Common Complaints

Fever

• Hx: Travel, exposure, infectious contacts, others sick at home? meds, immunizations, TB hx.
  • Rashes, murmurs, arthritis, lymphadenopathy, masses
• Labs: CBC & differential, blood culture, urine culture, urinalysis
  • Stool O&P, Gram stain, culture
  • CXR, TB skin test, sputum culture, LP
• DDx:
  • Infectious 
  • Neoplastic 
  • Autoimmune 
  • Drugs

Fatigue

• DDx: PS VINDICATE
  • P - Psychogenic (Depression, sleep disorder, life stress)
  • S - Sedentary
  • V - Vascular (stroke?)
  • I - Infectious: (viral (mono, HepB), bacterial (TB), fungal, parasitic, HIV)
  • N - Neoplastic (any)
    • Nutrition (Vitamin B12, Fe, anemia)
  • D - Drugs (B-blocker, anti-histamines, anticholinergics, antiepileptics, benzos.)
  • I - Idiopathic
  • C - Chronic Illness (CHF, COPD, liver/kidney disease)
  • A - Autoimmune (SLE, RA, polymyalgia rheumatica)
  • T - Toxin ( Substance use (EtOH), heavy metals)
  • E - Endocrine (Hypothyroidism, DM, Cushing's, Pregnancy)
• R/O Red Flags:
  • Weight loss, night sweats, fever, neurological deficits, ill-appearing
• Tx:
  • Treat cause (1/3 have no cause)
  • Reassure
  • Counseling
  • Encourage physical activity

Rhinitis

• Rhinitis:
  • Nasal Congestion
  • Anterior/Post rhinorrhea
  • Pruritis
  • Sneezing
• Conjunctivitis
  • Redness
  • Itchy
  • Tearing
  • Eyelid swelling
• Classification
  • Seasonal
    • During specific time of year
    • Common allergens: trees, grass, weed pollens, aiborne moulds
  • Perennial
    • sx throughout the year, varied intensity
    • Dust mites, animal dander, moulds

Diarrhea

• Acute <14d (likely infectious)
  • Majority of cases self-limiting
  • most commonly viral (i.e. rotavirus)
  • fever and bloody stools increase probability of bacterial infection
  • Consider C. diff if recent hospital visit, abx use, age >65, or immunosuppressed.
• Chronic >14d (likely non-infectious)
  • drugs (laxatives, abx), infection (bacteria, parasites), inflammation (IBD, diverticulitis), neoplasia (colon), malabsorption, maldigestion, IBS, indiopathic
• Tx:
  • Chronic:
    • loperamide - most effective (use scheduled, NOT PRN)
    • fibre (psyllium) - usually adjunctive
    • Oral Rehydration Solution - helps with electrolyte imbalances

Sleep Problems

• Classify source
  • Insomnia? (falling asleep, maintaining sleep, early waking, non-refreshing sleep)
  • Parasomnia (night terrors, nightmares, restless leg syndrome)
  • Excessive daytime sleepiness
  • Secondary causes:
    • Medical: COPD, asthma, CHF, hyperthyroidism, chronic pain, BPH
    • Drugs: EtOH, caffeine, nicotine, B-agonists, antidepressants, steroids
    • Lifestyle factors: shift-work?
• Investigations: sleep log, r/o medical conditions
• Tx:
  • Sleep hygiene:
    • avoid caffeine, nicotine, alcohol
    • exercise regularly
    • comfortable sleep + environment
    • Regular sleep schedule
    • No napping
  • Psychologic: (relaxation, stimulus control therapy, sleep restriction therapy)
  • Pharmacologic (short acting benzos, lorazepam, oxazepam, temazepam use <7 consecutive nights to break chronic insomnia.

Domestic Abuse

• Screening Questions:
  • In general how would you describe your relationship (lot of tension? some tension? No tension?)
  • Do you and your partner work out arguments with (great difficulty? some difficulty? No difficulty?)
• Classify abuse:
  • Physical, sexual, emotional, psychological, financial
• Management
  •  
  • Ensure patient safety (most at risk following separation or attempting to leave)
  • Provide community resources
    • Safety planning (safe place to go, money, meds, keys, clothes, documents)
    • Shelter or helpline for legal advocacy and counselling
  • Reassure:
    • They are not to blame for this.
    • Parter has a problem he needs help with.  
    • Spouse abuse is a criminal act.
  • Child Safety
• Document EVERYTHING (ask to photograph injuries etc..)
• FOLLOW-UP

Smoking Cessation

• 18% smoke in 2008 (lowest since 1965)
• withdrawal symptoms:
  • low mood, insomnia, irritability, anxiety, difficulty concentrating, restlessness, decreased heart rate, increased appetite.
• Willing to quit:
  • 5 A's
  • Ask if patient smokes
  • Advise patient to quit
  • Assess willingness to quit
  • Assist in quit attempt
  • Arrange follow-up
• Tx:  (if willing to quit)
  • Counselling Points:
    • Set quit date
    • tell family and friends,
    • anticipate challenges
    • remove triggers (lighters)
    • Educate:

      • •  onset of withdrawal 2-3hrs
        • peaks in 2-3 days
        • improves over 2-3 weeks.
        • Resolves over 2-3 months
        • Highest relapse within 2-3 months.

  • Drugs
    • Nicotine Resplacement Therapy (NRT)
      • 19.7% abstinent at 12mo with NRT vs. 11.5% placebo (OR1.66)
      • Reduces cravings & withdrawal symptoms w/o harmful substances in cigarettes.
      • Do not use if post-MI, serious/worsening angina, seriour arrhythmia.
    • Bupropion SR (Zyban (R))
      • 21% absinent at 12mo vs. 8% for placebo
      • Inhibits re-uptake of dopaine and/or norepinephrine (S/E: insomnia, dry mouth)
      • 150mg qAM x3d, then 150mg bid x7-12wks.
      • Decide on quit date, keep smoking 1-2wks until theraputic levels build up.
    • Varenicline (Champix (R))
      • Partial nicotinic receptor agonist (reduces cravings) and partial competitive nicotinic receptor antagonist (reduce response to smoked nicotine)
      • More effective than bupropion.
      • S/E: nausea, vomiting, constipation, headache, dream disorder, insomnia, increased risk of psychosis (careful with psych condition)
      • 0.5mg qAM x3d, then 0.5mg bid x4d, then 1mg BID x12 weeks
      • Begin tx 1wk before quit date for theraputic levels to build up.

• If Unwilling to quit (Motivational Intervention)
  • Motivational strategies (5 R's)
  • Risks of smoking (health/social, etc..)
  • Rewards/Benefits (money, food tastes better, good example for kids, improves health)
  • Road blocks / obstacles. (Fear of withdrawal, wt gain, failure, support)
  • Repetition (reassure unsucessful attempts that people try many times before quitting)

Alcohol

• CAGE Questionnaire
  • Have you felt the need to CUT down on our drinking
  • Have you ever felt ANNOYED at criticism of your drinking?
  • Have you ever felt GUILTY about your drinking?
  • Have you ever had a drink first thing in the morning to steady nerves or treat hangover (EYE OPENER)
• ≥2 for men, ≥1 for women suggest drinking problem (sensitivity 85%, specificity 89%)
• Investigate:
  • GGT
  • MCV
  • AST, ALT (usually AST:ALT approaches 2:1 for alcoholic), 
  • CBC (anemia, thrombocytopenia)
  • INR (liver disease)