Common-Clinical-Cond.. - School of Medicine

Common Clinical Conditionsin General Practice - IIDr. Brendan O’ SheaDepartment of Public Health and Primary CareConditions Covered• Session 1– Hypertension– Ischaemic heart disease / Angina / MI– Diabetes mellitus– URTI / LRTI• Session 2– Asthma– COPD– Low back pain– Arthritis / Joint pain– Thyroid DisordersAsthma• Case History– AM is an 8 y.o. boy who is brought in by his Mum.She says he has a terrible cough all the time, especiallyat night. He has a history of wheezing during viralinfections in the past.– What questions will you ask in the history?– What is your initial management plan?Asthma• Case History– He returns after a trial of salbutamol 2 puffs PRN for 6weeks.– Both he and his Mum feel he has been a lot better. Hisnight cough has settled. He uses his salbutamol mostdays, especially if it is cold outside. However, he had ahead cold 2 weeks previously and felt he was still quitewheezy during that week, despite the salbutamol.– What is your management plan?– What general advice will you give about preventingasthma flares?Asthma• Definition– Paroxysmal, reversible airways obstruction• Characterised by:– Airflow limitation, usually reversible spontaneously / with tx– Airway hyperresponsiveness to a wide range of stimuli– Inflammation of the bronchi• Prevalence– 5-8% of population (10-15% in 10-20 y.o. age group)– Occupational asthma accounts for 1-2% of adult cases– Assoc with FHx of atopy / asthma and PMHx atopy (e.g. hayfever / eczema); childhood bronchiolitis (40% develop asthma)Asthma• Diagnosis– Based on clinical picture – no diagnostic test– Symptoms and signs:• Wheeze• Paroxysmal SOB (esp at night / early morning, when peak flow dips)• Nocturnal cough (esp in children)• “Barrel chest” in chronic asthmatics– Consider:• Serial PEFR measurements – variability of airflow obstruction• Spirometry / PEFR: >15% ↑ FEV1 or PEFR post inhaled bronchodilator• Trial of corticosteroids: prednisolone 30mg OD x 2/52 - >15% ↑ FEV1 /PERF confirms reversibility and proves steroids will be beneficial in mgt• Bloods: FBC may show eosinophilia• CXR: usually normal; occasionally hyperinflation; excludes other causes1

Asthma• Common Precipitating / Exacerbating Factors– Exercise– Emotion– Weather – fog, cold air, thunderstorms– Air pollutants – smoke and dust– Household allergens – e.g. house dust mite, animal fur, feathers– Occupational exposure – animal products, wood dusts, graindusts, chemicals (e.g. isocyanates)– Smoking– Infection – e.g. viral URTI, chest infxns– Drugs – NSAIDs, β-blockers– GORDManagement of Asthma• Aims of Treatment– Abolish symptoms and minimise impact on lifestyle– Restore normal / best possible long-term airway function– Reduce risk of severe attacks– Enable normal growth in children• BTS / SIGN Guidelines on Mgt of Asthma (2004)– Primary Prevention – reduced incidence in breast-fed children– Non-Pharmacological Management• Allergen avoidance (esp smoking, house dust mite control)• Weight loss if obeseManagement of Asthma• BTS / SIGN Guidelines on Mgt of Asthma (2004)– Pharmacological Management• Treatment is based on stepwise approach– Start at step most appropriate to initial severity of symptoms– Aim to achieve early control, and then step down treatment– Ensure proper inhaler technique and trigger avoidance– A rescue course of steroids may be needed at any step, at any time• Selection of inhaler device– Use MDI if possible (dry powder inhalers are an alternative)– 75% of users have inadequate technique– Inhale slowly and hold breath for 10 seconds– Spacers / breath-activated devices are usefulManagement of Asthma• Drugs Used in the Treatment of Asthma– Short-acting β 2 -agonists – e.g. salbutamol (Ventolin), terbutaline(Bricanyl)– Anticholinergic bronchodilators – e.g ipratropium bromide(Atrovent) – preferred to salbutamol < 1y.o.– Long-acting β 2 -agonists – e.g. salmeterol (Serevent)– Inhaled corticosteroids – e.g. beclomethasone (Becotide),fluticasone (Flixotide), budesonide (Pulmicort)• Often available in combination with a long-acting β 2 -agonist – e.g.Seretide (salmeterol + fluticasone), Symbicort (formoterol + budesonide)– Leukotriene receptor antagonists – e.g. montelukast (Singulair)– Sodium cromoglycate and nedocromil sodium (Intal, Cromogen)Summary of Stepwise Management in Adults Summary of Stepwise Management in Children Aged 5-122

Summary of Stepwise Management in Children < 5 YearsCOPD• Case History– ET is a 68 year old lady who has recently transferred to yourpractice. She couldn’t manage the walk to her old GP anymore.She lives alone, and has a son living on the other side of the city– She gives hx of SOB when walking, especially if going uphill,or carrying anything. She maintains that she was fine up until 3months ago.– PMHx – known AAA, under surveillance.– What questions will you ask her in the history?– What signs will you look for on examination?– What investigations will you do?COPD• Case History– Her spirometry confirms the diagnosis of COPD (Stage 3).– What is your management plan?– She goes to see the vascular team. Her AAA is now 7cmdiameter. They recommend surgery as if it ruptures outside ofhospital she will almost certainly die – but surgery has a 10%mortality also. At assessment she is found to be physically unfitfrom a respiratory point of view. She is told that they will haveto wait and see what happens – she is terrified.COPD• Case History– Clinical Course / Follow-Up:– She remains clinically stable on Seretide 250mg 1 puff BD andsalbutamol for a few months. She can’t give up the cigarettes.– She gets a chest infection and is admitted to hospital where sheis found to be in Type II respiratory failure with a PaO2 of7.8kPa on admission (retaining CO2 d/t hypoventilation). Sherequires BiPap for ventilation but pulls through. She istransferred to Peamount for 3 weeks rehabilitation and goes tolive with her son on home oxygen. Her life expectancy isprobably less than a year.COPD – GOLD Guidelines• Definition– Slowly progressive disorder characterised by airflow limitationthat is not fully reversible– Risk Factors:• Cigarette smoking (also pipes and cigars) – including passive• Occupational dusts and chemicals (intense / prolonged exposure)• Indoor air pollution (cooking fuels in poorly ventilated environment)• Outdoor air pollution (↑ burden of inhaled particles)• Resp infxn in early childhood• Genetic (bronchial hyperresponsiveness, α 1 -antitrypsin deficiency)• Diet (poor diet and low birthweight)• Race (Chinese and Afro-Caribbean have ↓ susceptibility)COPD• Prevalence– ≈16% in 40-68 y.o age group (M>F)– Causes 5% of deaths in Ireland (CSO 2005)• Presentation– Symptoms:• Cough- may precede development of• Sputum productionairflow limitation by years• Dyspnoea• Episodic exacerbations– Signs of severe disease:• Tachypnoea, prolonged expiration, use of acc ms of resp / intercostalindrawing on inspiration and pursing of lips on expiration, poor chestexpansion, hyperresonant chest, cyanosis3

COPD• Diagnosis– Suspect if• Chronic cough• Chronic sputum production• Repeated episodes of acute bronchitis• Dyspnoea that is progressive, persistent (every day), worseon exercise, and worse during resp infxns• Hx of exposure to risk factors• Investigations– Spirometry to confirm• ↓ FEV 1 and FEV 1 /FVC ratioManagement of COPD• Goals of Treatment– Prevent disease progression– Relieve symptoms– Improve exercise tolerance– Smoking cessation• only intervention shown to decrease risk of developing COPD, and slowits progression• Components of Management– 1. Assess and monitor disease– 2. Reduce risk factors– 3. Manage stable COPD– 4. Manage acute exacerbationsManagement of COPD by Disease Severity• Stage 1– Mild COPD. Chronic cough and sputum, patient may feel fine;– FEV 1 /FVC

Low Back Pain• Red Flags– Age 50 years– Non-mechanical pain– Thoracic pain– Past history of malignancy– HIV– Taking steroids / other risk factors for osteoporosis– Systemically unwell– Weight loss– Widespread neurology– Structural deformity• Prevention– Regular exercise– Optimise weight– Advise re posture, working environment (ergonomics), lifting techniques– Correct any uneven leg lengthLow Back Pain• History– Circumstances of pain (SRC, OPD, SARA, PIT)– Assoc symptoms (e.g. numbness, weakness, bowel / bladdersymptoms)– PMHx – past illnesses (esp cancer), previous back problems• Examination– ROM – flexion, extension, lateral flexion, rotation– Observe mobility (e.g. getting on and off couch), gait– Prone – palpate for tenderness– Supine• Lower limb muscle wasting, power, sensation, reflexes• Straight leg raising – sciatica present if

Joint Pain / Arthritis• Definition – Arthritis:– Swelling and reduced mobility of the joint with associated heat, and ache orpain on movement– Joint pain makes up 7% of all morbidity presented to GPs• Differential Diagnosis– Osteoarthritis – single most important cause of locomotor disability• Metabolically active process involving whole joint – synovium, cartilage,bone, capsule and muscle – not just “wear and tear”– Rheumatoid arthritis– Gout– Viral infections– Seronegative spondyloarthropathies – ankylosing spondylitis, psoriaticarthritis, enteropathic, reactive / Reiter’s syndrome– Others: e.g. SLE, Behçet’s syndromeJoint Pain / Arthritis• History– Inflammation v. degeneration– Acute v. chronic– Pattern of joint involvement• RA: symmetrical small joint involvement is typical• Gout: 1 st MTPJ• OA: small joints or large weight-bearing joints, may be asymmetrical– Associated symptoms, travel history, PMHx, FHx• Examination– General exam, vital signs (esp fever)– Joint exam• Look – swelling, erythema, deformity• Feel – heat, tenderness, synovitis (boggy swelling), effusion• Move (active then passive) – ROM, painJoint Pain / Arthritis• Investigations– Bloods – FBC, ESR, uric acid, rheumatoid factor, autoantibody screen (espANA); serology if relevant– Plain Film X-Rays• OA: ↓ joint space, cysts, sclerosis in subchondral bone, osteophytes• RA: normal / soft tissue swelling in early stages; later – loss of joint space,erosions, periarticular osteoporosis, joint destruction• Management– Based on primary diagnosis– Weight loss if overweight – reduces load on joint in OA– Exercise helpful for some joints e.g. swimming– Physiotherapy (joint supports / strapping) / OT / rehabilitation– Analgesia – paracetamol / NSAIDs (for acute exacerbations)– DMARDs for rheumatoid arthritis– Refer early for joint replacement if likely to be necessary, as long waitinglistsThyroid Disorder• Interpretation of TFT’s– TSH ↓, T 4 ↑– TSH ↑, T 4 ↓– TSH ↑, T 4 ↔6

Thyroid Disorder• Interpretation of TFT’s– TSH ↓, T 4 ↑ Thyrotoxic– TSH ↑, T 4 ↓ Hypothyroid• Sometimes T 4 is normal butT 3 ↑• TSH ↓ if hypothyroidism isd/t pituitary failure (rare)• Prevalence– Affects 2% women and 0.2% men– Typical age at onset 20-49 y.o.Hyperthyroidism• Causes– Grave’s disease(thyroid-stimulating Ab’s); eye involvement– Toxic adenomal / toxic multinodular goitre (older women with hx of goitre)– Subacute (de Quervain’s) thyroiditis – self-limiting, painful goitre, ESR ↑– Amiodarone, self-medication with thyroxine; rarely lithium– Kelp ingestion (high iodine content)– TSH ↑, T 4 ↔ Subclincalhypothyroidism• Consider trial of tx if anysymptoms; otherwisemonitor annually• Presentation– Weight loss, tremor, palpitations, hyperactivity, heat intolerance, sweating,diarrhoea, emotional lability, itch, oligomenorrhoea, psychosis– Elderly patients may be confused / depressed / apathetic– Atrial fibrillation, eye changes, infertility can be only complaintHyperthyroidism• Management– Refer all patients to an endocrinologist– Treatment• β-blockers – useful for symptom control until antithyroid therapy takeseffect• Carbimazole– inhibits synthesis of thyroid hormones; doesn’t work for thyroiditis– 3/1000 risk of agranulocytosis, hepatitis, aplastic anaemia or lupus-likesyndromes– Stop and see doctor if sore throat / other infection– Propylthiouracil is an alternative• Radioactive iodine – takes 3- 4 mths for effects to become apparent• Surgery – partial / total thyroidectomy– Risk of RLN or parathyoid damageHypothyroidism (Myxoedema)• Prevalence– Common; insidious onset – may go undiagnosed for years– Typical patient is female in her forties (F:M = 6:1)• Screening– Check TFT’s in patients on amiodarone or with a history of radioiodine tx– Also – hypercholesterolaemia, infertility, depression, dementia, obesity, otherAI disorders (often coexists), Turner’s syndrome• Causes– Spontaneous primary atrophic hypothyroidism – common, AI d/o, assoc withDM, Addison’s disease, and pernicious anaemia; thyroid autoAb’s present– Post-thyroidectomy / Radio-iodine tx– Drug-induced – antithyroid drugs, amiodarone, lithium, iodine– Sub-acute thyroiditis– Iodine deficiency (poor diet)Hypothyroidism (Myxoedema)• Presentation– Non-specific symptoms – fatigue, lethargy, depression– Weight gain, constipation, hoarse voice, dry skin / hair– Signs often absent• May be goitre, slow-relaxing reflexes or non-pitting oedema of the hands,feet and eyelids• Management–

Men’s Health• Well Man Check– Cardiovascular• BP, cardiovascular risk factor profile, smoking– Alcohol use– Depression / Anxiety– Urology• Prostate exam +/- PSA (do PSA before DRE)• Testicular exam (teach re self-examination)• Erectile dysfunctionAll in a days work….• Anxiety• Multiple unexplained physical symptoms• Post Partum Depression• ‘I’m Tired….’• ‘He says I’ll have to do something about it…….’• ‘Could you just sign this for me Doctor……..’• ‘..and do you know I have to cook with the lightsout as well now Doc…………?’‘And while you’re at it…..’• ‘School refusal’• Evaluation of non accidental injury• Cheers for Minor Surgery• ‘Nobody told me anything……..’• ‘Just a full check up Doc…..’• Trauma• The Six Week Check up• ‘S(he)s drinking again doc…’If you have the time…….• The Medical Report• ‘..my prescription, if you could.’• ‘My mother in law will be staying with us..’• ‘My knee is totally fucked….’• ‘..and then they put a stent in me…?• ‘..they told me it was cancer….’• ‘..this doesn’t look too good Doc, does it ?If you have time to look…..• My God, Helen, look at the size of him now• Your father was a wonderful man• ‘….er, and did you want to become pregnant ?’• Just look at how far you’ve come with this• The journey from Grief to Acceptance• Being there8