Important topics in primary care Dr.shereenmohammed
GERD Most common cause is transient relaxation of LEF. Diagnosis can usually made by detailed history and confirmed by therapeutic challenge by antacids . If symptoms persists or in case of presence of risk factors endoscopy is indicated.
Irritable bowel syndrome Diagnostic criteria(Rome 2 criteria 1999): Abdominal pain or discomfort present for at least 12 weeks (not necessary consecutive) Two of the following: Change of the frequency of bowel movement Pain relieved by defecation Change in the form of stool
Treatment Establish strong physician –patient relationship Dietary manipulation Antispasmodic,anticholinergic ,tricyclicantidepressant,antidiarrhealagent,osmotic laxatives Reassurance regarding the benign nature of the condition (supportive psychotherapy)
headache Can be classified into primary and secondary Primary(examples) :migraine with or without aura, tension headache, cluster headache. Secondary: due to another disorder. (examples):trauma, vascular disorder, intracranial disorder,infection,ENT causes ,intracranial disorders
Vaginal discharge Vaginal candidiasis: thick white cur dish discharge.Treatment:topical azole agent .oral fluconazole 150. Bacterial vaginosis:thin grey homogenous fishy odor.Treatment:Metronidazole 500 twice daily for one week or clindamycin topically agents Trichomoniasis(STD):Copious ,frothy yellow green discharge.metronidazole for one week .Treat partner at same time
OCP Contraindications( category 4refrain from use) Venous thromboembolismCerebrovascular or coronary artery diseaseStructural heart diseaseDiabetes with complicationsBreast cancerPregnancyLactation (<6 weeks postpartum)Liver diseaseHeadaches with focal neurologic symptomsMajor surgery with prolonged immobilizationAge >35 years and smoke 20 cigarettes or more per dayHypertension (blood pressure of >160/100 mm Hg or with concomitant vascular disease)
Category 1 (no restrictions) Postpartum >=21 daysPostabortion, History of gestational diabetes Varicose veins Mild headaches Irregular vaginal bleeding patterns without anemia Past history of PID Current or recent history of PID Current or recent history of STD Increased risk of STD HIV-positive or at high risk for HIV infection or AIDS
Benign breast disease Family history of breast cancer or endometrial or ovarian cancerViral hepatitis carrierUterine fibroidsPast ectopic pregnancyObesityThyroid conditions
Dysmenorrhea Primary dysmenorrhea:begins within 3 years of the onset of menarche .It is due to increased level of prostaglandin Secondary dysmenorrhea :associated with pelvic pathology .Onset is usually later in relation to menarche .It is caused by endometroisis,adenomyosis ,PID,endometrial polyp ,Myomas,cervical stenosis and presence of IUCD.
Amenorrhea Primary amenorrhea: no menses by age of 14 in the absence of secondary sexual development or no menses by age of 16 in the presence of sexual development . Secondary: absence of menses for three months in women with previously normal menstruation and for nine months in women with previous oligomenorrhea. Secondary amenorrhea is more common than primary amenorrhea. primary Evaluation of secondary :history and exam, pregnancy test,TSH ,prolactin .
Depression Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning. At least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure. 1. Depressed mood 2. Diminished interest or pleasure 3. Significant weight loss or gain, or increase or decrease of appetite 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation
6-Fatigue or loss of energy 7. Feelings of worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate; indecisiveness 9. Recurrent thoughts of death, suicidal ideation, suicide attempt, or specific plan for suicide
Somatization disorder Diagnostic clues include multiple physical complaints with onset before the age of 30 years. These include each of the following: pain symptoms, GI symptoms, sexual dysfunction ,pseudo neurological symptoms. There is impairment of social or occupational functioning associated with these symptoms.
Common cold Most common problem presented in primary care. Rhinovirus is the most common pathogen (30-40%)influenza,parainfluanza,and RSV (15%) The combination of rhino rhea ,cough, congestion ,sneezing, and sore throat in the absence of high fever ,cervical nodes or an exudates virtually rules out streptococcal pharyngitis. Antibiotics have no role in the treatment of uncomplicated URI
Rhino sinusitis Causes include allergic,viral,bacterial and other organisms Acute bacterial rhino sinusitis is distinguished from viral mainly by presence of symptoms longer than 10 days from the onset of URTI or worsening of rhino sinusitis after period of improvement Treatment: mild disease no antibiotics only symptomatic by decongestant and or intranasal steroids
Otitis media Diagnosis: Recent abrupt onset of signs and symptom of middle ear inflammation and effusion Middle ear effusion indicated by limited mobility of the tympanic membrane ,bulging of the tympanic membrane, air fluid level or otorrhea. Middle ear inflammation indicated by distinct otalgia or distinct erythema of the tympanic membrane
Decision to treat is based on severity of illness ,certainty of diagnosis and age of the patient. The first line treatment is amoxicillin in high dose.
Osteoporosis Important risk factors: Age older than 65 Postmenopausal or hypo estrogenic state (early menopause or bilateral oophorectomy) Low body weight Cigarette smoking White or Asian race Sedentary life style Chronic use of some medication (anticonvulsants ,steroids) History of fragility fracture in first degree relative
Assess total Fasting lipid profile Normal profile LDL<2.6mmol/L LDL>2.6mmol/L R/O 2ry causes Screen every 5 years Assess risk factors CHD or equivalent risk LDL Goal < 2.6mmol Multiple risk factors+2 LDL goal < 3.36mmol 0-1 risk factors LDL goals < 4.1mmol A B C
Thyroid disorders Hypothyroidism is significantly more common than hyperthyroidism Subclinical hypothyroidism: elevated TSH levels in the presence of normal thyroid hormones Women are more likely than men to be affected by thyroid disease Most common cause of hypothyroidism is Hashimoto’s thyroiditis For elderly patients who has become depressed consider hypothyroidism
DM Diagnosis : Symptoms of DM and random blood sugar more than 11.1 2 Fasting more than 7 2 hour plasma glucose more or equal than 200 in GTT
Back pain Common diagnosis: Mechanical LBP or strain: pain in low back buttock or posterior thigh increased with activity or bending .examination: localized tenderness limited spinal motion.
Acute disc herniation :acute onset, sharp burning radiating pain ,increased by coughing straining and forward bending. Examination :positive straight leg raising ,possible weakness or asymmetric reflexes.
Spondylosis:stress fracture of the pars interarticularis ,seen mostly in athletes who perform repetitive spinal extension.
Spinal stenosis: pain aggravating by walking relieved with sitting and spinal flexion .examination: limited or painful spinal extension.
Anemia Classification based on cause: 1-production problem(IDA,thalasemia) 2-Destruction problem(SCD,spherocytosis) 3-Bloood loss problem(GI bleeding)
IDA Most common cause of anemia In premenopausal women is mostly due to excessive menstrual bleeding. In males and postmenopausal should consider GI bleeding until proved otherwise. Treatment should continue for 3-6 months.
A 40-year-old female comes to your office with a several-year history of lower abdominal pain associated with constipation (one hard bowel movement every three days) and the passage of mucus per rectum on a regular basis. She states that her abdominal pain feels better after she has a bowel movement. She has never passed blood per rectum. no fever, chills, weight loss or gain, jaundice, or any other symptoms. There is no relationship between the abdominal pain and specific food intake. On physical examination, there is a very mild generalized abdominal tenderness, but it does not localize.
MCQ What is the most likely diagnosis? A-hypothyroidism B-Crohn’s disease C-Ulcerative colitis D-lactose intolerance E-irritable bowel syndrome
MCQ 45 years old male presented with 4 weeks history of recurrent severe headache that wake him up in the middle of the night .It last for about 1 hour .It is described as burning pain behind left eye and associated with watery eyes ,nasal discharge and redness of left eye .There is no recent life change or stress. You diagnose him to have cluster headache .