Viral hepatitis serology
Thick and thin films
