WCS14 Introduction To Common Problems: Differentiating The Normal From The Abnormal Flashcards
What is a disease
Departure from normal
Statistically:
- >2 SD from mean
- increased risk of morbidity / mortality
Socio-culturally:
- not culturally desirable
Individual perception:
- I don’t feel well
Recognising common problems
- Common things are common
- URTI
- DM
- HT
- GE - Far more likely to encounter **uncommon presentations of common problems than **common presentations of uncommon problems
- itchy feet in DM > Kayser-Fleischer rings in Wilson’s disease
Systematic in problem solving
- Probability diagnosis
- Red flags
- Often missed
- Masquerades
- Trying to tell me something else (hidden agenda / psychosocial problems)
Most common problems presenting in primary care
- URTI
- Hypertension
- DM
- GE
- Lipid disorder
- Dermatitis
- Acute bronchitis
- Immunisation / check-up
- Allergic rhinitis
Top 30 presenting symptoms in primary care
- Fatigue
- Low back pain
- Skin complaints
- Atopic eczema
- Asteatotic eczema
- Stasis eczema
- Discoid eczema
- Lichen simplex chronicus
- Contact dermatitis
- Fungal infections
- Skin growths - Acute abdominal pain
- Headache
- Sinus headache
- Cluster headache
- Migraine
- Tension headache
- Brain tumour - Dizziness
- Chest pain
- Vaginal complaints
- Fatigue
- Chronic fatigue is ***abnormal
- fatigue from ***organic disease (15%) vs anxiety / depression
- infectious, anaemia, endocrine, sleep disturbances, meds, malignancy
- chronic fatigue syndrome (a specific clinical diagnosis)
Common diagnoses:
1. <45
- fatigue Not Yet Diagnosed (NYD) (45.8%)
- viral illness
- depression / anxiety / stress
- anaemia / sinusitis / mono
- > 45
- fatigue Not Yet Diagnosed (NYD) (45.8%)
- viral illness
- depression / anxiety / stress
- anaemia / CHF / medication / DM / COPD / IHD
- Low back pain
Common:
- Mechanical back pain
Red flags:
- **Neoplasm
- **Infections
- ***Cauda equina syndrome
Others:
- Visceral causes
- Inflammatory causes
Investigations:
- X-ray
> 45:
- Mechanical
- Sciatica
- Muscle strain
- Degenerative Disc Disease (DDD)
> 45:
- Mechanical
- DDD
- Sciatica
- Muscle strain
- Skin complaints
- Itchy rash
- Growth on skin
- Mole
Top diagnoses:
1. Eczema
2. Seborrhoeic keratosis
3. Warts (exclude genital)
4. Tinea
5. Psoriasis
Atopic eczema
Symptoms:
- Characteristic morphology + distribution
- Prominent pruritis
- Chronic + Relapsing course
- Personal / Family history of atopy
- Dryness
- Hyperlinearity of palms
- Keratosis pilaris
- ***Raised IgE
- Early onset
- Tendency to cutaneous infection
- Cheilitis (Lip inflammation)
- Pityriasis alba
Asteatotic eczema / Dry skin dermatitis
- Common in elderly
- Dry season / Central heating
- Limbs esp. legs
- Dry, slightly scaly + criss-crossed
- Itchy
Stasis eczema
- over ***ankles
- associated with ***Varicose veins
Etiology:
- Venous insufficiency
- Minor trauma e.g. scratching
- Allergy / Irritation by topical medications
Discoid (nummular) eczema
- Circumscribed / Oval plaques of eczema
- Common at extremities but can be generalised
- Once established, individual lesions tend to remain in same area for ***long time
Lichen simplex chronicus (circumscribed neurodermatitis)
- Thickened appearance of skin with accentuation of surface markings
- Circumscribed
- Resulted from ***repeated scratching / rubbing
Fungal infections
Dermatophytes (Tinea) / Yeasts (Candida)
- commensal, thrive in warm, moist environments
- contagious
- secondary bacterial infection
Skin growths
Benign skin growths
1. Warts
2. Moles
3. Corns
Malignant skin cancer
1. Malignant melanoma (ABCDE)
- Asymmetry: Irregular shape
- **Border: Ragged outline
- Colour: Variation
- Diameter: >6mm across / recent increase in size
- **Elevation: Raised above surface of skin
- Evolution: changes in size, colour, shape over time
- Basal cell carcinoma (BCC): **Raised pink borders, **Telangiectasia, ***Central ulceration
- Squamous cell carcinoma (SCC)
- Acute abdominal pain
Most likely: Viral GE
Red flags:
- Acute abdomen / Peritoneal signs (rigidity, guarding, absence of bowel sound)
Diagnosis:
- Does patient look toxic / seriously unwell? —> determine whether need hospitalisation
- Abdominal examination including muscle —> determine muscular / visceral nature
- Rectal exam if unsure —> look for blood
- Testes, Pregnancy test —> referred pain
- Other serious disease —> new onset of pain, change in bowel habit, weight loss, Virchow nodes (Troisier’s sign)
- Follow up next day if in doubt
- Headache
- Sinus headache
- ***recover from cold - Cluster headache
- **recurrent severe headaches on one side of the head
- typically around the **eye - Migraine
- female
- usually ***long history (since little) - Tension headache
- Brain tumour
Red flags:
- **worst headache (Subarachnoid haemorrhage)
- **visual loss / neurological deficits (Stroke)
- **new onset in elderly (Metastasis)
- **positional / worsening with valsalva (Brain tumour)
- **morning headache (Brain tumour)
- **headache in pregnancy (Pre-eclampsia)
- ***trauma / coagulation (Risk of bleeding e.g. Subdural haematoma)
- history of carcinoma (Metastasis)
Diagnosis:
- ask about drugs
- explore patient’s fears
- functional / psychiatric causes
Most common diagnoses:
<45:
- Headache NYD
- Sinusitis
- Tension
- Migraine
- Cervical disease
> 45:
- Headache NYD
- Cervical disease
- Tension
- Sinusitis
- Dizziness
- Light headed vs Spinning (Vertigo) vs Tiredness
- Vertigo: Central (milder symptoms but more serious) vs Peripheral (profound symptoms)
- Red flags: **Nystagmus, **Ataxia, ***Focal neurological signs
- Most common diagnosis of true vertigo: Vertigo NYD
- Acute vertigo:
—> Viral labyrinthitis (inner ear infection)
—> Benign paroxysmal positional vertigo (BPPV)
—> Eustachian tube dysfunction
—> Ménière’s disease (Vertigo + Tinnitus + Decreased hearing)
- Chest pain
History is key:
- Risk factors
- Precipitating factor (Exertional?)
- Duration
- Location
- Pattern
- Effect of TNG
- **Levine’s sign: Clenched fist held over chest when asked to describe the pain —> Coronary artery disease
- **Normal resting ECG does not rule out ischaemia
Most common diagnoses:
<45:
- Anxiety
- IHD
- Chest pain NYD
> 45:
- IHD
- Anxiety
- Chest pain NYD
- CHF
- Vaginal complaints
Presenting symptoms:
- **Itching (abnormal)
- **Odour
- Pain
- Discharge
- Bleeding (e.g. post coital)
Common diagnoses:
1. ***Atrophic vulvitis
- Infective
- **Bacterial vaginosis
- **Thrush
- ***Gonorrhoea - ***Physiologic
- Retained products
- ***Cervical ectropion (variation of normal: glandular cells / columnar epithelium present on the ‘outside’ of the vaginal portion of the cervix)
- Cervical polyp
- Neoplasm
- Allergy
