(i) Common infections (URTI, otitis media, diarrhoea)

(ii) Common skin problems (atopic eczema, napkin rash)

(iii) Common childhood problems (abdominal pain, enuresis, headache, asthma)
(iv) Preventive Paediatrics (advice on immunization)
2)URTI, hypertension, DM, allergic rhinitis, gastroenteritis, eczema, asthma, OA knees, hyperlipidaemia, dyspepsia, low back
pain, and depression

Motivational interview: RULE

Resist the righting reflex;

Understand the patients own motivations;

Listen with empathy

Empower the patient.

the importance of change for the patient (willingness) the confidence to change (ability) whether change is an immediate priority (readiness).

What concerns does he have about the effects of his drinking? What future goals or personal values are impacted by his drinking?
If you can think of a scale from zero to 10 of how important it is for you to lose weight. On this scale, zero is not important at all and 10 is
extremely important. Where would you be on this scale? Why are you at ____ and not zero? What would it take for you to go from ___ to (a
higher number)?

disadvantages of the status quo advantages of change optimism for change and intention to change

OARS: The basic skills of motivational interviewing

Example
Ask Open-ended questions*
I understand you have some concerns about your drinking. Can you tell
The patient does most of the talking me about them?

Gives the practitioner the opportunity to learn more about what the Versus
patient cares about (eg. their values and goals)
Are you concerned about your drinking?

Example
Make Affirmations
I appreciate that it took a lot of courage for you to discuss your drinking
. Can take the form of compliments or statements of
with me today
appreciation and understanding
You appear to have a lot of resourcefulness to have coped with these
. Helps build rapport and validate and support the difficulties for the past few years
patient during the process of change
Thank you for hanging in there with me. I appreciate this is not easy for
. Most effective when the patients strengths and you to hear
 efforts for change are noticed and affirmed
Use Reflections*
Involves rephrasing a statement to capture the
implicit meaning and feeling of a patients statement
Encourages continual personal exploration and
helps people understand their motivations more fully
Can be used to amplify or reinforce desire for
change
Use Summarising
Links discussions and checks in with the patient
Ensure mutual understanding of the discussion so
far
Point out discrepancies between the persons current intake, and youve had some feedback from your partner that she isnt
situation and future goals
Demonstrates listening and understand the patients
perspective
Example
You enjoy the effects of alcohol in terms of how it helps you unwind
after a stressful day at work and helps you interact with friends without
being too self-conscious. But you are beginning to worry about the
impact drinking is having on your health. In fact, until recently you
werent too worried about how much you drank because you thought
you had it under control. Then you found out your health has been
affected and your partner said a few things that have made you doubt
that alcohol is helping you at all
Example
If it is okay with you, just let me check that I understand everything that
weve been discussing so far. You have been worrying about how much
youve been drinking in recent months because you recognise that you
have experienced some health issues associated with your alcohol
happy with how much youre drinking. But the few times youve tried to
stop drinking have not been easy, and you are worried that you cant
stop. How am I doing?
 . What worries you about your blood pressure?

. What difficulties have resulted from your
status quo
drinking?
. In what way does your weight concern you?
I guess, if Im honest, if I keep drinking, I
am worried my family are going to stop
forgiving me for my behaviour

How would you like your health to be in 5

years time?

What are the advantages of reducing your If I lose weight, at least I wont have to
Advantages of change wake up feeling guilty every morning that I
drinking?
am not taking care of myself
What would be different in your life if you
lost weight?

When have you made a significant change in your life I did stop smoking a few years ago for a
before? How did you do it? year and I felt so much healthier. It was
Optimism for change
really hard, but once I put my mind to
What strengths do you have that would help you make a
something I usually stick at it
change?

In what ways do you want your life to be I never thought I would be living like this.
Intention to change I want to go back to being healthy and
different in 5 years? strong, with enough energy to enjoy my
friends and family. I want to manage my
 Forget how you would get there for a diabetes better
moment. If you could do anything, what would you
change?

Resist the righting reflex : tendency of health professionals to advise patients about the right path for good health.
Understand your patients motivations get a better understanding of the patients motivations and potential barriers to change.

Blamer Say nothing (let them vent, but dont encourage them)

Try to change the subject (oh, that reminds me.)

Make a non-commital response (You may be right )

You could make a flattering comment (Youve done a great job..)

To protect yourself, remain detached

Placater Blame may or may not work: Blaming may can also trigger a
stronger Placating response, if they feel too intimidated

encouragement and positive affirmation to help boost their self-

 esteem

Irrelevant Computer (super reasonable) stance until they switch, then

recalibrate to Placater or Blamer

stronger Distracter response in them

Sometimes can consider using physical contact to get

the patient to focus on the topic that you want to
discuss

Super reasonable blamer or placating stance,

1. Limit of anxiety

2. Limit of tolerance

3. Problems of living presenting as symptoms 4. Administrative

5. Preventive
1. Relevance - Encourage the patient to indicate why quitting is personally relevant.
2. Risks - Ask the patient to identify potential negative consequences of tobacco use.
3. Rewards - Ask the patient to identify potential benefits of stopping tobacco use.
4. Roadblocks - Ask the patient to identify barriers or impediments to quitting.
5. Repetition - The motivational intervention should be repeated every time an unmotivated patient has an interaction with
a clinician. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit
attempts before they are successful.

1. Ask - Identify and document tobacco use status for every patient at every visit. (You may wish to develop your own vital
signs sticker, based on the sample below).
2. Advise - In a clear, strong, and personalized manner, urge every tobacco user to quit.
3. Assess - Is the tobacco user willing to make a quit attempt at this time?
4. Assist - For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit. (See
Counseling Patients To Quit and pharmacotherapy information in this packet).
5. Arrange - Schedule followup contact, in person or by telephone, preferably within the first week after the quit date.

Alcohol:
CAGE: Screening for lifetime abuse/dependence; >1 (+)
answer 85% sensitive, 78% specific; Have you ever felt you should
Cut down on your drinking? Have you been Annoyed by criticism of
your drinking? Felt Guilty about your drinking or taken an Eye
opener first thing in the morning?

Show concern, give feedback: You are drinking more than is

medically safe & most adults drink less than you; my advice is to
quit or drink w/in healthy limits; EtOH likely causes your
GERD/HTN/fatigue
Engage: What do you think about your drinking? How do you feel
about cutting back?
Empathy: Quitting EtOH is difficult for many people
Options: A number of treatments are available including
medications, AA, counseling
Anticipate: What situations prompt you to drink? How can you
avoid them?
Follow-up: Let's schedule a f/u visit to track your progress
 RESPIRATORY / ENT

. Upper respiratory tract infection (URTI): viral / bacterial

. Acute pharyngitis

History Exam Counsel Treatment

non-suppurative throat culture Penicillin V

complications (e.g. or rapid
acute rheumatic fever) antigen children: 250 mg twice daily or TDS
and suppurative
complications (e.g. detection test Adolescents: 250 mg 4 times daily or
peritonsillar abscess, (RADT) 500 mg BD
and mastoiditis);
For 10 days

splenomegaly, Amoxicillin, oral

hepatomegaly,
Centor or McIsaac
or jaundice, 50 mg/kg once daily (max = 1000 mg) or 25 mg/kg (max = 500 mg)
scores rash (EBV, twice daily
acute HIV),
GAS pharyngitis is
significantly lower for
children under 3 years
amoxicillin 500 mg BID 10
of age
d, cephalexin 500 mg BID 10 d, clindamycin 300 mg TID 10 d;

Outbreak

Benzathine penicillin G, intramuscular

<27 kg: 600,000 U 27 kg: 1,200,000 U

stat

Azithromycin
 12 mg/kg once daily (max = 500 mg)

5 days

acetaminophen

except very rare infections by certain organisms such as Neisseria

gonorrhoeae and Corynebacterium diphtheria, antibiotic therapy is
of no proven benefit as treatment for acute pharyngitis caused by
other bacterial pathogens other than GAS.

Anti-streptococcal Antibody Titers

. Allergic rhinitis

History Exam Counsel Treatment

Itchy, runny, sneezy (often HEENT + skin (atopic Avoidance of allergens

paroxysmal), stuffy, post nasal drip;
dermatitis) & lung (asthma) Physical barriers
Minimizing Pharmacotherapy
itchy eyes & palate conjunctival hyperemia
upholstery & fabric
clear d/c (allergic
conjunctivitis), infraorbital reservoirs . Chlorphenamine, : less
Seasonal (grass, tree, weed pollens) vs. Regulation of
shiners anticholinergic
perennial (house dust mites, Ears: Serous otitis media humidity
(Eustachian tube dysfunction) Heat treatment
cockroaches, animal dander)
Symptoms : intermittent? Persistent
r/o rhinitis medicamentosa
Sleep disturbance,
impaired school/work performance,
impaired daily activities,
troublesome sx
.
Nose: Saddle-nose deformity
(Wegeners) or septal
deviation (trauma)
pallor of mucosa,
pallor/edema of turbinates;
allergic
salute Nasal saline irrigation
Insecticides & . diphenhydramine,
allergen-denaturing
promethazine, loratadine,
agents
cetirizine
Valuable adjunct: Mast cell stabilizer: Sodium
cromoglicate (intranasal)
Intranasal steroid need Ipratropium bromide intranasal
1 week to work
Allergen immunotherapy
Intranasal steroids:
Beclomethasone, fluticasone,
mometasone
 . Asthma

History Exam Counsel Treatment

n FEV1 of 12% (or Situational
200ml)
Manage asthma
PEF rate exacerbations:

60L/min (or Repetitive

20% of the administration
pre- of rapid-acting
bronchodilator inhaled 2-
PEF)
agonist (begin
with 2

to 4 puffs
every 20
minutes for
the first hour

then 4 puff q 3hr

severe: 10 puff q 2 hr

Physical activity is a
common cause of
asthma symptoms but
patients should not
avoid exercise
 newly
diagnosed

step 2 treatment

ask about home environment

cockroach

occupation

ask for gerd

GERD Control: 2 wk trial of
omeprazole 2040
Extra-esophageal: laryngitis, cough, asthma, (& possibly Abd obesity, smoking, mg QD as sensitive
sinusitis, pulm EtOH use, overeating; as 24
fibrosis, pharyngitis, recurrent otitis media) physiologic: Hiatal h pH monitoring in pts
hernia, LES w/ erosive
pressure, delayed esophagitis
gastric emptying,
loss of esophageal 30 mins prior to 1st
peristaltic function, meal
gastric hypersecretion
assoc w/ serum
avoid: gastrin, atrophic
e.g.: Chocolate, gastritis,
peppermint, onions, malabsorption (
garlic, carbonated Mg, Ca); may
drinks, citrus drinks, risk of C. diff
tomato products, fatty infection,
foods, large meals osteoporosis
lower LES tone ! not for patient on
clopidogrel

Ranitidine 150 mg
PO BID
.

. Chronic obstructive airways disease (COAD)

. Otitis media (OM): acute / chronic / serous

History Exam Counsel Treatment

The presence of - Bulging of the tympanic Acetaminophen and ibuprofen

middle ear effusion, membrane
which is
- Limited or absent
- Otorrhea mobility of the tympanic
membrane
- Air-fluid level behind
the tympanic membrane
refrain from smoking.
breastfeeding may reduce
the risk of their child
developing otitis media with
effusion
Grommet insertion is not a
contraindication to
swimming.
amoxicillin is used, the dose should be 80 to 90
mg/kg per day.
standard 10 days therapy for children less than 2
years and for those with severe disease ; in adult
500 mg PO TID 710 d (1st-line)
>6 yo one week

Come reer if not resolve in 3

middle-ear inflammation
as indicated by either
- Distinct otalgia
months
Alternative for penicillin allergy
>4 in 6 months referred to an
otolaryngologist Non-type I: cefdinir,
- erythema of the
tympanic membrane or cefuroxime, cefpodoxime,

crying alone may result in type I: azithromycin, clarithromycin

a transient hyperemic
tympanic membrane that
mimics AOM.
Pure tone audiometry
Pneumo-otoscopy
assess the hearing and its impact on speech
development

air bone gap of about 30 dB for fluid filled

 Decongestants, antihistamines or mucolytics
should not be used in the management of
OMEAOM

topical or systemic steroid therapy is not

recommended

Tinnitis Vascular disorders Tinnitus retraining therapy

Dural Avf or carotid sinus

fisutlar Masking devise

jaw joint (called the

temporomandibular joint), Petrous carotid system
severe anxiety, and neck bruit
injuries Biofeedback : control certain body functions,
Age-related hearing such as heart and breathing rate
loss : cochlear implants
= Presbycusis
Noise-induced hearing Reaction to tinnitus
loss

Other causes of
auditory system
dysfunction
(otosclerosis , tumour in CBT
auditory system)

Depression/ insomnia
Investigate: CT?

Tympanometry and otoscopy

Eustachian tube
dysfunction

symptoms may disappear

when the patient lies dow
unusual awareness of
their own voice
(autophony) and of ear
discomfort

Drug: ototoxic medication

Vestibular
schwannoma

A high-pitched
continuous tone is by
far the most
commonly described
type of tinnitus. High-
pitched tinnitus is
frequently a result of
a sensorineural
hearing loss or may
suggest cochlear
injury.
Low-pitched tinnitus
is often seen in
patients with Meniere
disease, although it
also can be
idiopathic.

Vascular :

rushing, flowing, or
humming is usually
vascular in origin. Patients
often describe an
increase in frequency and
intensity with exercise,
and some may recognize
a connection with their
pulse. Changes in
intensity or pitch with
head motion or body
position (lying down
versus sitting or standing)
also strongly suggest a
vascular tinnitus.

 . Otitis externa

History Exam Counsel Treatment

Factors increasing the Tenderness of clean the canal and keep it empty and dry. cleaning the outer ear canal using suction
risk
tragus/pinna, ear canal o Avoid getting water in your ear. or a probe and then prescribing cream
edema or erythema,
o cotton wick coated with the healing cream
otorrhea, regional LAD, If water enters, shake it out or use
Swimming or water TM erythema or cellulitis of into the ear canal.
Aquaear drops.
exposure the pinna
o Use moulded earplugs or a
bathing cap when swimming. P. aeroginosa > S. epidermidis > S. aureus
Any trauma of ear
o Use earplugs or a cap when
canal incl. prior
radiation therapy showering.
Devices: Hearing aids, o Use earplugs when washing your Topical Aminoglycoside ototoxicity a
ear phones, ear plugs hair. concern if tympanic membrane perforation
o Coat cottonwool with petroleum
Underlying Consider fluoroquinolone
jelly (Vaseline) before insertion in ears.
dermatologic/systemic o Avoid poking objects such as
condition hairpins and cotton buds in the ear to
clean the canal.
o The ear usually cleans itself
naturally. Do not attempt to clean it and
risk infection of the canal or damage to
the eardrum. If you have a problem,
contact your doctor for advice and
treatment.
o
Cerumen impaction Inspect auricle, mastoid, Explain: Cerumenolytic agents: olive oil/ plain
canal, TM, pneumatic Obstruction due to ear canal disease mineral oil
otoscopy for Narrowing of ear canal Irrigation: saline + water
Hearing loss, ear ache, drum mobility
ear fullness, dizziness, Failure of epithelial migration Manual removal
Overproduction
pruritus, tinnitus

Hearing loss:
Occupational noise
inflammation OE
exposure;
ototoxic meds also conductive
(salicylates, NSAIDS,
APAP, Exostosis: external canal
aminogylcosides
osteoma

Duration, sidedness &

symmetry, pain,
otorrhea,
head/ear trauma,
acoustic trauma

. Eustachian tube dysfunction

History Exam Counsel Treatment Prevention

intermittent blockage auto-inflation

in the ear, popping,
squelching, ringing, Yawning and swallowing
a feeling of fluid also help to open the
running from the ea Eustachian tube.
Recurrent sniffing should
be avoided because this
tends to remove air from
the middle ears down the
Eustachian tubes,
hear their own voice making the symptoms
amplified within their worse.
head when they talk
Otovent Balloon: blow
up balloon using nose

hearing test normal

stop inflammation:
feeling of fluid coming oral steroids, nasal
out but not physically saline

rinses and nasal

steroid sprays etc.

antihistamines,

formal allergy
testing and
 desensitization by
an Allergist.

. Sinusitis Cough Acute: consider URTI, acute bronchitis / pneumonia, acute sinusitis, asthma (acute flare)
Chronic: consider TB, carcinoma, post nasal drip (allergic rhinitis, chronic sinusitis), asthma (poorly controlled or new
diagnosis) Nasal discharge obstructions Remember nasopharyngeal carcinoma as an important cause of recurrent
symptoms. Cold remedies often contain sympathomimetics and these may cause palpitations and aggravate blood pressure
control. Sore throat The most common cause is viral (90%). If a bacterial cause is suspected, penicillin V is the treatment
of choice as Streptococcus pyogenes is by far the most frequent causal bacterium. Infectious mononucleosis is rare in the
Chinese population, but should be borne in mind in young adults. Earache discharge It is important to follow-up
children with acute OM as chronic serous OM can develop as a complication. This often results in hearing loss and delayed
speech development in young children.

. CARDIOVASCULAR

.
 . Hypertension

History Exam Counsel Treatment Prevention

3 Or More Properly Correcting Referral:

Measured Seated
BMI risk factors e.g.
Blood Pressure Malignant hypertension
Readings, At cut-off lifestyle
Least 1 Week points of modification, DBP > 130mmHg
Apart On Office 23 kg/m2 smoking
and 27.5 Heavy proteinuria
Visit 6. cessation
kg/m2
Cigarette smoking were added Papilloedema
healthy eating:
as points
Dietary
for public Encephalopathy
Obesity Approaches to
health
Stop
action. Accelerated hypertension:
Physical inactivity Hypertension
(DASH) DBP > 130mmHg and retinal
hemorrhage
Dyslipidaemia
Persistent BP >
Diabetes mellitus , dietary salt
220/120mmHg despite rest or
restriction: less
than ve grams drug treatment Pregnancy:
Microalbuminuria
(around one
or estimated GFR teaspoon of BP 140/90mmHg and >
< 60 ml/min table salt) 20 weeks gestation

Age (older than 55 Signs and symptoms of

 for men, 65 for , regular pre-eclampsia (headache,
women) physical activity proteinuria, oedema)
and stress
Family history of management Suspected secondary
can reduce
essential hypertension
blood pressure,
hypertension and enhance
premature Patients aged 30 or
antihypertensive
cardiovascular drug efficacy, below
and reduce
disease (men under 55 cardiovascular Hypertension in
or women under risk. pregnancy of less than
65)
20 weeks gestation
without signs

Maintaining and symptoms of pre-

good blood eclampsia
pressure
control, and Patients with progressive
complications e.g. target
Monitoring organ damage
potential
Medication problems for
complications
example:
and timely
referral to o severe drug
specialist care reaction
 when o treatment
resistance
indicated.
o multiple drug
intolerance

o multiple drug
contraindication

Pregnancy
Ischaemic Heart Disease (IHD)
 The diagnosis of essential hypertension should be made only after several blood pressure readings have been taken over a period of
time. Management should always include non-drug therapies such as stopping smoking, weight reduction, balanced diet and exercise.

IHD is becoming increasingly common and hence attention to preventative measures is vital for those at risk.

GASTROINTESTINAL

History Exam Counsel Treatment

Lose weight, if . omeprazole 40 mg od

DYSPEPSIA appropriate.
Consider stress full dose 1 month
. non-ulcer or functional dyspepsia (6070%)
factors.

. peptic ulcer disease (1520%) . Review medication

(e.g. calcium
antagonists,
. gastro-oesophageal reflux disease (GORD) (1520%) nitrates,
theophyllines,
. upper GI cancers bisphophonates, . prokinetic agent (e.g.
corticosteroids metoclopramide or
and NSAIDs).
domperidone) for 1 month.
. relationship to food, periodicity, waking at night
. worse on lying flat . Stop smoking. . orr ranitidine 150 mg bd

vs gerd . Reduce coffee and

alcohol intake.
. worse on lying flat
GERD:

Elevate the head of the

bed. .
Red flag:

. chronic gastrointestinal bleeding Avoid eating late in

the evening.
. progressive unintentional weight loss
Avoid large meals.

. dysphagia

. iron deficiency anaemia (excluding NSAIDs and

menorrhagia)

. persistent vomiting

. epigastric mass

. suspicious barium meal.

Helicobacter pylori . Full dose PPI (e.g. lansoprazole 30
mg) bd amoxicillin 1 g bd
clarithromycin 500 mg bd for 7
days

Irritable bowel Abdominal Hb, ESR and FOBs .

exam should all be normal.
. abdominal pain (colonic or dyspeptic) and disordered bowel
habit (diarrhoea and constipation occurring alone or in
combination . constipation: laxatives, e.g.
reassure
ispaghula husk one sachet in
3 d/mo last 3 mos (w/ Discuss the nature of water bd
sx onset >6 mos prior to dx) & at least 2 of the following:
1. Improvement of sx w/ defecation the illness and its
2. Onset assoc w/ change in stool frequency relation to stress . antispasmodics, e.g.
3. Onset assoc w/ change in stool form or appearance mebeverine 135 mg tds 20
(relaxation minutes before meals, or
.
techniques, peppermint oil 12 capsules
. the passage of mucus
psychotherapy, etc.). tds
. the sensation of incomplete evacuation.
Discuss diet: . dysmotility symptoms (e.g.
bloating, nausea):
avoid foods which metoclopramide 10 mg tds
may exacerbate the prn
symptoms e.g. lactose
 intolerance

- fibre . diarrhea: codeine phosphate 30 mg

may 34 times
have
some use .

encourage a high- . TCA : central / visceral pain

fibre diet and plenty of
. . Constipation: give Polyethylene
fluids
glycol
. consider referral to a
. Diarrhea: rifaximin, loperamide
dietician for e.g. an
exclusion diet. . SSRI

Exercise is good . Antispasmodics : hyoscyamine

Constipatio . Stimulants, e.g. senna 28 tablets

nocte

. Bulk-forming agents, e.g. ispaghula

husk, are rarely necessary if
the diet is high in fibre. They
are useful for patients with
 colostomies, ileostomies,
haemorrhoids, anal fissure,
IBS, etc.

. Osmotic agents, e.g. lactulose 15 ml

bd or Movicol 13 sachets dail

. Stool softeners, e.g. liquid paraffin

and magnesium hydroxide
emulsion 20 ml prn

Gastroenteritis: viral / bacterial / parasitic, acute / chronic

79

Chronic hepatitis B carrier

Dyspepsia (ulcer / non-ulcer)

Gastroenteritis
History Exam Counsel Treatment

Investigation

Tropical vs. temperate Norovirus Antimotility agents /

climates (Calicivira) > antiemetics / antibiotics not
Rotavirus normally indicated
Nausea > diarrhoea > vomiting
(vaccinations!) >
> abdominal pain May have enteric
URTI symptoms (~10%) Adenovirus > For inflammartory:
Astrovirus
ciprofloxacin 500 mg BID
35 d) if: >50 y or
immunocompromised, fever
>102F, severe dysentery, sx
incubation < 48 h
>1 wk,
Red flags: Sx <3 mos duration,
severe dehydration
>5 kg wt loss, nocturnal
predominance, continual
Otherwise:
(rather than intermittent) sx,
(oral rehydration,
ESR,
loperamide, bismuth
anemia, albumin all suggest
subsalicylate; probiotics can
organic, not functional etiology stool freq &
duration of sx 24 h (
 Adequate rehydration is essential, especially in young children. Anti-diarrhoeal medications are never used in children
because of adverse effects. Dietary and / or meal habit advice is a very important, but often forgotten, area of management
in all digestive problems.

GENITOURINARY (GU)

Urinary tract infection (UTI)

History Exam Counsel Treatment

Investigation

Risk Refer if Reassurance &

explanation, Advice,
Symptoms Come back if Prescription, Referral,
Red flags Anticipatory care Investigations,
Observation,
Ddx Management Prevention.
Socioeconomic Necessary for compliance

ICE

Risk Suprapubic loin Refer if Phenazopyridine 200

mg PO TID
- sexually active ask contraceptive method tenderness
- older menopause - pregnant
prostatic hypertrophy Dipstick for protein - child
- Antibiotic may be
- men
Nirite unnecessary
Symptoms: suprapubic pain - catheterized
Leucocyte - fail to
Haematuria response to
Nitrofurantoin
Urinary incontinence antibiotic monohydrate
macrocrystals 100 mg
Acute retention of urine PO BID 5 d

Red flag: come back if loin pain

Trimethoprim 200 mg
Loin pain fever chills, vomiting >2 UTI ./ year bd or amoxicillin 250
prevention: cranberryjuice , mg tds for 3 days.
DDx: hydration? Postcoidal
Post menopausal :
voicd ; probiotic ; wiping
Atrophic vaginitis topical estrogen
front to back
Trauma from sex
Urethritis Management . nitrofurantoin 50
mg befre sex
Genital : candida chlamydia increasing fluid intake

DDx: urinating more frequently

Complicated UTI:
Gonococcal or Chlamydial urethritis using a lubricant with Ciprofloxacin 500 mg
Interstitial cystitis: frequent voids occurring over mos;
Irritants: Reaction to tampons,
intercourse PO BID/ 714 d in
Vaginal infections (i.e., trichomonas, candidiasis) or PID:
passing urine after
intercourse
Investigation: plain
improving perineal AXR
hygiene
Follow by USG
avoiding tight clothing urinary tract or IVU:
cortical scars
avoiding scented soaps,
bubble bath, etc.

- Contraception
History Exam Counsel Treatment

Investigation

Risk Refer if Reassurance &

explanation, Advice,
Symptoms Come back if Prescription, Referral,
Red flags Anticipatory care Investigations,
Observation,
Ddx Management Prevention.

Socioeconomic Necessary for compliance

ICE

Dysmenorrhea . common in young girls. . prostaglandin

within 12 months mefenamic
acid 250500
. smoking, overweight, alcohol and stress.
of the menarche.
mg
. within 12 months of the menarche. .
. COC
Red flags: Suspect 2o cause if onset > age 25 y, pain not related to
menses, AUB, nonmidline
dyspareunia, sx severity
referral to OB/GYN
.
 Secondary . speculum and . . r removing an in
bimanual situ IUCD.
examination
. everal years after the menarche. to exclude . mefanemic acid
any obvious 250-500mg tds
. impact to lifestyle pelvic prn
pathology.
. COC:

. Progestogen:
norethisterone
10-15mg daily

. GnRH analogues

Menohaggia . Bimanual . Hb . Menstrual diary

examination
Passing of clots +/- pelvic . Refer/ come back if onset . IUCD removal
ultrasound of menorrhagia
Tranexamic acid 1g
Anaemic symptoms sudden
. Serum FSH for tds /qds at start of
menopausal heavy bleeding
Coagulopathy . Not responding to
treatment Mefenamic acid
. Pap smear / test
Initial studies: Must r/o pregnancy (-hCG); CBC, TSH; if uterine for 250mg tds : at worst
enlargement or irregularities TVUS; consider w/u for nongenital tract chlamydia . Organic cause suggestion: few days of period
causes
COC : high
Endometrial biopsy: Indicated in perimenopausal women >45 y w/ progesterone diet
AUB, women <45 y w/ persistent abnl bleeding, hx unopposed
estrogen, or no response to Rx,

Primary amenorrhoea. (i.e. when the menarche has not started by the . Serum prolactin (raised in . Menopause:
age of 16 years): hyperprolactinaemia). estrogen cream

. Causes: familial, structural (e.g. imperforate hymen), genetic (e.g. Avoid using latex
Turners) and endocrine. . Serum FSH/LH (raised in
condoms,
diaphragms, or
premature
. Examine the external genitalia, and look for the development of cervical caps for
menopause). up to 72 hours
secondary sexual characteristics. after using
. Serum testosterone This medicine is
. Check weight to exclude anorexia nervosa. (slightly raised, along often used at
with LH and bedtime
sometimes prolactin, Vaginal creams
. Refer to a gynaecologist or suppositories
in polycystic
will melt and leak
ovarian syndrome).
. Secondary amenorrhoea. The usual cause is recent rapid weight out of the vagina-
loss, emotional upset or post-hormonal contraception, i.e. > sanitary
hypothalamic napkin will
protect your
. Always exclude pregnancy. The cause is otherwise nearly always . TFTs clothing.
hormonal. Do not use
. tampons (like
those used for
menstrual
periods) since
 they may soak
up the medicine
Avoid exposing
your male sexual
partner to your
vaginal estrogen
cream or
suppository by
not having
sexual
intercourse right
after using these
medicines.
For estradiol vaginal
inserts or rings:

not necessary to
remove the
vaginal insert for
sexual
intercourse
unless you prefer
to remove it.
can replace the
vaginal insert in
the vagina after
washing it with
lukewarm water.
Never use hot or
boiling water.
 If it slips down,
gently push it
upwards and
back into place.
Replace the
vaginal insert
every 3 months.

Cervical cancer Use of . Combined

combined oral contraception:
contraceptives for 5 years Yasmin:
or longer is associated with
. drospirenone/ethinyl
a small increased risk of
estradiol
cervical cancer

Breast cancer There is a . gallstones . heart

small increase in the risk of disease
having breast cancer associated with
diagnosed in women taking pulmonary
the combined oral hypertension or
contraceptive pill; this risk of
relative risk may be due to embolus .
an earlier diagnosis. history during
pregnancy of
more likely localize cholestatic
to the breast jaundice
 Vagina discharge . Candida: pruitic ; Bacterial: fishy
dysuria and smelling:
Candida and Gardnerella (bacterial vaginosis BV) , trichomatous dyspareunia metroconazole 400mg
TRICHOMONAS bd
. Vaginal discharge is not, in itself, an indication for chlamydia . topical . frothy and yellow.
testing clotrimazole .
500mg . Metronidazole 400 mg bd
Itching, burning, pessary for 5 days.
dysuria, vaginal d/c; : Penile itching/irritation nocte
Metronidazole 2 g PO 1 or Tinidazole 2 g PO 1; or
metronidazole 500 mg BID 7 d . Clotrimazole 1%
. for vulval

. Stop antibiotics

. Chlamydia Gonorrhoea Genital wart:

podophyllin for 4-6
. PID - PID? Do hours ad wash off
cervical every 3- 7days
. Tubal infertility excitation
- IM ceftriazone Imiquimod cream 3
. Ectopic times per week
Dual therapy: Ceftriaxone
pregnancy 250 mg IM 1 &
(azithromycin
. Doxycycline 1 g PO 1 or doxycycline
100mg bd 100 mg PO BID 7 d if cant
for 7 days or take
 azithromycin azithro)
1g

. Erythromycin
500mg qds

STD . Genital herpes : Syphilis

. valaciclovir 500 RPR

mg bd for 5 (FTAABS,
TPPA, ELISA);
days

. analgesia: Direct dark field microscopy

acyclovir
Firm, painless sore (chancre)
cream/ on genitals, anus, or
mouth;
.

Vaginitis: candidiasis, atrophic vaginitis etc.

Menstrual irregularity: menorrhagia, menopause etc.

r/o pregnancy (-hCG); CBC, TSH; if uterine

enlargement or irregularities TVUS; consider w/u for nongenital
tract causes
History Exam Counsel Treatment
 Sexually transmitted disease: trichomoniasis, herpes, HIV etc. Children with UTIs need to have their GU tract
investigated because of the potential of renal scarring. Antibiotics will often precipitate an episode of vaginal candidiasis
(thrush). If thrush is recurrent and there is no history of antibiotic prescribing, consider diabetes. STD is often
asymptomatic.

History Exam Counsel Treatment

Herpes bacterial superinfection 14% of individuals will Valacyclovir 1000 mg PO

of the skin have a 2nd episode of TID, famciclovir 500 mg PO
>50 yo, zoster; in TID, or acyclovir 800 mg PO
immunosuppression immunocompromised 5/d 7
(s/p transplant, pts ( d; time to resolution of
meningitis lesions if given within the
autoimmune disease,
immunosuppressive first 72 h,
medications esp MMF,
malignancy, HIV ),
grouped (herpetiform) immunocompromised hosts:
gender, trauma, stress
erythematous to Avoid contact with Treat all pts
violaceous edematous
papules
 pregnant lady
Prodromal HA & fatigue;
skin pain, burning,
itching often (Hutchinson sign
in dermatome

Ramsay Hunt syndrome):

in CN VII dermatome,
geniculate ganglion; p/w
ipsilateral facial
paralysis, ear pain,
occipital HA, vesicles in
the auditory canal &
auricle; numbness over
jaw, taste, vestibular
symptoms

NEUROLOGICAL

Headaches: migraine, tension headache etc.

History Exam Counsel Treatment

worst headache of my life
Change in characteristics
Ppt by valsalva maneuvers
New onset after 55 years of
age Post trauma
Fever
Stiff neck
pitfall:
ask for med overuse
Migraine
Migraine without aura:
Unilateral,
throbbing, modsevere intensity,
aggravated by routine activity;
may
progress to include allodynia
Foca neurological defect?
CNVI pulsy; mass venoussinus
thrombosis
Altered mental stus?
Papilloedema?
N/V
Headache diary: Tension:
triggers, pattern, freq,
assoc sx, & NSAIDs, APAP, ASA, analgesics
response to tx Prophy: TCAs (nortriptyline), biofeedback
Counseling: Avoid Cluster: Unilateral orbital/temporal pain,
triggers when possible, restless, worse w/ EtOH &
caution: re: use of nitro, 15 mins3 h attacks, typically clustered in
abortive
tx >23/wk med bouts of 7 d
unless chronic variant; Tx: Oxygen, nasal/SC
overuse HA
sumatriptan, nasal
lidocaine; CCB (verapamil) for ppx
Environment: Advise Triptans: 5HT agonists
quiet, dark room if Efficacy if given at HA onset, typically
episode occurs, ineffective if
avoid motion, stay pt has progressed to allodynia
hydrated; Meds: Take 100 mg sumatriptan
abortive Rx ASAP for
max Do not use w/in 24 h of ergot derivatives
efficacy; avoid using serotonin syndrome
>2/wk as can
overuse HA;
OCP for menstrual
trigger / not for aura
migraine
Aura L zig zag line Caffeine : also may overuse Headache

Metoclopramide

Opioid not recommended

Prophylaxis:

TCA: depression

Verapamil: HTN/ AF

Gabapentine

Propranolol

Topiramate

Pseudotumor cerebri (Idiopathic Dx: MRI w/ gad & MRV TxWt loss, acetazolamide, CSF
Intracranial HTN): > , age 20 (to r/o mass/VST), bland diversion (large-volume LPs, shunt)
40s, assoc w/ obesity, meds (Vit LP w/
A derivates, tetracycline, OCPs); opening pressure >25 cm;
S/sx: Worse w/ supine position,
blurred vision/grey spots,
pulsatile
tinnitus,
 Dizziness / vertigo

Weakness / parasthesiae: cerebrovascular accidents, entrapment syndromes, nerve palsies etc. Neurological
problems in family medicine covers a huge area and most often present with one of the above symptoms. Headaches and
dizziness are among the commonest and a recurrent or chronic presentation of these should alert the doctor to the possibility of
depression.

EYE

Conjunctivitis: bacterial, viral, allergic

History Exam Counsel Treatment

Excess: Warn cinoress

Ingrowing eyelash Swabbing with moisten cotton

wool
Hay fever
Foreign body Duct probing under anesthesia?

Correcrive surgery

tear drainage

URTI

Entropion

Ectropion

Block tear duct

. STYE . occluded Meibomian . warm steaming

gland if
chronic . Consider antibiotic eyedrops, e.g.
. red, painful swelling at the lid margin. chalazion chloramphenicol or fusidic
acid.
. lid erythema + focal palpable / tender
nodule

. ----

. Chalazion . Excision can be considered

a distance from the lid margin.

.
. Blepharitis
. Acute red eye
. Assess the level of pain.
. no= conjunctivitis
. subconjunctival hemorrhage
Painfu:
Corneal abrasion.
Dandruff like flakes on lashes ,
hyperemia
VA in each eye, level of
discomfort & photophobia,
presence of
lid edema and/or discharge,
diffuse or focal conjunctival
hyperemia,
pupillary reaction, EOM, corneal
clarity, anterior chamber
abnormalities
preauricular LAN
. avoid rubbing the eyes and pay
attention to cleaning the lid
margins with warm water.
. Baby lotion or diluted baby
shampoo wiped over the lid
margins / warm compress
. Treat associated seborrhoeic
dermatitis
. Erythromycin oint BID if severe
Herpes zoter infection .
Rash on nose ANGLE CLOSURE
GLAUCOMA
- periorbital
severely painful red eye, may be
- soreness
vomiting, and complains of having
of eyes seen haloes around lights.
4% pilocarpine drops every minute
for 5 minutes, then every 5 minutes
 Herpes zoster infection. Corneal abrasion: will reduce the intraocular pressure.

Arc eye/snow blindness. tetracaine drops, 500 mg of acetazolamide iv

Corneal foreign body. chloramphenicol ointment and an

eyepad initially.
Episcleritis and scleritis.

Acute glaucoma.

Acute iritis. Little or no photophobia

Acute keratitis. Fluorescein stain

. Ask about visual acuity. (Test if in Mild to moderate pain

doubt.) Is there any
discharge? Is there any
photophobia? Could there be a
risk of a foreign body in the eye?

Red flags for vision-threatening etiologies:

Severe pain &
photophobia, significantly vision relative
to baseline or worse than
20/200, recent eye surgery or trauma, abnl
pupil exam, corneal
opacities, acute sx onset in a contact lens-
wearer
. Conjunctivitis
Irritation, grittiness, dryness, itching,
stinging or soreness are common
complaints in conjunctivitis. In m
vasodilation of the
conjunctiva cobblestone
oedema of the conjunctiva under
the eyelids purulent discharge.
The eye should be kept . topical antibiotics, e.g.
clean. Hygiene advice chloramphenicol drops qds
is important. Treat with
. --> no response: fusidic acid
No contact lens wearing
eyedrops bd for a further
week.

. allergic: loratadine 10 mg od,

0.5% erythromycin oint QID 7 d

?

if severe bacterial : Ofloxacin

0.3% 1 gtt QID 7 d

. allergic: give artificial tear, topical

. antihistamine
 SKIN

Infections: bacterial, viral, fungal, parasitic

History Counsel Treatment

Fungal: If given steroid: Podiatry referral for onchomycosis

+KOH, +PAS
Microsporum, Trichophyton, and Epidermophyton. inflammatory response is PO terbinafine ( LFTs
decreased leading to the condition antifungal tincture (ciclopirox), PO
known as tinea incognito. check DM
Malassezia furfur, a skin commensal, can cause pityriasis no well defined margins and
versicolor and pityrosporum folliculitis. scaling faintly demarcated

tinea faciei: face;

tinea manuum: hands; diffuse hyperkeratosis; can be annular;

pompholyx like on palmar aspect; infection of only 1 hand is
common

tinea corporis: glabrous skin, pink-to-red annular or arciform

patches and plaques with scaly or vesicular borders ;expand
peripherally with a tendency for central clearing.

tinea cruris: crural folds;

tinea pedis

interdigital, moccasin, ulcerative and vesiculobullous.

Pompholyx like lesions on the hands are the classic

dermatophytid reaction.
Onychomycosis
Eczema: atopic, contact
History
an itchy skin condition plus 3
of the following:
visual flexural dermatitis
involving skin creases (or visible
dermatitis on cheeks and or
extensor areas in children 18
months)
personal history of flexural
dermatitis (for typical age
specific pattern as above)
dry skin in the last 12 months
personal history of asthma or
allergic rhinitis (or history of
Exam Counsel Treatment
Dry skin and Avoid exacerbating factors Emollients or Moisturisers
pruritus (skin
creases) Temperature, humidity, at least three times a day including after bathing
Excoriation and water, wool, stress, sweat, ceramides and pseudoceramides are developed
erythema targeting to the pathophysiology of atopic
Thickened skin astringents, detergents, solvents dermatitis
and fibrotic papules steroid sparing
Fissuring and
Protect (restore / hydrate) skin
lichenification Topical Corticosteroids (TCS)
Cotton, gloves; emollients:
the ointment base is more potent than cream base.
ointments, creams > lotions
mild TCS for areas prone to adverse effect including
face, neck, axilla and groin.
4. Face and neck: moderate or potent TCS for 3-
5 days
5. Axillae and groin: moderate or potent TCS
no more than 1-2 weeks
atopic disease in a first degree 6. Trunk and limbs: potent TCS for no more
relative of than 2 weeks

children <4 years ) Mild

onset of signs and symptoms hydrocortisone

under the age of 2 years Moderate

clobestasone butyrate
Identification of Triggers

Food allergy clinical history Potent

exacerbations of eczema 9. betamethasone dipropionate

include milk, eggs, 10. fluocinolone acetonide
peanuts, soy and wheat.
very potent:

betamethasone dipropionate in propylene glycol

clobetasol proprionate

Wet-wrap with Diluted TCS

 11. Topical Calcineurin Inhibitors
potential risk of the development of lymphoma
skin cancer

Tacrolimus (Protopic)* Pimecrolimus

(Elidel)**

Azathioprine

Check for low TPMT myeotoxic and hepatotoic

Phototherapy: UVA or UVB

Narrow band UVB and long wave UVA

Phototherapy is useful in older children with chronic

stages of atopic dermatitis

 cow's milk protein allergy (CMPA), a trial of

extensively hydrolysed or amino- acid formula for 6-8
weeks is recommended

Soy-based formula contains phytoestrogens and is not

recommended for children <6-10 months in UK and
some European countries.

Super potent Psoriasis clobetasol Not face, groin, axillae,

Hand eczema (Dermovate) under breasts

0.05% oint

High Adult eczema mometasone Same as above

(Elomet) 0.1% oint

Medium Children eczema mometasone Limit groin area

(Elomet) 0.1% cream

Low Eyelid Diaper area HC 1%

Rash: allergic, viral exanthems (chicken pox, roseola...)

 80

Acne Potent topical steroids are often abused and used for long periods unnecessarily.

Use only the mildest steroid cream on the face e.g., 12 or 1% Hydrocortisone.

MUSCULOSKELETAL

Back and neck problems: cervical spondylosis, lumbar disc problems...

History Exam Counsel Treatment

MSK pain . Tenderness in the neck muscles NSAIDs

Diazepam tablets 25 mg tds
. Weakness and wasting in the
. symptoms of pain or weakness in ?Sick leave needed?
arms or legs, which suggest
Lifestyle recommendation or
the arms or legs. a radiculopathy or
activity modification
myelopathy,
o Type of exercise or activity (e.g. R: Reassurance, Address
walking, swimming, cycling)
Less common but serious: concerns (bio-psycho- social)
o Intensity or Specific workloads
(e.g. watts, walking speed, target heart to relieve anxiety / stress
Neoplastic rate (THR) range and estimated rate of
perceived exertion (RPE) A: Advices on Activity
Neuromuscular disease o ROM exercise: 2-3 sets per day, modification to limit extent of
around 10 repetition injury/disease or promote
o Progression
 Metabolic o Precautions regarding certain healing
orthopedic (or other) concerns or related
congenital comments P: Drug or exercise to Reduce
symptoms and Improve
functions, Sick leave for rest /
sociopsychological Empowering self- responsibility time for other interventions
Psychological support
Family and social support R: - Orthopedic surgeon for
o activity of daily living
+/-referral serious pathology or operative
o family and relationships o work and Prevention intervention
income Follow-up
- PT / OT / Allied health team
o sexuality to Reduce symptoms and
Improve functions
o Acute: anxiety / stress o Chronic:
depression o Sleep I: Confirm Dx,

O: Monitor progress

P: Prevent future episodes /

injury

Cervical and lumbar spondylosis (i.e. . Tractionkle

Neck pain and Low back pain)

Ankle sprain . Ankle X ray needed only if pain R. I. C. E.

 - Inversion injury
ATFL most commonly
. Bony tenderness in
- Complicated or
uncomplicated ? weight
bear after walk
in malleolar zone _ Paracetamol /
NSAIDs
Posterior tip of lateral Early mobilization
malleolus
Physiotherapy
Posterior tip of medial
malleolus
Splinting(Short period )
Cannot bear weight
immediately or in AED Surgery

Foot X ray:

Pain in

- Base of 5th mettarsal

- Navicular

Gout Look for tophus . Reduce alcohol intake. Avoid being . Serum uric acid.

- Trigger overweight. . . C&Es. In chronic gout it is

necessary to exclude
- . Avoid purine-rich foods (e.g. offal,
- oily fish, pulses).
- Differential Diagnosis
- septic arthritis or
bursitis
- cellulitis
- rheumatoid arthritis
- pseudogout (or
chondrocalcinosis) -
- joints
- osteoarthritis
kidney damage.
. maintain fluid . Lipids.
. joint aspiration
Consider joint aspiration Indomethacin 25-50 mg
orally TDS
polymorphonuclear leukocytes
and intracellular monosodium (rule out renal
urate crystals (needle-shaped and involvement )
negatively birefringent) in
synovial fluid aspirated from an
inflamed joint Colchicine as a second-line
. treatment if NSAIDs are
contraindicated. 0.5mg q2hr to
TDS max 10 dose
- nausea vomiting
diarrhea
. lower the
serum urate level
below 5 to 6 mg/dL
 . Allopurinol 100mg daily
increase 100mg per
week; HLAB 5801

. maximum
recommended
dosage of 800 mg
daily

. give colchicine 0.6mg QD- BID

during start

. Febuxostat: 40mg starting dose

0g

s/e include abnl LFTs, nausea,

rash, arthralgias;
.

OA . Crepitus . X ray not helpful : early stages of the . Paracetamol

diseas . NSAID: bg evening dose
Pain + three of
Reduce range of motion
. ibuprofen S/R 800 mg, two
o Over 50 years of age
o < 30 minutes of morning stiffness
o Crepitus on active motion
o Bony tenderness
o Bony enlargement
o No palpable warm of synovium
Red flag:
Early morning stiffness
Exacerbated by recent injury
Tennis elbow
occupational stress or unaccustomed
activity for activity modification
Soft tissue swelling . Advice
Gait: limping
Aim for ideal weight.
Encourage mobility/activity:
ROM strengthening +
aerobic
Financial problem? work
Educational leaflets and support
groups
Depression
. . Occupational therapy
. . Relative rest = avoiding the
precipitating activity
tablets nocte.
. omeprazole 10 mg
. glucosamine 1500 mg a day
. Consider physiotherapy
. Intraarticular steroid:
methypred 40mg for
knee
. Walking aid/ Knee brace /
+/- insole
. / +/- walking aid
. Topical capsaicin / NSAID
. Intra-articular corticosteroid
. Brace
. NSAID
 . Injection of corticosteroid

. Exercise

. Ultrasound

. Surgery

Bruising, -> fractured neck of the . - ACJ pathology (usually arthritis):

Shoulder problem . Physiotherapy : frozen
humerus, especially in an elderly scarf test, forced adduction test,
Any history of trauma, such as a fall person following a fall. O'Brien's test shoulder not that
on the arm. useful
. - Shoulder tendinopathy: Empty Can
Previous episodes of similar Test, Hawkin's-Kennedy Test
Limitation of movement of the
. There were no
problems. difference between
glenohumeral joint, in frozen . - Biceps tendonitis: Yergason's Test,
shoulder. Due to contraction of Speed's Test steroid injection
Neck pain.
the GHJ capsule and physiotherapy
Occupation and handedness: plus NSAID at 2
loss of ROM (especially in
repetitive use of the arm may account and 12 weeks (no
external rotation),
for blinding)
asso with DM rotator cuff
shoulder problems. tendinopathy, biceps tendinopathy .

, previous trauma
. Good for painful arc
Primary syndrome

Secondary: Intrinsic - eg. . NSAID

rotator cuff, biceps tendon
. Steroid injection to
Extrinsic - eg. breast surgery, subacromial space :
cervical radiculopathy, chest wall methypred 40mg
tumour,

The painful arc: pain increases as

the shoulder is abducted to about
90o, but reduces again as the arm
is raised further above the head.
This is a feature of supraspinatus
tendonitis.
LOW BACK PAIN weakness of dorsiflexion of the ESR, and PSA NSAIDs
ankle and extensor hallucis (L4
typical patterns: L5 prolapse) >4 weeks. MRI
Weak opioids
1.Transient backache following weakness of the peroneal muscles, . Mild low back pain discomfort) often
toe flexors, calf and tibialis Noradrenergic or
muscular activity = back strain requires reassurance only.
posterior (L5S1). Noradrenergic- Serotoninergic
antidepressants
2 .Sudden, acute pain and sciatica= . Mobilisation
disc prolapse or osteoporotic Multi-disciplinary treatment
compression fracture . Analgesic: (bio-psycho- social model)
Exercise therapy
3. Chronic low back pain, with or . Opiate + laxative
without sciatica = lumbar spondylosis, CBT
AS, infection, bony disease . Diazepam 5mg tds for muscle relaxant Manipulation/mobilization
4. Back pain plus pseudo for short term
Straight-leg test: Percutaneous electrical
claudication = spinal stenosis nerve stimulation
Flexibility of spine; palpation of . FU 1 month
5.Severe and constant pain= tumor, spine; toe/heel walk, rising Neuroreflexotherapy
infection, fracture from chair; neuro exam (strength, . Educate on posture
sensation, reflexes); pedal pulses;
 . notify your employer and
Red flag: report in full details Labour
Department within 14 days
Age 20 and 55.
Compensation up to 24 +/- 12
Nocturnal pain. months sick leave from public
sector Medical Assessment
Thoracic pain. Board (MAB)
Patient on oral steroids. Weight . Traffic accident victum
loss. assistance scheme
Past history of carcinoma.

Reassure 90% patient with acute non

specific back pain improve in <2
Sociopsychological:
weeks without intervention
. Compensable low back pain
Good lifting technique

Education books
. Depress?
phyusical activity as tolerated
. Reduce activity?
Weight loss, smokinehavioral g cessation

Cognitive b
immediate orthopaedic referral are:

bladder paralysis

extensive muscle weakness

objective neurological signs.

Perianal numbness

Chronic back pain . Physical therapy, e.g.

physiotherapist,
depression osteopath, chiropractor.
hidden agenda carer stress.
. Orthopaedic or
neurosurgical referral:

. MRI scan for prolapsed

disc

. surgery.

. Rheumatology referral:
facet joint injection.
 . Antidepressants.

. Local back pain sufferers

group.

. Physiotherapists back
school.

PLANTAR FASCIITIS
. advise soft heels and heel padding. . short course of NSAIDs
first steps in the morning
. injection of hydrocortisone with local .
ender point just in front of the bony
anaesthetic
part of the heel.
Ddx: ice, heel cord stretching & plantar fascia
Tibial nerve compression (Tinel stretches
sign behind medial malleolus),

bursitis at Achilles insertion,

silicone gel heel cups;
posterior tibial tendinitis (palpate
tendon behind medial malleolus)
 Many patients consulting for limb cramps/paraesthesiae NOT because they cannot tolerate the symptoms but because they fear the
symptoms are due to some serious diseases. Non-steroidal anti-inflammatory drugs (NSAID) are commonly used and
patients should always be warned of the side effects, especially the gastrointestinal. NSAID should always be given together
with allopurinol for gout as allopurinol can precipitate an acute attack. For this reason, allopurinol should not be started during
an acute gouty attack. ENDOCRINE

Diabetes Mellitus

History Exam Counsel Treatment Prevention

calculation of maintain optimal Referral for insulin

body mass index body weight and
optimal blood (a) Who are acutely ill
(BMI) and, ideally, glucose control in all practise healthy
measurement of diabetic patients A lifestyles. (b) Who have heavy
waist and to reduce ketonuria
microvascular and
circumference (WC) macrovascular (c) Who have a blood
complications. Pneumococcal
assessment of vaccines and glucose level 25.0
physical activity HbA1c goal of seasonal mmol/L
<7% influenza
levels vaccination (d) Who present with
value more
than 8% diabetic ketoacidosis
dietary assessment
intensive (DKA)
treatment
review of smoking
(e) Who present with
status without diabetic hyperosmolar
significant risk non-ketotic syndrome
measurement of of
hypoglycaemia (HONK)
blood pressure
or adverse
effect of Referral to specialist
measurement of
treatment.
blood lipids >7 if advanced (a) Young patients
DM (age<30 years) with
complications diabetes
especially if
there is a (b) Patients with
history of features suggestive of
check for symptoms severe
of macrovascular endocrinopathies e.g.
hypoglycaemia
diseases, e.g. chest Cushing
pain, transient target blood pressure
in people with syndrome
ischaemic attack
diabetes is below A
(TIA), 130/80 mm Hg. (c) Heavy proteinuria or
presence of haematuria
Angiotensin- in the absence of other
converting
enzyme complications
(ACE)
inhibitors, (d) Presence of
calcium 1++ complications (e)
channel
blockers, Women who are
 thiazides and pregnant
-blockers

- palpate
peripheral Beta-blockers are not
pulses
recommended as first
- ECG for cardi
- Urine dipstick line therapy but may be
or 24 hour considered if patients
urine are intolerant to ACE
inhibitors or have
eye examination
previous heart attacks
- Foot
examination
anti-platelet agents as a
secondary prevention in
those with A a history
of cardiovascular and
cerebrovascular
diseases Aspirin
 Thyroid disease

Remember thyroid disease can present in many different ways such as tiredness, mood changes or even menstrual irregularity.

PSYCHOLOGICAL

Depression

History Exam Counsel Treatment

Depressed mood Look for: Referral when : Ddx:

Anhedonia tearfulness 2. high suicide risk 1.

3. Severe depression with/without 2. Dysthymia
slowed thinking 3. Adjustment disorder-
and speech psychotic features
4. Severe postnatal depression
4 of the indecisiveness 5. Bipolar disorder (1) Education and guided self-help : BT (2)
6. There are co-morbid medical Psychotherapy (3) Pharmacotherapy (4)
sighing Combination of psychotherapy and
- sleep conditions for which expertise is
anxiety. required regarding pharmacotherapy
- fatigue
- poor appetite PHQ 9 drug-drug interactions.
- psychomotor
retardation or 6. There is diagnostic difficulty. moderate and severe depressive disorders with
7. One or two trials of medication melancholic features, TCAs are still the initial drug
agitation
have failed.
irritability low dose tricyclics (typically 75-100mg)
8. If augmentation or combination
withdrawl therapy is needed.
- poor self
 ESTEEM 9. Those with co-morbid substance continued for at least 4 weeks (6 weeks in the elderly)
- difficult abuse or severe psychosocial before considering whether to switch antidepressant due
problems. to lack of efficacy.
concentration 10. The patient is pregnant or plans to
- suicidal ideation become pregnant. fluoxetine, sertraline and paroxetine : for sertraline
concomitant anxiety symptoms :

mixed episode; bipolar: Advice on

ask prior episodes, sertralinenot with alcohol
- Sleep hygiene
prior manic or
- anxiety anxiety: benzodiazepine
hypomanic episodes,
substance FU: reviewed every 12 weeks at the start of
antidepressant treatment. (C)
abuse and other warn about suicidal risk in young patient
psychiatric illnesses.
also for seual dysfunction, HI side effect
cause of great distress

not cause by substance

use
. fluoxetine 20 mg od or citalopram 20 mg od.
not due to normal Contraindications to SSRI
grieve of love one
i. Hypersensitivity to SSRIs or any other
component . response is poor, consider second-line antidepressants,
e.g. venlafaxine, trazodone.
ii. Escitalopram is contraindicated in
 1. co-existing patients hypersensitive to citalopram
medical
conditions, iii. Manic phase
family history of
mental illness, iv. Concomitant use with MAOIs

risk of suicide, self-

harm and risk of harm
to others must be
included in the
assessmen Encourage a problem-solving mindset

Think about alternatives and solutions

self-reflective mindset

Medical conditions What are my views and perceptions?

associated with What are my blind spots or distorted
depression thinking? Labeling of cognitive distortions

Hypothyroidism Reattribution
Malignancy
Parkinsons disease Avoid placing all the blame on self The
Myocardial infarction pie chart technique
Stroke
Endocrinopathies
(Cushings syndrome,
adrenal insufficiency, Relaxation and meditation
carcinoid, Deep breathing relaxation Mental imagery
hyperparathyroidism) relaxation Meditation

Infections COUNSELLING FOR DRUGS

Chronic disease
(congestive heart . antidepressants are not
failure, diabetes, addictive
systemic lupus
erythematosus, . they correct the chemical
rheumatoid arthritis) imbalance that is causing the
Alcoholism or other
patients symptoms.
substance abuse/
dependence
. Warn the patient that the
Fibromyalgia/ chronic
therapeutic benefit will not be felt
fatigue syndrome
B12 or folate for the first 1014 days.
deficiency
Sleep disorders . Side-effects: common
side-effects which usually settle
within the first 2 weeks include
nausea, nervousness and insomnia.
i. Sometimes I will
also do some
counseling or . Contraindications: avoid if
talking about
problems with the patient enters a manic phase.
patients,
.
 do you want to
tell me more?

Rule out worries Reattribution 1. Making the assessment and feeling understood :
Somatic symptom and complaint typical day ; assess mood; explore social and family
- assessment of symptoms factor , ICE,
- broadening the agender from
and related disorders physical to emotional and social 2. Broadening the agenda
and sumarising finding
- I wonder if these things are related physical examination or investigations and reflect back
in some way on their physical symptoms
Nonspecific symptoms
I wonder if....could be linked in any way
high level of suspicion;
assess sleep 4. Making the link
1. provide a
Frequent consulter pathophysiological How would it sound if I told you that I think your
explanation symptoms are related to the stresses you are currently
More unrelated 2. use of symptoms under?
symptoms and not diary
responding to treatment 3. review of family Patho-physiological explanations
members and
try to explain the Relate life events
friends with a
symptoms, avoid
similar complaints
blaming the patient for b) Depression lower pain threshold
them, and work with
the patient to develop a Viscious cycle
symptom management
planq
.
active listening

- open ended 5. Negotiating treatment

question Review ICE
- checking
- legitimizing Relaxation: Slow breathing exercises Progressive
patients feeling muscle relaxation : contract and relax
- surveying the
patient resources 10 minute Cognitive behavioural therapy (CBT)
- offering support Symptom diary
- negotiating
priorities Treat depression

non verbal cues

- state the
bservation

ANXIETY . Explain the condition to the patient. . Treat any underlying depression
 . Reassure about the absence of physical . Symptomatic hyperventilation may be relieved by
disease. rebreathing expired air via a paper bag.
. Exclude physical
disease . Explain symptoms in terms of
autonomic stimulation.
. in panic attacks, use diazepam 25 mg tds,
. Try relaxation techniques: tapes, groups,
yoga. 10-12 breaths per min . chronic anxiety consider an SSRI, e.g. citalopram 20
mg od, or a tricyclic, e.g. clomipramine 1075
. mg od

. Encourage regular exercise.

BZD: short term only

. Offer counselling.

. Self-help leaflets.

. Discuss complementary therapies.

. Offer cognitive behavioural therapy by

referral to a psychologist, if
available.

. Involve the psychiatric services if the

 patients life is affected to any
significant degree:

psychiatric social
worker

community
psychiatric nurse

consultant referral.

OCD: . Reassure benign SSRI group of antidepressants are the most useful, e.g.
fluoxetine 2060 mg od.
unwanted thoughts or
.
ideas that keep coming
into the mind the need
to perform rituals

anxiety at the thought

of not completing the
rituals

how long it takes to

perform the ritual each
time

how many times a day

the ritual has to be
repeated

interference with
daily life, schoolwork,
sleep

other mental illness,

e.g. brain injury, tics,
Tourette syndrome.

Insomnia Avoid day- . Reassure that insomnia is not a disease. . For short-term treatment requiring rapid relief of
symptoms, i.e. no longer than 2 weeks, prescribe,
timesleep . Treat the underlying cause, if any (see e.g.:
day-time sleeping,
e.g. in the elderly above).
Avoid going to . temazepam 1020 mg nocte, or
stimulants, e.g. bed too early . Try to avoid prescribing for chronic
insomnia. . zopiclone 7.515 mg nocte.
caffeine
Avoid large
drugs, e.g. SSRIs . Offer self-help leaflet. Short acting if cant get asleep
meals, alcohol and
caffeine . Advise a regular bedtime routine. difficulty staying asleep should receive longacting
physical symptoms, Rx (doxepin, eszopiclone, temazepam, zolpidem ER);
e.g. pain, cough, nasal Avoid . Advise avoidance of stimulants, e.g.
obstruction strenuous physical caffeine, alcohol.
and mental
anxiety/depression . Inform addiction potential for
activities in the
benzodiazepam
trauma, physical or evening
psychological regular sleep schedule, do not remain in
Encourage bed longer than 20
min if unable to sleep, avoid naps, sleep as
jet lag activity early long as needed to feel
morning and late refreshed the next day but not more,
change of afternoon preserve bedroom comfort
environment, e.g. (light, sound, & temperature), reserve the
bed for sleep, exercise
admission to a nursing Get up ay a regularly but not close to bedtime, avoid
home. regular time each mentally or emotionally
challenging activities before bedtime, avoid
day caffeine/tobacco 46 h
before bed
Minimize use .
of sleeping tablets

Try to relax
before bedtime

Avoid
watching TV till
late

Avoid too
 many blankets

Keep a daily
record or sleep
wake diary

Fifty per cent of cases of depression are missed in family medicine.

Psychological problems often present with somatic symptoms. Think about

psychological diseases as a possible cause of multiple vague complaints that are
 resistant to treatment.

A high index of suspicion should be maintained for all psychological problems as patients may have a hidden agenda when the
presenting complaint is a physical one (somatisation).

PREVENTION

Screening of chronic and degenerative diseases: obesity, BP, diabetes, cancer (cervical, breast);

Contraception;

History Investigation /Counsel Treatment

COC: Long- acting reversible contraceptive methods (IUD, IUS, depot combined pills, progestogen-only pills,
injections and implants) are more cost-effective than the COC. injectable and implanted progestogens,
Absolute contraindications condoms, diaphragms, intrauterine
Discussion of safe sex and the prevention of HIV infection and contraceptive devices, natural methods and
DVT or emboli. other sexually transmitted infections should be part of the routine surgical sterilisation.
advice given to the sexually active.
coitus interruptus, the use of spermicides
Heart disease (valvular or
alone and contraceptive sponges,
ischaemic).
YASMIN
Hypertension ( 160/100).
COC:
Hyperlipidaemia. The failure rate is in the range 0.13/100 women-years.

start the COC

Focal or severe migraine/TIAs.
. Start on day 1 to 5 and no extra contraceptive precautions are
 Cancer of the breast/cervix.
From 4 weeks before to 2 weeks
after major surgery.
Rare:
liver disease (active)
polycythaemia; sickle cell
anaemia
porphyria
hydatidiform mole (recent)
hyperprolactinaemia
diabetic complications.
Drug interaction:
Liver enzyme inducers, e.g.
phenytoin, carbamazepine, and
topiramate, increase the
necessary.
. Alternatively, start after day 5 and take extra precautions for
the first 7 days. (The COC may in fact be started on any
day of the cycle, provided that extra precautions are
taken for 7 days, but initial bleeding will be
unpredictable.)
. Take 1 tablet daily for 21 days. Subsequent courses repeated
after 7-day pill- free interval.
Risks of taking the COC
Smoking 15 cigarettes per day increases the risk of coronary
heart disease by three times.
Vascular disease in general is increased by about three times.
Hypertension develops in 5% of pill users after 5 years.
There is a 1.2 relative increase of carcinoma of the breast during
use and for10 years after stopping the COC; this does not appear
to be related to duration of use.
counterbalanced by the protective effect against cancers of the
ovary and endometrium.
metabolism, and thus elimination Side-effects
in the bile,
Breakthrough bleeding. (This usually settles within 23
broad-spectrum antibiotics (e.g. months.)
ampicillin, tetracyclines and
griseofulvin) alter gut flora and Nausea, breast tenderness, weight gain, PMT, bloating (fluid
reduce oestrogen absorption retention),

depression, headaches, reduced libido, chloasma.

oestrogen-dominant pill (e.g. Brevinor,

Mercilon, Trinordiol, Logynon, . Vomiting and severe diarrhoea EMERGENCY
Marvelon, Femodene or Dianette):
CONTRACEPTION
for progestogen excess:

vaginal dryness sustained weight

gain Come back when DVT symptoms

SOB
depression loss of libido
lassitude breast tenderness Chest pain
acne hirsutism.

most risky pills to miss are those in the first or last week of
the pack, as the 7-day pill-free interval is lengthened.

Progestogen dominant pull for

relative oestrogen excess (e.g.
Loestrin 30, Microgynon 30 or Eugynon
30):
nausea dizziness PMT
cyclical weight gain bloating
vaginal discharge.
Progestogen only
. over 35 years old who smoke. (In
. If pills are missed, take the last missed pill as soon as possible
and then resume the normal schedule.
. If the missed pills are in week 3, the pill-free interval should be
omitted.
. If pills are missed in week 1 (because the pill-free interval has
been extended), emergency contraception should be
considered if UPSI occurred in the pill-free interval or
in week 1.
. Use condoms or abstain from sex for 7 days if: two or more
20 g pills have been missed three or more 30 g pills
have been missed.
. contraindications: past or present severe arterial disease or an > 3 hours late (12 hours for Cerazette), protection
may be lost.
exceptionally high risk of the same recent hydatidiform mole
porphyria.
 women over 40 years old the
POP is as effective as the COC.)
It can relieve PMT and

climacteric symptoms.

no evidence of an increased risk of

thrombosis.

PROGESTOGEN-RELEASING
IMPLANT (IMPLANON)

. POSTCOITAL (EMERGENCY)
. contraindications: pregnancy porphyria . The failure rate is 12%.
CONTRACEPTION

. The sooner it is started after unprotected

. LMP
intercourse, the greater the efficacy.

. normal menstrual cycle

. Nausea occurs occasionally. If vomiting occurs

times of all unprotected intercourse during the present cycle present within 2 hours of taking it, a further
method of contraception. dose should be taken together with an

antiemetic.
 . The next period may be early or late.

. Barrier methods should be used until the next

period.

. Discuss future contraception.

. There is no known teratogenic effect if the

method fails.

. A pill taker should continue to take her usual

pills in the normal way and be warned

that she may get spotting in that cycle.

. This method may be used more than once in any

one cycle.

. Emergency IUCD can be used for postcoital contraception in women with a past history of an Advice
ectopic pregnancy in nulliparous women and in women with a recent history
. Nonemergency first 14 days of the of pelvic inflammatory disease (providing antibiotic cover is given) . The patient should check the threads weekly for
cycle and the contraceptive 6 weeks, and monthly thereafter, ideally
 effect is immediate. Ask:
right at the end of a period.
. LMP normal menstrual cycle times of all unprotected intercourse
during the present cycle present method of contraception. . Warn the patient about crampy pains for 23

days after insertion.

Indication:

. The IUCD can be fitted up to 5 days after unprotected intercourse or up to . Tampons can be used.
5 days after the most probable calculated date of ovulation

. Irregular spotting may occur in the first cycle.

. contraindications:

undiagnosed irregular genital tract bleeding
. Periods may be heavier and more prolonged.

pregnancy
. Any normal discharge may be heavier.

pelvic inflammatory disease (within the previous 6 months)

. Menstrual irregularity and pelvic pain require

exclusion of an ectopic pregnancy.

previous ectopic pregnancy
Follow-up. At 6 weeks, and then

distortion of the uterine cavity annually: Check threads. Check

smear status. Exclude anaemia, if
appropriate. Consider

past history of bacterial endocarditis or valve replacement.
the IUCD is less suitable for nulliparous women and those with
menorrhagia or dysmenorrhoea
replacement/alternative contraception, if
appropriate.
. IUCD is in situ, there is an increased risk of

miscarriage and, therefore, of infection

. (1 in 1020 pregnancies occurring with the IUCD

. Dysmenorrhoea and menorrhagia (especially in the first 3 months). are extrauterine.) The patient should be
advised to report pelvic pain or abnormal

. Pelvic infection (see p. 45). bleeding.

. Perforation.

. Expulsion.

. Lost threads. If the threads are lost, exclude pregnancy and advise
.
temporary alternative contraception.

.
CALENDAR METHOD 28-day cycle, ovulation is around day 14 and the fertile period is between
days 8 and 17
. for religious people

. shortest and longest menstrual cycle over the previous 12 months.

. To derive the first day of the fertile period, subtract 20 from the length of

the shortest cycle. (14 days maximum length of a luteal phase; 6

days maximum sperm survival.)

. Last dat of fertile period subtract 11 from the length of the longest
cycle.

+/- mucothermal method:

. a rise in basal body temperature thinning of cervical mucus (Billings

method).
 81

Childhood and adult immunisations;

History Exam Investigation /Counsel Treatment

Child assessment Physiological
jaundice appears after
48 hours and usually
disappears by day

710 of life.

Jaundice persisting
or presenting after 10
days of age (14 days
in immature

babies) is abnormal
and the baby should
be referred for
assessment. If the
prolonged jaundice is
associated with breast-
feeding it should fade
by 6 weeks of age.

. Jaundice within 24
hours of birth is
always
 pathological.

Colic babies Nocturnal enuresis Dipstick urine for glucose, nitrite, leucocytes Specific treatment is unnecessary under the age of 7
Consider volvulus, intussusception or . dry at night by the age and protein send an MSU for MC&S. years. Ten per cent of 5-year-olds still wet the bed.
acute infection (e.g. otitis media or of 3 ,90% are dry
UTI). by the age of 5and . enuresis alarm can be used if the above methods
95% by the age of fail
10.
. Ask about: Advice . . desmopressin nasal spray (synthetic
congenital abnormality analogue of ADH) 2040 g at bedtime.
Whether the child has ever been dry. (A
period of dryness suggests that the
of the urinary tract, a . Drinks should be avoided in the evening.
urinary tract infection or
problem is not organic unless the child
a neuropathic bladder. .
. Lifting the child to the lavatory when the
has an acute UTI.)
All children under 5 years of age with a first
parent goes to bed may be helpful. confirmed UTI should be
Whether the child wets during the day.
(After the age of 4 this suggests a referred to a paediatric urologist for further
neuropathic bladder and the child should . A star chart with stars given for dry beds
investigation (e.g. renal tract ultrasound,
encourages the child.
micturating cystourethrogram, DMSA scan, IVP).
be referred.)

Family history: children often follow a .

familial pattern.

Any behavioural or emotional

problems.

Heavy sleeping.
 Childhood developmental screening: growth, school, behaviour and mood;

History Exam Investigation /Counsel Treatment

Measure and plot the infants Full exam Referral if suspected complication or >/< 3
weight and head circumference at percentile
2-weekly intervals and plot all Large head
previous measurements. The most common
Discuss milk intake, diet, nature cause of head
and frequency of stools, and enlargement is a
parental attitude and concerns. familial large head,
where the head
Check urine for protein, nitrite circumference may
and leucocytes and send for cross centiles upwards
culture.
Examine the baby for
signs of raised
intracranial pressure.

Length: = [fathers
height+ (mothers
height +/- 12.5 cm)]/2
Bronchiolitis
irritable cough with tachypnoea after
coryzal symptoms in infants and
toddlers
feeding difficulty and a low-grade fever.
paracetamol, fluids and provision of warm
moist air,
widespread crepitations,
especially on expiration. Refer if there is significant feeding difficulty or
if the child is ill or distressed.

RSV is usually the culprit

Croup steamy room (e.g. boil the kettle without a lid)

Nebulised steroids, e.g. budesonide 2 mg, can be

helpful

Refer if there is intercostal recession or if the child

is ill.

Asthma (nasal polyps, allergic
shiners or rhinitis),
skin (AD), full chest &
. persistent nocturnal cough pulm exam
. recurrent wheezing
inhaled steroids if:
using inhaled 2 agonists more than
three times per week
symptomatic in the day more than
three times per week or at night more
. Age 02: MDI spacer and face mask.
Bronchodilator syrups, e.g. salbutamol
syrup 100 g/kg tds prn
3-12: MDI + spacer; breath actuated device
. inhaled short-acting 2 agonist, e.g. salbutamol 2

puffs tds
 than once per week . inhaled steroid, e.g. beclometasone 100 g bd.

there has been an exacerbation of

asthma in the last 2 years. 25 years consider trial of leukotriene receptor antagonist

Allergen avoidance: Dust mites: Use

bedding encasements, wash
sheets weekly in hot water, avoid down,
HEPA filter

Irritant avoidance: smoking

Immunization: influenza and PSV 23

Non febrile convulsion . . Admit all infants with a convulsion under the
. Ensure that the airway is patent.
loss of consciousness shaking age of 6 months.
or jerking . Give diazepam 0.3 mg/kg iv slowly, or rectally
. Refer older children who have had a
incontinence convulsion to a paediatric 2.5 mg (age 1), 5 mg (age 13), 10 mg

neurologist. (age 3).

postictal state

period of amnesia family . Children with epilepsy should not cycle in

history
Febrile convulsion The child has a fever . Reassure:
and often an upper
respiratory tract
infection. Look for signs
of meningitis.
Examine ears and throat,
chest and abdomen.
traffic. They may swim in the
. Admit the child if fitting continues.
presence of a responsible adult.
.
. The tendency to have seizures resolves during
childhood in 60% of children.
. Admit if:
risk of recurrence after one febrile convulsion is . 1. meningitis is suspected
about 20%
. 2. this is the first attack
.
. 3. the child is 18 months old
. 4. the fit lasts for more than 10 minutes
. 5. the child is clearly unwell
. 6. there are persistent neurological signs
. 7. more than one fit occurs during one febrile
episode.
Paracetamol doses: age 3 months to 1 year, 60120
mg, 46 hourly prn; age 15 years, 120250 mg, 4
6 hourly prn; age 612 years, 250500 mg, 46
 hourly prn (maximum of four doses in 24 hours).

Lifestyle modification: diet, exercise, unsafe sex, smoking, alcohol, recreational drugs;

Travel immunisation and advice: diet, hydration, malaria prophylaxis etc;

History Exam Investigation /Counsel Treatment

To appreciate the role of family relation and dynamics in health promotion.

Elderly:

Dementia

History Exam Investigation /Counsel Treatment

memory difficulties 1. Age. FBC and ESR . Agitation at night: e.g. promazine (Sparine) 2575 mg on.
(particularly short-term)
2. Time. C&Es, LFTs and glucose TFTs
speech difficulties
3. Remember
address: 42 West vitamin B12 and folate
 personality changes
uncharacteristic behaviour 5. Where are we
loss of abstract reasoning. 6. Do you know
Rule out secondary causes:
depression
Parkinsonism
hypothyroidism 10. Count
deafness stigmata of
alcoholism acute steroid
withdrawal.
Street. 4. Year. VDRL (or equivalent) . Aggression: e.g. risperidone 1 mg od or bd.
now? . Nocturnal wakefulness: haloperidol 2 mg bd.
. Depression:
who I am?
7. Date of birth. . Sexual disinhibition: benperidol 0.25 mg od to 0.5 mg tds.
Counsel :
8. Year of First
World War. - hidden patient: relative:
. Anticholinesterase inhibitors, e.g. donepezil or
-
9. Name of galantamine,
present Prime - Depression: treat in the
Minister. usual way
- Aggression
backwards from
20 to 1.
- Wandering and other safety
aspects: Medic Alert
bracelet.
A score of less
than 8 is
- Financial difficulties:
abnormal. suggest early application
for enduring power of
attorney (see solicitor).
treat depression, which may
 manifest as agitation; citalopram
has shown efficacy in depression in
dementia
-

Exercise
-

-
-
- referred to a neurologist if
the diagnosis is uncertain or
unusual (for a CT brain), or
to a psychogeriatrician, if
available.

MOCA AMT 5mMOCA

Visuospatial (5) Balls
Cube
Clock
Naming (3) Animals
Memory recall (0) 5 vocabs Mid-Autumn 5 vocabs (5)
CE name
Attention (6) Digits 20>1
Clap
 Serial 7
Language (3) Repeat Fluency (9)
Fluency
Abstraction (2) Similarity
Delayed recall (5) 5 vocabs Address 5 vocabs (10)
Orientation (6) TP TP TP (6)
P (N/D)
Personal recall Age
Birthday
Syste Conditions Generic name amount route dosing frequenc duratio prn
m y n reason
a0 memory donepezil 5mg PO tablet q.d. 4-6
problem weeks
rivastigmine 1.5mg PO tablet b.i.d. 2
weeks
galantamine 4mg PO tablet b.i.d. 4
(immediate weeks
release)
memantine 5mg PO tablet q.d. 2
(immediate weeks
release)
depression fluoxetine 20-60mg PO tablet q.d. 4
(morning weeks
)
sertraline 50-300mg PO tablet q.d. 4
weeks
amitriptyline 25-150mg PO tablet q.d. 4
(bedtime weeks
)
anxiety escitalopram 10mg PO tablet q.d. 2
weeks
diazepam 2-10mg PO tablet b.i.d. - 4
q.i.d. weeks
 sleep zolpidem 5mg PO tablet q.d. 2 poor
(immediate (bedtime weeks sleep
release) )
a1
a2 dry eyes hypromellose ophthalmic NA eye drop eye drop q1hr 1 week dry
sodium cromoglicate ophthal 2%-4% eye drop eye drop q4-6h 1 week itchy
mic
diclofenac ophthalmic 0.1% eye drop eye drop q.i.d. 1 week pain
bacterial azithromycin ophthalmic 1% eye drop eye drop b.i.d. 1/7 5 days
conjunctivi ->
tis q.d. 4/7
ofloxcin ophthalmic 0.3% eye drop eye drop q.i.d. 1 week
stye erythromycin ophthalmic 0.5% eye drop eye drop q.i.d. 1 week
a3 common paracetamol 500mg PO tablet q4-6h 1 week prn max
cold 4000mg
oxymetazoline nasal 0.025%, 1- intranasal spray q.i.d. 1 week prn
2 sprays
bacterial amoxicillin 500mg PO tablet b.i.d. 10 prn
pharyngitis days

aphthous hydrocortisone 2.5mg topical pellets q.i.d. 10 prn

ulcers days
gingivitis chlorhexidine rinse 0.12% PO rinse and solution b.i.d. 10 prn
15mL spit days
allergic cetirizine 5-10mg PO tablet q.d. 1 week prn
rhinitis
diphenhydramine 25-50mg PO tablet q4-6h 1 week prn
 chlorpheniramine 4mg PO tablet q4-6h 1 week prn
(immediate)
azelastine nasal 137- intranasal/no spray b.i.d. 1 week prn
274ug/spr stril
ay aerosol,
1-2 sprays
beclometasone nasal 80ug/spra intranasal/no spray q.d. 4
y, 2 sprays stril weeks
Ear wax saline solution
OM paracetamol 10- PO tablet/suspen q4-6h 2 prn pain
15mg/kg sion weeks
OE ofloxacin otic 0.3%, 10 ear drop ear drop q.d. 7 days
drops
b0
b1 asthma salbutamol 100ug/dos inhalation puff q.i.d. 1 prn
e MDI inhaler SOB/5min
s b4
exercise
fluticasone inhaled 50ug/dose inhalation puff q.d. 1
MDI2- inhaler
6puffs/day

b2 COPD ipratropium inhaled 20ug/dose inhalation puff q.i.d. 1 prn

, 2 puffs inhaler
tiotropium inhaled 18ug/dose inhalation puff q.d. 1
, 1puff inhaler
b3
c0
c1 IHD aspirin 75-150 PO tablet q.d. 3
mg months

isosorbide mononitrate 25-60 mg PO tablet q.d. 3 prn

(extended release) months

c2 HTN lisinopril 10-40 mg PO tablet q.d. 3

months

c3 metoprolol (immediate- 50-200 PO tablet b.i.d. 3

release) mg months

amlodipine 2.5-10 mg PO tablet q.d. 3

months

bendroflumethiazide 5 mg PO tablet q.d. 3

months

d1a GERD omeprazole 20 mg PO tablet q.d. 8

weeks
functional famotidine 40 mg PO tablet q.d. 4
dyspepsia weeks
d1b
d1c GE oral rehydration solution
IBS loperamide (anti-diarrheal) 2-4 mg PO tablet q.i.d. 1 prn
month diarrhea
max
16mg/day
 lactulose (laxative) 10- PO solution q.d. 1 prn
20g/15- month constipati
30mL on max
40g/day
hyoscyamine (Anti- 0.125- PO tablet t.i.d.- 1 prn gut
spasmodic) 0.25mg q.i.d. month spasm
max
1.5mg/da
y
d2 UTI nitrofurantoin 100 mg PO tablet b.i.d. 5 days
(modified-
release)
LUTS/BPH alfuzosin 10 mg PO tablet q.d. 3
months

d3 menopaus estrogen, 0.3/1.5mg PO tablet q.d. 3

e conjugated/medroxyprogest months
erone
vulvo- estrogens, conjugated 0.625 per vaginal ring q.d. 1-2
vaginitis vaginals mg/g, 0.5- (night) weeks
2g
metronidazole 500 mg PO tablet b.i.d. 7 days
butoconazole vaginal 2%, 5g per vaginal applicator q.d. 3 days
(night)
e1 DM metformin 500-1000 PO tablet q.d. 3
mg months
 gliclazide 40-80mg - PO tablet q.d. 3
320mg months

sitagliptin 100mg PO tablet q.d. 3

months

exenatide 5-10 ug SC injection b.i.d. 1

month
empagliflozin 10-25mg PO tablet q.d. 3
months

acarbose 25mg PO tablet q.d.- 3

b.i.d. months

insulin glargine SC injection q.d.

(morning
)
insulin lispro SC injection q.d.
(pre-
meal)

Dyslipidem atorvastatin 40-80mg PO tablet q.d. 3

ia months

rosuvastatin 20 mg PO tablet q.d. 3

months
 simvastatin 20-40 mg PO tablet q.d. 3
months

thyroid carbimazole 20-40 mg PO tablet q.d. 1

month
propylthiouracil 150- PO tablet t.i.d. 1
400mg/da month
y
propranolol 80-160 PO tablet q.d. 1
mg (extended- month
release)
levothyroxine 100-150 PO tablet q.d. 1
ug month
osteoporo alendronic acid 10 mg PO tablet q.d. 3
sis months

vitamin D ergocalciferol 50,000 IU PO tablet q.d. 8

insufficien weeks
cy
e2 Eczema hydrocortisone topical 0.5-2.5% topical topical unit b.i.d. 3
months

skin fungal terbinafine topical 1% topical topical unit b.i.d. 1-3

infection weeks
nail terbinafine 250 mg PO tablet q.d. 6
weeks
finger/
 12
weeks
toe
OA/pain diclofenac sodium topical 11.6mg/ topical topical unit q.i.d. 3
1g months

paracetamol 500- PO tablet q6h 3 prn pain

1000mg months max
4000mg/d
ay
diclofenac sodium 100 mg PO tablet q.d. 3 prn pain
(extended months
release)
gout ibuprofen 800 mg PO tablet t.i.d.- 10-14
q.i.d. days
allopurinol 100-800 PO tablet q.d. 1
mg month
shoulder/ ibuprofen 200-400 PO tablet q4-6h 1 prn pain
frozen, mg month max
tendonitis 2400mg/d
ay
plantar naproxen 500 mg PO tablet b.i.d. 1 prn pain
fasciitis month max 1250
mg/day
back pain tramadol 50-100 PO tablet q4-6h 3 prn pain
mg (immediate- month max
release) 400mg/da
y
f0
f1
f2 influenza oseltamivir 75 mg PO tablet q.d. 1 week
g0
g1
System Conditions Generic name dosing amount freque route durati prn
ncy on reason
a0 memory donepezil tablet 5mg q.d. PO 4-6
problem weeks
rivastigmine tablet 1.5mg b.i.d. PO 2
weeks
galantamine tablet (immediate 4mg b.i.d. PO 4
release) weeks
memantine tablet (immediate 5mg q.d. PO 2
release) weeks
depression fluoxetine tablet 20-60mg q.d. PO 4
(morni weeks
ng)
sertraline tablet 50- q.d. PO 4
300mg weeks
amitriptyline tablet 25- q.d. PO 4
150mg (bedti weeks
me)
anxiety escitalopram tablet 10mg q.d. PO 2
weeks
 diazepam tablet 2-10mg b.i.d. - PO 4
q.i.d. weeks
sleep zolpidem tablet (immediate 5mg q.d. PO 2 poor
release) (bedti weeks sleep
me)
a1
a2 dry eyes hypromellose ophthalmic eye drop NA q1hr eye drop 1 dry
week
sodium cromoglicate eye drop 2%-4% q4-6h eye drop 1 itchy
ophthalmic week
diclofenac ophthalmic eye drop 0.1% q.i.d. eye drop 1 pain
week
bacterial azithromycin ophthalmic eye drop 1% b.i.d. eye drop 5 days
conjunctivitis 1/7 ->
q.d. 4/7
ofloxcin ophthalmic eye drop 0.3% q.i.d. eye drop 1
week
stye erythromycin ophthalmic eye drop 0.5% q.i.d. eye drop 1
week
a3 common cold paracetamol tablet 500mg q4-6h PO 1 prn max
week 4000mg
oxymetazoline nasal spray 0.025%, q.i.d. intranasal 1 prn
1-2 week
sprays
bacterial amoxicillin tablet 500mg b.i.d. PO 10 prn
pharyngitis days
aphthous hydrocortisone pellets 2.5mg q.i.d. topical 10 prn
ulcers days
gingivitis chlorhexidine rinse solution 0.12% b.i.d. PO rinse and 10 prn
15mL spit days
allergic rhinitis cetirizine tablet 5-10mg q.d. PO 1 prn
week
diphenhydramine tablet 25-50mg q4-6h PO 1 prn
week
chlorphenamine tablet (immediate) 4mg q4-6h PO 1 prn
week
azelastine nasal spray 137- b.i.d. intranasal/no 1 prn
274ug/sp stril week
ray
aerosol,
1-2
sprays
beclometasone nasal spray 80ug/spr q.d. intranasal/no 4
ay, 2 stril weeks
sprays
Ear wax saline solution wax-softening 'Never
drops put
anythin
g
 smaller
than
your
elbow
in the
ear'.

OM paracetamol tablet/suspension 10- q4-6h PO 2 prn pain

15mg/kg weeks
OE ofloxacin otic ear drop 0.3%, 10 q.d. ear drop 7 days
drops
b0
b1 asthma salbutamol puff 100ug/do q.i.d. inhalation 1 prn
se MDI inhale SOB/5mi
r ns b4
exercise
fluticasone inhaled puff 50ug/dos q.d. inhalation 1
e MDI2- inhale
6puffs/da r
y
b2 COPD ipratropium inhaled puff 20ug/dos q.i.d. inhalation 1 prn
e , 2 puffs inhale
r
 tiotropium inhaled puff 18ug/dos q.d. inhalation 1
e, 1puff inhale
r
b3
c0
c1 IHD aspirin tablet 75-150 q.d. PO 3
mg month
s
isosorbide mononitrate tablet 25-60 mg q.d. PO 3 prn
(extended release) month
s
c2 HTN lisinopril tablet 10-40 mg q.d. PO 3
month
s
c3 metoprolol (immediate- tablet 50-200 b.i.d. PO 3
release) mg month
s
d0 amlodipine tablet 2.5-10 q.d. PO 3
mg month
s
hydrochlorothiazide tablet 12.5-25 q.d. PO 3
mg month
s
d1a GERD omeprazole tablet 20 mg q.d. PO 8
weeks
 functional
dyspepsia
d1b
d1c GE oral rehydration solution
IBS loperamide tablet 2-4 mg q.i.d. PO 1 prn
month diarrhea
max
16mg/da
y
lactulose solution 10- q.d. PO 1 prn
20g/15- month constipati
30mL on max
40g/day
hyoscyamine tablet 0.125- t.i.d.- PO 1 prn gut
0.25mg q.i.d. month spasm
max
1.5mg/da
y
d2 UTI nitrofurantoin tablet (modified- 100 mg b.i.d. PO 5 days
release)
LUTS/BPH alfuzosin tablet 10 mg q.d. PO 3
month
s
d3 menopause estrogen, tablet 0.3/1.5m q.d. PO 3
conjugated/medroxyproge g month
sterone s
vulvo-vaginitis estrogens, conjugated ring 0.625 q.d. per vaginal 1-2
vaginals mg/g, (night) weeks
0.5-2g
metronidazole tablet 500 mg b.i.d. PO 7 days
butoconazole vaginal applicator 2%, 5g q.d. per vaginal 3 days
(night)
e1 DM metformin tablet 500-1000 q.d. PO 3
mg month
s
gliclazide tablet 40-80mg q.d. PO 3
- 320mg month
s
sitagliptin tablet 100mg q.d. PO 3
month
s
exenatide injection 5-10 ug b.i.d. SC 1
month
empagliflozin tablet 10-25mg q.d. PO 3
month
s
 acarbose tablet 25mg q.d.- PO 3
b.i.d. month
s
insulin glargine injection q.d. SC
(morni
ng)
insulin lispro injection q.d. SC
(pre-
meal)

Dyslipidemia atorvastatin tablet 40-80mg q.d. PO 3

month
s
rosuvastatin tablet 20 mg q.d. PO 3
month
s
simvastatin tablet 20-40 mg q.d. PO 3
month
s
thyroid carbimazole tablet 20-40 mg q.d. PO 1
month
propylthiouracil tablet 150- t.i.d. PO 1
400mg/d month
ay
 propranolol tablet (extended- 80-160 q.d. PO 1
release) mg month
levothyroxine tablet 100-150 q.d. PO 1
ug month
osteoporosis alendronic acid tablet 10 mg q.d. PO 3
month
s
vitamin D ergocalciferol tablet 50,000 IU q.d. PO 8
insufficiency weeks
e2 Eczema hydrocortisone topical topical unit 0.5-2.5% b.i.d. topical 3
month
s
skin fungal terbinafine topical topical unit 1% b.i.d. topical 1-3
infection weeks
nail terbinafine tablet 250 mg q.d. topical 6
weeks
finger
/
12
weeks
toe
OA/pain diclofenac sodium topical topical unit 11.6mg/ q.i.d. topical 3
1g month
s
 paracetamol tablet 500- q6h PO 3 prn pain
1000mg month max
s 4000mg/
day
diclofenac sodium tablet (extended 100 mg q.d. PO 3 prn pain
release) month
s
gout ibuprofen tablet 800 mg t.i.d.- PO 10-14
q.i.d. days
allopurinol tablet 100-800 q.d. PO 1
mg month
shoulder/ ibuprofen tablet 200-400 q4-6h PO 1 prn pain
frozen, mg month max
tendonitis 2400mg/
day
plantar fasciitis naproxen tablet 500 mg b.i.d. PO 1 prn pain
month max 1250
mg/day
back pain tramadol tablet (immediate- 50-100 q4-6h PO 3 prn pain
release) mg month max
400mg/d
ay
f0
f1
f2 influenza oseltamivir tablet 75 mg q.d. PO 1
week
g0
g1