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

    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

     

    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)
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