Inflammatory arthritis

• Rheumatoid arthritis is an autoimmune condition mainly affecting the joints of the body.

• Typical features are morning stiffness, joint pain relieved by movements and aggravated by rest.

• Basic investigations for patients with suspected rheumatoid arthritis/inflammatory arthritis
• FBE
• UEC
• LFT
• ESE
• CRP
• Anti CCP
• RA
• ANA
• ENA 

• DMARDs have made significant improvement in patients with RA. We don't see patients with RA with severe deformities anymore. The best outcome is when patients are started on DMARDs early, so refer early. 

• Methotrexate is the first line DMARD for RA at the moment. Cheap, relatively easy and safe to take. Common side effects: nausea and mouth ulcers. Monitor LFT and FBE monthly. 

Anxiety disorder

• Anxiety disorder is common. GPs encounter patients with anxiety disorders everyday, so it is important to have some basic understanding of the disorder and also management plans

• Anxiety disorders include: general anxiety disorder, phobias, OCD, PTSDs, panic attack, substance induced anxiety and anxiety secondary to general medical condition

• My personal approach is that I do not prescribe benzodiazepam to anyone who comes in with anxiety disorder. As it is often lifelong and most patients ended up becoming dependent on benzodiazepam. I will usually bring this straight up during the first consultation, which prevents them from coming in for benzodiazepam prescription in the future

• Use DASS 21 or K10 to assess level of distress 

• Substance abuse or comorbid psychiatric disorders are common in this population, make sure you screen for them 

• Management plan
• Avoid benzodiazepam. You are not doing the patient any good by prescribing them. 
• Psychoeducation 
• It is the key to many psychological condition 
• use the flight/fight model to explain the purpose of anxiety
• Cognitive behavioural therapy
• Essential to mention this in the exam 
• Do a mental health plan and refer to psychologist 
• National e-therapy centre for anxiety
• Medications
• Some SSRIs have anti anxiety effect but only escitalopram is currently listed to use in GAD 
• Avoid Paroxetine in young women who have not completed their family

   

SaveSave

Approach to Dysnoea

Probability diagnosis

• bronchial asthma
• bronchioligitis (children)
• COPD
• Ageing; lack of fitness
• Left heart failure
• Obesity 

Serious disorders not to be missed

• Cardiovascular
• Acute heart failure
• arrhythmia 
• pulmonary embolism
• fat embolism
• pulmonary hypertension 
• dissecting aneurysm 
• cardiomyopathy
• pericardial tamponade
• anaphylaxis
• Neoplasia
• bronchial carncma, other malignancy
• Severe infections
• SARS
• avian influenza
• pneumonia
• acute epiglottitis
• Respiratory disorders
• inhaled foreign body
• upper airways obstruction 
• pneumothorax
• atelectasis
• pleural effusion 
• tuberculosis
• acute respiratory distress syndrome
• Neuromuscular disease
• infective polyneuritis
• poliomyelitis

Pitfalls

• interstitial lung disease 
• idiopathic pulmonary fibrosis 
• extrinsic allergic alveolitis
• sarcoidosis
• chemical pneumonitis
• metabolic acidosis 
• radiotherapy 
• kidney failure (uraemia)
• multiple small pulmonary emboli

Severn masquerades checklist

• Depression 
• Diabetes
• Drugs 
• Anaemia 
• Thyroid disorder 
• Spinal dysfunction 

Is the patient trying to tell me something?

• Consider functional hyperventilation 

Approach to the disturbed patient

Approach to the disturbed patient

Probability diagnosis

• The 4Ds
• Dementia
• Delirium 
• Depression 
• Drugs: toxicity, withdrawal
• Serious disorders not to be missed
• Cardiovascular 
• CVAs
• Cardiac failure
• Arrhythmia 
• ACS
• Neoplasia
• cerebral
• Cancer
• Severe infections 
• septicaema
• HIV infection 
• infective endocarditis
• Hypoglycaemia
• Bipolar disorder/mania
• Schizophrenia states
• Anxiety/panic
• Subdural haematoma 
• Pitfalls 
• illicit drug withdrawal
• Fluid and electrolyte disturbances
• Faecal impaction 
• Urinary retention 
• Hypoxia 
• Pain syndromes
• Rarities
• Hypocalcaemia
• Kidney failure
• Hepatic failure
• Prion diseases
• Seven masquerades checklist 
• Depression 
• Diabetes
• Drugs
• Anaemia 
• Thyroid disorder 
• Spinal dysfunction 
• UTI 
• Is the patient trying to tell me something?
• 
  

Approach to Diarrhoea

A diagnostic approach

Probability diagnosis

• Acute:
• Gastroenteritis/infective enteritis
• Dietary indiscretion 
• Antibiotic reaction 
• Chronic
• Irritable bowel syndrome
• Drug reaction 
• Chronic infections 

Serious disorders not to be missed

• Neoplasia
• Colorectal cancer
• Ovarian cancer
• Peritoneal cancer
• HIV infection (AIDS)
• Infections
• Cholera
• Typhoid.paratyphoid
• Amoebiasis
• Malaria
• Enterohaemorrhagic E.coli enteritis
• Inflammatory bowel disease
• Crohn/ulcerative colitis
• Pseudomembranous colitis
• Intussusception 
• Pelvic appendicitis/pelvic abscess
• Acute ischaemic colitis

Pitfalls

• Coeliac disease
• Faecal impaction with spurious diarrhoea 
• Lactase deficiency 
• Giardia lamblia infection 
• Cryptosporidium infection 
• Malabsorption states
• Vitamin C and other oral drugs
• Nematode infections
• Strongyloides
• whipworm
• Radiotherapy
• Diverticulitis
• Post GIT surgery
• Ischaemic colitis 
• Rarities
• Addison disease
• Carcinoid tumours
• short bowel syndrome
• amyloidosis
• toxic shock
• Zollinger Ellison syndrome

Red flag pointers for diarrhoea 

• unexpected weight loss
• persistent/unresolved
• Fever
• Overseas travel
• Severe abdominal pain 
• Family history: bowel cancer, crohn disease

Acute gastroenteritis

Condition

• Acute Gastroenteritis

Potential causes

• Rotavirus and adenovirus
• Bacterial: C. jejuni and Salmonella sp, E. Coli and Shigella
• Protozoal: G. Lamblia, E. histolytica, Cryptosporidium 
• Food poisoning: staphylococcal toxin 

Investigation

• No investigation is usually required if < 7 days
• if > 7 days, send Stool MCS

Management

• Invariably a self-limiting problem
• No antibiotic is required
• If antibiotic is required, wait for culture

Coeliac disease

Condition

• Coeliac disease: an autoimmune condition characterised by chronic inflammation at the small intestinal mucosa caused by gluten 

History

• can present in many different ways e.g. tiredness, change of bowel habits etc
• low threshold of ordering coeliac serology for non specific symptoms e.g. fatigue, depression 
• The following is from NICE guideline, the following presentation warrants coeliac blood test

• 
  

Examination

• often normal 

Investigation

• Coeliac serology: IgA tTg, IgA EMA, IgA DGP , IgG tTg
• HLA DQ2 / HLA DQ 8: negative test essentially excludes coeliac disease
• micronutrient levels 

Management

References:

• http://www.racgp.org.au/afp/2014/october/coeliac-disease-where-are-we-in-2014/

Pseudomembranous colitis

Condition

• Pseudomembranous colitis

Clinical features

• Profuse, watery diarrhoea
• Abdominal cramping and tenesmus +/- fever
• Within 2 days of taking antibiotic (can start p to 4 to 6 weeks after usage)
• Persists 2 weeks (up to 6) after ceasing antibiotic
• Augmentin duo forte is the common culprit 

Treatment

• Metronidazole 400 mg tds for 10 days

I have seen multiple C. Diff colitis as a registrar last year. Most of the time secondary to inappropriate antibiotic prescription. For some reasons, some GPs like to prescribe augmentin duo forte as the first line antibiotic. If we follow the antibiotic guideline, there are not many conditions which requires augmenting duo forte. Ironically, the cases I saw they didn't even require antibiotic at the first place. 

** Reminder to myself: prescribe antibiotic according to the antibiotic guideline **

Myocardial ischaemia

Condition

• Myocardial ischaemia

History

• Any pain waist line and above is cardiac until proven otherwise
• Quality of the pain is usually described as pressure, heaviness or tightness
• May have associated symptoms: dysnoea, dizziness, nausea and vomiting and sweating
• Ask family and risk factors

Examination

• could be normal
• variable ? arrhythmias
• Gallop rhythm 
• Murmur of MI
• Basal crackles

Ix

• ECG is a must
• Troponin probably does not have a role at general practice unless you have a cath lab
• CXR helps to exclude causes e.g. pneumothorax
• Myocardial perfusion study
• High negative predictive score
• Risk stratify into 3 categories: reversible ischaemia, normal/equivocal and non diagnostic
• Normal/Equivocal --> CTCA
• Limitations: patients' compliance to the exercise requirements of the study, low sensitivity and radiation dose 
• Stress echocardiagraphy
• can use to risk stratify like myocardial perfusion study
• needs expert operator
• CTCA
• Needs the HR < 60 bp
• Be able to breath hold
• very high negative value approaching 100 %
• Limitations: sometimes can be difficult to get the heart rate down (anyone ever works at ED will tell you that) and high calcium in the arteries can also obscure the view
• Scan protocol (Triple rule out) using CTCA to rule out PE, Aortic dissection and MI have been employed by some centres in the state. Watch out for this space in Australia

Management

• For GPs, the main thing is recognising it and send the patient to ED. This could be life saving. 
• I used to feel terrible for sending someone in who end up did not have a MI. Feeling that I have wasted their time and ED's time and ED's discharge letter will definitely make you feel that way. 
• Don't forget that we will never be 100 % correct. We got some and we missed some. For those who did not have MI, you have just excluded a life threatening condition! Well done!

References

1. John Murtagh

2. http://www.racgp.org.au/afp/2014/may/imaging-for-cardiac-disease/

Idiopathic thrombocytopenia purport

Condition

• Immune destruction of platelets

Clinical features

• easy bruising
• epistaxis and menorrhagia common 
• no systemic illness
• splenomegaly rare
• isolated thrombocytopenia
• other blood cells normal
• normal physical examination 
• normal bone marrow with normal or increased megakaryocytic

Murtagh's triad

• bruising + oral bleeding + epistaxis = ITP

Management

• no treatment 
• avoid contact sports
• watch and wait
• likely to resolve spontaneously 
• wide range of practice within Australia. At Westmead children's hospital, they are more pro-watch and wait and avoid treatment

Henoch-Schonlein purpura

Condition

• Commonest vasculitis of children 

Classic triad 

• non thrombocytopenic purpura 
• large joint arthritis
• abdominal pain 

History 

• upper respiratory tract infection including a group A streptococcal tonsillopharyngitis
• mainly in children
• rash, mainly on buttocks and legs
• arthritis: mainly ankles and knees
• abdominal pain - colicky 
• haematuria
• associations
• kidney involvement - deposition of IgA immune complex
• Malaena
• intussusception 
• Scrotal involvement

Investigaions

• FBE
• UEC
• Urine: protein and blood: spun specimen, micro for casts

Management

• Analgesics 
• Check UEC 
• Beware of renal failure 

Approach to arthritis

**Red flags**

• Fever
• Weight loss
• Profuse rash
• Lymphadenopathy
• Cardiac murmur
• Severe pain and disability
• Malaise and fatigue
• Vasculitic signs 
• 2 or more systems involved

Arhritis in children: causes to consider

Infections

• rheumatic fever
• septic arthritis
• meningococcaemia
• osteomyelitis
• reactive arthritis
• tuberculosis
• viral infections

Inflammation - chronic arthritis

• juvenile idiopathic/chronic arthritis
• oligo articular
• seropositive polyarticular
• seronegative polyarticular
• systemic onset arthritis 
• enthesitis related arthritis
• Psoriatic juvenile arthritis

Haematological disorders

• thalassaemia
• sickle-cell anaemia
• haemophilia

Neoplasms

• Leukaemia
• Lymphoma
• Neuroblastoma

Orthopaedic conditions

• perthes
• slipped upper femoral epiphyses
• chondromalacia

Others

• Henoch-schonlein purpura
• kawasaki syndrome
• scurvy
• traumatic arthrits
• osteochondritis
• psychogenic rheumatism
• malignant tumour
• bone
• cartilage
• synovium

Approach to abdominal pain

**Red flags**

• History
• collapse at toilet 
• lightheadedness
• ischaemic heart disease 
• progressive-vomiting pain, distension 
• menstrual abnomalities
• malignancy
• Signs
• Pallor and sweating 
• Hypotension 
• Atrial fibrillation or tachycardia
• Fever
• Prostration 
• Rebound tenderness and guarding 
• Decreased urine output

• Key history
• Dysphagia/odynophagia
• Nausea/vomiting
• Loss of appetite 
• Reflux
• Abdominal pain 
• Abdominal distension 
• Altered bowel habit
• systemic symptoms: malaise/fatigue/jaundice/fever

Murtagh Triad

• Pale child + severe colic + vomiting = acute intussusception
• intense pain + pale and 'shocked' +/- back pain = ruptured AAA
• Anxiety and prostration + intense central pain + profuse vomiting +/- bloody diarrhoea = mesenteric arterial occlusion 
• Localised RIF pain + a/n/v + guarding = acute appendicitis 
• Colicky central pain + vomiting + distension = SBO
• Colicky pain + distension +/- vomiting = LBO
• Sudden severe pain + anxious, still, 'grey', sweaty + deceptive improvement = perforated peptic ulcer
• Intense pain (loin) --> groin + microscopic haematuria = ureteric colic
• acute pain + left sided radiation + fever = acute diverticulitis

Indigenous health

Approach to indigenous health

**common exam topic**

**In your management plan, must mention aboriginal health worker**

Common clinical problems in children

Perinatal

• Low birthweight
• Asphyxia
• Infections 

Preschool

• Failure to thrive
• Malnutrition 
• Anaemia -- check for hookworm 
• Respiratory infection 
• Diarrhoea disease
• hepatitis B
• Skin infection/infestation 
• scabies
• Urinary tract infection 
• Meningitis 
• Joint and bone infection 
• Chronic suppurative otitis media 
• Trachoma

Later childhood and adolescence

• Bacterial and viral infections 
• Parasitic infestation 
• Streptococcal infection:
• Rheumatic fever
• Glomerulonephritis
• Trauma 
• Substance abuse
• Chronic suppurative otitis media 

Adults

• Diabetes
• Cardiovascular disease
• Injury (and youth suicide)
• Kidney disease
• STIs
• Mental health
• Poor nutrition 
• Ear infections 
• Women's problems

Socioeconomic

• Education of aboriginal children
• Housing 
• Water supply
• Alcohol and substance misuse
• Domestic violence and sexual abuse
• Child abuse 
• Gambling 
• Unemployment

Immunisation schdule

• Normal 
• Aboriginal and Torres Strait Islander People 

Central retinal artery occlusion

Condition

• Central retinal artery occlusion: infarction of retina 

What is it ?

• Infarction 
• Can either be caused by thrombosis or embolic occlusion
• Thrombosis
• systemic hypertension 
• dyslipidemia 
• hyper coagulable states
• Embolus
• cervical carotid bifurcation 
• abnormalities of cardiac valves, wall or rhythm e.g. atrial fibrillation

How does it appear ?

• Sudden painless loss of vision usually confined to one eye
• Afferent pupil defect in affected eye
• Milky appearance of retina because ischemic swelling causes loss of its transparency
• Cherry-red spot in fovea (spared because it is nourished by choroidal rather than retinal arteries)

Management

• Refer to hospital immediately for further evaluation 
• Needs stroke workup
• Massage globe digitally 

References

- the eye have it 

Faecal incontinence

Key points:

• most likely caused by constipation 
• RCH website has good summary on laxatives
• don't forget psychological cause 
• refer early if not winning, as this can be problematic for the child and the family 

What causes faecal incontinence?

• Functional 
• constipation associated faecal incontinence, involuntary
• non retentive faecal incontinence (encopresis)
• may have a psychosocial basis 
• Organic 
• anorectal malformation, spinal disorders, hirschsprung's disease, CP, mental retardation etc

Assessment ?

• General history
• Bowel habit details
• frequency of defecation 
• consistency of stool 
• intestinal hurry - soiling 
• toilet posture, school practices re: toilet 
• Fluid intake 
• Diet/fibre intake/cow's milk history
• Bristol stool chart. Normal is type 3 and 4.

Examination?

• Developmental 
• nutritional 
• abdominal 
• neurological 
• spine/reflexes
• anorectal exam ? PR (not necessary)
• anal tone/sensation 

What are the investigations?

• bowel chart/diary
• abdominal x-rays (esp if no faecal retention found on rectal exam)
• abdominal ultrasound (rectal diameter for rectal distention > 2.9 cm). Not every centre knows how to do it, check with radiology first, otherwise, it will just be wasting of time
• anorectal manometry 
• blood tests limited value (TFTs, Ca)

What is the management ?

• Good flow chart from DCH lecture 

• Education 
• Laxatives 
• disimpact if significant retention 
• maintenance therapy, 6 months at least 
• Toileting program: bowel opening post meals 
• Treat anal fissures
• Toilet diary (behaviour modification) 

Toileting program 

• Ensure adequate fluid intake (50ml/kg/day)
• Ensure adequate fibre intake
• Toilet posture
• support feet with a stool, it helps relaxing pelvic floor muscle
• toilet sit after meals (gastrocolic reflex)

References

• Diploma of child health: encopresis and enuresis lecture 

Approach to constipation

• Constipation is common, occurring in 30 % of children

• Red flags
• constipation presents early in life < 6 weeks
• functional constipation is the most common cause of constipation in childhood 

• Some other less common causes 
• Medical: cow milk allergy, coeliac disease, hypercalcaemia, hypothyroidism 
• Surgical: hirschsprung disease, meconium ileus, anatomic malformations of anus and spinal cord abnormalities

• History
• Timing of meconium passage
• Painful/frightening precipitant
• Straining 
• Toilet refusal, hiding while defecting, crossing legs or other withholding behaviour 
• Faecal or urinary incontinence, day or night 
• Weight loss, vomiting or PR blood loss - suggests possible organic disease
• Stool description 

• Examination 
• Height and weight -- failure to thrive
• Abdomen - palpable faeces
• Spine - deep sacral cleft or tuft of hair 
• Neurology - assessment of lower limbs 
• Anal area - visually examine for fissures, internal examination not required

• Management 

• Behaviour modifications
• Toilet sits - 5 minutes 3 times a day, preferably after meals 
• use chart or diary 
• Diet 
• Medication
• Titrate medicaion aiming for one soft, easy to pass bowel action per day 
• children: stool softener or iso-osmotic laxative 
• infants 6-12 months: colocyl drops or lactulose 
• infants < 6 months: coloxyl drops 

References: 

• RCH 
• John Murtagh

Approach to enuresis

• Enuresis can be defined as daytime wetting (diurnal enuresis) after age 4 years or night-time wetting (nocturnal enuresis) after 6 years. Usually no treatment is required before that. 

• Red flags
• Referral > 6 years old or any age with continual dripping to paediatric nephrologist
• Any child with a febrile urinary tract infection with abnormal renal US
• Any child with a congenital anatomic genitourinary concern  (posterior urethral valves, vesicoureteral reflux, hydronephrosis, ureteropelvic junction obstruction, bladder or urethral abnormalities or genital malformation)

• It is very common. About 50% of children aged 3 years wet the bed, as do 20% of children aged 4 years and 15% of children aged 5. 

• Usually there is no underlying cause found but we tend to blame:
• parents: there is a genetic tendency
• small bladder
• deep sleeper
• kidneys like to produce urine at night 
• Constipation (make sure the child is not constipated)

• Some disorders that we like to exclude:
• urinary tract infection 
• diabetes mellitus
• diabetes insipidus
• neurogenic bladder
• urinary tract abnormality

• Investigations
• Urine MCS
• Renal ultrasound 

• Management for nocturnal diuresis
• it is mainly behavioural
• the most effective way is using a bed alarm 
• it takes 6-8 weeks for it to work 
• takes some effort and parents will need to be happy to get involved
• first step: get a bed alarm. it sounds obvious but some parents do not want to because financial reasons
• second step: practice using it with the child. Pour salting water on to it and listen to the alarm
• Practice routine when the alarm goes off. The child needs to get up, turn the alarm off, go to the toilet and empty bladder completely, come back and change the sheet/material on top of the alarm and turn the alarm back, go back to sleep
• The child is better only to wear underpants to go to sleep rather with trousers 
• for parents handout: go to http://www.rch.org.au/kidsinfo/fact_sheets/bedwetting/

• Medication if alarm fails:
• DDAVP 200-400 mcg tablets 
• if that fails, use that with an alarm 

References:

• General practice 5th edition by John Murtagh
• RCH 

Approach to common paediatric problems

Crying and fussing in infants

Blocked nasolacrimal duct

Failure to thrive (FTT)

Short stature

Enuresis

Encopresis

Constipation

Approach to delayed puberty

Definition

• Absence of pubertal development in 
• girls > 14 years 
• boys > 15 years

Causes

• Constitutional delay (commonest, usually familial)
• Chronic illness (coeliac etc)
• Poor nutrition and exercise
• anorexia nervosa 
• Turner syndrome and gonadal failure

Investigations

• FBE and ESR
• Kidney function 
• Thyroid function tests
• chromosomal analysis (usually in girls to exclude turner's syndrome 
• serum FSH, LH, Prolactin, testosterone (exclude kallman syndrome) 
• x-ray of the wrist to determine bone age 
• pelvic ultrasound in girls 

Management 

• Refer to endocrinologist 

References:

1. http://www.apeg.org.au/Portals/0/Resources/Hormones_and_Me_6_Delayed_Puberty.pdf

2. John Murtagh

Approach to short stature

The three major growth factors are genetic, nutritional and hormonal. The hormones that are essential for a normal growth process are growth hormone and insulin-like growth factor I (the key), thyroxine, cortisol and sex steroids.

Ten essential questions from murtagh

1. Is the child actually short ?
2. Is the child short compared with other children?
3. Is the child unexpectedly short from a genetic viewpoint?
4. Is the child's growth slowing ?
5. If the growth is slow, what is the reason?
6. How dose the child feel about the short stature?
7. How does the height percentile match against a growth velocity chart?
8. Has puberty commenced?
9. Is there any specific investigation warranted?
10. Is there any specific therapy warranted?

The causes of short stature can be grouped into the following categories:
1. Organic causes
2. Constitutional delay
3. Familial short stature

Examination
1. General inspections includes dysmorphic features and nutritional status. Measure all anthropometry (height, weight, GV, upper/lower segment ratio) and compare with percentile charts
2. Measure skeletal proportions
3. Assess pubertal status

Investigations
If GV is < 25th percentile for bone age, consider

• TSH
• FBE and ESR
• Coeliac disease
• Chromosomes in all girls. Karyotype to exclude Turnes 45 XO 
• Growth hormone studies: IGF - 1 
• Kidney function 
• Bone age x-ray (left wrist) 

Management:

- May require growth hormone 

References:;

John Murtagh 

http://www.rch.org.au/uploadedFiles/Main/Content/MedEd/fracp/short%20stature%20NEJM.pdf

Failure to thrive / poor growth

Don't forget that there are two patients during the consultation. (Mum and baby)

Most common cause > 90 %. Normal variant and nutritional deprivation

History and examination is the key. No use ordering a lot investigations

Measure weight, height and head circumference and plot them on growth chart

** Feeding history is the key **

General observation is the key to this examination. Mother baby interaction, signs  of abuse and neglect, loss of muscle bulk and subcutaneous fat sores.

Red flags:

• Signs of abuse or neglect
• Poor carer understanding 
• Signs of family vulnerability e.g. drug and etoh abuse, domestic violence, social isolation, no family support 
• signs of poor attachment 
• parental mental health issues
• already/previously case managed by child protection services
• did not attend or cancelled previous appointments
• signs of dehydration 
• signs of malnutrition or significant illness

Investigation (if required):

• FBE, ESR
• UEC, LFT
• Iron studies
• Calcium, phosphate
• Thyroid function 
• Blood glucose
• Urine MCS
• Coeliac screen
• Stool MCS
• Stool for fat globules and fatty acid crystals 

Management depends on the cause. Most of the time can be managed in the community. Admission may be required if the child is dehydrated and unstable social situation. 

References:

RCH

John murtagh

unsettled or crying babies

Background

- It is normal for babies to cry
- The mneumonic is PURPLE crying

• P for peak of crying. Peaking at about 2 months
• U for unexpected crying. 
• R for resists soothing. 
• P for pain like face
• L for long lasting. Crying can last for several hours a day
• E for evening. Cry more in the late afternoon and evening

- Common non pathological causes of crying 

• Excessive tiredness
• Hunger 

- Differential diagnoses to consider include:

• Cow milk/soy protein allergy 
• GORD
• Lactose overload/malabsorption 

Red flags:

- Sudden onset of irritability and crying should not be diagnosed as colic, a specific cause is usually present
- The maternal and family psychosocial state must be taken into account. Maternal post-natal depression may be a factor in presentation. Note that excessive crying is the most proximal risk factor for shaken baby syndrome

- Suspect cow milk/soy protein allergy if

• vomiting/blood or mucus in diarrhoea/poor weight gain/family history in first degree relative/signs of atopy (eczema/wheezing)/significant feeding problems (especially worsening with time) 
• gastro-esophageal reflux is diagnosed
• lactose malabsorption is diagnosed in formula fed babies

Investigation

• really depends on the history 
• for acute cry
• Urine MCS (if acute crying and vomiting)
• Fluoroscein staining of eyes (if history suggestive)

Management

• Exclude medical cause (including mum--> ? depression) 
• Explanation and reassurance

1. Engage in a partnership with the parents

2. Explain normal crying and sleep patterns

3. Assist parents to help their baby deal with discomfort and distress

• Give mother permission to rest once per day 

4. Assess maternal and emotional state and mother baby relationship

5. Sometimes when you are really frustrated, it is ok to put your baby down few minutes and calm yourself down

Written information

Conclusion

• Most of the time it is normal and no medical cause is found 
• The most important thing is to gain the parents trust
• Give them clear explanation 
• Minimal intervention from us is the best intervention

References:

John Murtagh 

RCH website

Hyphaema

Hyphaema : blood in the anterior chamber. When clot fills the anterior chamber it is called an 8-ball hyphema.

History:

• symptoms: pain, blurred vision, loss of vision 
• injury: blunt trauma? what happened ? when ? how ?
• Bleeding diathesis: disorders, medications, history of sickle cell disease 
• Use of eye protection 

Examination:

• Visual acuity - variable 
• External examination: check for concomitant head and facial injury 
• pupillary reflex
• Tonometry 
• Slit lamp examination if there is one available 
• Fundoscopy and red reflex 

Investigation and management

• Oral analgesia and topical cycloplegics for comfort, Consider antiemetics.
• Remain upright 
• Apply an eye shield (how to pad an eye)
• Avoid blood thinners
• Treat secondary glaucoma
• Surgical evacuation 
• review by an opthalomologist within 24 hours 

Hospital admission criteria

• non compliant patients
• children 
• increased IOPs
• sickle cell disease
• bleeding diathesis or blood dyscrasia 

Follow up and discharge advice

• examine by an ophthalmologist on a daily basis (or on day 3 on a microhyphema)
• refrain from strenous physical activities for 1 week after the initial injury or a rebleed

Complications

• rebleeding 
• glaucoma
• corneal staining
• traumatic iritis 

References: 

- life in the fast lane 

Burns

I am scared of burns. I don't know what to do but after seeing burns for a few times, I start to get some understandings of it. I tend to follow the following principles (hopefully most of the burns we see at GP clinic is just minor burns):

1.  Assess the whole person, follow the principle of ABC 

2.  Know when to refer, the burns unit is available 24/7 for you to get advice (please go to RCH website), refer 

• All full thickness burn
• Circumferential burns
• All burns to face, eyes, ears, hands, feet, genitalia, perineum or a major joint, even if less than 10 %
• Chemical burns
• Electrical burns
• Burns associated with significant fracture or other major injury 
• All inhalation or airway burns
• Burns in children under the age of 12 months
• It is out of your/your hospital's comfort zone 

3. Assess the TBSA of burns. In children, their palm size is around 1 % of their body surface area. In adults, you can use your palm to gauge

4. Categorize burns into the following 3 categories and treat accordingly:

• superficial: only epidermis is involved
• superfical partial thickeness: dermis is involved, forms blister, fixomull 
• superficial deep thickness: hist white slough, red mottled, sluggish capillary return
• Full thickness: dry, charred whitish, absent capillary return 

5. 

superficial burn --> can leave it open, in infants  use non adherent dressing

partial thickness burn --> mepilex Ag Tm with crepe bandage or acticoat 3/7

Full thickness burn --> refer 

Reference:

1. RCH burns guideline 

About me

This site serves a few purposes:

1. Fulfil the RACGP training requirement

2. Capture some of my study notes and summarise notes for common presentations to general practice

3. Verbal diarrhoea

I am a GP registrar who finds out actually does not want to be a GP at all. Unfortunately, too deep into the training program and with no other specialty to turn to, is getting stuck being a GP for eternity.

After accepting this as a reality, trying hard to be a good GP and resist in prescribing antibioticss and benzos. Got into at least one argument per day with patients as I refuse to prescribe them the medications they want.

Also has a special interest in dermatology and trying to learn as much as I can on this topic. Hoping to get into dermatology training in my next life or the next next life.

My life is propelled forward by two external forces. One is my wife and one is my daughter. The reason I am going to work is mainly because of them. Children are expensive and I don't have the courage to rob a bank or smart enough to sell drugs on the street. The only option that left is continued being a gp.

Approach to tiredness/fatigue

Tiredness/chronic fatigue: diagnostic strategy model

Probability diagnosis

• Stress and anxiety
• Depression
• Viral/postviral infection 
• Sleep-related disorder (e.g. sleep apnoea)

Serious disorders not to be missed

• malignant disease
• cardiac arrhythmia (e.g. sick sinus syndrome)
• cardiomyopathy
• anaemia 
• hidden abscess
• haemochromatosis
• HIV infections 
• Hepatitis C

Pitfalls

• 'Masked' depression
• Food intolerance
• Coeliac disease
• Chronic infection (e.g. lyme disease)
• Incipient CCF
• Fibromyalgia
• Lack of fitness
• Drugs: alcohol, prescribed, withdrawal
• Menopause syndrome
• Pregnancy
• Neurological disorders
• post-head injury
• CVA
• Parkinson disease
• Kidney failure
• Metabolic (e.g. hypokalaemia, hypomagnesaemia)
• Chemical exposure (e.g. occupational)
• Rarities
• Hyperparathyroidism
• Addison disease
• Cushing syndrome
• Narcolepsy
• Multiple sclerosis
• Autoimmune disorders

Minimal investigations from John Murtagh General practice 5th edition:

• FBE
• ESR/CRP
• TFTs
• Coeliac serology
• LFT
• CMP
• BSLs
• Iron studies
• Urine MCS

Approach to sore throat

Sore throat: diagnostic strategy model

Probability diagnosis

• Viral pharyngitis
• Streptococcal tonsillitis
• Chronic sinusitis with postnasal drip
• Oropharyngeal candidiasis

Serious disorders not to be missed

• Cardiovascular 
• angina
• myocardial infarction 
• Neoplasia
• cancer of oropharynx, tongue
• Blood dycrasias (e.g. agranulocytosis, acute leukaemia)
• Severe infections:
• acute epiglottitis 
• peritonsillar abscess
• pharyngeal abscess
• diphtheria 
• HIV/AIDS

Pitfalls (often missed)

• Foreign body 
• Epstein-Barr mononucleosis
• Candida
• common in infants
• steroid inhalers
• STIs:
• gonococcal pharyngitis
• herpes simples (type II)
• syphilis
• Irritants (e.g. cigarette smoke, chemicals)
• Reflux oesophagitis --> pharyngolaryngitis
• Tonsilloliths
• Cricopharyngeal spasm
• Kawasaki disease
• Chronic mouth breathing 
• aphthous ulceration 
• Thyroiditis
• Rarities
• scleroderma
• behcet disease
• sarcoidosis 
• malignant granuloma 
• tuberculosis

Breaking bad news

Unfortunately, it is part of the job. Everyone will develop their own styles. The following is the guideline I try to follow adopted from John Murtagh's general practice:

1. Plan the consultation, check facts, set aside ample time
2. Meet in an appropriate room with privacy and no interruption
3. Ask the patient if they would like company
4. Make good eye contact and be alert for non-verbal responses
5. Use simple, understandable language
6. Be honest and diplomatically to the point (don't cover up the issue)
7. Allow time, silence, tears or anger
8. Don't give precise predictions about life expectancy


References:
1. John Murtagh General Practice 5th edition

Paediatric sleep disorder

Paediatric sleep disorder is very common. Most of the time it is behavioural and does not require  medication. Recently, there is a huge surge in melatonin prescription and most of the scripts come from paediatricians. I also have parents coming in asking for melatonin to help their kids going to sleep. The following is a structured approach I use in a consultation:

History taking. I use this mneumonic called BEARS.

B: Bedtime problems.

E: Excessive daytime sleepiness

A: Awakenings during the night

R: Regularity and duration of sleep

S: Sleep disorder breathing

After history, you can usually able to categorise the child into one of the sleep disorder categories.
1. Not enough sleep (difficulty initiating or maintaining sleep)--> behavioural intervention
2. Increased need for sleep (excessive sleepiness or hyper somnolence) --> refer
3. Fragmented sleep  (episodic disturbances e.g. sleep related breathing disorders or movement disorder)--> refer

At GP setting, the most common sleeping disorder we encounter is not enough sleep. This often happens with infants or young children. Parents come in complaining that they are not getting enough sleep and demand something to be done straight away. They cannot handle this anymore. There is always a sense of urgency and as a GP, you always feel pressure to do something to relieve their distress.

There are some resources out there which I use as a guideline when I am under the pump from the parents or when I need some guidance:

Behavioural sleep problems in school aged children

Sleep health foundation has plenty of information about sleeping and children


The reality is that most parents want quick fix and when you tell them that there is no quick fix or you don't prescribe what they want. They get upset pretty quickly so parental rapport is very important at the beginning of the consultation.

Limp in Children : diagnostic strategy

Probability diagnosis

• post trauma/intense exercise causing strain syndromes
• ill fitting shoes
• Hip disorders, esp. transient synovitis
• Heel disorders (12-14 years)

Serious disorders not to be missed

• A. Toddlers
• DDH
• Child abuse
• Septic arthritis
• Foreign body (e.g. needle in foot)
• 4-8 years
• Perth's disorder
• Transient synovitis
• Adolescents
• SCFE
• Avulsion injuries (e.g. ischial tuberosity)
• Osteochondritis dissecans of knee
• Duchenne muscular dystrophy
• All groups
• Septic infections
• septic arthritis
• osteomyelitis
• tuberculosis
• Tumour
• Juvenile chronic arthritis
• Spinal disorders
• discitis
• fracture
• Pitfalls
• Foreign body 
• Osteochonndritis (aseptic necrosis)
• femoral head - Perthes' disorder
• knee - osgood-schlatter disorder
• calcaneum - sever disorder
• navicular - kohler disorder
• Myalgia 
• growing pains
• Overuse syndrome 
• patellar tendonopathy 
• Stress fracture
• Paget's disease 

Paget's disease

Paget's disease

• a chronic disorder of the adult skeleton in which new soft bone replaces localised areas of normal bone
• cause unknown 

Clinical features

• M:F ratio 2:1
• 95% asymptomatic 
• symptoms include joint pain and stiffness (e.g. hips, knees), bone pain (usually spine), deformity. headache and deafness
• Bone pain is typically deep and aching; it occurs at rest, particularly at night
• signs may include deformity, enlarged skull, bowing of tibia, waddling gait and hyper dynamic circulation 

Diagnosis

• Page's disease is diagnosed radiologically 
• early: lytic lesions or flame shaped, advancing lytic wedges in long bones
• late: mixed lytic and sclerotic areas, thickened trabecular, bone expansion, cortical thickening and deformity
• isotope bone scanning is more sensitive

Investigation (2)

• Plasma alkaline phosphatase
• Liver function tests
• Vitamin D levels
• Isotope bone scan
• Radiography of affected bones

Treatment 

• Asymptomatic disease dose not require treatment
• indications for treatment 
• pain 
• neurological complications 
• significant osteolytic lesions 
• involvement of long bones, vertebrae or base of skull 
• before surgery involving pagetic bones
• significant joint involvement 
• Recommended drugs
• zoledronic acid 5 mg single dose, given IV over 15 mins
• alendronate 40 mg daily, given orally for 3-6 months
• risedronate 30 mg daily, given orally for 2 months

References

1. John Murtagh p.747
2. http://www.racgp.org.au/afp/2012/march/paget-disease-of-bone/