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/

Approach to hoarseness

History

- Red flags (please see figure 1)
- Presence of heart burn?
- Any recent upper respiratory infection ?
- steroid inhaler user? Gargling after each use?
- Recent injury / surgery to the neck?
- Recent intubation?
- Other systemic diseases: hypothyroidism, neurological disease such as parkinson's disease or myasthenia graves, and inflammatory or autoimmune conditions, such as rheumatoid arthritis.


Examination
- listen to the voice and note the quality, pitch and volume
- Ask the patient to sustain the vowel sound 'ah' for as long as they can and time it, < 8 secs is usually pathological
- Ask the patient to cough and listen to the quality
- During the respiratory examination, listen to stridor
- palpate the neck and thyroid for any masses
- other systems, if indicated

Investigation and management
-

Reference:

APF 2016 June Approach to hoarseness