Table of contents
- 1. Fever
- 2. Fatigue
- 3. Rhinitis
- 4. Diarrhea
- 5. Sleep Problems
- 6. Domestic Abuse
- 7. Smoking Cessation
- 8. Alcohol
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
Chronic Fatigue Syndrome
- New/Definite onset of unexplained fatigue not relieved by rest resulting in dysfunction. Need 4/5 of criteria lasting >6mo.
- Criteria not listed here.
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
- Seasonal
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
- Chronic:
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.
- Sleep hygiene:
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.
- Nicotine Resplacement Therapy (NRT)
- Counselling Points:
- 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)
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