Common Symptoms/Complaints in Family Medicine

Medicine and SkinDr Edmond CW Chan

Medicine

Dizziness A 69 yo woman who has no children and her

husband has married again 2 years ago and he has migrated to USA. She has 5 years history of NIDDM and HT and now on Diamrion 80mg BD and Natrilix 2.5mg om

She complained severe dizziness for few days. Reviewed the has history, she has repeatedly attended to A&E for dizziness in recent 2 years.

What questions will you ask? Definitioin of dizziness Vertigo Posture: Tinnitus: which ear? Balance Severity: Associated symptoms: N, Vomiting, pallor, sweating chest

pain, palpitation, neurological symtoms Drugs hx psychosocial

Physical examination Cardiovascular system:

BP: supine and erect(S:20;D:10) both arms

Pulse: regular or irregular heart murmur, carotid bruitCNS:

muscle power and tone, gait eyes movement, Nystagmus cranial nerves V, VIII ( corneal reflex) cerebellar signs

Features of cervical spondolysis Otoscope:

ear wax chronic otitis media

Hearing test: Rinne’s test and Weber’s test Other systems to look for any primary tumor

( probably brain secondary)

Further investigations CBP Na, K, H’stix, glucose and HbA1c Head tilt test: starting from sitting position to hyperextend

the neck when lying supine and turned the head to one sideVertigo and nystagmusadaptation

ECG Caloric test Others like X-ray, CT brain, MRI, autonomic functional

test etc if indicated

Differential diagnosis Vertigo: Benign positional vertigo Vestibular neuronitis (without tinnitus or deafnes

s) Acute labyrinthitis (hearing loss) Meniere’s syndrome (vertigo, tinnitus, sensorineur

al deafness, recurrent episodes) Acoustic neuroma Brain stem migraine Multiple sclerosis

Differential diagnosis Pseudovertigo: Drugs Anaemia Perimenopausal syndrome Postural hypotension Cardiac arrhythmias Complete partial seizure Brain secondary Psychosocial

Vestibular neuronitis

Usually a viral infection of vestibular nerve causing a prolonged attack of vertigo lasting for several days

Can be severe enough for asking admission Precedes with some URI symptoms (viral

infection) Without tinnitus or hearing loss Abrupt onset with nausea, vomiting, dizziness and

vertigo

May take 6 week or so to subside Nystagmus present because of involving the vestib

ular system DDx: Acute labyrinthitis

Tx: Stemetil 1 tab tds or im if severe beware of extra-pyramidal side effects

relieved by benadryl diphenhydramine

Meniere’s syndrome Usually over diagnosed 30-50 aged group Paroxysmal attacks of vertigo, tinnitus, nausea and

vomiting, sweating and pallor, sensorineural deafness

Abrupt onset Lasts 30 mins to several hours Variable interval between attacks, recurrent

episodes Nystagmus (usually opposite to the affect ear)

Treatment: explanation and advice on stress management Avoid coffee and smoking Low salt diet Drug: cyclizine 50mg tds

Betahistine (Serc 8-16mg tds) Refer to ENT for persistent Meniere’s syndrome

for any surgical treatment such as operative decompression of the saccus endolymphaticus or labyrinthectimy

Benign positional vertigo

All age group Recurs periodically for several days Brief and subsides rapidly (changing position or

adaptation) Not associated with nausea, vomiting or deafness Treatment: explanation and reassurance

avoidance measures

Palpitation

A 46 yo woman, single, working as accounting manager, chronic smoker with BMI >28 has history of thyrotoxicosis 20 yrs ago and has been put on Carbimazole but stopped for more than 5 yrs because of normal TFT. She has complained occasional palpitation for recent few months. Previously she has experienced chest discomfort but did not seek for any medical help.

What questions will you ask? For discussion

Physical examination

General appearance:Xanthoma/Xanthelasma/arcus senilisBMIGoitreAnxiety/depressedsweating, pallor

CVS:BPpulse: rate, volume and regularityJVP

heart murmurs, mid-systolic click

carotid bruit

Any signs of thyrotoxicosis

Any signs of infection

Further investigation

For discussion

Differential diagnosis Sinus tachycadia:

feveranaemiaperimenopausalThyrotoxicosisPhaeochromocytomaCarcinoid syndromePorphyriaAnxiety/Depression (effort syndrome)Drugs, tea, coffee, alcohol, cigarette smoking

Paroxysmal bradycardia:Sick sinus syndromeheart blocks

Paroxysmal tachycardia:supraventricular (narrow QRS)—Atrial ectopicsSVTAtrial flutterAtrial fibrillationWolff-Parkinson-White syndrome

Ventricular (wide QRS)—Ventricular ectopicsVentricular tachycardiaVentricular fibrillation

Note: It is important to look for the underlying cause of each arrhythmia and the provoking factors

Supraventricular tachycardia: Rate: 150-220/min Sudden onset Passing copious urine after an attack (ANP) Predisposing factors: thyrotoxicosis, WPW Treatment:

carotid sinus message (no carotid bruit)valsalva maneuverimmersion face to waterdrink a glass of ice waterVerapamil/Diltiazem (monitor BP)DC cardioversion (haemodynamically unstable)

Wolff-Parkinson-White syndrome

Risk of sudden death Congenital abnormality with bundle of Kent Can present with SVT or AF EPS and radiofrequency ablation of the abnormal

pathway

Atrial fibrillation

Common causes of AF:IHDThyrotoxicosisValvular lesions like ASD, mitral valve diseaseAlcohol-related heart diseaseimpaired ventricular functionIdiopathic

AF

Acute or chronic? Sinus rhythm converted or ventricular rate

control ? Chemically converted or DC cardioversion? Anticoagulant? Risks: disease itself and the treatment

Chest Pain

A 40 yo man, chronic smoker and social drinker who is working in the construction site. He has history of epigastric pain with PPU and patch repair done 5 years ago. Incidentally AXR found a small radio-opaque asymptomatic gallstone. He complained sudden onset of chest discomfort for few hours during duty and then run to your clinic for medical help.

DDX and immediate treatment?

What questions will you ask?

Site: retrosternal, epigastric, superficial Onset: acute, progressive, crescendo, chronic Quality: crushing, tight, heavy Duration: Angina-few mins, Infaration >30mins Radiation:

jaw, shoulders: angina/infarctionback: dissecting aneurysm/PPU/acute pancreatitisdermatome: shingles

Aggravating factors: supine– reflux oesopagitisexercise, emotion, large meal, sexual intercourse- anginainspiration—acute pericarditis

Relieving factors:rest, TNG —angina/oesophageal spasmleaning forward– acute pericarditisantacid, standing up, belching --GRED

Associated symptoms: SOB, palpitation, headache, fatigue, sweating, ankle swelling, nausea and profound vomiting

Risk factors:smoking, alcohol, occupation, lifestyle, obesity

Family history: lipid, Marfan’s Medication: TNG, Antacid, OCP Life events and worries: cardiac neurosis

Physical examination

For discussion General appearance:

P/E

CVS:

Chest:

Abd:

Others:

Further investigation

For discussion:

Differential diagnosisConsider anatomically from the skin to deep inside and the referral pain

Skin infection or inflammation Costochondritis/ Ribs fracture IHD (Angina/MI) Acute pericarditis Dissecting thoracic aorta Pneumothorax Reflux oesophagitis/oesophageal spasm Peptic ulcers Gallstones diseases, pancreatits, shingles Cardiac neurosis/Effort syndrome

Pectoris angina

Sudden onset of retrosternal chest pain radiating to the jaw or left shoulder lasting 3-5mins only and relieving by rest and TNG, aggravated by exertion.

Risk factors found P/E unremarkable ECG: no change at rest Further investigation like TMT and echo TNG and risk factors modification

Myocardial infaraction

Sudden onset of restrosternal chest pain at rest lasting more than 15 mins associated with distress and not relieved by TNG

Beware the painless presentation in DM ECG: ST elevation, T wave inverted and pathologi

cal Q-wave Elevated CE: CK, AST, LDH

CK-MB, Troponin I/T Echo: EF, akinesia, valvular lesions

Medical treatment:StreptokinaseSymptoms control: Morphine, nitratesAspirinBeta-blockers

Risk factors modifications ? Primary PTCA CABG Cardiac rehabilitation

Common skin problem in FM

Diagnosis in dermatology mainly based on Clinical history Morphology Distribution Further investigation

Dermatology terms

Macule: skin colour change without elevation Papule: palpable elevation <5mm Nodule: palpable mass >5mm Plaque: palpable plateau-like elevation >2cm Vesicle: small blister <5mm of clear fluid within o

r below the epidermis Bulla: larger vesicle >5mm Pustule: visible collection of free pus in a blister

Wheal: an area of dermal odema Crust: dried serum and exudate Excoriations: lesions caused by scratching that res

ults in loss of the epidermis Erosion: superficial break in the epidermis not ext

ending into the dermis Ulcer: extending into the dermis Lichenification: chronic thickening of the skin wit

h increased skin markings

Eczema/Dermatitis

3 hallmarks: 1) pruritus 2) ill defined border of the lesions 3) epidermal elements:

Acute, subacute– papules, vesicles, weeping Chronic– lichenification, xerosis, scaling

Endogenous vs exogenous

Atopic eczema Chronic, relapsing, pruritic disorder 10% population, Strong genetic predisposition: Associated with asthma, hay fever, allergic rhinitis Elevated serum IgE in 80% Infantile type: 1-6 months Itchy scaly weeping lesions over the face, trunk, e

xtensor of elbows and knees Remit between 2-5 yo (50 % by 5 yo)

Actopic eczema:

Childhood type : Lichenification at antecubital, popliteal fossa, nap

e of neck

around adolescence (80% by 10 yo) Adult type: Poor prognosis Bad prognostic factors: strong family hx, onset aft

er 2yo, social & maternal deprivation, discoid type, extensor area, associated with ichthyosis

Treatment:

General: Explanation and reasuurance Avoid soap or detergents Avoid irritating woolen clothing Avoid sudden temperature & humidity change Removal of common allergens (house dust mite)

Emollients: (use adequately and frequently) Aqueous cream, emulsifying ointment Urea cream (also as humectant) Topical steroids: Avoid potent one Oral antihistamines: piriton, clarityn Topical /systemic antibiotics: aureomycin, fucidin,

bactroban, cloxacillin, macrolides, quinolones Tar onitment or bath

Tinea

Common superficial fungal infection Incidence high in summer Individual susceptibility Chronic itchy erythematous scaly lesions with acti

ve margin Cause agents: trichophyton, microsporum, epider

matphyton Diagnosis: clinical picture, skin scarping, Wood’s

lamp (tinea capitis)

Tinea capitis: scalp Tinea pedis: feet, toe web Tinea manuum: hand Tinea unguium: nail Tinea crutis: groin Tinea corporis: trunk Tinea faciale: face

Treatment: Topical: Imidazole, Allylamine, Whitfield onitme

nt, tolnaftate Systemic:

GriseofulvinImidazole (ketoconazole, miconazole)Triazole (itraconazole, fluconazole)Allylamine (terbinafine)

Usually use for longer term and beware the LFT