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Common
Symptoms/Complaints in
Family Medicine
Medicine and Skin
Dr Edmond CW Chan
Medicine
 Dizziness
 A 69 yo woman who has no children and her
husband has married again 2 years ago and he
has migrated to USA. She has 5 years history of
NIDDM and HT and now on Diamrion 80mg BD
and Natrilix 2.5mg om
 She complained severe dizziness for few days.
Reviewed the has history, she has repeatedly
attended to A&E for dizziness in recent 2 years.
What questions will you ask?
 Definitioin of dizziness
 Vertigo
 Posture:
 Tinnitus: which ear?
 Balance
 Severity:
 Associated symptoms: N, Vomiting, pallor, sweating chest
pain, palpitation, neurological symtoms
 Drugs hx
 psychosocial
Physical examination
 Cardiovascular system:
BP: supine and erect(S:20;D:10)
both arms
Pulse: regular or irregular
heart murmur, carotid bruit
CNS:
muscle power and tone, gait
eyes movement, Nystagmus
cranial nerves V, VIII ( corneal reflex)
cerebellar signs
 Features of cervical spondolysis
 Otoscope:
ear wax
chronic otitis media
 Hearing test: Rinne’s test and Weber’s test
 Other systems to look for any primary tumor
( probably brain secondary)
Further investigations
 CBP
 Na, K, H’stix, glucose and HbA1c
 Head tilt test: starting from sitting position to hyperextend
the neck when lying supine and turned the head to one side
Vertigo and nystagmus
adaptation
 ECG
 Caloric test
 Others like X-ray, CT brain, MRI, autonomic functional
test etc if indicated
Differential diagnosis
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Vertigo:
Benign positional vertigo
Vestibular neuronitis (without tinnitus or deafness)
Acute labyrinthitis (hearing loss)
Meniere’s syndrome (vertigo, tinnitus,
sensorineural deafness, recurrent episodes)
 Acoustic neuroma
 Brain stem migraine
 Multiple sclerosis
Differential diagnosis
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Pseudovertigo:
Drugs
Anaemia
Perimenopausal syndrome
Postural hypotension
Cardiac arrhythmias
Complete partial seizure
Brain secondary
Psychosocial
Vestibular neuronitis
 Usually a viral infection of vestibular nerve
causing a prolonged attack of vertigo lasting for
several days
 Can be severe enough for asking admission
 Precedes with some URI symptoms (viral
infection)
 Without tinnitus or hearing loss
 Abrupt onset with nausea, vomiting, dizziness and
vertigo
 May take 6 week or so to subside
 Nystagmus present because of involving the
vestibular system
 DDx: Acute labyrinthitis
Tx: Stemetil 1 tab tds or im if severe
beware of extra-pyramidal side effects
relieved by benadryl diphenhydramine
Meniere’s syndrome
 Usually over diagnosed
 30-50 aged group
 Paroxysmal attacks of vertigo, tinnitus, nausea and
vomiting, sweating and pallor, sensorineural
deafness
 Abrupt onset
 Lasts 30 mins to several hours
 Variable interval between attacks, recurrent
episodes
 Nystagmus (usually opposite to the affect ear)
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Treatment:
explanation and advice on stress management
Avoid coffee and smoking
Low salt diet
Drug: cyclizine 50mg tds
Betahistine (Serc 8-16mg tds)
 Refer to ENT for persistent Meniere’s syndrome
for any surgical treatment such as operative
decompression of the saccus endolymphaticus or
labyrinthectimy
Benign positional vertigo
 All age group
 Recurs periodically for several days
 Brief and subsides rapidly (changing position or
adaptation)
 Not associated with nausea, vomiting or deafness
 Treatment: explanation and reassurance
avoidance measures
Palpitation
 A 46 yo woman, single, working as accounting
manager, chronic smoker with BMI >28 has
history of thyrotoxicosis 20 yrs ago and has been
put on Carbimazole but stopped for more than 5
yrs because of normal TFT. She has complained
occasional palpitation for recent few months.
Previously she has experienced chest discomfort
but did not seek for any medical help.
What questions will you ask?
 For discussion
Physical examination
 General appearance:
Xanthoma/Xanthelasma/arcus senilis
BMI
Goitre
Anxiety/depressed
sweating, pallor
 CVS:
BP
pulse: rate, volume and regularity
JVP
heart murmurs, mid-systolic click
carotid bruit
Any signs of thyrotoxicosis
Any signs of infection
Further investigation
 For discussion
Differential diagnosis
 Sinus tachycadia:
fever
anaemia
perimenopausal
Thyrotoxicosis
Phaeochromocytoma
Carcinoid syndrome
Porphyria
Anxiety/Depression (effort syndrome)
Drugs, tea, coffee, alcohol, cigarette smoking
 Paroxysmal bradycardia:
Sick sinus syndrome
heart blocks
 Paroxysmal tachycardia:
supraventricular (narrow QRS)—
Atrial ectopics
SVT
Atrial flutter
Atrial fibrillation
Wolff-Parkinson-White syndrome
Ventricular (wide QRS)—
Ventricular ectopics
Ventricular tachycardia
Ventricular fibrillation
Note: It is important to look for the underlying cause
of each arrhythmia and the provoking factors
Supraventricular tachycardia:
 Rate: 150-220/min
 Sudden onset
 Passing copious urine after an attack (ANP)
 Predisposing factors: thyrotoxicosis, WPW
 Treatment:
carotid sinus message (no carotid bruit)
valsalva maneuver
immersion face to water
drink a glass of ice water
Verapamil/Diltiazem (monitor BP)
DC cardioversion (haemodynamically unstable)
Wolff-Parkinson-White syndrome
 Risk of sudden death
 Congenital abnormality with bundle of Kent
 Can present with SVT or AF
 EPS and radiofrequency ablation of the abnormal
pathway
Atrial fibrillation
 Common causes of AF:
IHD
Thyrotoxicosis
Valvular lesions like ASD, mitral valve disease
Alcohol-related heart disease
impaired ventricular function
Idiopathic
AF
 Acute or chronic?
 Sinus rhythm converted or ventricular rate control ?
 Chemically converted or DC cardioversion?
 Anticoagulant?
 Risks: disease itself and the treatment
Chest Pain
 A 40 yo man, chronic smoker and social drinker
who is working in the construction site. He has
history of epigastric pain with PPU and patch
repair done 5 years ago. Incidentally AXR found a
small radio-opaque asymptomatic gallstone. He
complained sudden onset of chest discomfort for
few hours during duty and then run to your clinic
for medical help.
 DDX and immediate treatment?
What questions will you ask?
 Site: retrosternal, epigastric, superficial
 Onset: acute, progressive, crescendo, chronic
 Quality: crushing, tight, heavy
 Duration: Angina-few mins, Infaration >30mins
 Radiation:
jaw, shoulders: angina/infarction
back: dissecting aneurysm/PPU/acute pancreatitis
dermatome: shingles
 Aggravating factors:
supine– reflux oesopagitis
exercise, emotion, large meal, sexual intercourseangina
inspiration—acute pericarditis
 Relieving factors:
rest, TNG —angina/oesophageal spasm
leaning forward– acute pericarditis
antacid, standing up, belching --GRED
 Associated symptoms:
SOB, palpitation, headache, fatigue, sweating,
ankle swelling, nausea and profound vomiting
 Risk factors:
smoking, alcohol, occupation, lifestyle, obesity
 Family history: lipid, Marfan’s
 Medication: TNG, Antacid, OCP
 Life events and worries: cardiac neurosis
Physical examination
 For discussion
 General appearance:
P/E
 CVS:
 Chest:
 Abd:
 Others:
Further investigation
 For discussion:
Differential diagnosis
Consider anatomically from the skin to deep inside and the referral pain
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Skin infection or inflammation
Costochondritis/ Ribs fracture
IHD (Angina/MI)
Acute pericarditis
Dissecting thoracic aorta
Pneumothorax
Reflux oesophagitis/oesophageal spasm
Peptic ulcers
Gallstones diseases, pancreatits, shingles
Cardiac neurosis/Effort syndrome
Pectoris angina
 Sudden onset of retrosternal chest pain radiating to
the jaw or left shoulder lasting 3-5mins only and
relieving by rest and TNG, aggravated by exertion.
 Risk factors found
 P/E unremarkable
 ECG: no change at rest
 Further investigation like TMT and echo
 TNG and risk factors modification
Myocardial infaraction
 Sudden onset of restrosternal chest pain at rest
lasting more than 15 mins associated with distress
and not relieved by TNG
 Beware the painless presentation in DM
 ECG: ST elevation, T wave inverted and
pathological Q-wave
 Elevated CE: CK, AST, LDH
CK-MB, Troponin I/T
 Echo: EF, akinesia, valvular lesions
 Medical treatment:
Streptokinase
Symptoms control: Morphine, nitrates
Aspirin
Beta-blockers
 Risk factors modifications
 ? Primary PTCA
 CABG
 Cardiac rehabilitation
Common skin problem in FM
 Diagnosis in dermatology mainly based on
 Clinical history
 Morphology
 Distribution
 Further investigation
Dermatology terms
 Macule: skin colour change without elevation
 Papule: palpable elevation <5mm
 Nodule: palpable mass >5mm
 Plaque: palpable plateau-like elevation >2cm
 Vesicle: small blister <5mm of clear fluid within
or below the epidermis
 Bulla: larger vesicle >5mm
 Pustule: visible collection of free pus in a blister
 Wheal: an area of dermal odema
 Crust: dried serum and exudate
 Excoriations: lesions caused by scratching that
results in loss of the epidermis
 Erosion: superficial break in the epidermis not
extending into the dermis
 Ulcer: extending into the dermis
 Lichenification: chronic thickening of the skin
with increased skin markings
Eczema/Dermatitis
 3 hallmarks:
 1) pruritus
 2) ill defined border of the lesions
 3) epidermal elements:
Acute, subacute– papules, vesicles, weeping
Chronic– lichenification, xerosis, scaling
 Endogenous vs exogenous
Atopic eczema
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Chronic, relapsing, pruritic disorder
10% population, Strong genetic predisposition:
Associated with asthma, hay fever, allergic rhinitis
Elevated serum IgE in 80%
Infantile type:
1-6 months
Itchy scaly weeping lesions over the face, trunk,
extensor of elbows and knees
 Remit between 2-5 yo (50 % by 5 yo)
Actopic eczema:
 Childhood type :
 Lichenification at antecubital, popliteal fossa, nape
of neck
around adolescence (80% by 10 yo)
 Adult type:
 Poor prognosis
 Bad prognostic factors: strong family hx, onset
after 2yo, social & maternal deprivation, discoid
type, extensor area, associated with ichthyosis
Treatment:
 General:
 Explanation and reasuurance
 Avoid soap or detergents
 Avoid irritating woolen clothing
 Avoid sudden temperature & humidity change
 Removal of common allergens (house dust mite)
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Emollients: (use adequately and frequently)
Aqueous cream, emulsifying ointment
Urea cream (also as humectant)
Topical steroids:
Avoid potent one
Oral antihistamines: piriton, clarityn
Topical /systemic antibiotics: aureomycin, fucidin,
bactroban, cloxacillin, macrolides, quinolones
 Tar onitment or bath
Tinea
 Common superficial fungal infection
 Incidence high in summer
 Individual susceptibility
 Chronic itchy erythematous scaly lesions with
active margin
 Cause agents: trichophyton, microsporum,
epidermatphyton
 Diagnosis: clinical picture, skin scarping, Wood’s
lamp (tinea capitis)
 Tinea capitis: scalp
 Tinea pedis: feet, toe web
 Tinea manuum: hand
 Tinea unguium: nail
 Tinea crutis: groin
 Tinea corporis: trunk
 Tinea faciale: face
 Treatment:
 Topical: Imidazole, Allylamine, Whitfield
onitment, tolnaftate
 Systemic:
Griseofulvin
Imidazole (ketoconazole, miconazole)
Triazole (itraconazole, fluconazole)
Allylamine (terbinafine)
 Usually use for longer term and beware the LFT