MISC Flashcards
BP
GEN POP: > 18 screening 2 yearly.
MOD RISK: 6-12 monthly
HIGH RISK: 6-12 weekly
EXISTING : 6 monthly.
CHOL
GEN POP: > 45, 5 yearly.
ATSI : > 35
LOW RISK: 5 yearly
MOD RISK: 2 yearly
HIGH/EXISTING: 6 monthly-12 monthly
DM
- Dx > 7 fast BSL;
- Dx > 11.1 Random BSL;
- Dx >6.5 HBA1c,
- Dx >7 + 11 OGTT
- 2 occasions
SCREEN w AUSDRISK: 3 yrly > 40, ATSI > 18.
HIGHER RISK : FASTING BSL/HBA1c 3 yearly
= >40 w obesity,
AUSDRISK > 12,
first degree relatievs w DM,
high risk race,
CVA/CVD,
women w GDM, (but normal OGTT post partum)
women w PCOS,
anti-psychotics
CKD
screen only if high risk: BP, ACR, eGFR 1-2 yearly.
= smoking,
BMI > 30
FHx CKD
DM
HTN
ATSI > 30
CVD/CHD/PVD
history AKI.
Impaired OGTT/fasting BSL/preDM
Impaired:
HBa1c 6-6.4–> repeat 1 year.
fasting BSL 5.5-6.9 –> OGTT
12 monthly fasting glu/HBA1c
OGTT NON PREGNANT
OGTT:
1) < 7.8 at 2 hours, but impaired fasting = IFG.
then retest in 1 year.
2) < 7 fasting, but >7.8- 11 2 hour = IGT .
then retest 1 year.
3) >7 + >11 = DM.
GDM
RF: previous GDM, hyperglycaemia; previously elevated BSL, hx IGT, > 40, ATSI, FHx DM in primary relatives/sister w GDM, prepregnancy obesity > 30, fetal macrosomia in previous pregnancy, PCOS, use of drugs causing hyperglyceamia.
High risk = test 12 weeks; otherwise 24-28 per guidelines
no HBA1c Dx, > 5.5% –> OGTT
GDM Dx at > 12 weeks
criteria:
fasting BSL >5.5
2 hour > 8
(can also have DM in pregnancy, > 7 fasting, >11 2 hour / random).
repeat OGTT 6-12 weeks post partum.
Behavioural modification
- ask, advise, asses, assist, arrange f/u # precontemplation: GP to raise doubt and increase patient preception of risk and problems w current behaviour. # contemplative: weigh up pro/con of change w the patien and work on helping tip balance: - exploring ambivalence, alternative. - identify reasons or chagne/risks of not changing - increase confidence w ability to change. # preparation: goal setting, SMART #maintenance: identify and use strategies to prevent relapse # relapse: renew process of contemplation and action without demoralisation.
PCV
GEN POP:
- >70 should receive prev13.
- or at tiem fo diagnosis w at risk condition (asplenia, immunosupp, lung path).
- otherwise child = x 3.
ATSI
- < 5yo = x 4 + pneumo23 at 4.
- >50, prev13
+ 12 mo later pneumo23 + 2nd 23 at 5yr
Catch up
1) Previous 23 dose.
• 1 dose of prev13 12mo after last 23 dose
- … only need 2 lifetime adult doses of pneumo23.
2) no previous pneumo 23 dose
- prev 13 asap, then pneumo23 + also give another 23, so total 2 doses – but needs to be at least 5 years after the previous 23, and at least 12 months post prevenar13
• Can given 2-12 months later if needed between 13 and 23.
smoking cessation
ax readiness to quit
use the scale – how much to do you want to quit? how much do you think you will be able to quit?
ax nicotiene dependence (>10/day, craving/withdrawls, < 30 mins from waking).
ask about past experiences/concerns.
SMART goal
non pharma
- behavioural support w regular appts
- counselling: Quitline
- cbt: deep breathe, drink water, do somethign else.
- best evidence: behavioural support + pharmacotherapy.
NRT
10/day = 21, > 10 = use also lozenger/gums.
1 x 12 week course on pbs; more for atsi/ctg
caution w post CVasc event. pregnancy try cold turkey first then rx.
varenicline: champix
12 weeks, starter pack + then contuing pack
dream/nausea/constipaton ; reduce w renal impairement.
can do up to 24 weeks on PBS and not smoking by 12.
nortriptyline
bupropion
- not w pregnancy, seizures, MAOI or EDs.
- reduce etOH required.
- 9 week course; caution w concurrent SSRI use
etOH
1) all about 6 months, need support, CBT, regular review, trusted supply
A) disulfiram 100mg OD
- cannot drink! bad reaction, inc. seizures/flushing/cvasc/autonomic,r elated to malabsorption
- need to be generally fit and well
B) acamprosate 666mg, 333mid + nocte
- really excreted
- not in acute periods of w/drawl
C) naltrexone
- not good for opiate concurrent use
- reduced pleasurable FX so good for binge drinking
- LFT monitoring pre/post.
glaucoma - chronic
IOP > 22
peripheral vision loss, usually has a FHx, usually incidental finding and open angle.
RF” advancing age, FHx, african descent, previous trauma, short sightedenss (myopia), systemic HTN, long term steroid use.
screening : > 40 = 2-5 yearly screening. if FHx then from 30 yo.
timolol BD. vs. latoprost OD. vs. OT
glaucoma - acute
IOP > 22
acute red eye w peripheral field loss, severe haeadche, photophobia, sometimes halos around lights
age > 60. fhx of same. female. myopia.
ED
opiaiod/antiemetic to stop vomitting
if ophthalm not available immediately: timolol drops; and acetazolamide/manniotrl
cataract
Sx vary depending on degree/site.
main cause of monocular diplopia, can also get halos around lights.
Cause: age, DM, smoking, steroids, RTx, TORCH, trauma, uveitis, dystrophia myotonic, galctosaemia.
OE: reduced red refelx, reduced VA, normal direct pupillary light reflex.
Prevent: sunglasses. control RF as above
Rx: ophthalm
NIPT
> 10/40 to about 14/40
about $350
cell free DNA + trisomy 21, 18, 12 + turners/kleinferlters + geneder
about 98-99% sensitivity
if negative, 1: 20 000 trisomy change, if positive –> almost diagnostic.
but its screening, rare, but there are flase negatives –> amnio/cvs.
also need to repeat uss , for morph.
takes 2 weeks for results
CFTS
9-13+6/40
trismony 13 (patau , 1st week, intel/birth), 18 (edwards - fatal pre birth/within first yr), 21.
85%-90% detection rate.
if high risk –> amnio/cvs. (1:20 will ahve pos diagnostic, otherws will be negative).
so screen positive rate is about 5% (NIPT 0.1%)
cocp adjustment
- nausea = reduce oestrogen, take at night, change to LARC, exclude pregnancy
- breast tenderness= reduce O/P, change P. consider alt. cocp : yasmin/yas
- bloating: reduced O. change P (yasmin/yas)
- headache : reduce O and or P change.
- dysmenorrhoea: skips sugar pills, increase/change P.
- decreased lipido: no evidence one type will change this over another
- BTB: increase O (to 30mcg/35mcg); change P type if already on 35. try alt.
- depression: not well linked, consider changing P
- weight loss: not well inked.
good for acne: yas, yasmin, diane/brenda/juliette (all the same)
Fibromyalgia
- non inflammatory MSK pain + fatigue, cognitive clouding, sleep changes
- not diurnal, constant pain
- RF: women, 40-50, anxiety history (IBS/headaches/urinary frequency)
- OE:
- pain on both sides, UL and LL, axial skeleton.
- tender digital palpation at > 11/18 specific sites.
- Ix: no specific – exclude alt w autoimmune screen.
- Mx:
- reassurance re: no inflammatory – not doing damage.
- ‘oversensitised alarm’ going off for pain –> need to ‘muffle’ it
- goal = manage pain, not remove it. improve QL
- ex phys, increase coping, CBT, goodsleep, educate family.
- can trial
- endep
- dulox 30-120
- pregab 25-75
*
Perma +
- Positive emotion:
- What have you gotten through, what makes you happy, what makes you smile
- Engaement
- Hobby/distraction/routine
- Releationship
- Who supports you/cares about you
- Meaning
- What gives you a sense of purpose
- Achievement
- What are you proud of? What have you gotten through?
- +
- Diet
- Exercise,
- Smoking
- alcohol
- sleep
- sleep
FM non pharma
- reassurance
- graded eerobic exercise program to improve fatigue/pain
- reduce situational stressors./ CBT coping strategies
- good sleep practices
- family education
chronic fatigue
- controversial diagnosis
- persisting fatigue with variet of somatic + cognitive symptoms
- diagnosis: presence of unexlpained persistent or relapsing fatigue,
- 6/12.
- not attributable to exertion.
- with significant functional impairmeent
- must be at leat 4 / 8
- post exertional amalaise alsting > 24 housr
- unfreshing sleep
- impaired memory or cocnentration
- muscle pain
- joint pain without swelling/erythema
- headache of new type/severity
- tender cervical/axillary LN
- sore throat.
- peak incidence 20-40 yo. women > men.
- ?post viral, altered immune function, neuropsych, enviro toxins/imms reactions all theoretical causes. no firm evidence fo any of these.
- difficult prognostication.
- Mx: MDT input
nephritic syndrome
- moderate to severe HTN
- haematuria
- GFR reduction usually mod/severe
due to
- post stre GP
- can be AKI (or nephrotic)
- IGA nephropathy (happens while you have the sore throat!)
Nephrotic syndrome
- cause:
- minimal change GN(most common cause)
- secondary: SLE / Dm / drugs
- BP mildly increased or normal
- normal/mild reduction to GFR
-
proteinuria
- ( >3.5g/day)
- hypoalbuminaemia
- oedema (facial)
bladder
- overactive = nocturia, increased urgency, consider oxybutynin. but a diagnosis of exclusion
- interstitial cystitis = cystological Dx; discomfort w bladder filling meaning they PU more often, only thing to relive that feeling
- incontinence
- stress - pelvic physio, weight loss.
- urge - same as for stress –> old more each time. consider pessary/oxybutynin for urge.
- mixed
- remember for all: fluid/caffine intake, smoking, oestrogen status, obesity. relation to intercourse (interstitial)
- remember for incontience: med SFX: alpha adrenergic, antidept, ccb, antihistmaine = sfx.
scrotal lump
- hydrocele - painless, gradual increase in size.
- epidydimal cyst - all ages, common, usuaully pea sized at top of teste, Rx w OT. benign
- varicocele - swelling of vein about teste. starts after puberty. can affect fertility. Rx w OT
- spermatocele - benign. contain sperm/sperm like cells. usually connected to teste.
- hydatdi of morgagni - lump / cyst at top of teste, movable.only painful if they twist. dont need Rx unless twist/Sx
- epidydmitis - obvious. STI.
- orchitis - obvious, dont forget mumps/rubella
- torsion - obvious.
- undescended teste - bloc off LHS inuignal + touch w R, should reach down to the bottom of scrotum, without pressure - then when you release shoudl pop back up. wait for 3/12 if palpable –> dont uss, then uss if still not there and refer.
remember undescended teste can also (ontop of interfility) cause cancer RF.
Hearing loss
conductve = bone > air
sensory = air + bone both reduced
mild = 20-40 (background noise issue)
mod = 40-60 (miss most convo, child = poor pronunciation)
severe = 60-90 (wont hear most speech, child = =delayed speech )
age related = mild/mod high frequency snhl both ears
uniltaeral SNHL = always think ddx acousitc neuroma
nsaids general
- naproxen 250-500 BD safest for Cvasc (Cox 1). (MR will increase GIT build up)
- diclofenax 25 - 50 BD/TDS (non selective) = safer for GIT but higher CVasc risk so avoid here. .
- cox 2 = better for GIT, try to avoid w Cvasc
- celexocib (100-200mg, OD to BD)
- meloxican (7.5-15mg, OD).
- most unsafe for cvasc = meloxican 15mg.
potentially can use fish oil - but in ghigh qquantities of tablets, up to 3 capsules OD.
PMR
morning stiffness >45 mins. hip girdle dicomfort. bilateral shoulder. proximal weakness. no other joints. > 2 weeks usually
pain improves post shower/activity.
Dx: Sx, raised ESR/CRP, rapid response to pred 15mg OD (BIRD CRITERIA).
+ negative RF/CCP
Mx: reduce pred down by 2.5 every 4-8 weeks. educate: long course; monthly blood initially. relapse common. gentle tapering required.
associated GCA- you know this. OE: bitermporal artery tenderness/pulselessness.
rotator cuff
- passive ROM non painful (Frozen shoulder it is).
- movement loss identified by stressing tendons w isometric movements.
- DO NOT USS to diagnose. (even if uss an astympatmoic shoulder, would see a rotator cuff issue). no XR either.
- 1/4 improve by 1 month; 50% within 3 months. will progress over time likely; rotator cuff atrhrotpahty –> OA GH.
- Mx: rest, warmth
- range of motion and strengthenning with physio.
- simple oral analgesia
- consider s/acromial c/steroid injection for rapid pain relief w SA bursitis.
- 3/12 not improved: surg review.
repeat dislocations
- watch for bankhart lesion (GH fracture) + humeral head # (hill sach lesion).
= if repeated dislocations/instability then OT for athroscopy + repair.
thoracic outlet syndrome
- compression of n/vasc structures coursing from neck to axillae through outlet
- often 1st rib compression
- and anterior scalene + upper border of first rib
- RF: overhead athelte, poor posutre w dropping shoulders, congenital, # clavicle, psyueodarhtorsis, malunion fo clavicular fracture
- get mixed Sx
- arterial/venous/nerve.
- localised pain
- numbness/tingling in entire upper limb
- arm feels weak/fatigued
- venous engorgement.
- arterial/venous/nerve.
- OE: can have no signs.
- special tests:
- adsons test (lateral neck rotation + head extended , w arm abducted and breathe in- lose radial pulse)
- roo test - hands up, open close for 1-3 mins + reproduces Sx.
- Mx:
- physio: correction of shoulderspostural/body mechanics.
- surg consult and treatment if neurogenic symptoms not responding to physio. / if vasc compromise/thrombus
- physio: correction of shoulderspostural/body mechanics.
hawkins kennedy
beer can
elbow in, flexed, push against me trying to int rotate
full extension of shoulder, try to push forwards into flexion
1) positive (int rotation), with subacromial impingement
2) positive , with supraspinatus pathology.
3) infraspinatus
4) biceps
golfers
tennis
flexor = medial epi.
pain w resistance to flexion./pronation
extensor = lateral
pain w resistenace to extension/supination.
Mx:
graduated exercise program w physio - progressive loading increase
stretch out the flexor (for tennis)/extensor (for golfer)
strapping/band : limited evidence 10cm below joint
correct predisoposing factors
return to exercise gradaully.
physio.
ulnar nerve entrapment syndrome
posteromedial elbow pain. sensory Sx like pins/needs in ulnar/ulnar forearm. tender to tap around medial epi.
cause: progressive weight training/repetitve stress, recurrent subluxation of nerve due to trauma/stress, irregular ulnar groove, traction injury
Dx: nerve conduciotn studies
Mx: surgeon/neurologist. consider OT
RA signs/Sx
Hx
- fhx inflam arthritis (mostly wrist/MCJP/PIPJ/MTPJ)
- early morning stiffness > 1 hour
- swelling > 5 joints
- symmetrical
- bilatearl compression tenderness to MTJP
- > 6 weeks
OE:
- z deformity of thumbs
- ulnar devisiton
- swan neck deformities
- sometimes nodules on elbows.
DX:
- bony erosions on XR, RF / Anti CCP, ESR/CRP, or rhematuoid notdules. can also have seronegative disease.
RA mx
prognosis = proportional to CCP.RF titres, chronically elevated inflam markers, > 20 joints swollen, or impaired function in early disease/erosions on XR + smoking.
Mx:
- pharma
- urgent referral for urgent starting DMARDS - to try to aviod irreversible joint damage.
- nsaid/fish oil if in remossion.
- non pharma
- regular aerobic exercise, and anaerobic to prevent muscle wasting/weight bearing.
- no specific diet - but eat healthy
- stop smoking
- MDT: inc. using arthritis australia, pain management.
- self Mx for early exacerbations once in remission.
- manage associated conditions
- atherosclerosis, OP, vasculitis, depression, lung disease, neuropathy
- optimise immune status given immunosuppressed.
gamers thumb mx
OE: ulnar stlyoid on table, ulnar deviation - shoudl cause pain on the radial side –> if not then pull down +/- flex thumb in = dx. + tender MT1
- Rx:
- c/steroid injection
- splint for 6 weeks
- nsaid.
- stretching w OT. and grauated strengthenning. pen build up for work
carpel tunnel
- median (1, 2, 3, radial 4)
- RF: pregnancy, DM, RA, hypothyroid, overuse of forearms.
- wake at night w paraesthetsia/pain.
- OE: tinel (tap) positive; phallen (60 sec) positive.
- Dx: USS, nerve conduction studies (to exclue C6 radiculopathy).
Mx:
- 1/3 spontensouly resolve.
- other 2/3: Rx medical condition; nsaid, c/steroid injection , splinting/hand brace short relief, noctural elevation on pillow. OT definitive
lateral hip pain
- greater trocnhanter pain syndrome = pain at GT, trendeleberg gait, pain on hip abd. (hurts to lie on that side)
- glute medius tendonitis = pain between GT and iliac crest, pain at outside of hip , pain w legs crossed. (worse w movement/getting out of car)
ddx: labral tear, OA, GT impingement, NOF, SA, synovitis. rim lesion. lumbar radiculopathy (SUFE, pethes)
both more common in older women – menopause does affect tendon health, more disposed to microteras.
osteitis pubis
women who has suddenly gone back to gym. classical presentation.
OE: tender pubis. adductor stress pos (squeeze fist w knees), and bring in hips against resistance: pain to osteitis pubis.
CT +/- bone scan/MRI (ddx stress fracture)
Mx:
conservative, supervised ex program w strengethenning adductors. pelvic floor. gradual return to work.
obturator nerve entrapment
medial thigh pain/sensory changes. starts out as proximal groin pain on exercise.
OE: extension or lateral leg movement increase pain
RF: rbugy/afl. ddx intrapelvic mass lesion : CT.
Dx: nerve conduction tests
P: physio, consider surgical release.
knee pain
- child: osgood shlater - conservative mx, clinially: lump
- ITBS: tender 2-3 cm above lateral joint line (ober test). conservative mx inc. dry needling/massage
- meniscus: tender joint line; pos mcmurry/apley grind
- patellar tendonitis (jumpers knee). tender at inferior patella /anterior knee–> tender w quad traction/tensing/cant squat : uss to diagnose. Physio.
- patellofemoral syndrome - anterio knee pain, older. stairs/squat aggrevate. XR to exclude sinister (tuour/oa) but CLINICAL Dx– physio. bracing w patellar stabilisation. rest. taping, ice/analgesia. foot orthoresis to ralign.
- prepatellar bursitis - housemaids knee. worry re: infective –> PO Abx/ortho. can inject w hlca.
- gout/pseudogout (calcium / haemachromatosis/loo diuretics). joint aspiration: calcium crystals in fluid.
bakers cyst
- posteriomedial painful swollen mass at joint line
- end of knee flexion can be restricted/squat.
- uss can show, but not intraarticular structures (which are mostly the cause in adults)
- mri usually the gold standard.
- Mx:
- child: resolves
- Adutl: almost always communicates w knee joint – secondary to intraarticualr pathology. can aspirate + reinject HCLA/surg if very painful
osteochondritis dissecans
child/adolescet.
pain/swelling at joint, brough on by sports.
can be knee/elbow/ankle.
Dx w XR
sometimes heals alone, if severe then can separate and float around –> OT
peroneal nerve entrapment
foot drop.
numbness/tingling/pain w drop.
sensation: front + side o leg, top of feet.
herniated lumbar disk/knee fracture/replacement/tumour / cyst compressing nerve, ALS/MS/PD related
OE; cant pick up toe/DF ankle. disting gait w knee is raised high
Dx: nerve conduction
P: surgical repair/splint
cervical radiculopathy
- radiating arm pain, corresponding to a dermatomal pattern
- neck pain, paraesthesia, muscle weakness in myotomal pattern, relfex impariement, headaches, scapular pain.
- amplified by side flexion towards the side of pain + when an extension or rotation of th eneck takes place .
- (spurlings test: neck extended, head rotated - downward pressure applied on head; positive if pain radiates to limb in ipsilatearl side.
- cause : spondlyosis, disc herniation less common - more likely in younger patients.
- mx
- settles over time mostly.
- icing in acute phase
- nsaids
- reduce nerve compressive forces: manual tass/avoid osutring.
- wait 6-8 weeks. if not improved then MRI. +/- HLCA/laminectomy.
- remember: can also trial lyrica - low dose, 25-50mg nocte. increase from there.
ank spond
- morning stiffness
- loss of lordosis
- increased kyphosis
- months duration
- have associated sacroilitis + axial spine pain
- months duration
- Ix: HLAB27 assocaited. can also have CRP?ESR high. seronegative spondlyoarthropty
- XR: can show fusion/bamboo sign if severe.
- if pos HLAB27/history pos, and negeative XR w strong sucpion: MRI.
- OE: pain to SIJ/axial spine; modified schober test (reduced lumbar flexion), occiput to wall distance, chest expansion can be abnormal if progressive
- Mx: NSAID, physio. if refractory: DMARD. stop smoking.
- long term exercise program.
enteropathic arthritis
- IBD.
- often axial spine/achilles/plantar fasc/sacroilitis
- if peripehral, oligoarticular and asymmetrical, mainly in LL
JIA
- joint pain/inflammation
- < 16 yo
- recurrent
- > 6 weeks duration
- Types
- RF pos (likely RA)
- RF neg (more common, asymmetrical)
- entehsitis related (boys, HLAB27 pos usually w fhx ank spond)
- sysetmic:
- fever, aslmon pink rash, lymphoadenopathy, polyserosisitis, arthritis.
- Mx specialist for rx
- non pharma GP:
- GPMP for allied heatlhf unding
- consider imapct life/self/moods/social
- consider financial burden to parents + contrcaeption w methotrexate
- need paed rheum involved
- dont smoke
- imms up to date.
- nsaids PRN.
- specialist: injectable steroids.
pagets
ALP elevated
pagetic lesions on XR
sometimes asymptoamtic initially.
Rx: bisphosphonates.
raynauds
primary: without CTD
secondary: with CTD.
fingesr/toes bilatearl vasopasms. can get ulcers.
Mx:
gloves. avoid cold. dont smoke. avoid touchign cold. trial vasodilators if BP OK. topical nitrate gels.
RF
suspect in any child w fever, joint pain, new movements disorder
particularly in ednemic/ATSI/hx of preceeding GAS
Dx: Jones criteria
Mx: can try PO phhenoxymethylpenicllin BD for 10 days but need v strict adherence
empirical benzathine pencilling G, repeat 1.2 million units, every 21028 days for 10 years after most recetn ep; or until 21. sometimes up to 40 is severe.
dental health important.
scleroderma
finger discomfort, arthralia, GORD = scleroderma.
1) morphea - skin only, often kids w no systemic features; sabre strokes (can be over joint/deeper so atch).
2) CREST
- calcinosis, raynauds, esophageal dysmotility, sclerodactyl, telangiectasia.
- pulmoanry HTN fiboriss, renal compromise.
3) diffuse sysetmic disease / systemic sclerosis
* can be mild/skin only + can go into rapid progression to renal crisis/htn crisis.
puts pt at higher cvasc risk *so does SLE - atherosclerosis!
Sjrojens
Sicca without CTD/RA.
dry eyes, dry mouth, arthritis.
ENA Ro/La positive. chrimers test (tears). + inflam markers, ana pos.
non pharma: avoid smoking, avoid dry/heated air, consider TCA/anticholindergis, good hydration, biotene /eye drops, vagina lubricant. artificial tears. dental checks.
antidept.
- 1) escitaloparm 20mg, start at 10mg, review in 2-4 weks to increase by 5mg up to 20mg. (less libido SFX)
- 2) fluoxetine 20mg. start slowly. weight neutral.
- 3) sertraline 50mg up to 100mg. ‘safe’ for pregnancy.
- mirtazepine 7.5-15mg nocte, increase to 30mg after a few days if tolerating. 2-4 week review
- SNRI: duloxetine 30mg, then 60mg. after 2-5 weeks.
- agomelatine expensive and only for teratmet resistance
- TCA: endep 25-75mg nocte. psychiatrist involvement.
ED
- common
- causes: organic, psychosocial combined.
- meds” BBlockers, antidep, anticholinergic, thc, narcotics, etOH, antihsitamines.
- OE: look for plaques/peyronies/hypospadia/tesicular atrophy (or size < 4mL + kilnefelter )
- look for cvasc system inc. wcc < 94cm. carotid bruits.
- look for peripheral neuropathy
- Ix: DM, hypogonadism, cvsc disease.
- Rx
- mod RF modification:
- smoking cessation, reduce etOH, improve diet, weight loss, stress reduction, illicit drug cessation. compliance w cvsac meds
- PDE5 inhibitors - try 8 times prior to saying it doesnt work. sfx: GIT, myalgia, headace, flushing, cvasc/lower BP w other nitrates. no amyl
- mod RF modification:
Premature ejcaulation
- no clear medical cause - often a psychological problem.
- hx: primary vs. secondary; intravaginal ejaculatory latency time, previous sexual function, hx of relationships, percieved degree of control. is fertility an issue?
- trauma/prostatitis/hyperthyroid/meds/psych history
- taboo/belief improtant.
- if painful - need DRE/prostatisi work up.
- manage cause:
- behavioural technique: stop/start, extended foreplay, preintercourse masturbation, cognitive distractions, alternative positions, interval sex, increase frequency.
- SSRI / sertraline 50mg.
- secondary: consider PDE5 inhib to continue erection post ejaculation.
- CBT
- local anaesthetic spray.
male infertility
(kleinfelters: small tesicular volumne < 4mL, taller than average, reduced facial hair, reduced body hair, breast development, feminine fat distribution. (see androgen def w 2 low level morning tesoterones, LH and FSH both elevated, and see karyotype 47 xx. )
- > 12 month twice/week uprotected vaginal intercourse.
- look for:
- etste atrophy (androgen def)
- undescended teste history
- psychosexua issues
- past STI hx
- androgen use.
- ?having sex at fertile times.
- female history.
- lifestyle: diet, exercise, alcohol, smoking cessation.
- pubertal developmental history.
- inguinal/genital/pelvic surg history
- meds/etOH
- OE:
- scrotal/testicular exam. testicular volume (15-35mL). penile exam; seconary sex characteristis. if concerns re prostatic Sx: prostate exam. cvasc risk exam.
- Ix: semen analysis.
- then: FSH, LH, total testosterone. PRL.
- tesiticular USS
- FSH high = seprmatogenesis is poor (primary testicular hafilure).
- low testsoterone/high LH: androgen def.
androgen def
tesicular 1’ = chromosomal (kleinefelters), undescended testes, trauma, infections (mumps orchitis), HCT< thallassaemia, myotonic dystrophy, meds/surg procedures e.g. spiro/ketoconazole/ctx.
hypothalamic/pituitary 2’ : hypogonotrophic hypogonadism, pituitary micro/macro adenoma, pituitary trauma/disease, meds/surg.
OE:
pre pubertal: micropenis, small testes.
peripubertal: delayed/incomplete sexual matruation, small testes, abnormal penile enlargment/pigmentation of scortum, laryngeal development, growth of facial hair/body hair, muscle development/gynaecomastia
postpubertal: regression of virilisation. mood changes, lowl ibido, letahrgy, hot flushes. reduced growth/facial/body hair, low semen volume. low BMD.
Ix: LH, FSH, serum tesosterone. (PRL, iron, anti pit function, karyotyping if suspecting kleinefelter, MRI brain).
Rx: TRT. (injectable, patch, gel, cream, oral BD to TDS)
DONT GIVE: if prostate/breast cancer. or hct > 55%.) relative c/i: Hct > 50%, untreaetd OSA, severe LUTS, or BPH, advanced CCF.
hyperparathyroidism
- commonly benign. rarely cancerous.
- RF: women>men. Post menopausal, lithium, neck irradiation.
- Sx: bones, stones, psychic moans.
- mostly asymptoamtic and find w high Ca2+/fractures
- can cause fatigue, weakness, LOA, abdo pain, mood changes.
- constipation w high Ca2+.
- primary hyperPTH: high with high Ca2+. (or normal w elevated Ca2+)
- secondary: low calciums tates: CKD, vit D Def, GI malabsorption.
Ix: - urinary calcium/creatninie ratio. (LOW if familial hypocalciuric hypercalcaemia); NORMAL in hyperparathyroidism).
complications: renal impairement, renal calculi.
P: endo refer. watch for renal caucli, OP. avoid diuretics. avoid dehydration/prolonged bed rest. ensure adquate vit D.
secondary hypertension: (OSA/non compliance)
- primary hyperaldosteronism (conns syndrome) = aldosterone secreting adenoma
- Sx: HTN, hypokalaemia, aldsoterone excess, supressed plasma ernin activity
- screen: plasma aldosterone: renin ratio - if elevated –> specialist.
- specialist will go on to do a plasma aldosterone + 24 hour urinary aldosterone/sodium/creatining level w specialist advise.
- cushing syndrome (see separately):
- screening: 1 mg dex suppresion test.
- or measure free late night salivary cortisol/24 hour urine cortisol
- phaeochromocytoma:
- screening: 24 hour urinary metanephrines.
- if Sx: plasma metanephrines.
cushings
- OE:
- facial puffiness/moon faecies
- central obesity
- thinning of skin
- wekness , proximal.
- easy bruising
- bufalloe hump
- moon faceies
- facial plethroa
- hirsutism
- menstrual distrubances
- psychiatric/mood disorders
- pityriasis versicolour
- complicated by DM, HTN, hyoperhcol, OP.
- child: growth failure, delaeyd matruation.
hyperclcaemia of malignancy
mostly lung/breast/prostate/blood/renal.
Sx: polydipsia, severe constipation, confusion, increased pain/malaise/fatigue/anorexia.
always think in palliative pts w these Sx
Rx:
establish goals of care
stop thiazide diuretics, vit D/calcium.
ED if wanting actiev treatment, CoCA > 4 –> seizure/arrythmia risk.
addisons def
primary adrenal insuf.
usually autoimmune.
Sx:
- coritsol def: fatigue, anorexia, weight loss. postural hypotnesion
- excess ACTH; skin pigmentation from melanin production/suntanned/somtimes buccal hyperpigmentation
- aldosterone def: hyponatremia, hyperkalaemia, acidosis, tachycardia, hypotnesion, low volate ECG, postural hypotnesion, salt cravings.
Ix:
- hyperkalaemia
- hyponatremia
- positive short synacthen test.
- elevate ACTH.
- elevated plasma renin
Mx: specialist
if unwell: pulse hydrocort. fludricort always as baseilne.
regular BMD 2 yearly, also check coealiac/thyroid/t1dm/pernicious anaemia.
hyponatremia
depends on fluid status, you know the Sx
- euvolemic (fluid restrict mildly, fix cause), only Rx if severe Sx w CNS involvement - hypertonic saline
- SIADH (illness/maligancy, or drugs - ssri; or cerebral path for too much ADH)
- hypohtyroid
- adrenal insuf
- pscyhogenic
- hypervolaemia
- ccf/cirrhosis/ckd/nephritic syndrome
- hypovoaemia (NSaline, stop drugs taht might cause).
- accelerated losses w free water intake
- thiazide diuretics
- sodium wasting states
- primary adrenal insuf
- psuedo: hyperglyaemaic. hypertrigliceridaemia.
ARR
risk of outcome in control group - risk of outcome in treatment group = absolute difference in rates of events between th two groups. giving us the idea of basleine risk and treatment effect.
ARR = 0 = no difference.
ARR 0.05 = 5% reduction in the event.
= CER - EER.
NNT = 1/ARR
RR
RR = hwo many times more likely it is that an ecvent will occur in the treatement group relatie to the control group.
RR = 1 means no difference, RR < 1 = treatement decreases the risk of the outcome.
RR> 1 meanas treatment increases the risk.
RR = risk of outcome in the treatment group / risk of oucome in the control croup
RRR
relative risk reduction = complement of RR (1-RR).
tells us the reduction in the rate of the outcome in the treatment group, relative to that of the control group.
NNT = 1/ARR.
e.g. 15% of the control group died and 10% of the treatment group died at 2 years. . what is the NNT/ARR/RR/RRR
- RR = risk of outcome treatement / risk of outcome in control
- 0.1/0.15 = 0.67... which means the treatment reduces the risk of death as RR < 1. (when > 1 = increased risk of the outcome).
- ARR = 15%-10% = 0.15-0.1=-.05= absolute benefit of treatement is a 5% reduction in death rate.. if arr = 0 then no difference.
- NNT but need to treat 20 people for 1 to benefit (NNT =1/0.05=20 = 1/ARR)
- RRR = 1-RR = 0.33 = the treatment reduced the risk of death by 33% relative to that occuring in the control group.
So if the COCP increaes the clotting risk from population 5: 10 000 to 12: 10 000, in absolute terms has only gone up 5 / 10 000… but in relatiev terms
0.0012/0.0005=2.4 = doubles the risk of the outcome comapred to the treatement group = rr
Arr = 0.0005-0.0012= -0.0007
= so slightly less risk in the control group… but still very low risk overall.
sen spec
