GP Companion 2009 by GPRA Publications

An essential reference guide for General Practice rotations

Sponsored by

GENERAL PRACTICE STUDENTS NETWORK

A joint initiative of GPRA and AMSA

Produced with funding support from General Practice Education and Training Limited

This ebook has been produced with support from Medical Indemnity Protection Society (MIPS) – 1800 061 113

Medical editors: Dr Abhi Varshney and Kerry Summerscales. Subeditor: Jan Walker. Graphic design: Marie-Joelle Design & Advertising. We would like to acknowledge General Practice Education and Training (GPET) for their funding support. Thanks to the GPRA Board for their guidance and a special thank you to Professor John Murtagh for use of material from his book General Practice.

First published in Australia in 2010 by General Practice Registrars Australia, Level 4, 517 Flinders Lane Melbourne VIC 3001 Copyright © 2010 by General Practice Registrars Australia Ltd ISBN 978 0 9808672 0 6 Typeset in Australia www.gpra.org.au

1: About Your GP Companion

GP Companion has been prepared by the General Practice Students Network (GPSN) and General Practice Registrars Australia (GPRA) . It has been designed as a handy reference containing essential information to help you get the most out of your General Practice rotations.

Contents 1: About Your GP Companion

10: Respiratory Medicine

61 62 64 68 69 70

2: Maximising Your GP Rotation

How to Get the Most from Your GP Rotation

Asthma Diagnosis and Management Spirometry CXR Interpretation Smoking Cessation

3: General Practice Resources at Your Fingertips

11: Other Tests – Haematology and Biochemistry

Resources in General Practice Common Medical Abbreviations Pathological Sieves

9 13 18

4: Preventive Health

Men’s Preventive Health Checks Men’s Health – PSA Women’s Preventive Health Checks

20 22 23

5: Contraception and Pregnancy

Contraception Antenatal Care

26 33

6: Paediatrics

Paediatric Developmental Milestones 36 National Immunisation Program Schedule 38 Normal Parameters for Paediatric Vital Signs 40 7: Dermatology

Dermatological Assessment Dermatitis and Psoriasis Skin Cancer Differentiations

42 44 45

8: Diabetes and Endocrinology

Glucose Testing – Diabetes Diagnosis and Management Endocrinology Reference Ranges (Excluding Glucose)

Haematology Acute Phase Reactants Immunohaematology Coagulation Studies Renal Function Tests – Urinalysis, UEC and GFR Estimation Liver Function Tests Ca, Mg, PO4 and Urate Lipids Arterial Blood Gases Assessing Arterial Blood Gases – Acid-Base Balance

71 77 79 81 83 86 88 90 91 92

12: Drug Information

Therapeutic Drug Intervals

47 50

9: Cardiovascular Medicine

HTN Classification and Management ECG Interpretation Cardiac Enzymes Peripheral Vascular Disease

54 57 59 60

Contents 1: About Your GP Companion

2: Maximising Your GP Rotation

How to Get the Most from Your GP Rotation Beginning the Placement »» Identify your own interest areas within General Practice and your personal learning objectives »» Meet with your GP to discuss and formulate shared learning objectives for the rotation »» During your orientation at the practice, meet all of the staff members »» So that you can adequately participate in the diagnostic and management processes, ask to be shown how: • To use the practice software • To write referrals to specialists • To order investigations at the local pathology and radiology services • To fill out prescriptions • Billing procedures work »» Determine the level of involvement you are comfortable with according to your year level, whether it is in the form of: • Observing the GP in consultation • Being observed by the GP while consulting with patients • Seeing patients in an individual consulting room • Observing the GP perform procedures and operations • Performing procedures under supervision • A combination of all of the above »» Inform your GP about: • Particular procedural skills you would like to see, learn or practise; for example: –– Vaccinations and injections –– Pap smears –– Otoscopy –– Fundoscopy –– Spirometry –– ECGs –– Giving oxygen therapy –– Instructing patients how to use their asthma medication –– Dermoscopy –– Cryotherapy –– Phlebotomy/venepuncture –– Wound exploration/debriding/suturing

–– Applying bandages or plasters • Conditions or examinations you would like to know more about, or that you have a particular interest in; for example: –– Diabetes annual checks –– Child health checks –– Antenatal checks –– Well woman checks –– Skin checks –– Mental health screening »» Negotiate some time with your GP for formal teaching at least once a week »» Arrange for a review at a halfway point through the rotation to discuss your experiences so far, your performance and your learning objectives During the Placement »» Make the most of every opportunity in the practice: • Go to after-hours clinics • Make home or nursing home visits with your GP • Attend educational evenings; for example, with the local Divisions of General Practice • Spend time with the practice nurse and other allied health professionals »» Note any learning objectives or questions you come across throughout the day and make a concerted effort to research these areas »» Never just sit in the corner! If your GP doesn’t involve you there are a number of options: • Ask more questions • Ask your GP Supervisor if you can interpret patients’ investigation results and read the patients’ charts and relevant correspondence • Ask to take some aspect of the consult – either the history or exam • Ask to take alternate patients, either in front of the GP or in a separate room • If none of these options work –– Raise the issue with your GP –– Raise the issue with your coordinator

How to Get the Most from Your GP Rotation 2: Maximising Your GP Rotation

»» If a patient doesn’t allow you in the consulting room, use this time effectively • Ask the allied health staff to teach you. The practice nurses in particular have many skills that are useful for medical students such as debriding and dressing wounds, giving vaccinations, organising diabetes and mental health management plans, etc • Take another patient into a consulting room to present to the GP • Research your learning objectives »» Halfway through your rotation have a feedback session with your GP, discuss your rotation so far and negotiate any necessary changes »» Follow-up patients: • Find a patient with a chronic disease and follow them throughout the rotation • Look for results from investigations and correspondence from hospitals and specialists’ discharges on patients you’ve seen »» Think about screening tests and examinations that can be done on each patient following the consultation and ask to perform them either during or following the consult »» Seek to understand administrative processes within the practice including: • Billing and referral systems • Documentation in patient charts • Ordering investigations • Writing prescriptions

How to Get the Most from Your GP Rotation 2: Maximising Your GP Rotation

3: General Practice Resources at Your Fingertips

Resources in General Practice Databases

Journals

Many databases are available online which can be used to search for journal articles. Some offer free access to these articles, whereas others charge on a pay-per-view basis or charge a monthly or annual subscription fee. Many universities have subscriptions to these databases and allow students free access via their library websites. Here are a few of the best databases.

Searching directly through a specific reputable journal can take a lot less time than searching a database when you want information quickly. Here are a few of the most respected journals in General Practice. Journals are available in print or online.

PubMed Free search for any journal articles, links to full text articles and other resources, over 17 million citations, www.pubmed.gov Cochrane The Cochrane Library contains systematic reviews of different trials. It takes into account not only the outcomes of the research but also the quality of the study design and how reliable the results are, www.cochrane.org.au ProQuest Available free for RACGP members at www.racgp.org.au UpToDate The latest information, members only site, www.uptodate.com

British Medical Journal Offers reputable articles on all medical topics at www.bmj.com There is also a student version at student.bmj.com The Lancet The be all and end all of high quality medical journals, www.thelancet.com Australian Family Physician The official journal of the Royal Australian College of General Practitioners, peer-reviewed and dedicated to General Practice topics. Available free online or purchase a print copy at www.racgp.org.au American Academy of Family Physicians Similar to the Australian Family Physician, available online at www.aafp.org/afp Websites

MD Consult Offers a free 30 day trial, see www.mdconsult.com

We all know that Google and Wikipedia are a great help to medical students, but for some more trusted websites with information on health, try these: HealthInsite An Australian Government initiative providing links to up-to-date health and wellbeing information and health services in Australia, www.healthinsite.gov.au The Merck Manual Easy-to-read information on what a disease is,

Resources in General Practice 3: General Practice Resources at Your Finger tips

what causes it, how to examine, diagnose and treat patients, and what the prognoses are, www.merck.com MedlinePlus Basic health information on many conditions from the National Library of Medicine in the United States, www.nlm.nih.gov/medlineplus/ Family Doctor This is produced by the American Academy of Family Physicians and provides basic information. It’s a great reference to recommend to patients, www.familydoctor.org How to Treat Series in Australian Doctor Provides a good online database of cases and management.This is an online version of the weekly “How to Treat” articles that appear in the Australian Doctor journal, www.australiandoctor.com.au

Guidelines for General Practice Therapeutic Guidelines Therapeutic Guidelines is written principally for prescribers to provide them with clear, practical, succinct and up-to-date therapeutic information for a range of diseases. They are based on the latest international literature, interpreted by some of Australia’s most eminent and respected experts, with input from an extensive network of general practitioners and other users. Therapeutic Guidelines is published in print format as a series of pocket-sized books, and also in electronic formats suitable for both personal and handheld computers. Australian Immunisation Schedule The Australian National Immunisation Program Schedule provides information on risks and benefits of immunisation and information on all vaccines, available online at www.immunise.health.gov.au Child Health Record The Victorian Government Health Information website contains growth charts, health and development assessments and child health information for parents and practitioners. Go to www.health.vic.gov.au/childhealthrecord/index.htm Medical Journal of Australia Guidelines The Medical Journal of Australia provides current Australian clinical guidelines on a wide variety of topics which are based on expert review of scientific literature. Go to www.mja.com.au/public/guides/guides.html RACGP Guidelines The Royal Australian College of General Practitioners endorses a variety of guidelines for general practitioners on their easy-to-navigate website www.racgp.org.au/guidelines

Resources in General Practice 3: General Practice Resources at Your Finger tips

Other important guidelines »» Green and Red Books on Preventive Health »» SNAP Guidelines »» Acute Coronary Syndrome Guidelines »» Chronic Heart Failure Guidelines »» Chronic Kidney Disease Guidelines »» Dementia Guidelines »» Diabetes Management Guidelines »» Guidelines on Abuse and Violence »» Guidelines for Care in Aged Care Facilities »» Intimate Partner Violence Guidelines »» Management of Incontinence Guidelines »» Management of Rheumatic Heart Disease Guidelines »» Management of Stroke Guidelines »» Physical Activity with CVD Guidelines

Books General Practice by John Murtagh Written by Australia’s most respected GP, this is considered the “bible” for both medical graduates and students alike. This user-friendly reference details a broad range of conditions met in General Practice and discusses how to approach a patient, perform a thorough clinical examination, form a differential diagnosis and choose treatment strategies. It also includes clinical pearls used by the author himself, including easy-to-remember triads for diagnosing a condition based on three key symptoms. This book has easy-to-read charts and figures, and the fourth edition also includes full colour clinical photos. General Practice Companion Handbook by John Murtagh Written to accompany the full version of General Practice, this smaller, portable version is designed to carry in your pocket for quick reference. It contains a concise synopsis of common conditions met in General Practice. Oxford Handbook of General Practice Although this UK publication begins with a lot of information about the British health system and prescribing and billing in the UK, it also contains an exhaustive amount of information on a huge range of health topics related to General Practice. This book would suit students who are used to the typical Oxford Handbook style. General Practice: An Illustrated Colour Text by Taylor, McAvoy and O’Dowd This book is great for students who like colour diagrams, shiny pages and easy-to-read language. It demonstrates the importance of evidencebased medicine and also discusses conditions in a General Practice context as opposed to the usual hospital-based orientation of medical textbooks.

Resources in General Practice 3: General Practice Resources at Your Finger tips

Churchill’s Pocketbook of General Practice This concise handbook addresses common conditions according to diagnosis and management and also has highlighted boxes to demonstrate the important points to the reader. A Textbook of General Practice by Anne Stephenson This text encompasses many of the factors about General Practice that other books leave out such as how to talk to patients, how to handle home visits, where GPs fit into the broad scheme of primary care and health promotion. Clinical Cases for General Practice Exams by Susan Wearne This book contains 50 clinical cases in the exam format of either 8-minute short cases or 19-minute long cases. It contains information for the examiner, student and also a suggested approach to each case. It also contains information on the RACGP exam and how to conduct role plays, however it does not detail what standard could be expected for a pass. The role plays are taken from real clinical scenarios and are also useful for medical students preparing for clinical examinations. Australian Medicines Handbook The AMH is a prescription drug reference formed by the Pharmaceutical Society of Australia (PSA), the Royal Australian College of General Practitioners (RACGP) and the Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists (ASCEPT). It is regularly updated and totally independent from commercial advertising or sponsorship. Available at a discounted price for RACGP members at www.racgp.org.au

Self-Education GP Learning GP Learning is an online tool developed by the RACGP and available free to members. It contains about 200 learning activities including women’s health, children and young people, mental health, acute serious illness, aged care and chronic conditions. Aimed at both experienced GPs and GP Registrars, the program is accredited for CPD points, however it is also interesting and beneficial for medical students. A free trial is available. Go to www.gplearning.com.au/index.html Rural and Remote Medical Education Online (RRMEO) Available free to Australian College of Rural and Remote Medicine (costs $11 for students to join and free to MRBS scholars), RRMEO is an online learning platform set up to help rural doctors keep up to date without having to travel to conferences constantly. Not only can you keep an inventory of practical skills and look up academic events across Australia, you can also develop your knowledge through online training modules in areas such as toxicology and dermatology. Go to www.rrmeo.com Continuous Home Evaluation of Clinical Knowledge (check) Program The check program was developed by RACGP and provides a range of cases written by expert clinicians. Each case includes a brief clinical scenario followed by a series of questions designed to bring out the important issues for general practitioners to consider in the clinical history, examination, investigation and/or management of a problem. A 12- month subscription is available free when you sign up as an RACGP member. Current and past issues are also available for sale from www.racgp.org.au/check

Resources in General Practice 3: General Practice Resources at Your Finger tips

Common Medical Abbreviations A AAA AAL ABG ABI ABL AC ac ACA ACE ACEI ACIR ACL ACR ACS ACTH ADH ADL ADT AF AFB AFP AGA AIDS ALP ALT AMI AML ANA ANCA AOM AP APTT AR ARC ARDS AS ASA ASD ASIS AST AV

abdominal aortic aneurysm anterior axillary line arterial blood gases ankle brachial index Australian bat lyssavirus acromioclavicular before meals anterior cerebral artery angiotensin-converting enzyme angiotensin-converting enzyme inhibitors Australian Childhood Immunisation Register anterior cruciate ligament albumin creatinine ratio acute coronary syndrome adrenocorticotrophic hormone antidiuretic hormone activities of daily living adult diphtheria and tetanus vaccine atrial fibrillation acid-fast bacilli acute flaccid paralysis appropriate for gestational age acquired immunodeficiency syndrome alkaline phosphatase alanine aminotransferase acute myocardial infarction acute myeloid leukaemia anti-nuclear antibodies anti-neutrophil cytoplasmic antibodies acute otitis media anterior posterior activated partial thromboplastin time aortic regurgitation AIDS-related complex acute respiratory distress syndrome aortic stenosis acetylsalicylic acid atrial septal defect anterior superior iliac spine aspartate aminotransferase atrioventricular

B BCC BCG BhCG BM BMI BP BPH BPPV

basal cell carcinoma bacillus of Calmette and GuĂŠrin (TB vaccination) beta human chorionic gonadotrophin bowel movement body mass index blood pressure benign prostatic hyperplasia benign paroxysmal positional vertigo

C CABG CAD CBT CCB CCF CDT CF CHD CI CK CLL CMC CMV CN CO COPD COX CPAP CPK CRFM CSF CSFM CT CTD CTS CVA CVP CVS CXR

coronary artery bypass grafting coronary artery disease cognitive behaviour therapy calcium channel blocker congestive cardiac failure combined diphtheria/tetanus vaccine cystic fibrosis coronary heart disease contraindications creatinine kinase chronic lymphocytic leukaemia carpometacarpal cytomegalovirus cranial nerve cardiac output chronic obstructive pulmonary disease cyclo-oxygenase continuous positive airway pressure creatinine phosphokinase chloroquine-resistant falciparum malaria cerebrospinal fluid chloroquine-sensitive falciparum malaria computerised tomography connective tissue disorder carpal tunnel syndrome cerebral vascular accident central venous pressure cardiovascular system chest X-ray

Common Medical Abbreviations 3: General Practice Resources at Your Finger tips

D D&C D&V DBP DDST DIPJ DM DNR DRE dsDNA DTaP DTR DUB DVT Dx

dilation and curettage diarrhoea and vomiting diastolic blood pressure Denver Developmental Screening Test distal interphalangeal joint diabetes mellitus do not resuscitate digital rectal examination double-stranded deoxyribonucleic acid diphtheria, tetanus, acellular pertussis deep tendon reflexes dysfunctional uterine bleeding deep vein thrombosis diagnosis

E EBM EBV ECF ECG eGFR ELISA EOM ER EtOH ESR

evidence-based medicine Epstein-Barr virus (glandular fever) extracellular fluid electrocardiogram estimated glomerular filtration rate enzyme-linked immunosorbent assay extraocular eye movement external rotation alcohol erythrocyte sedimentation rate

F FB FBC FBE FEV1 FH/FHx FOBT FOOSH FRC FSH FTT FUO FVC

foreign body full blood count full blood examination (same as above) forced expiratory volume in 1 second family history faecal occult blood test fall onto outstretched hand functional residual capacity follicle stimulating hormone failure to thrive fever of unknown origin forced vital capacity

G GABHS

group A betahaemolytic streptococcus

GGT GH GIT GNB GNBC GNC GORD GPB GPC GTN GVHD G6PD

gamma glutamyl transferase growth hormone gastrointestinal tract gram-negative bacilli gram-negative bacilli-cocci gram-negative cocci gastro-oesophogeal reflux disease gram-positive bacilli gram-positive cocci glyceryl trinitrate graft versus host disease glucose-6-phosphate dehydrogenase

H HAV Hb HBcAb HBcAg HBsAg HBsAb HBV HCG HCV HCW HDL Hib HIV HLA-B27 HMG HPV HR HRT HTN Hx

hepatitis A virus haemoglobin hepatitis B core antibody (testing for past contact) hepatitis B core antigen (testing for current virus) hepatitis B surface antigen (testing for current virus) hepatitis B surface antibody (testing for immunity or past contact) hepatitis B virus human chorionic gonadotrophin hepatitis C virus health care worker high density lipoprotein Haemophilus influenzae type b human immunodeficiency virus human leukocyte antigen (B27) hydroxymethyl-glutaryl human papillomavirus heart rate hormone replacement therapy hypertension history

I IA IBD IBS ICH

intra-articular inflammatory bowel disease irritable bowel syndrome intracranial haemorrhage

Common Medical Abbreviations 3: General Practice Resources at Your Finger tips

ICP ICS IHD IM IMI INR IOFB IPJ IPV IR ITP IU IUCD IUD IV IVC

intracranial pressure intercostal space ischaemic heart disease intramuscular intramuscular injection international normalised ratio intraocular foreign body interphalangeal joint inactivated polio vaccine internal rotation idiopathic thrombocytopenia purpura international units intrauterine contraceptive device intrauterine device intravenous inferior vena cava

J JE JVP

Japanese encephalitis jugular venous pressure

L LA LABA LAP LD LDL LFTs LGA LH LHRH LIF LLL LLQ LMNL LMP LOC LP LRTI LSCS LUL LUQ LUT LV

local anaesthetic long-acting beta agonist left atrial pressure lactate dehydrogenase low density lipoprotein liver function tests large for gestational age luteinising hormone luteinising hormone releasing hormone left iliac fossa left lower lobe (lung) left lower quadrant lower motor neuron lesion last menstrual period loss of consciousness lumbar puncture lower respiratory tract infection lower section caesarean section left upper lobe (lung) left upper quadrant lower urinary tract left ventricle

LVF LVH

left ventricular failure left ventricular hypertrophy

M MAL MAOI MCA MCL MCPJ MCU MCS Mets MI mm Hg MMR MR MRI MS MSK MSU MVP

midaxillary line monoamine oxidase inhibitor middle cerebral artery medial collateral ligament metacarpophalangeal joint microscopy and culture of urine microscopy, culture and sensitive metastasis myocardial infarction millimeteres of mercury measles, mumps, rubella vaccine mitral regurgitation magnetic resonance imaging multiple sclerosis musculoskeletal mid-stream urine mitral valve prolapse

N NAD NESB NH NHL NIP NOF NOH NR NSAIDs NSTEMI NSVD NSU N/V

no abnormalities detected non-English speaking background nursing home non-Hodgkinâ&#x20AC;&#x2122;s lymphoma National Immunisation Program neck of femur neck of humerus normal range non-steroidal anti-inflammatory drugs non-ST segment elevation myocardial infarction normal spontaneous vaginal delivery non-specific urethritis nausea/vomiting

O (o) OA OCD OCP O/C/P

taken orally osteoarthritis obsessive compulsive disorder oral contraceptive pill ova, cysts and parasites

Common Medical Abbreviations 3: General Practice Resources at Your Finger tips

O/E OM OPV OTC

on examination otitis media oral poliomyelitis vaccine (no longer in use) over the counter

P PA Pap smear PAT PCL PCOS PE PEF PHN PID PIH PIPJ PKU PMH PMR PMS PND PO POF POP PPH PPI PR PRL PROM PSA PSH PSIS PSVT Pt PTH PTSD PUD PV PVC PVD

posterior anterior Papanicolaou smear paroxysmal atrial tachycardia posterior cruciate ligament polycystic ovary syndrome pulmonary embolism peak expiratory flow post-herpetic neuralgia pelvic inflammatory disease pregnancy induced hypertension proximal interphalangeal joint phenylketonuria past medical history polymyalgia rheumatica premenstrual syndrome paroxysmal nocturnal dyspnoea per oral premature ovarian failure plaster of Paris post-partum haemorrhage proton pump inhibitor per rectal prolactin premature rupture of membranes prostate-specific antigen past surgical history posterior superior iliac spine paroxysmal supraventricular tachycardia patient parathyroid hormone post-traumatic stress disorder peptic ulcer disease per vaginal premature ventricular contraction peripheral vascular disease

R RA RBC RDS RFTs RICE RIF RLL RML RN ROM ROS RR RRV RSI RSV RUL RUQ RVF RVH

rheumatoid arthritis red blood cell respiratory distress syndrome respiratory function tests rest, ice, compression, elevation right iliac fossa right lower lobe (lung) right middle lobe (lung) registered nurse range of movement removal of sutures respiratory rate Ross River virus repetitive strain injury respiratory syncytial virus right upper lobe (lung) right upper quadrant right ventricular failure right ventricular hypertrophy

S SABA SAH SARS SBP SC SCC SD SES SGA SH SI SIADH SIDS SL SLE SOB SOL SSRI SSSS STEMI

short-acting beta agonist subarachnoid haemorrhage sudden acute respiratory syndrome systolic blood pressure subcutaneous squamous cell carcinoma standard deviation socioeconomic status small for gestational age social history sacroiliac syndrome of inappropriate ADH sudden infant death syndrome sublingual systemic lupus erythematosus shortness of breath space occupying lesion selective serotonin reuptake inhibitors staphylococcal scalded skin syndrome ST segment elevation myocardial infarction

Common Medical Abbreviations 3: General Practice Resources at Your Finger tips

STI SUFE SVC SVT

sexually transmitted infection slipped upper femoral epiphysis superior vena cava supraventricular tachycardia

T TA TB TC TCA TENS TFT TG TGA TIA TIBC TM TMJ TOP TORCH TSH T3 T4

temporal arteritis tuberculosis total cholesterol tricyclic antidepressants transcutaneous electrical nerve stimulation thyroid function test triglyceride Therapeutic Goods Administration transient ischaemic attack total iron binding capacity tympanic membrane temporomandibular joint termination of pregnancy toxoplasmosis, rubella, cytomegalovirus, herpes virus thyroid stimulating hormone tri-iodothyronine thyroxine (free)

U UC UEC UGI UMNL URTI U/S UTI

ulcerative colitis urea, electrolytes, creatinine upper gastrointestinal upper motor neuron lesion upper respiratory tract infection ultrasound urinary tract infection

V VAPP VF VRDL VSD VZV

vaccine-associated paralytic poliomyelitis ventricular fibrillation Venereal Disease Research Laboratory test (for syphilis) ventral septal defect varicella-zoster virus

W WCC WHO WPW

white cell count World Health Organisation Wolff-Parkinson-White syndrome

+ve –ve ↑ ↓ ♀ ♂  +/-

positive negative increase decrease female male leading to with or without

Common Medical Abbreviations 3: General Practice Resources at Your Finger tips

Pathological Sieves There are numerous diagnostic sieve mnemonics around. The following systematic approaches to diagnosis are commonly used in General Practice. “LINDOCARF” – for describing pain: L – locations I – intensity N – nature D – duration O – occurrence C – concurrence A – aggravation factors R – relieving factors F – features (other associated features) “VINDICATES” – for differential diagnosis: V – vascular I – inflammatory or infectious N – neoplastic D – degenerative (“wear and tear” such as OA) I – iatrogenic (caused by treatment such as medications, etc) or idiopathic C – congenital A – autoimmune or atopic (allergy) T – trauma or toxins E – endocrine and/or metabolic S – substance abuse or psychological Don’t forget the grand masquerades described by John Murtagh: D – depression D – diabetes mellitus D – drugs – prescription, non-prescription, recreational and illicit A – anaemia T – thyroid (and other endocrine problems) S – spinal dysfunction U – urinary infection (especially in the elderly)

Pathological Sieves 3: General Practice Resources at Your Finger tips

4: Preventive Health

Men’s Preventive Health Checks Test/Assessment

Frequency

How

Additional Information

Age

Smoking habits

Opportunistic

Ask about smoking habits

See Smoking Cessation for 5As on page 69

Teen - 65+

Nutrition

Every 2 yrs

Ask about fruit, Every 6 mths for those with vegetable and higher risks such as overweight, portion size CVS risks, diabetes and ATSI people

Teen - 65+

Alcohol

Every 3 - 4 yrs

Ask quantity, frequency and CAGE* questions

Teen - 65+

Physical activity

Every 2 yrs

How often Advise 30 mins moderate moderate activity 5 days a wk physical activity

Teen - 65+

Weight

Every 2 yrs

Assess BMI and waist circumference

Annually for diabetics, CVD, stroke, gout, liver or gallbladder disease and ATSI people

Teen - 65+

Depression

Opportunistic

Ask about feelings of hopelessness, depression or loss of interest in activities

Always ask about suicide if you suspect depression

18 - 65+

Chlamydia

Opportunistic

Urinary PCR

Skin Ca examination

Opportunistic

Dermoscopy exam

Consider up to 3/12 for high risk Give sun protection advice

30 - 65+

Colorectal Ca

Every 2 yrs

FOBT

Earlier for high risk groups eg – first degree relative diagnosed with bowel cancer < 55 yrs of age

50 - 65+ ATSI: 25 - 65+

See PSA on page 22 for further information Always use in conjunction with DRE

50 - 65+

More often if change of treatment indicated

45 - 65+

PSA and DRE

Absolute CVS risk

Every 2 yrs

Opportunistically if other risk factors or behavioural issues

15 - 25

Men’s Preventive Health Checks 4: Preventive Health

Test/Assessment

Additional Information

Age

Blood pressure

Every 2 yrs

Frequency

Measure

Used for absolute CVS risk Discuss lifestyle and consider pharmacotherapy Every 12 mths for increased CVS risk and 6 mths for high CVS risk

18 - 65+ ATSI: 15 - 65+

Lipids

Every 5 yrs

Fasting chols, triglycerides and HDL

Used for absolute CVS risk Discuss lifestyle and diet Consider pharmacotherapy if indicated Every 2 yrs > 45 yrs if high risk Every 12/12 if increased risk and chronic disease

45 - 65+

Type 2 diabetes

Every 3 yrs

Fasting glucose

If there is glucose intolerance offer early intervention Discuss lifestyle and dietary risk factors

40 - 65+ ATSI: 18 - 65+

Stroke risk

Annual with risk

Annual with AF, previous MI or chronic kidney disease

45 - 65+

Kidney disease

Every 5 yrs

Urinary dipstick and U&E

Annually if HTN, DM or history of renal disease

50 - 65+ ATSI: 45 - 65+

Assess risk

Bone mineral densitometry if indicated

Variable

Osteoporosis

How

Falls risk

Annually

Consider OT home review

Every 6 mths if increased risk or history of previous fall

65+

Vision and hearing

Annually

VA, visual field, hearing test

Consider glaucoma assessment (especially with history of DM)

65+

Adapted from RACGP – Preventive Activities over the Lifecycle – Adults and RACGP Red Book – www.racgp.org.au

*CAGE questions for alcohol consumption C – Ever felt you should CUT DOWN on your drinking? A – Ever been ANNOYED at people criticising your drinking? G – Ever felt GUILTY about your drinking? E – Ever had a drink as an EYE-OPENER?

Men’s Preventive Health Checks 4: Preventive Health

Men’s Health – PSA Prostate Specific Antigen (PSA) PSA reference ranges are laboratory, methodology and age-dependent – refer to the specific laboratory reference ranges provided with results. Results should not be interpreted in isolation but in conjunction with digital rectal examination (DRE) and generalised history and clinical examination findings. The value of PSA as a regular screening test for men is contentious. PSA is useful for monitoring the progression and treatment of prostatic carcinoma once diagnosis has been made. Normal or only slightly elevated levels do not exclude prostatic carcinoma. The role of screening tests and the possible interpretations and implications of results should be discussed with every patient prior to testing. Possible Causes for Elevation »» Benign prostatic hyperplasia »» Prostatic carcinoma »» Prostatitis »» Prostatic ischaemia »» Prostatic infarction »» Acute renal failure

Men’s Health – PSA 4: Preventive Health

Women’s Preventive Health Checks Test/Assessment

Frequency

How

Additional Information

Age

Smoking habits

Opportunistic

Ask about smoking habits

See Smoking Cessation for 5As on page 69

Teen - 65+

Nutrition

Every 2 yrs

Ask about fruit, Every 6 mths for those with vegetable and higher risks such as overweight, portion size CVS risks, diabetes and ATSI people

Teen - 65+

Alcohol

Every 3 - 4 yrs

Ask quantity, frequency and CAGE* questions

Teen - 65+

Physical activity

Every 2 yrs

How often Advise 30 mins moderate moderate activity 5 days a wk physical activity

Teen - 65+

Weight

Every 2 yrs

Assess BMI and waist circumference

Annually for diabetics, CVD, stroke, gout, liver or gallbladder disease and ATSI people

Teen - 65+

Depression

Opportunistic

Ask about feelings of hopelessness, depression or loss of interest in activities

Always ask about suicide if you suspect depression

18 - 65+

Domestic violence

Opportunistic

Ask about Increased domestic violence in home situation pregnancy and adolescence

Teen - 50

Pap smear

Every 2 yrs

Speculum Pap smear collection

18 - 70

Chlamydia

Opportunistic

Cervical swab All sexually active young women 15 - 25 or urinary PCR – consider while doing Pap smear

Preconception care

Opportunistic

Ask about folate and iodine intake

Give advice on high folate and iodine foods, supplements and general nutrition

15 - 50

Mammogram

Every 2 yrs

Breast Screen Australia

Teach younger women breast self-examination and encourage review if concerns

50 - 70

Skin Ca examination

Opportunistic

Dermoscopy exam

Consider up to 3/12 for high risk Give sun protection advice

30 - 65+

Opportunistically if other risk factors or behavioural issues

For all women 1 - 2 yrs after becoming sexually active Cease at 69 if 2 normal smears in last 5 yrs

Women’s Preventive Health Checks 4: Preventive Health

Test/Assessment

Frequency

How

Age

Colorectal Ca

Absolute CVS risk

Every 2 yrs

Blood pressure

Every 2 yrs

Measure

Used for absolute CVS risk Discuss lifestyle and consider pharmacotherapy Every 12 mths for increased CVS risk and 6 mths for high CVS risk

18 - 65+ ATSI: 15 - 65+

Lipids

Every 5 yrs

Fasting chols, triglycerides and HDL

Used for absolute CVS risk Discuss lifestyle and diet Consider pharmacotherapy if indicated Every 2 yrs > 45 yrs if high risk Every 12/12 if increased risk and chronic disease

45 - 65+

Type 2 diabetes

Every 3 yrs

Fasting glucose

If there is glucose intolerance offer early intervention Discuss lifestyle and dietary risk factors

40 - 65+ ATSI: 18 - 65+

Stroke risk

Annual with risk

Annual with AF, previous MI or chronic kidney disease

45 - 65+

Kidney disease

Every 5 yrs

Urinary dipstick and U&E

Annually if HTN, DM or history of renal disease

50 - 65+ ATSI: 45 - 65+

Assess risk

Bone mineral densitometry if indicated

Variable

Osteoporosis

FOBT

Additional Information

Every 2 yrs

Earlier for high risk groups eg – first degree relative diagnosed with bowel cancer < 55 yrs of age

50 - 65+ ATSI: 25 - 65+

More often if change of treatment indicated

45 - 65+

Falls risk

Annually

Consider OT home review

Every 6 mths if increased risk or history of previous fall

65+

Vision and hearing

Annually

VA, visual field, hearing test

Consider glaucoma assessment (especially with history of DM)

65+

Adapted from RACGP – Preventive Activities over the Lifecycle – Adults and RACGP Red Book – www.racgp.org.au

*CAGE questions for alcohol consumption (see page 21)

Women’s Preventive Health Checks 4: Preventive Health

5: Contraception and Pregnancy

Contraception Contraception is defined as the prevention of fertilisation and/or implantation of the ovum, thus preventing pregnancy. Method of Action

Advantages

Disadvantages

Failure Rate

»» Predicting time of maximum fertility (ie ovulation)

»» Free »» Acceptable for religious groups »» No side effects

»» Relies on regular cycle »» Lengthy instruction »» ↑ commitment required »» High failure rate

High

»» Free »» Acceptable for religious groups »» No side effects

»» High failure rate »» Pre-ejaculate contains spermatozoa

High

»» Free »» Acceptable for religious groups »» Minimal side effects

»» Ovulation 2 wks before first period, so may be fertile and not know

Significant

Natural Methods Rhythm method

• Menstrual calendar • Charting body temp (↑ at ovulation) • Thickening of mucus • Ovulation predictor kits

Coitus interruptus

»» Not ejaculating inside the ♀

»» During Lactation breastfeeding amenorrhoea hormonal changes stop ovulation and periods »» Must be 100% breastfeeding, amenorrhoeic and less than 6 mths post-delivery

Contraception 5: Contraception and Pregnancy

Method of Action

Advantages

Disadvantages

Failure Rate

Barrier Methods Both are best used in conjunction with spermicidal creams Condoms

»» Condom placed on erect penis before any vaginal contact

»» ONLY method that offers protection against STIs

»» Apply before contact »» May decrease male sensation

2.0 -15.0

Diaphragm

»» Soft dome-shaped rubber cap placed over cervix

»» Can be inserted a few hrs before sex

»» Apply before contact »» Must be fitted

2.0 -15.0

Contraception 5: Contraception and Pregnancy

Method of Action

Advantages

Disadvantages

Failure Rate

Hormonal Methods Note: Contraindications to combined OCP listed on page 32* »» Inhibits ovulation Combined »» Inhibits FSH release oral contraceptive »» Prevents follicular ripening pill »» Prevents LH surge »» Alters endometrium »» Alters cervical mucus

»» Reliable if taken correctly »» Convenient »» Doesn’t affect spontaneity »» Can reduce dysmenorrhoea and PMS

»» Must be taken every day »» Prescription only »» Side effects may include:

Progesterone »» Inhibits ovulation in 50 - 60% of cycles only pill »» Alters endometrium »» Alters cervical mucus »» ↓ tubal motility

»» Reliable if taken correctly »» Convenient »» Doesn’t affect spontaneity »» Most commonly used in breastfeeding women

»» Must be taken same time every day »» Prescription only »» Side effects may include:

»» IMI of progestogen Injectable every 3/12  progesterone ensures high-dose progestogen gradually released into circulation »» Inhibits ovulation »» Alters endometrium »» Alters cervical mucus

»» Reliable »» Longer lasting »» Doesn’t affect spontaneity »» No daily action required »» Often causes amenorrhoea

»» Prescription only »» Side effects may include:

• Weight gain • Acne • ↓ libido • Breast discomfort • Mood disturbances • Breakthrough bleeding • Headache • HTN

• Irregular bleeding • Weight gain • Moodiness • Acne

0.2 - 3.0 Failure risks associated with diarrhoea, vomiting and antibiotic use

0.3 - 4.0 Failure risks associated with diarrhoea, vomiting and antibiotic use 0.0 -1.0

• Weight gain • ↓ libido • Irregular bleeding • Breast discomfort • Mood disturbances • Must wait for injection to wear off • Delay in return to fertility up to 18 mths

Contraception 5: Contraception and Pregnancy

Implanon

Vaginal ring

Method of Action

Advantages

Disadvantages

»» Progestogen implant in upper arm  effective for 3 yrs »» Inhibits ovulation »» Alters endometrium »» Alters cervical mucus

»» Reliable »» Longer lasting »» Doesn’t affect spontaneity »» No daily action required »» Used for ♀ who cannot take oestrogen  >35 yrs, smoker, breastfeeding »» Periods usually cease »» No waiting period for return of fertility »» Can be removed

»» Prescription only »» Side effects may include:

»» Soft plastic ring inserted into vagina »» Slow release of low doses of oestrogen and progestogen »» Left in place for 3 wks

»» Reliable »» Less side effects than OCP »» No daily action required »» Failure risks of OCP avoided as GIT absorption not required

»» Prescription only »» Relatively expensive

0.0 -1.0

»» May still be effective up to 72 hrs postcoitus »» Available without prescription in pharmacies »» Useful when unplanned intercourse has occurred

»» Effectiveness decreases as time from unprotected sex increases »» May be associated with nausea and vomiting (not effective if vomiting occurs within 3 hrs)

2.0 - 5.0

»» High doses of Emergency oestrodiol and contraceptive progestogen pill »» Makes endometrium unfavourable for implantation »» Interference with corpus luteum function

Failure Rate 0.0 - 1.0

• Weight gain • ↓ libido • Irregular bleeding • Breast discomfort • Mood disturbances

Contraception 5: Contraception and Pregnancy

Method of Action

Advantages

Disadvantages

Failure Rate

Intrauterine Devices Note: Contraindications to IUCD listed on page 32** »» Device inserted IUCD into the uterus (Intrauterine contraceptive »» Prevention of blastocyst device) implantation »» Inhibition of sperm movement

»» Reliable »» Can remain for up to 5 yrs »» No hormonal side effects »» Doesn’t affect spontaneity »» No daily action required

»» Prescription only »» Periods may be heavier »» Potential risk of:

0.3 - 2.0

• Infection • Perforation of uterus • Migration or expulsion of device

»» Insertion may be uncomfortable for certain women Mirena

»» Device inserted into the uterus »» Secretes small amount of progestogen »» Prevention of blastocyst implantation »» Inhibition of sperm movement »» Alters endometrium »» Alters cervical mucus

»» Reliable »» Can remain in place for 5 yrs »» Many become amenorrhoeic »» Minimal hormonal side effects »» Doesn’t affect spontaneity »» No daily action required

»» Prescription only »» Spotting can occur for up to 3 mths »» Small risk of:

0.0 - 0.2

• Infection • Perforation of uterus • ↑ risk of ectopic pregnancy • Migration or expulsion of device

»» Insertion may be uncomfortable for certain women

Contraception 5: Contraception and Pregnancy

Method of Action

Advantages

Disadvantages

Failure Rate

Sterilisation »» GP or surgeon referral »» Permanent »» Need 2 postprocedure sperm samples to be aspermic, usually after 3 mths

Male

»» Vasectomy – ligation of vas deferens via scrotal incision, thus spermatozoa do not enter seminal fluid

»» Reliable »» Conducted under LA »» Considered permanent »» Doesn’t affect spontaneity »» No daily action required

Female

»» Surgery to clip the fallopian tubes thus preventing sperm getting to the ova »» Modern techniques include insertion of “coils” into tubes thus creating scar tissue (takes 3 mths to be effective)

»» Surgical »» Reliable »» Considered procedure under GA permanent »» Permanent »» Doesn’t affect spontaneity »» Can take 3 mths to be effective »» No daily action required »» Potentially reversible

0.0 - 0.4

Termination of pregnancy

»» < 8/40 – Mifepristone with prostaglandin analogue »» < 12/40 – Dilation of cervix and vacuum aspiration »» >12/40 – Dilation of cervix and evacuation of uterine contents via crushing and curettage

»» Reliable

Not applicable

»» Risk of: • Infection • Retained tissue • Damage to cervix • Incomplete abortion • Psychological stress if not adequately counselled

0.0 - 0.5

Contraception 5: Contraception and Pregnancy

* Contraindications to Combined OCP Absolute

»» Pregnancy Relative »» First 2 wks post-partum »» Personal history of thromboembolic disease »» Cerebrovascular disease »» Liver disease »» Migraines with aura »» Previous oestrogen-dependent tumour »» Recent hydatidiform mole

»» Family history of thrombosis »» Hypertension »» Migraines »» Varicose veins > 35 yrs »» ↑ BMI »» Smoking »» Breastfeeding »» Diabetes

** Contraindications to IUCD Absolute

»» Pregnancy »» Previous ectopic pregnancy »» Active PID »» Undiagnosed uterine bleeding »» Previous tubal surgery

Relative

»» Very large or very small uterus »» Anaemia »» Impaired immune system »» Impaired clotting mechanisms »» Valvular heart disease »» Previous history of PID

Contraception 5: Contraception and Pregnancy

Antenatal Care The general practitioner is often the first medical person to confirm a pregnancy for a woman or couple. This can be both an exciting and challenging role for a GP, and the care of a pregnant woman is imperative to increase the opportunity for a good outcome. Women and couples contemplating pregnancy should be advised of the importance of good general health and folic acid 0.5mg/day for one month prior to conception and continued use until the 12th week of gestation as this can decrease the rates of neural tube defects. Other supplements such as calcium, fluoride and iron are not necessary unless there is a deficiency. Women at high risk of Vitamin D deficiency should however be screened. There are varied patterns of care for pregnant women including entirely midwifery care, shared care with a GP and hospital obstetricians, hospital midwife with obstetrician, and private obstetrician care.

Timeline of Visits Initial consult »» With GP – confirm pregnancy »» Early pregnancy ultrasound to confirm dates »» Early pregnancy screening blood tests • BhCG • FBC • Blood group and antibody screen • Rubella screen • Cervical cytology (if required) • Hepatitis serology • HIV serology • Syphilis serology • Vitamin D • Urine M/C/S »» Discuss diet, promote smoking cessation, promote no alcohol. Assess any physical or psychosocial risks, etc 12/40 »» Can do Down screen – nuchal translucency ultrasound and bloods (PAPP-A and Free BhCG) 14/40 »» FBC »» Blood group and antibody screen »» Antenatal serology »» MSU »» Discuss choices of care »» Childbirth education information 15-16/40 »» Amniocentesis if indicated 15-20/40 »» Maternal serum screening 18-20/40 »» Obstetric ultrasound

Antenatal Care 5: Contraception and Pregnancy

22/40 »» R/V ultrasound »» R/V serum screening »» Check antenatal classes booked 26-28/40 »» FBC and OGCT »» OGTT if OGCT > 7.8mmol/L »» Blood group and antibody screen »» Prophylactic anti-D if Rh D neg »» Assess foetal and maternal wellbeing »» Discuss feeding plans 32/40 »» Wellbeing and foetal growth check 34-36/40 »» 2nd prophylactic anti-D »» Consultant obstetrician check if shared care »» Wellbeing and foetal growth check »» Low vaginal swab for group B streptococcus »» Discuss benefits of breastfeeding 38 and 40/40 »» Progress review »» Wellbeing and foetal growth check »» Discuss induction of labour at 40/40 Adapted from www.health.sa.gov.au, www.rcpa.edu.au and FMC Antenatal Schedule for clinics

6 week Post-Natal Check: Assess: »» General health of mother and baby and bonding between mother, partner and baby. How are the mother and partner coping with the changes? Are there any supports? »» Any indications of post-natal depression or mood dysfunction? »» How is the baby feeding and what are they being fed – breast, formula or mixed? »» Have periods recommenced and, if so, when was LMP? »» Last Pap smear – if > 2 yrs, should conduct now »» Rubella status – vaccinate if not previously immune. NEVER to be given during pregnancy! »» Has sexual intercourse resumed and are there any problems with sexual activity? »» What contraception is being used? If patient wants to use hormonal and still breastfeeding – progestin only as opposed to combined therapy »» Any urinary or faecal incontinence? Examine: »» BP »» Breast and nipples for any cracking, tenderness or mastitis »» Abdominal wound (if applicable) to assess healing »» Perineum/pelvic exam – vagina, vulva, perineum, uterus, adenexa, cervix and perineum Refer: »» Any complications to other services such as post-natal support services, lactation nurses, mood disorders clinic, continence clinic, social worker, etc Conduct: »» A well baby check

Antenatal Care 5: Contraception and Pregnancy

6: Paediatrics

Paediatric Developmental Milestones Gross Motor

Fine Motor

6 wks

»» Moro response »» Good head control when pulled

»» Not able to assess

»» Coos »» Startles at loud noise

Speech and Language

»» Smiles in response

Social Skills

3 mths

»» Rolling »» Prone – raises head »» No head lag

»» Reach and grasp »» Objects to mouth

»» Coos »» Responds to voice »» Laughs and squeals

»» Smiles »» Eye contact »» Recognises parent

6 mths

»» Sitting »» Prone – weight on hands

»» Ulnar grasp

»» Begins to babble »» Responds to name

»» Stranger anxiety »» Beginning of object performance

9 mths

»» Crawling »» Pull to stand

»» Mama, Dada, »» Reaches for toys imitates one word »» Palmar to fingerthumb grasp »» Understands “no” »» Follows fallen toys »» Fixes on small objects

»» Separation and stranger anxiety »» Plays games »» Hand and foot regard

12 mths

»» Walking with support

»» Pincer grasp »» Throws objects

»» 2 words (with meaning) »» Follows one step commands

»» Drinks with cup »» Waves bye-bye

18 mths

»» Walking independently »» Climbs stairs 2 feet to a step »» Climbs onto and sits on chair

»» Tower of 3 cubes »» Takes off shoes and socks »» Picks up 100s and 1000s »» Scribbling

»» 10 words »» Points to body parts »» Follows simple commands

»» Uses spoon »» Domestic mimicry »» Developing toilet awareness

2 yrs

»» Climbs up and »» Tower of 6 cubes down stairs »» Helps with »» Running undressing »» Kicks ball

»» 2-3 word phrases »» Uses “I”, “me” and “you” »» 50% intelligible

»» Parallel play »» Helps to dress

Paediatric Developmental Milestones 6: Paediatrics

Gross Motor 3 yrs

»» Tricycle »» Stands on one foot »» Jumping

Fine Motor »» Threads beads on a string »» Dresses and undresses fully »» Copies a circle and a cross »» Builds 8-cube tower »» Letter matching using charts

Speech and Language »» Counts to 10 »» Short sentences »» Understands prepositions (eg “on”) »» 75% intelligible

Social Skills »» Toilet trained – dry by day »» Plays with other children »» Knows sex and age

Red Flag Signs Red Flag Developmental Signs 6 - 8 wks

»» Asymmetrical Moro response »» Excess head lag »» No visual fixation/following »» No startle or quietening to sound »» No responsive smiling

8 mths

»» Persistent primitive reflexes »» Not weight bearing on legs »» Not reaching out for toys »» Not fixing on small objects »» Not vocalising

10 mths

»» Unable to sit unsupported

1 yr

»» Showing of hand preference »» Not responding to own name

18 mths

»» Not walking »» No pincer grip »» Persistence of casting

3 yrs

»» Inaccurate use of spoon »» Not speaking in sentences »» Unable to understand simple commands »» Not interacting with other children

Paediatric Developmental Milestones 6: Paediatrics

National Immunisation Program Schedule Age

Vaccine

Birth

Hepatitis B (hepB) a

2 mths

Hepatitis B (hepB) b Diphtheria, tetanus and acellular pertussis (DTPa) Haemophilus influenzae type b (Hib) c,d Inactivated poliomyelitis (IPV) Pneumococcal conjugate (7vPCV) Rotavirus

4 mths

Hepatitis B (hepB) b Diphtheria, tetanus and acellular pertussis (DTPa) Haemophilus influenzae type b (Hib) c,d Inactivated poliomyelitis (IPV) Pneumococcal conjugate (7vPCV) Rotavirus

6 mths

Hepatitis B (hepB) b Diphtheria, tetanus and acellular pertussis (DTPa) Haemophilus influenzae type b (Hib) c Inactivated poliomyelitis (IPV) Pneumococcal conjugate (7vPCV) e Rotavirus

12 mths

Hepatitis B (hepB) b Haemophilus influenzae type b (Hib) d Measles, mumps and rubella (MMR) Meningococcal C (MenCCV)

12 - 24 mths

Hepatitis A (Aboriginal and Torres Strait Islander children in high risk areas) f

18 mths

Varicella (VZV)

18 - 24 mths

Pneumococcal polysaccharide (23vPPV) (Aboriginal and Torres Strait Islander children in high risk areas) g Hepatitis A (Aboriginal and Torres Strait Islander children in high risk areas)

4 yrs

Diphtheria, tetanus and acellular pertussis (DTPa) Measles, mumps and rubella (MMR) Inactivated poliomyelitis (IPV)

10 -13 yrs h

Hepatitis B (hepB) Varicella (VZV)

12 -13 yrs i

Human papillomavirus (HPV)

15 -17 yrs i

Diphtheria, tetanus and acellular pertussis (dTpa)

Please refer to page 39 for footnotes

National Immunisation Program Schedule 6: Paediatrics

Age

Vaccine

15â&#x20AC;&#x2030;-â&#x20AC;&#x2030;49 yrs

Influenza (Aboriginal and Torres Strait Islander people medically at-risk) Pneumococcal polysaccharide (23vPPV) (Aboriginal and Torres Strait Islander people medically at-risk)

50 yrs and over

Influenza (Aboriginal and Torres Strait Islander people) Pneumococcal polysaccharide (23vPPV) (Aboriginal and Torres Strait Islander people)

65 yrs and over

Influenza Pneumococcal polysaccharide (23vPPV)

Please refer to page 39 for footnotes

Footnotes to National Immunisation Program Schedule a Hepatitis B vaccine should be given to all infants as soon as practicable after birth. The greatest benefit is if given within 24 hrs, and must be given within 7 days. b Total of three doses of hepB required following the birth dose, at either 2 mths, 4 mths and 6 mths or at 2 mths, 4 mths and 12 mths. c Give a total of 4 doses of Hib vaccine (2 mths, 4 mths, 6 mths and 12 mths) if using PRP-T Hib containing vaccines. d Use PRP-OMP Hib containing vaccines in Aboriginal and Torres Strait Islander children in areas of higher risk (Queensland, Northern Territory, Western Australia and South Australia) with a dose at 2 mths, 4 mths and 12 mths. e Medically at-risk children require a fourth dose of 7vPCV at 12 mths of age, and a booster dose of 23vPPV at 4 yrs of age. f Two doses of hepatitis A vaccine are required for Aboriginal and Torres Strait Islander children living in areas of higher risk (Queensland, Northern Territory, Western Australia and South Australia). Contact your State or Territory Health Department for details. g Contact your State or Territory Health Department for details. h These vaccines are for one cohort only within this age range, and should only be given if there is no prior history of disease or vaccination. Dose schedules may vary between jurisdictions. Contact your State or Territory Health Department for details. i These vaccines are for one cohort only within this age range. Contact your State or Territory Health Department for details. j Third dose of vaccine is dependent on vaccine brand used. Contact your State or Territory Health Department for details. Note: The Gardasil HPV vaccination is available for girls from 12 yrs up to 27 yrs of age. The Cervarix vaccination is available from 25 to 45 years. Both these vaccinations are given as a series of three vaccinations over 6/12. The Australian Immunisation Handbook -- www.immunise.health.gov.au

National Immunisation Program Schedule 6: Paediatrics

Normal Parameters for Paediatric Vital Signs Neonate

Infant (6 mths)

Toddler (2 yrs)

Pre-School

School Age (7 yrs)

Adolescent (15 yrs)

Heart rate – awake (beats/min)

100 -180

100 -160

80 -150

70 -110

65 -110

60 - 90

Heart rate – asleep (beats/min)

80 -160

70 -120

60 - 90

50 - 90

Respiratory rate (breaths/min)

30 - 80

30 - 60

24 - 40

22 - 34

18 - 30

12 - 20

Temperature (°C)

36.5 - 37.5

36.0 - 37.2

Normal Parameters for Paediatric Vital Signs 6: Paediatrics

7: Dermatology

Dermatological Assessment Site Site and distribution

»» Flexure or extensor surfaces, etc »» Psoriasis more noted on knees, elbows, scalp, etc »» Eczema more noted in flexures »» Acne usually seen on the face and upper body »» BCCs more common on prominences of the head and neck

Characteristics of Lesion Type

»» Bulla, macule, nodule, papule, plaque, pustule, ulcer, vesicle or weal

A and B – asymmetry and border

»» Shape – round, oval, annular, linear »» “Asymmetrical” or “irregular” borders »» Definition of borders

C – colour

»» Describe the actual colour – red, pink, purple, brown, black, white »» Describe any uneven distribution of colour

D – diameter (size)

»» Should be actual measures

Surface

»» Crust, excoriation, horn, lichenification, maceration, scale

Superficial or deep

»» Is lesion superficial to the skin or within the skin itself? »» What does lesion look like under any crustiness? »» Does the lesion blanch?

Secondary Sites Site and distribution

»» Are there other sites where the lesion can be seen? »» Look for patterns of secondary sites: • Psoriasis – nails • Scabies – finger webs and wrist folds • Fungal infections – toe webs, other webbed/flexure regions

Dermatological Assessment 7: Dermatology

Abscess Angio-oedema Bulla Crust Excoriation Lichenification Maceration Macule Nodule Papule Plaque Pustule Scale Telangiectasia Ulcer Vesicle Weal

Localised collection of pus in a cavity > 1cm diameter Diffuse area of oedema extending into subcutaneous tissue Visible collection of fluid within the skin surface > 0.5cm in diameter Accumulation of dried exudative material Superficial ulceration secondary to scratching Thickening of skin surface secondary to chronic scratching or rubbing Surface appears softened secondary to excessive moisture Circumscribed area of altered skin colour < 1cm diameter Well-circumscribed region of skin > 0.5cm that is palpable or visible Well-circumscribed and raised area of skin < 0.5cm in diameter A flat-topped palpable mass > 1cm diameter Visible collection of pus within the skin surface Accumulation of excess keratin that presents as flaking Visible dilation of small cutaneous blood vessels Circumscribed deep defect with loss of all the epidermis and part or all of the dermis Visible collection of fluid within the skin surface < 0.5cm in diameter Area of dermal oedema (any size)

Adapted from www.healthinsite.gov.au, www.virtualskincentre.com and various other sources

Dermatological Assessment 7: Dermatology

Dermatitis and Psoriasis Contact Dermatitis

Atopic Dermatitis (Eczema)

Psoriasis

Site Site

»» Site of “contact”

»» Antecubital and popliteal fossae »» Dorsum of feet

»» Scalp »» Elbows, knees

Distribution

»» Any cutaneous surfaces

»» Flexures

»» Extensor surfaces

Type of lesions

»» Erythematous lesions »» Vesicles

»» Erythematous lesions »» Oedematous »» Leads to vesicles

»» Plaques »» Vesicles »» Pustules

Shape/border

»» Asymmetrical »» Depends on type of contact

»» Asymmetrical »» Ill-demarcated border

»» Symmetrical »» Well-demarcated border

Colour

»» Red with white scales »» Red with white scales

Characteristics

»» Pink plaques surrounded by silvery scale

Secondary Sites Secondary site

»» Face, wrists, forearms

»» Nails

Dermatitis and Psoriasis 7: Dermatology

Skin Cancer Differentiations BCC

Melanoma

Morphology

»» Flesh-coloured »» Scaling »» No central depression »» No telangiectasia »» No raised border

SCC

»» Pearly »» No scaling »» Central depression »» Telangiectasia »» Raised, rolled border

»» Multiple colours: black, blue, brown, pink, white, tan »» Asymmetrical, irregular border

Distribution

»» Commonly sun-exposed areas »» Head, neck, hands and forearms

»» Sun-exposed areas »» Face, neck, upper trunk and limbs

»» Generalised

Hx – exacerbating factors

»» Sunlight exposure

Associated findings

»» Sun-damaged skin »» Actinic keratosis

»» Sun-damaged skin »» Any change in lesion needs review

Epidemiology

»» Less common »» Usually > 50 yrs

»» Relatively common »» Rarely inherited »» Basal cell nevus syndrome

»» Uncommon »» Rarely familial

SCC = squamous cell carcinoma BCC = basal cell carcinoma Melanoma ABCDE: A appearance asymmetry B border C colour D diameter distribution E evolution

Skin Cancer Differentiations 7: Dermatology

8: Diabetes and Endocrinology

Glucose Testing – Diabetes Diagnosis and Management Serum glucose is used to detect hyperglycaemia and hypoglycaemia, as well as detection of diabetes mellitus and monitoring of glycaemic control.

Serum Glucose Fasting Glucose 4.0 - 6.0 mmol/L Random (> 2 hrs post-prandial) 3.0 - 7.7mmol/L

Diagnostic of Diabetes Mellitus Equivocal for Diabetes Mellitus »» Symptoms of diabetes mellitus AND

»» Fasting Glucose > 7.0 mmol/L on 2 occasions OR

»» Fasting Glucose between 5.6 - 6.8 mmol/L OR

»» Random Glucose between 7.8 -11.0 mmol/L

Unlikely Diabetes Mellitus »» Fasting Glucose < 5.5 mmol/L AND/OR

»» Random Glucose < 7.8 mmol/L

»» Random Glucose > 11.1mmol/L (> 2 hrs post-prandial) on 2 occasions ÆÆ No Oral Glucose Tolerance Test (GTT) required

ÆÆ Conduct an Oral GTT

ÆÆ No Oral GTT indicated

Note: Fasting means the only intake is water for 8 hrs before the sample is collected Oral Glucose Tolerance Test Patients are to have a 3-day period of eating an adequate carbohydrate diet (150g/day). Then a 75g load of carbohydrate drink is given after an 8-hr fast. Blood is taken for serum glucose at fasting (time 0) and then again at 2 hrs. Children are given a carbohydrate load of 1.75g/kg to a maximum of 75g. Oral GTT should not be conducted with patients who: »» Are known diabetic patients »» Are currently unwell as infection, recent surgery or trauma impair glucose tolerance »» Have 2 fasting glucose samples confirming or excluding diabetes »» Are currently talking corticosteroids or β adrenergic agonists as the test may be invalid Indications of Oral GTT: »» Elevated fasting or Random Serum Glucose »» Abnormal Glucose Challenge Test in 26 - 28 wk gestational screening test Pregnant women at high risk of gestational diabetes Fasting Serum Glucose

2 Hour Serum Glucose

Interpretation

< 5.5 mmol/L

< 7.8 mmol/L

Normal glucose metabolism

> 7.0 mmol/L

> 11.1mmol/L

Diabetes mellitus

Glucose Testing – Diabetes Diagnosis and Management 8: Diabetes and Endocrinology

Diabetes Mellitus: Glycaemic Control – the Good, the Bad and the Ugly! Glycaemic Control – Plasma Glucose (mmol/L) Ideal Before Meals – Fasting After Meals – 2 hrs Post-Prandial HbA1C %

Acceptable

Suboptimal

< 5.5

5.5 - 7.0

> 7.7

7.0 -10.0

> 11.0

< 7%

< 8%

> 11%

»» HbA1C is an index of mean plasma glucose levels over the preceding 2 - 3 mths (the red blood cell lifecycle) »» Normal reference range of 3.5 - 6.0% Management of Type 2 Diabetes Mellitus Promote healthy lifestyle changes such as: »» Smoking cessation »» Healthy diet low in saturated fats and refined carbohydrates »» Alcohol intake reduction (see goals) »» Physical activity (see goals) When dietary and exercise control fails to reduce serum glucose: For Those Able to Take Metformin 1

Start metformin

Monitor glycaemic control

3 4

For Those Unable to Take Metformin Start sulphonylurea

If inadequate control, increase dosage If still inadequate control, consider: »» Adding a sulphonylurea, +/- glitazone or arcarbose »» Insulin

If still inadequate control, consider: »» Glitazone or arcarbose »» Insulin

Glucose Testing – Diabetes Diagnosis and Management 8: Diabetes and Endocrinology

Goals of Management of Diabetes Mellitus Fasting Blood Glucose 4.0 - 6.0 mmol/L HbA1C % < 7.0% Cholesterol < 4.0 mmol/L LDL Cholesterol < 2.5 mmol/L HDL Cholesterol > 1.0 mmol/L Blood Pressure Without proteinuria < 130/80 mm/Hg With proteinuria (1g/day) < 125/75 mm/Hg BMI < 25 Urinary Albumin Excretion Timed overnight collection < 20µg/min Spot collection < 20 mg/L Albumin:Creatinine Ratio Men < 2.5 mg/mmol Women < 3.5 mg/mmol Cigarette Consumption Nil Alcohol Intake Men � 2 standard drinks/day (� 20g/day) Women � 1 standard drink/day (� 10g/day) Exercise At least 30 mins moderate exercise 5 or more times a week (total 150 mins/wk) Adapted from Murtagh’s General Practice, www.rcpa.edu.au, www.health.gov.au, www.diabetesaustralia.com.au and www.racgp.org.au

Glucose Testing – Diabetes Diagnosis and Management 8: Diabetes and Endocrinology

Endocrinology Reference Ranges (Excluding Glucose) Testosterone Male Pre-Pubertal

Female Adult

Pre-Pubertal

Adult

< 0.5

< 4.0

170 - 510

Free Testosterone (pmol/L) < 0.5

Total Testosterone (nmol/L)

8 - 35

< 4.0

1- 2.5

Dihydrotestosterone (nmol/L) Possible Interpretations Male Increased

»» Precocious puberty

Decreased

»» Testicular failure »» Primary hypopituitarism »» Secondary hypopituitarism

Female »» Hirsutism »» Virilisation »» Women with total androgen insensitivity

Note: In plasma, testosterone is bound to SHBG, so abnormal levels of SHBG may cause a discrepancy between free and total testosterone Follicle Stimulating Hormone IU/L

Luteinising Hormone IU/L

Oestadiol (pmol/L)

Progesterone (nmol/L)

Adult Male

1.0 - 5.0

2 -10

Adult Female Early Follicular Phase

1.0 - 8.0

2 -15 100 - 200

2.0 - 4.5

Pre-Ovulatory Phase

500 -1,700 10 - 30

Ovulation

Highest levels of the cycle 500 - 900

Luteal Phase Post-Menopausal

>18

15 -100

7.0 - 70.0

70 - 200

Possible Interpretations Increased FSH

»» Primary gonadal hypofunction »» Pituitary gonadotroph tumours »» Menopausal state »» Castration

Decreased »» Ovarian or testicular failure • Pituitary disease • Hypothalamic disease »» PCOS

Endocrinology Reference Ranges (Excluding Glucose) 8: Diabetes and Endocrinology

Increased

Decreased

»» Primary gonadal failure »» Increased LH:FSH ratio in PCOS »» Castration »» Menopause

»» Hypothalamic suppression »» Pituitary failure »» Eating disorders

Oestrodiol

»» Precocious puberty »» Exogenous oestrodiol • Oestrogen therapy • IVF

»» Hypothalamic disease »» Pituitary disease

Note: Progesterone levels that do not increase during the luteal phase may indicate an anovulatory cycle or corpus luteum inadequacy Prolactin Increased Levels of Prolactin Seen in: Physiological

Pathological

»» Stress »» Strenuous exercise »» Pregnancy »» Breast palpation »» Nipple stimulation

»» Prolactinomas »» Pituitary tumours »» Hypothalamic disorders associated with amenorrhoea-galactorrhoea syndrome »» Some medications • Phenothiazines • Metoclopramide • Oestrogens

BhCG – Beta Human Chorionic Gonadotrophin and Progesterone Gestational age wks post-LMP

Days after conception

BhCG levels for single foetus (IU/L) 0

Before Pregnancy

Progesterone levels for single foetus (nmol/L) 1- 28 7- 47

Conception to 12 Weeks Week 3

0 -50

Week 4

14 (next period due)

5 - 425

Week 5

20 - 7,000

Week 6

1,000 - 56,000

Weeks 7 - 8

35 - 42

4,000 - 220,000

Weeks 9 -12

49 - 70

25,000 - 285,000

Endocrinology Reference Ranges (Excluding Glucose) 8: Diabetes and Endocrinology

Gestational age wks post-LMP

Days after conception

BhCG levels for single foetus (IU/L)

Progesterone levels for single foetus (nmol/L) 17 -146

Weeks 12 - 28 Week 13 - 16

13,000 - 250,000

Week 17 - 24

4,000 - 165,000

Weeks 25 - Birth

3,640 -117,000

4 - 6 Weeks Post-Birth

Less than 5

55 - 200

Notes: 1. BhCG can be detected in some women approximately 8 days post-conception, but most will be positive by 11-12 days post-conception 2. BhCG doubles every 1.5 days for 5 wks post-implantation, and then doubles every 3.5 days from 7 wks post-implantation 3. BhCG will be highest between 8 -11 wks of pregnancy 4. BhCG lowers at approximately 12 wks and 16 wks of pregnancy 5. BhCG can be detected at low levels for up to 4 - 6 wks after miscarriage 6. At levels of 1,500 - 2,000 IU/L the intrauterine gestational sac becomes visible on ultrasound 7. Low levels of progesterone during first 12 wks can indicate miscarriage 8. Higher than expected levels of BhCG and progesterone may indicate multiple pregnancy 9. Higher than expected levels of BhCG alone may indicate molar pregnancy Adapted from www.imvs.com.au and www.rcpamanual.edu.au

Thyroid Hormones Hormone

Reference Range

Thyroid Stimulating Hormone (TSH)

0.4 - 5.0 mIU/L

Free Tri-Iodothyronine (T3)

4.0 - 8.0 pmol/L

Free Thyroxine (T4)

10 - 25 pmol/L TSH

Free T3

Free T4

↑

Normal - ↓

↓

Normal or ↓

Normal - ↓

↓

↑

Normal - ↓

Hypothyroidism »» Primary »» Secondary (Pituitary Dysfunction) Hyperthyroidism Sick Euthyroid

Note: Elevations in the above are seen in such disorders as pancreatitis and alcohol abuse The table above has been adapted from Murtagh’s General Practice All reference ranges obtained from www.rcpamanual.edu.au unless otherwise stated

Endocrinology Reference Ranges (Excluding Glucose) 8: Diabetes and Endocrinology

9: Cardiovascular Medicine

HTN Classification and Management Classification and Follow-Up of BP Levels in Adults Diagnostic Category1

Systolic (mmHg)

Diastolic (mmHg)

< 120

< 80

Recheck in 2 yrs or earlier as guided by patient’s absolute cardiovascular risk

High-normal

120 -139

80 - 89

Recheck in 1 year or earlier as guided by patient’s absolute cardiovascular risk

Grade 1 (mild) hypertension

140 -159

90 - 99

Confirm within 2 mths2

Grade 2 (moderate) hypertension

160 -179

100 -109

Reassess within 1 mth2

Grade 3 (severe) hypertension

≥ 180

≥ 110

Reassess within 1 - 7 days2

Isolated systolic hypertension

≥ 140

< 90

As for category corresponding to systolic BP

Normal

Follow-Up

Notes: 1. When a patient’s systolic and diastolic BP levels fall into different categories, the higher diagnostic category and recommended actions apply 2. See When Should a Therapeutic Plan Be Instigated? on page 55 Lifestyle Factors that Can Decrease BP and Decrease Cardiac Risk S – Smoking N – Nutrition A – Alcohol P – Physical activity SNAP Factors to Assist in Decreasing BP S – Smoking

»» Smoking cessation is greatest lifestyle modification »» Effects will be ↓ CVD risk as opposed to ↓ BP directly »» Counselling, Quitline referral and pharmacotherapy

N – Nutrition

»» Weight reduction »» To lose weight energy intake must be less than energy output »» Salt intake < 90mmol/day (4g/day) »» Be aware most dietary salt comes from processed foods »» Advise to use low salt (< 120mg sodium/100g) or “no added salt” foods »» Encourage mainly plant-based foods and wholegrains »» Moderate amounts of lean meats and reduced fat dairy »» Portion size control »» Small amounts of dietary fats

HTN Classification and Management 9: Cardiovascular Medicine

SNAP Factors to Assist in Decreasing BP A – Alcohol

»» ↓ in alcohol intake can ↓ BP in many patients »» Males: � 2 standard drinks/day with 2 alcohol free days per week »» Females: � 1 standard drink/day with 2 alcohol free days per week

P – Physical activity

»» Weight reduction »» To lose weight energy intake must be less than energy output »» 30 mins of moderate physical activity 5 days a week

When Should a Therapeutic Plan Be Instigated? »» Any patient with any grade of hypertension should have a therapeutic treatment plan instigated »» Exclude secondary causes of hypertension »» Lifestyle changes (SNAP) should be the first line treatment – although convincing the patient is often the hardest part Secondary Causes of Hypertension: »» Glomerulonephritis »» Reflux nephropathy »» Renal artery stenosis »» Diabetes »» Primary aldosteronism »» Cushing’s syndrome »» Phaeochromocytoma »» OCP »» Coarctation of the aorta »» Pregnancy »» Drugs When to Instigate Pharmacotherapy »» Evidence of end organ disease »» Grade 3 HTN

Begin pharmacotherapy

»» None of the above but grade 1 or 2 HTN with: • Mild risk factors

»» Monitor and reassess in 6 -12 mths time, begin lifestyle modification (SNAP) »» At reassessment – if >150/95  pharmacotherapy

• Moderate risk factors

»» Monitor and reassess 3 - 6 mths time, begin lifestyle modification (SNAP) »» At reassessment – if > 140/90  pharmacotherapy

• High or very high risk factors

»» Begin lifestyle modification (SNAP) »» Consider pharmacotherapy

HTN Classification and Management 9: Cardiovascular Medicine

Risk Factors Include: »» Associated clinical conditions: • Diabetes • CVS disease • Heart disease • Chronic kidney disease • Aortic disease • Peripheral vascular disease »» Age (male > 55 yrs, female > 65 yrs) »» Male gender »» FHx HTN or premature CVS disease »» Smoking »» High cholesterol »» Diabetes mellitus »» Obesity (BMI > 30kg/m2) »» Sedentary lifestyle »» Excessive alcohol intake »» Psychosocial factors »» ATSI people »» Lower socioeconomic status Basic Guidelines for Pharmacological Treatment of HTN First Options 1. ACE inhibitors, angiotensin II receptor antagonists, OR 2. Ca++ channel blocker, OR 3. Low dose thiazide diuretic

Goals Not Achieved

Add second agent and then increase doses

Goals Not Achieved on Goals Not Maximum Doses Achieved Consider adding other antihypertensive agents, eg moxonidine, alpha blockers or centrally acting agents such as clonidine or methyldopa

Refer for specialist assistance

Adapted from Hypertension Management Guidelines for Doctors 2004, Guide to Management of Hypertension from www.health.gov.au and www.heartfoundation.org.au

HTN Classification and Management 9: Cardiovascular Medicine

ECG Interpretation ECG – Establishing Rate If regular – 300 divided by the number of large squares (R-R interval) Large Squares between R-R Interval

Heart Rate – Beats/Min

300

150

100

ECG – Leads and Orientation

Right Arm

-120°

L+

-90°

-aV

-60°

-150°

-30° 0°

30°

90°

60°

+aVF-

Lea

180° 150° 120°

Left Arm Lead 1

Lea

Orientation Region of Heart (Dysfunction)

Corresponding Leads

Anterior region

V3 - V4

Inferior region

II, III and aVF

Lateral region

I, aVL, V5 - V6

Septal region

V1 and V2

ECG Interpretation 9: Cardiovascular Medicine

What to Look for: 1. Rhythm 2. P Wave Abnormalities »» Are they present »» Tall, peaked • Right atrial hypertrophy »» Broad, notched • Left atrial hypertrophy

• Left or right ventricular hypertrophy • May be inverted in leads V1- V3 in pulmonary embolism • BBB 7. U Waves »» Can be normal »» Hypokalaemia

3. The Cardiac Axis »» Right axis deviation • QRS complex predominantly downwards in lead I • S wave > R wave in lead I »» Left axis deviation • QRS complex predominantly downwards in leads II and III • S wave > R wave in lead II 4. The QRS Complex »» Width • If wide  ventricular origin or BBB »» Height • Tall R waves in lead V1  right ventricular hypertrophy • Tall R waves in lead V6  left ventricular hypertrophy »» Transition point • R and S waves are equal in the chest leads over the interventricular septum  normally lead V3 or V4 »» Q waves 5. The ST Segment »» Raised in acute MI and pericarditis »» Depressed in ischaemia and with digoxin 6. T Waves »» Peaked in hyperkalaemia »» Flat and prolonged in hypokalaemia »» Inverted in: • Normal in some leads • Ischaemia • Infarction ECG Interpretation 9: Cardiovascular Medicine

Cardiac Enzymes Cardiac enzymes are used to determine if chest pain may be attributable to a myocardial infarction. Troponin T is now considered the gold standard cardiac-specific blood test for acute myocardial infarction and is available as point of care testing. However, be aware of the timeframes for elevation post-infarct. Analyte

Reference Range

Timeframe of Elevation Post-MI

Comments

Troponin T

Not normally detected

»» Begins 4 - 8 hrs post-MI »» Peaks at 10 -12 hrs post-MI »» Remains elevated for up to 7 days

Highly specific for myocardial damage

Creatine Kinase MB (CK-MB)

0 -10 U/L < 5% of total CK

»» Begin 4 - 8 hrs post-MI »» Peaks 20 - 22 hrs post-MI »» Remains elevated for up to 48 hrs

»» Is the cardiac iso-enzyme of CK-MB »» More specific of cardiac damage than CK alone

»» Begins 10 -12 hrs post-MI »» Peaks at 20 - 22 hrs post-MI »» Remains elevated for up to 48 hrs

CK can be elevated in myocardial damage or skeletal muscle damage such as: »» Post IM injection »» Excessive exercise »» Rhabdomyolysis »» Myopathies »» Hypothyroidism

12 - 72 hrs post-MI

Also elevated in hepatocellular disease and skeletal muscle damage

Neonate: Creatine Kinase (CK) 70 - 380 U/L Adult female: 30 -180 U/L Adult male: 60 - 220 U/L

AST

< 40 U/L

Adapted from www.rcpamanual.edu.au and www.heartfoundation.org.au

Cardiac Enzymes 9: Cardiovascular Medicine

Peripheral Vascular Disease Differentiation of Arterial Insufficiency vs Venous Insufficiency Arterial Insufficiency

Venous Insufficiency

Pulses

»» Decreased or absent

»» Normal or difficult to palpate because of oedema

Colour

»» Marked pallor on elevation »» Dusky red on dependency

»» Brown pigmentation of chronic disease

Temperature

»» Cool

»» Normal

Oedema

»» Absent to mild

»» May be marked, usually present

Skin

»» Thin and shiny »» Loss of hair »» Thick rigid nails

»» Brown pigmentation »» Stasis dermatitis

Cap Refill

»» Slow

»» Normal

Bruits

»» May be present

»» Absent

Buerger Test

»» Positive

»» Negative

Ulceration

»» At points of trauma, eg toes, plantar aspect of feet »» Commonly distal to ankle »» Deep ulceration »» Regular “punched out” margin

»» Ankle and lower third of leg »» Commonly just above medial and lateral malleoli »» Shallow ulceration »» Irregular margins »» Granulating base »» Often significant ooze

BrodieTrendelenburg Test

»» Negative

»» Positive

6Ps of Arterial Insufficiency Pain Pulselessness Pallor Polar (cool temperature) – “perishingly cold” Paresthesia Paralysis

Peripheral Vascular Disease 9: Cardiovascular Medicine

10: Respiratory Medicine

Asthma Diagnosis and Management Asthma is a common condition in which there is inflammation of the airways, excess mucus production and bronchoconstriction. These bring about the typical expiratory wheeze and obstructive airway picture seen in asthma (and COPD). Asthma is now referred to as a united airways disease. Diagnosis of Asthma Is Based on a Combination of: History

Physical Examination

Diagnostic Testing

»» Variable symptoms of: • Expiratory wheeze • Chest tightness • SOB and SOBOE • Cough and/or allergic rhinitis • Seasonal or known triggers • Symptoms > night or early morning • History of atopic conditions – eg eczema

»» Chest hyperventilation »» Spirometry (see »» Expiratory wheeze (beware the silent chest) Spirometry section on page 64) »» Crackles on auscultation  other »» Chest X-ray diagnosis (or concurrent diagnosis) »» Allergic rhinitis indications – to exclude »» Speech rate to assess severity (sentences other causes if – mild, words – moderate, single words indicated »» Specialist testing: only – severe disease) »» Respiratory rate • Challenge tests »» Presence of cyanosis • Allergy testing

Asthma Medications Preventers – Anti-inflammatory agents that reduce symptoms and exacerbations of asthma – prophylactic agents. Ciclesonide

Alvesco Flixotide Qvar

Inhaled corticosteroids (ICS)

Fluticasone propionate

Negligible oral bioavailability due to swallowed component high hepatic first pass

Beclomethasone dipropionate

Low hepatic first pass and active metabolite  systemic bioavailability

Pulmicort

Budesonide

Intal

Sodium cromoglycate

Tilade Singulair

Cromones Leukotriene receptor antagonist

Initial prevention treatment for children with mild asthma

Nedocromil sodium Montelukast sodium

Prevention of day/night-time symptoms and exercise-induced bronchoconstriction treatment for aspirin-sensitive asthma

Asthma Diagnosis and Management 10: Respirator y Medicine

Relievers – Have a direct bronchodilator effect and relieve symptoms of asthma. Mainstay treatment for acute asthma. Stimulation of beta2 receptors (mainly bronchial), thus relaxation of the bronchial smooth muscle. Salbutamol

Airomir Asmol Epaq

SABA

Acute relief of asthma Symptom relief in maintenance treatment phase Protection against exercise-induced asthma No anti-inflammatory effect

Ventolin Bricanyl

Terbutaline

Atrovent

Ipratropium bromide

Inhaled anticholinergic bronchodilator and slow onset (COPD or COPD and asthma)

Nuelin

Theophylline

Bronchial smooth mm relaxation Increased diaphragm contractility Anti-inflammatory effect

Symptom Controllers – LABAs that induce prolonged bronchodilation (up to 12 hrs). Protect airways against other airway stimulants. Foradile Oxis

Eformoterol

Has rapid onset of action therefore can be used as reliever medication as well as in addition to ICS for optimal lung function

Salmeterol

Delayed onset of action  do not use as reliever treatment

LABA

Serevent

Combination Preventer and Symptom Controllers – Fixed dose combination inhalers are just as effective as separate inhalers. Used when ICS alone are not as effective as desirable, when wanting to decrease ICS dosages and when initiating treatment in moderate-severe asthma. Seretide Symbicort

LABA and inhaled corticosteroids

Fluticasone and salmeterol

Delayed onset of action  do not use as reliever treatment

Budesonide and eformoterol

Has rapid onset of action therefore can also be used as reliever medication

Patients should have an Asthma Care Plan to monitor their symptoms and control of asthma. Patients should also have an Asthma First Aid Plan (and their family or friends should be aware of this) in case of emergencies. For further information and treatment guidelines see www.nationalasthma.org.au and National Asthma Council’s Asthma Management Handbook. Adapted from www.nationalasthma.org.au

Asthma Diagnosis and Management 10: Respirator y Medicine

Spirometr y Classifications of ventilatory abnormalities by spirometry Obstructive

Restrictive

Mixed

FEV1

↓

↓ or normal

↓

FVC

↓ or normal

↓

↑

↓

FEV1/FVC

FEV1 = Forced Expired Volume in one second FVC = Forced Vital Capacity Notes: 1. Obstructive ventilatory defects includes asthma and chronic obstructive pulmonary disease, emphysema 2. Restrictive ventilatory defects include interstitial lung disease, respiratory muscle weakness and thoracic cage deformities 3. Mixed ventilatory defects occur with a combination of both obstruction and restriction or obstruction post-airway closure with gas trapping One of the key features of diagnosis of asthma is respiratory obstruction that is significantly improved via use of a bronchodilator (usually salbutamol). % improvement =

100 x FEV1(post-bronchodilator) – FEV1 (baseline) FEV1 (baseline)

SPIROMETRY flow volume curves 10

FEV25%

Flow [l/sec]

FEV1

Expiration

2 0

Inspiration

FVC

FEV50% 4 FEV75%

FIV25%

FEV - forced expiratory volume FEV1 - forced expiratory volume in 1 second FVC - forced vital capacity FIV - forced inspiratory volume

Vol [l] 2

FIV75% 6 FIV50% 8 10

Spirometr y 10: Respirator y Medicine

Schematic diagram illustrating idealised shapes of flow volume curves and spirograms for obstructing, restrictive and mixed ventilatory defect Spirometry Performed

Abnormal Ventilatory Function

Volume

Time

Flow

Time

Flow

Time

Mixed Volume

Restriction Volume

Normal

Volume

Obstruction

Volume

Adapted from page 11 of Spirometry: The Measurement and Interpretation of Ventilatory Function in Clinical Practice at www. nationalasthma.org.au/images/ stories/manage/pdf/spirometer_ handbook_naca.pdf

Adapted from page 12 of Spirometry: The Measurement and Interpretation of Ventilatory Function in Clinical Practice at www.nationalasthma. org.au/images/stories/manage/pdf/ spirometer_handbook_naca.pdf

d) restrictive lung disease (eg pulmonary fibrosis)

Flow

c) severe obstructive disease (eg emphysema)

Flow

Volume

b) obstructive airway disease (eg asthma)

Flow

a) normal subject

Flow

Maximum expiratory and inspiratory flow volume curves with examples of how respiratory disease can alter its shape

e) fixed major airway obstruction (eg carcinoma of the trachea)

Spirometr y 10: Respirator y Medicine

Respiratory function tables Adult respiratory function tables are shown on the following pages. For childhood and adolescent respiratory function charts, see pages 123 -126 of Asthma Handbook 2006 at www.nationalasthma.org.au Mean Predicted Normal Values in Healthy Adults The mean predicted normal values (FEV1, FVC, FEV1/FVC) for adult Caucasian males (aged 20 - 80 yrs) and females (aged 18 - 80 yrs) are given in the following tables. Contact your local lung function laboratory for advice about predicted values, including lower limits of normal and the effect of ethnicity. These tables are based on asymptomatic lifelong non-smokers who participated in the National Health and Nutrition Examination Survey (NHANES III): Hankinson JL, Odencrantz JR and Fedan KB. Spirometric reference values are from a sample of the general US population. American Journal of Respiratory and Critical Care Medicine 1999;159:179-187. FEV1 (L) Male Age 145cm 150cm 155cm 160cm 165cm 170cm 175cm 180cm 185cm 190cm 195cm

20 3.19 3.40 3.61 3.83 4.06 4.30 4.54 4.79 5.05 5.31 5.58

25 3.08 3.29 3.51 3.73 3.96 4.19 4.44 4.69 4.95 5.21 5.48

30 2.97 3.18 3.39 3.62 3.85 4.08 4.33 4.58 4.83 5.10 5.37

35 2.85 3.06 3.27 3.50 3.73 3.96 4.20 4.45 4.71 4.98 5.25

40 2.72 2.93 3.14 3.37 3.60 3.83 4.07 4.32 4.58 4.85 5.12

45 2.58 2.79 3.01 3.23 3.46 3.69 3.94 4.19 4.44 4.71 4.98

50 2.44 2.64 2.86 3.08 3.31 3.55 3.79 4.04 4.30 4.56 4.83

55 2.28 2.49 2.70 2.93 3.15 3.39 3.63 3.88 4.14 4.41 4.68

60 2.12 2.32 2.54 2.76 2.99 3.23 3.47 3.72 3.98 4.24 4.51

65 1.94 2.15 2.37 2.59 2.82 3.05 3.30 3.55 3.80 4.07 4.34

70 1.76 1.97 2.19 2.41 2.64 2.87 3.12 3.37 3.62 3.89 4.16

75 1.57 1.78 2.00 2.22 2.45 2.68 2.93 3.18 3.43 3.70 3.97

80 1.37 1.58 1.80 2.02 2.25 2.48 2.73 2.98 3.24 3.50 3.77

55 2.95 3.22 3.51 3.80 4.10 4.42 4.74 5.07 5.41 5.76 6.12

60 2.80 3.07 3.36 3.65 3.95 4.26 4.59 4.92 5.26 5.61 5.97

65 2.63 2.91 3.19 3.48 3.79 4.10 4.42 4.75 5.09 5.44 5.80

70 2.45 2.73 3.01 3.31 3.61 3.92 4.24 4.57 4.91 5.26 5.62

75 2.26 2.54 2.82 3.11 3.42 3.73 4.05 4.38 4.72 5.07 5.43

80 2.06 2.33 2.62 2.91 3.21 3.52 3.85 4.18 4.52 4.87 5.22

Adapted from page 121 of Asthma Handbook 2006 at www.nationalasthma.org.au

FVC (L) Male Age 145cm 150cm 155cm 160cm 165cm 170cm 175cm 180cm 185cm 190cm 195cm

20 3.63 3.91 4.19 4.48 4.79 5.10 5.42 5.75 6.09 6.44 6.80

25 3.57 3.85 4.13 4.43 4.73 5.04 5.36 5.69 6.03 6.38 6.74

30 3.50 3.78 4.06 4.36 4.66 4.97 5.29 5.62 5.96 6.31 6.67

35 3.42 3.69 3.98 4.27 4.57 4.89 5.21 5.54 5.88 6.23 6.59

40 3.32 3.60 3.88 4.17 4.48 4.79 5.11 5.44 5.78 6.13 6.49

45 3.21 3.49 3.77 4.06 4.37 4.68 5.00 5.33 5.67 6.02 6.38

50 3.09 3.36 3.64 3.94 4.24 4.55 4.88 5.21 5.55 5.90 6.25

Spirometr y 10: Respirator y Medicine

FEV1/FVC (%) Male Age All Heights

20 83.9

25 82.9

30 81.9

35 80.8

25 2.64 2.81 2.98 3.16 3.35 3.54 3.74 3.95 4.16 4.37 4.59

30 2.57 2.74 2.91 3.09 3.28 3.47 3.67 3.88 4.08 4.30 4.52

40 79.8

45 78.8

50 77.7

55 76.7

60 75.7

65 74.6

70 73.6

75 72.6

80 71.5

FEV1 (L) Female Age 145cm 150cm 155cm 160cm 165cm 170cm 175cm 180cm 185cm 190cm 195cm

18 2.72 2.89 3.07 3.25 3.44 3.63 3.83 4.03 4.24 4.46 4.68

20 2.70 2.87 3.05 3.23 3.41 3.61 3.80 4.01 4.22 4.43 4.65

35 2.49 2.66 2.83 3.01 3.20 3.39 3.59 3.79 4.00 4.22 4.44

40 2.40 2.57 2.74 2.92 3.11 3.30 3.50 3.70 3.91 4.13 4.35

45 2.30 2.46 2.64 2.82 3.01 3.20 3.40 3.60 3.81 4.03 4.25

50 2.18 2.35 2.53 2.71 2.90 3.09 3.29 3.49 3.70 3.92 4.14

55 2.06 2.23 2.41 2.59 2.78 2.97 3.17 3.37 3.58 3.80 4.02

60 1.94 2.10 2.28 2.46 2.65 2.84 3.04 3.24 3.45 3.67 3.89

65 1.80 1.97 2.14 2.32 2.51 2.70 2.90 3.10 3.31 3.53 3.75

70 1.65 1.82 1.99 2.17 2.36 2.55 2.75 2.95 3.16 3.38 3.60

75 1.49 1.66 1.83 2.01 2.20 2.39 2.59 2.80 3.01 3.22 3.44

80 1.32 1.49 1.66 1.85 2.03 2.23 2.42 2.63 2.84 3.05 3.27

55 2.63 2.85 3.08 3.31 3.55 3.80 4.05 4.32 4.59 4.87 5.15

60 2.51 2.72 2.95 3.18 3.42 3.67 3.93 4.19 4.46 4.74 5.02

65 2.36 2.58 2.80 3.04 3.28 3.53 3.78 4.05 4.32 4.59 4.88

70 2.20 2.41 2.64 2.87 3.11 3.36 3.62 3.88 4.15 4.43 4.71

75 2.01 2.23 2.46 2.69 2.93 3.18 3.43 3.70 3.97 4.25 4.53

80 1.81 2.03 2.25 2.49 2.73 2.98 3.23 3.50 3.77 4.04 4.33

Adapted from page 122 of Asthma Handbook 2006 at www.nationalasthma.org.au

FVC (L) Female Age 145cm 150cm 155cm 160cm 165cm 170cm 175cm 180cm 185cm 190cm 195cm

18 2.97 3.19 3.42 3.65 3.89 4.14 4.39 4.66 4.93 5.21 5.49

20 2.98 3.20 3.42 3.66 3.90 4.15 4.40 4.67 4.94 5.21 5.50

25 2.99 3.21 3.43 3.67 3.91 4.15 4.41 4.67 4.94 5.22 5.51

30 2.98 3.19 3.42 3.65 3.89 4.14 4.40 4.66 4.93 5.21 5.49

35 2.95 3.16 3.39 3.62 3.86 4.11 4.37 4.63 4.90 5.18 5.46

40 2.90 3.11 3.34 3.57 3.81 4.06 4.32 4.58 4.85 5.13 5.41

45 2.83 3.05 3.27 3.50 3.75 3.99 4.25 4.51 4.78 5.06 5.35

50 2.74 2.96 3.18 3.42 3.66 3.91 4.16 4.42 4.69 4.97 5.26

FEV 1/FVC (%) Female Age 18 20 25 30 35 40 45 50 55 60 65 70 75 80 All Heights 87.0 86.6 85.5 84.4 83.4 82.3 81.2 80.2 79.1 78.1 77.0 75.9 74.9 73.8

Spirometr y 10: Respirator y Medicine

CXR Interpretation »» Name and date on the film »» Orientation and if PA or AP • Assess mediastinal size on PA – cardiothoracic ratio should be < 50% • If AP cardiothoracic ratio may appear falsely elevated »» Assess rotation by looking at the relationship of sternoclavicular joint to the midline »» Note patient position – upright or supine ABCs: A Airways »» Trachea and mainstream bronchi • Pneumothorax – deviates towards opposite side • Pleural effusion – deviates towards opposite side B Breathing »» Lung fields/fissures • Apex • Upper lobes –– collapse  tracheal deviation • Middle lobes –– collapse  triangle adjacent to R) heart with loss of border • Lower lobes –– collapse  mediastinal shift –– L) collapse as triangle behind heart –– collapse/consolidation  loss of definition of diaphragm »» Costophrenic angles – lost in pleural effusion »» Peribronchial changes »» Pleura – thickening/effusion

S Soft tissues and skeleton »» Bilateral breast shadows in women »» Foreign body »» Retrosternal goitre »» Flattened diaphragm (COPD) »» Raised hemidiaphragm »» Gas under the diaphragm »» Subcutaneous emphysema »» Mediastinal enlargement »» Ribs, clavicle, humerus »» Thoracic spine (particularly crush fractures)

C Circulation »» Vasculature in the lungs »» Pulmonary artery and aortic knuckle »» L) ventricle and heart size »» Hilar – lymph nodes, tumour, vasculature – pulmonary HTN

CXR Interpretation 10: Respirator y Medicine

Smoking Cessation Smoking is a large public health problem, contributing to many chronic disease states. Its effects should not be taken lightly – nor should the hold tobacco has on people. Smoking cessation should be encouraged in patients, however the need to not “nag” or “judge” the patient is also imperative if there is to be success. The current guidelines follow the 5As: Smoking Cessation – 5As 5As

Explanation

Ask

Ask smoking status How long after waking do they have their first cigarette How much do they smoke in a day Have they ever tried to quit before

Assess

Feelings towards their smoking How much do they want to quit smoking What are their motivations to quit smoking

Advice

Ensure non-judgmental advice – that is do not make it “an order” or guilt patient Give advice on setting of a date Advise of the common withdrawal symptoms and advise on coping techniques Advise of the benefits of smoking cessation

Assist

Self-help pamphlets and Quitline information Develop a plan for smoking cessation – may include pharmacotherapy assistance Discuss the barriers to smoking cessation and counter measures to these

Arrange

Quitline referral (131 848) Support for the patient – possibly partner, family member, or you and your practice Book follow-up appointments to track patient’s success

Adapted from www.racgp.org.au and John Litt: How to provide effective smoking cessation advice in less than a minute without offending the patient; Australian Family Practitioner;Vol 21, No 12, December 2002, pp 1087 - 1093 (John Litt is the senior lecturer for Department of General Practice at Flinders University – jlitt@flinders.edu.au)

Smoking Cessation 10: Respirator y Medicine

11: Other Tests â&#x20AC;&#x201C; Haematology and Biochemistry

Haematology Full Blood Count and Erythrocyte Sedimentation Rate (ESR) Indices

Reference Range Adult male

130 -180g/L

Adult female

115 -165g/L

Adult male

4.5 - 6.5 x 1012/L

Adult female

3.8 - 5.8 x 1012/L

Packed Cell Volume (PCV) (Haematocrit – HCT)

Adult male

0.40 - 0.54

Adult female

0.37 - 0.47

Mean Corpuscle Volume (MCV)

HCT/RCC

80 -100 fL

Mean Corpuscle Haemoglobin (MCH)

Hb/RCC

27-32pg

Mean Corpuscle Haemoglobin Concentration (MCHC)

Hb/HCT or Hb/(MCV x RCC)

300 -350 g/L

Haemoglobin (Hb) Red Cell Count (RCC)

4.0 -11.0 x 109/L

Leucocyte Count – White Cell Count (WCC) Leucocyte Differential – Adult »» Neutrophil

% x WCC/100

2.0 -7.5 x 109/L (40 -75%)

»» Lymphocyte

% x WCC/100

1. 5 - 4.0 x 109/L (20 - 45%)

»» Monocyte

% x WCC/100

0.2 - 0.8 x 109/L (2 -10%)

»» Eosinophil

% x WCC/100

0.04 - 0.4 x 109/L (1- 6%)

»» Basophil

% x WCC/100

< 0.1 x 109/L (0 - 0.1%) 150 - 400 x 109/L

Platelet Count ESR

Male (17- 50 yrs)

1-10 mm/hr

Male (> 50 yrs)

2 -14 mm/hr

Female (17- 50 yrs)

3 -12 mm/hr

Female (> 50 yrs)

5 - 20 mm/hr

Reticulocyte Count

10 -100 x 109/L (0.2 - 2.0% of RCC)

Haematology 11: Other Tests – Haematology and Biochemistr y

Notes: 1. Red Cell Distribution Width may be given and is an indication of the variation in cell size 2. RDW RR: 11.5 -14.5% >14.5% indicates anisocytosis (variation in cell size) 3. Poikilocytosis is increased red cell variation in shape 4. Reticulocytes are immature RBCs and are elevated when there is increased erythropoiesis 5. When a specific white cell differential is higher than the reference range, accompanied with an elevated white cell count, it is an absolute value – for example, “absolute neutrophilia”, etc 6. When a specific white cell differential is higher than the reference range, but a normal white cell count, it is a relative value – for example, “relative neutrophilia”, etc 7. ESR is an acute phase reactant and is elevated in infection, inflammation, megaloblastic cells and rouleaux formation Child Leucocyte Differential x 109/L Neonate

1- 3 yrs

4 - 7 yrs

8 -12 yrs

Neutrophils

4.5 -12.0

1.5 -7.0

1.6 - 9.0

1.4 -7.5

Lymphocytes

2.2 -7.0

2.2 - 5.5

2.0 - 5.0

1.4 - 3.8

Monocytes

0.2 -1.6

0.1-1.5

0.06 -1.0

0.06 - 0.08

Eosinophils

< 0.2

0.1- 0.5

0.1-1.4

0.04 - 0.75

Basophils

< 0.1

< 0.2

Anaemia is low Hb concentration Classification of Anaemia Microcytic Anaemia (MCV < 80 fL)

Normocytic Anaemia (MCV 80 - 95 fL)

Macrocytic Anaemia (MCV > 95 fL)

»» Iron deficiency »» Thalassaemia »» Acute phase response »» Sideroblastic anaemia »» Basophils

»» Acute blood loss »» Anaemia of chronic disease »» Hypoproduction of RBC • Renal failure • Bone marrow failure »» Pregnancy »» Hypothyroidism

Megaloblastic Bone Marrow »» B12 and/or folate deficiency »» DNA synthesis affecting medications – eg phenytoin) Non-Megaloblastic Bone Marrow »» Liver disease »» Alcohol abuse »» Hypothyroid and hypopituitary »» Hypoplastic anaemia »» Accelerated erythropoiesis

Haematology 11: Other Tests – Haematology and Biochemistr y

Iron Studies Adult

Iron

10 - 30µmol/L

Iron Binding Capacity (TIBC)

45 - 80µmol/L

Transferrin

1.7 - 3.0 g/L

Transferrin Saturation

0.15 - 0.45 (15 - 45%)

Ferritin

Male

30 - 300µg/L

Female

15 - 200µg/L 120 - 680 pmol/L

Vitamin B12 Folate

RBC folate

360 -1,400 nmol/L

Serum folate

7- 45 nmol/L

Interpretation of Iron Studies Se Iron

Iron Binding Capacity (TIBC)

Transferrin Saturation

Ferritin

Trial of Oral Iron

Iron Efficiency

↓

↑

↓

Haemoglobin normalises

Iron Deficiency AND Acute Phase Response

↓

N to ↓

Normal but <100µg/L

Partial response

Acute Phase Response

↓

↑

No response

Thalassaemia

↑

↓

↑

No response

Sideroblastic Anaemia

↑

↓

↑

No response

Iron Overload

↑

N to ↓

↑

N/A

White Cell Possible Interpretations: Neutrophilia Physiological »» Stress »» Vigorous exercise »» Pregnancy »» Emotional stress

Infection »» Bacterial »» Rickettsial »» Occasionally viral – HSV/VZV

Inflammation »» Tissue damage • Burns • Surgery • Trauma »» Connective tissue disease »» Rheumatoid arthritis

Tissue Necrosis »» Myocardial infarction »» Carcinoma

Haematology 11: Other Tests – Haematology and Biochemistr y

Neutrophilia Acute blood loss

Myeloproliferatives

Hyposplenism »» Atrophy »» Splenectomy »» Trauma

Drugs »» Corticosteroids »» Cytokines »» Clozapine »» Lithium »» Tobacco use

Neutropaenia Decreased Production

Increased Destruction

Decreased Production and Increased Destruction

»» Drug reactions • Cytotoxics* • Alcohol • Anti-thyroids • NSAIDS »» Bone marrow failure • Irradiation* • BM infiltration* • Acute leukaemia* • Myelodysplasia* »» Megaloblastic anaemia »» Familial »» Idiopathic

»» Immune • SLE • Rheumatoid arthritis • Drugs, penicillins »» Hypersplenism »» Haemodyalisis »» Idiopathic

»» Viral infection • IM/CMV/rubella • HIV • Dengue »» Bacterial infections • Septicaemia • Typhoid fever »» Protozoan infections • Malaria • Trypanosomiasis »» Hairy cell leukaemia

*More pancytopaenia noted than just neutropaenia Lymphocytosis »» Infection • Mononucleosis-like syndromes –– Atypical lymphocytes –– IM –– CMV –– HIV –– Toxoplasmosis

• Reactive lymphocytes –– Pertussis –– Viral infections • Hyposplenism –– Atrophy –– Splenectomy –– Trauma »» Physiological stress

»» Lymphoproliferative • CLL • B/T/NK – cell lymphoproliferative »» Lymphoma »» Hairy cell leukaemia

Haematology 11: Other Tests – Haematology and Biochemistr y

Lymphocytopenia »» Acute stress »» Infection • Bacterial • Early viral • HIV »» Advanced carcinoma »» Irradiation*

»» Hodgkin’s disease »» Malnutrition »» Anorexia nervosa »» Renal failure »» Immune • SLE • Rheumatoid arthritis

»» Protein losing enteropathy »» Cushing’s syndrome »» Drugs • Cytotoxics • Corticosteroids »» Sarcoidosis

*More pancytopaenia noted than just neutropaenia Eosinophilia »» Drug reactions »» Atopic reactions • Eczema • Asthma • Food allergy »» Skin disorders • Psoriasis • Scabies (especially nursing homes)

»» Parasitic infections • Malaria • Toxocara species • Ascaris lumbricoides • Strongyloides stercoralis (especially in remote indigenous communities and nursing homes)

»» Malignancy • Radiation treatment – especially lung Ca • Hodgkin’s disease • Myeloproliferative disorders • Eosinophilic granuloma

»» Urticaria »» Myxoedema »» Chronic myelomonocytic leukaemia

»» Haemolysis »» Polycythaemic rubra vera

Basophilia »» Viral infections »» Hyposplenism • Atrophy • Splenectomy • Trauma Pancytopaenia Bone Marrow Failure

Bone Marrow Infiltration

Ineffective Haematopoiesis

Hypersplenism

»» Aplastic anaemia • Cytotoxic • Irradiation • Viral infection • Parvovirus B19 • AIDS »» Myelodysplasia »» PNH

»» Disseminated carcinoma »» Acute leukaemia »» Miliary TB »» Multiple myeloma »» Myelofibrosis »» Lymphoma »» Hairy cell leukaemia

»» Myeloblastic anaemia »» Myelodysplasia »» PNH

»» Immune • SLE • Drugs

Haematology 11: Other Tests – Haematology and Biochemistr y

Monocytosis Normal Morphology

Abnormal Morphology

»» Acute/chronic bacterial infection • Especially TB »» Carcinoma »» Hodgkin’s disease »» Recovery from agranulocytosis »» Cytokines »» Hyposplenism • Atrophy • Splenectomy • Trauma

»» Myelodysplasia • Chronic myelomonocytic leukaemia »» Acute myelomonocytic leukaemia

Adapted from www.rcpamanual.edu.au

Haematology 11: Other Tests – Haematology and Biochemistr y

Acute Phase Reactants Acute phase reactants are plasma proteins that elevate when the system is under duress from tissue injury, inflammation, infection and malignancy. C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR) are useful indicators of acute phase response, but normal results do not exclude disease. Other acute phase reactants that may elevate during an episode include: »» Fibrinogen »» Ferritin »» Haptoglobins »» α1 – antitrypsin »» Caeruoplasmin »» Factor VIII »» von Willebrand factor Other serum proteins may decrease during an episode and these include: »» Albumin »» Prealbumin »» Transferrin

Erythrocyte Sedimentation Rate (ESR) ESR is a non-specific screening test for acute phase reaction (as opposed to being one of the reactants as in the case with CRP) and is used as a screening test for symptomatic patients. CRP is more sensitive and elevates earlier than ESR. Reference Range: Child: 2 -15 mm/hr Adult female: 17- 50 yrs: 3 -19 mm/hr 51-70 yrs: < 20 mm/hr > 70 yrs: < 35 mm/hr Adult male: 17- 50 yrs: 51-70 yrs: > 70 yrs:

1-10 mm/hr < 14 mm/hr < 30 mm/hr

C-Reactive Protein (CRP) CRP is an actual acute phase reactant and can be used for the assessment of inflammatory, infective and neoplastic disorders. Applications of CRP include monitoring inflammatory arthritis, monitoring women after premature rupture of membranes and querying developing infection. It’s worth noting that it also rises after surgery due to the acute phase response. CRP is often assessed in conjunction with FBC or biochemistry. Reference Interval < 5mg/L Elevation of CRP is indicative of an acute phase response or active disease in a chronic inflammatory condition and is more sensitive at an earlier stage than Erythrocyte Sedimentation Rate (ESR). Exceptions are disorders such as SLE and ulcerative colitis, in which case ESR is more sensitive.

Acute Phase Reactants 11: Other Tests – Haematology and Biochemistr y

Possible Interpretations Elevated ESR

Low ESR

»» Increases with age »» Pregnancy »» Anaemia »» Polymyalgia rheumatic »» Acute inflammation »» Chronic inflammation »» Infection »» Neoplastic disease

< 1mm/hr: »» Polycythaemia rubra vera »» Sickle cell disease

> 100 mm/hr: »» Multiple myeloma »» TB »» Temporal arteritis

Acute Phase Reactants 11: Other Tests – Haematology and Biochemistr y

Immunohaematology Blood Group and Antibody Screen For all blood grouping and antibody screens it is imperative that both the request form and the collection tube must have patient’s first name and surname in full; record number; date of birth; date and time of collection; signature or initials of the collector. The ABO System and Rh(D) of red blood cell antigens are the main components of blood grouping. Unlike most antibodies, the ABO antibodies develop within the plasma without previous exposure to the antigen. Red Cell Antigens and Plasma Antibodies Red Blood Cell Antigens

Corresponding Antibodies in Plasma

Anti-B

Anti-A

Nil

Anti-A and anti-B

Rh(D) “Pos”

Nil

“Neg”

Nil unless exposed to Rh(D) antigen

For blood grouping, the plasma and red blood cells are separated and the red blood cells washed to remove any erroneous antigens, etc. The patient’s red blood cells are tested with anti-A, anti-B and anti-D sera to determine the ABO or forward group and the Rhesus factor (ie positive or negative). The patient’s serum is then tested with pooled A1 and B red blood cells to confirm the forward group. This is known as the reverse group. Blood Grouping Forward Group Against

Blood Group

Anti-A

Anti-B

Anti-D

Patient Serum

A Pos

Patient Cells

A Neg

B Pos

B Neg

AB Pos

AB Neg

O Pos

O Neg

Immunohaematology 11: Other Tests – Haematology and Biochemistr y

Blood Grouping Reverse Group Against

Patient Serum

Blood Group

A1 Cells

B Cells

Patient Cells

Extended phenotyping (that is, other red cell antigens panel) is conducted for transfusion, when alloantibodies are detected, assessment of haemolytic disease of the newborn (HDNB) risk and in cases of haemolytic disease. Direct Antiglobulin Test (DAT) Washed patient’s red blood cells are placed with a polyspecific anti-human globulin serum to determine if antibodies and/or complement are bound to the red blood cells. A positive result brings about agglutination of the patient cells. Monospecific antisera for IgG, IgM and complement can be used to further investigate a positive DAT. Positive results seen in: »» Autoimmune haemolysis »» HDNB »» Drug-induced immune haemolysis (eg G6PD, etc) »» Incompatible blood transfusions

Immunohaematology 11: Other Tests – Haematology and Biochemistr y

Coagulation Studies Intrinsic Pathway – Factors XII – X APTT – Activated Partial Thromboplastin Time Extrinsic Pathway – Factors VII and X PT – Prothrombin Time (converted to INR) Common Pathways – Factors X, V, II, I (Fibrinogen)  Fibrin Clot Fibrinogen (I)  Fibrin Clot TT – Thrombin Time Test

Reference Range

Comments

Bleeding Time

2.0 - 8.5 mins

Exclude aspirin and other NSAIDS 1/52 prior

APTT – Normal

25 - 35 secs

With PT  ? coagulopathy Baseline prior to heparin treatment

APTT – Continuous Heparin Infusion 1.5 - 2.5 x baseline

Monitor heparin treatment

11-15 secs

See interpretation

International Normalised Ratio (INR)

1.0 -1.2

INR enables standardisation of PT

INR – Therapeutic for Anticoagulant Treatment

2.0 - 4.5

See table below

Fibrinogen

1.5 - 4.0g/L

D-Dimer

< 500 mg/mL

↑  recent or ongoing fibrinolysis eg DIC, malignancy, post-surgery

Warfarin affects the “TV” factors, ie factors X, IX, VII and II Suggested International Normalised Ratio (INR) Values 2.0 - 2.5

Short-term prophylactic treatment for DVT

2.0 - 3.0

»» Short-medium term prophylactic treatment for hip or femur surgery »» Treatment of venous thromboembolism • DVT or • PE »» Peripheral arterial thrombosis and grafts »» Coronary artery thrombosis »» Mitral stenosis with embolism (long-term treatment) »» AF

3.0 - 4.5

Long-term treatment recurrent DVT Long-term treatment prosthetic heart valves

Coagulation Studies 11: Other Tests – Haematology and Biochemistr y

Prolonged APTT Normal PT Normal TT

Prolonged PT Normal APTT Normal TT

Prolonged APTT Prolonged PT Normal TT

Prolonged APTT Prolonged PT Prolonged TT

Factor VIII, IX or XI deficiency

Factor VII deficiency

Factor II, V or X deficiency

Fibrinogen (I) deficiency

Lupus inhibitor

Combined factor II, VII and X deficiency »» Vitamin K deficiency »» Warfarin treatment or »» Liver disease

Combined factor II, VII and X deficiency »» Vitamin K deficiency »» Warfarin treatment or »» Liver disease Prolong PT > APTT

Impaired conversion of fibrinogen to fibrin »» Heparin treatment »» FDP »» Dysfibronogenaemia

Factor VIII or IX inhibitor

Lupus inhibitor Prolong APTT > PT

Adapted from www.rcpamanual.edu.au and www.gpnotebook.com

Coagulation Studies 11: Other Tests – Haematology and Biochemistr y

Renal Function Tests – Urinalysis, UEC and GFR Estimation Urinalysis Should be conducted within 4 hrs of collection Application

Interpretation

Check for therapeutic treatment

»» Alkaline – possible distal renal tubular acidosis

Protein

Will not detect microalbuminuria Suspected nephritic syndrome, UTI or glomerulonephritis

»» Suggestive of glomerular dysfunction allowing protein to pass or inflammatory exudate in the urinary tract

Glucose

Diabetes mellitus NOT to be used to diagnose hyperglycaemia or hypoglycaemia

»» Hyperglycaemia at time of urine formation »» Renal glucosuria Note: A patient in a diabetic coma may demonstrate glucosuria from previous hyperglycaemic episode »» Is NOT an adequate indicator of gestational diabetes

Ketones

Diabetic ketoacidosis Starvation ketosis

»» In diabetes – ketoacidosis

Bilirubin

Differential diagnosis of jaundice

»» Positive in hepatocellular or obstructive jaundice »» If negative in jaundice patient, jaundice is unconjugated bilirubin, eg haemolysis

Blood

Inflammation, trauma, trauma of renal tract, haemoglobinuria, myoglobinuria

»» Be aware of menstruation in females »» RBCs due to inflammation, trauma, tumour in renal tract »» Urine becomes cloudy if blood is mixed within the urine, eg within the kidney or bladder as opposed to urethra

Urobilinogen

Unreliable in patients with liver disease

»» Increased in haemolysis »» Unreliable determinant of liver disease

Nitrite

Product of bacterial metabolism

»» Positive in most bacterial UTIs »» May be negative in UTIs from gram-positive or Pseudomonas sp.

Leukocytes

UTI

»» Positive when neutrophils present

Renal Function Tests – Urinalysis, UEC and GFR Estimation 11: Other Tests – Haematology and Biochemistr y

UEC – Urea, Electrolytes and Creatinine Reference Range

Elevated in

Decreased in

Urea

Neonate: 1.0 - 4.0 mmol/L Adult: 3.0 - 8.0 mmol/L

»» Conditions with decreased GFR • Pre-renal or renal disease • Bleeding into GIT • Hypercatabolic state

»» Pregnancy »» Water retention »» ↓ synthesis »» ↓ protein intake »» Severe liver disease »» Urea-cycle defects

Bicarbonate

22 - 32 mmol/L

»» Metabolic alkalosis »» Compensated respiratory acidosis

»» Metabolic acidosis Note: ↓ if collection tube is only partly filled or left uncapped, due to loss of CO2

Chloride

95 -110 mmol/L

»» Metabolic acidosis due to renal tubular acidosis »» Metabolic acidosis due to bicarbonate loss

»» Metabolic alkalosis

Potassium

Plasma: 3.4 - 4.5 mmol/L Serum: 3.8 - 4.9 mmol/L

»» Acidosis »» Tissue damage »» Renal failure »» Mineralocorticoid deficiency Note: Poor collection, delay in separation refrigeration of unseparated blood can cause elevation

»» Loop or thiazide diuretic therapy »» Vomiting or diarrhoea »» Alkalosis »» Treatment of acidosis »» Mineralocorticoid excess

Sodium

135 -145 mmol/L

»» Dependent upon state of hydration »» IVT with isotonic saline

»» Volume replacement with dextrose »» Some diuretic treatment, especially elderly

8 -16 mmol/L Anion Gap (Na + K) – (Cl + HCO3). Creatinine

»» Accumulation of an anion other than chloride, eg lactate  metabolic acidosis

Child (< 12 yrs): »» Conditions with 0.04 - 0.08mmol/L decreased GRF »» Pre-renal – hypovolaemia, Adult female: hypotension 0.05 - 0.11mmol/L »» Renal or post-renal • Obstruction Adult male: • Renal failure 0.06 - 0.12mmol/L

»» Patients with reduced muscle mass Note: In this setting, it may mask impaired renal function

Renal Function Tests – Urinalysis, UEC and GFR Estimation 11: Other Tests – Haematology and Biochemistr y

Estimated Glomerular Filtration Rate: Cockcroft-Gault formula: Estimated Creatinine Clearance (mL/min):

{(140 – age in yrs) x (weight in kgs) x 1.23 constant} Plasma Creatinine in µmol/L

Note: Remember to convert mmol/L to µmol/L by x 1000 Multiply by 1 for males, multiply by 0.85 for females Interpretations Normal Creatinine Clearance Mild Impairment Creatinine Clearance Moderate Impairment Creatinine Clearance Severe Impairment Creatinine Clearance

> 50 mL/min 25 - 50 mL/min 10 - 25 mL/min < 10 mL/min

MDRD Formula – Modification of Diet in Renal Disease Formula GRF(mL/min/1.73m2) = 186 x (Plasma Creatinine in µmol/L / 88.4)-1.154 x (age in yrs)-0.203 Multiply by 0.742 if female Staging for Chronic Kidney Disease Stage 1 90 mL/min/1.73 m2 with proteinuria or haematuria Stage 2 (Mild) 60 - 90 mL/min/1.73 m2 Stage 3 (Moderate) 30 - 60 mL/min/1.73 m2 Stage 4 (Severe) 15 - 30 mL/min/1.73 m2 Stage 5 (End-Stage) < 15 mL/min/1.73 m2 Adapted from www.rcpamanual.edu.au and www.kidney.org.au

Renal Function Tests – Urinalysis, UEC and GFR Estimation 11: Other Tests – Haematology and Biochemistr y

Liver Function Tests Total Protein

Neonate

Adult

Interpretation

40 -75g/L

62 - 80g/L

Increased: »» Dehydration »» Acute phase response »» Hyperalbuminaemia »» Hyperglobulonaemia Decreased: »» Overhydration »» Chronic liver disease »» Burns »» Malnutrition »» Protein losing disorders

Albumin

22 - 40g/L

32 - 45g/L

Increased: »» Dehydration »» Acute phase response Decreased: »» Overhydration »» Chronic liver disease »» Protein losing disorders »» Malnutrition »» Burns

Bilirubin

< 200µmol/L

Total: < 20µmol/L Direct: < 7µmol/L

ALT

< 50 U/L

ALK PHOS (ALP) 50 - 300 U/L

AST

< 40 U/L

Increased: »» Hepatocellular disease »» Biliary disease »» Haemolysis »» Megaloblastic anaemia

< 35U/L

Increased: »» Associated with hepatocellular damage • Inflammation • Infection »» Skeletal muscle disease

25 -100 U/L

Increased: »» Cholesostasis »» Osteoblastic activity (Paget’s) »» Bony metastases

< 40 U/L

Increased: »» Associated with hepatocellular damage • Inflammation • Infection • Myocardial infarction

Liver Function Tests 11: Other Tests – Haematology and Biochemistr y

GGT

Neonate

Adult

Interpretation

Male: < 50 U/L

Female: < 30 U/L

Increased: »» Cholestatic liver disease »» Hepatocellular disease (mild) »» Diabetes »» Excess alcohol intake »» Drugs (eg phenytoin) »» Pancreatitis »» Prostatitis

ALT: Alanine aminotranferase AST: Aspartate aminotransferase

ALP: Alkaline phosphatase GGT: Gamma glutamyl transferase

Patterns Disease Process

ALT

AST

ALP

GGT

↑↑

↑↑ ↑AST < ↑↑ALT

↑

↑↑

Chronic Obstruction

↑

↑↑

Advanced Alcoholic Liver

↑

↑↑ ↑↑ AST > ↑ALT

End-Stage Liver Disease

↓

Acute Inflammatory Process Acute Obstruction

Notes: 1. ALT and AST in cytosol of hepatocytes »» ↑ indicate leakage through cell wall caused by swelling and inflammation »» AST:ALT ratio > 1 in alcoholic liver disease »» AST:ALT ratio < 1 in non-alcoholic liver disease 2. ALP and GGT in hepatcyte wall »» ↑ together indicate leaching from hepatocelluar wall caused by regurgitation of bile in obstructive pathology 3. GGT elevates at approximately 3 standard drinks, so if elevated alone – probably due to alcohol intake Adapted from www.rcpamanual.edu.au

Liver Function Tests 11: Other Tests – Haematology and Biochemistr y

Ca, Mg, PO 4 and Urate Calcium: Reference Range: Total Calcium: 2.10 - 2.60 mmol/L Corrected Calcium: 2.15 - 2.60 mmol/L Ionised Calcium: 1.16 -1.30 mmol/L Calcium measurement is ideally collected without application of a tourniquet to minimise venostasis. Corrected Calcium = Total Calcium + 0.02 (40 – Albumin g/L) In most instances corrected calcium should be used for clinical assessment as opposed to total calcium. Ionised calcium is used in instances when complex calcium may be elevated – such as during a large transfusion. In instances such as alkalosis and acidosis ionised calcium should also be used. Hypocalcaemia can be due to artifact if EDTA or oxalate collection is used. Possible Interpretations Hypocalcaemia

Hypercalcaemia

»» Investigation if clinically hypocalcaemic »» Monitoring thyroid or parathyroid surgery »» Hypoparathyroidism »» Renal disease »» Osteomalacia »» Rickets »» Monitoring post-transfusion (large)

»» Investigation if clinically hypercalcaemic »» Investigation of clinical hyperparathyroidism »» Malignancy – especially lung »» Bone and kidney metastases »» Multiple myeloma »» Sarcoidosis »» Vitamin D toxicity »» Vitamin A toxicity

Phosphate: Reference Range: Adult: 0.8 -1.5mmol/L Children: Slightly higher in children There is a post-prandial depression of phosphate, so a fasting sample should be collected if hypophosphataemia is suspected. Sample should be forwarded for separation ASAP. Possible Interpretations Hypophosphataemia

Hyperphosphataemia

»» Primary hyperparathyroidism »» Some hypercalcaemia associated with malignancy »» Renal tubal disorders »» Magnesium and aluminium antacid use

»» Low parathyroid hormone »» Hypercalcaemia »» Malignancy »» Renal failure

Ca, Mg, PO 4 and Urate 11: Other Tests – Haematology and Biochemistr y

Magnesium: Reference Range: Neonates: 0.6 - 0.9 mmol/L Adults: 0.8 -1.0 mmol/L Possible Interpretations Hypomagnaesaemia

Hypermagnesaemia

»» Cardiac arrhythmias »» Neuromuscular disorders »» Refractory hypocalcaemia »» Increased renal or GIT loss »» Decreased intake

»» Renal failure – assessment rarely required

Urate: Reference Range: Female: 0.15 - 0.40 mmol/L Male: 0.20 - 0.45 mmol/L Diagnostically, the main purpose of monitoring urate are in such situations as diagnosis and monitoring of gout and pregnancy-induced hypertension, monitoring malignancy treatment (high rates of cell destruction corresponding with high levels of uric acid production) and diagnosis of SIADH. Possible Interpretations Hypouricaemia

Hyperuricaemia

»» Low purine intake »» SIADH »» Medications – eg allopurinol

»» Gout – ↑ risk if consistently > 0.42mmol/L. Urate alone is not diagnostic »» Impaired renal function »» Pregnancy-induced hypertension »» Diuretics use »» Fasting »» Hyperlactataemia

Ca, Mg, PO 4 and Urate 11: Other Tests – Haematology and Biochemistr y

Lipids Analyte

Reference Range

Interpretations

Considerations

Total Cholesterol

< 4.0 mmol/L

»» Increased risk of coronary artery disease • Genetic: –– Familial hypercholesterolaemia • Secondary: –– Biliary obstruction –– Hypothyroidism –– Nephrotic syndrome

»» Should be assessed in conjunction with HDL/LDL and triglycerides »» Levels falsely reduced up to 8/52 after an acute illness »» Levels should be assessed in fasting state and not immediately postcardiovascular exercise

High Density Lipid (HDL)

Population RR: 0.9 - 2.2 mmol/L Therapeutic RR: > 1.0 mmol/L

“The Bad”

Population RR: 2.0 - 3.4 mmol/L Therapeutic RR: < 2.5 mmol/L

»» LDL is calculated via Friedwald equation: LDL = TC – HDL – Triglyceride/2.2

»» Unreliable when triglycerides > 4.5 mmol/L »» Prolonged tourniquet can artificially elevate LDL up to 20%

Triglyceride

< 1.7 mmol/L

»» Increased risk for coronary artery disease • Primary hypertriglycerideamia • Secondary: –– Nephritic syndrome –– Hypothyroidism –– Pancreatitis –– Diabetes mellitus –– Alcoholism –– OCP use –– Corticosteroid use

“The Good” Low Density Lipid (LDL)

Adapted from www.heartfoundation.org.au and www.rcpamanual.edu.au

Lipids 11: Other Tests – Haematology and Biochemistr y

Ar terial Blood Gases Reference Intervals

Interpretation Increased

Decreased

pO2

80 -100 mmHg

»» Hyperventilation »» O2 therapy

»» Hypoventilation »» V/Q mismatch »» Alveolar-capillary block »» R) – L) shunt

pCO2

35 - 45 mmHg

»» Respiratory failure »» Respiratory acidosis »» Compensatory phenomenon »» Metabolic alkalosis

»» Compensatory phenomenon »» Metabolic alkalosis »» Hyperventilation »» Respiratory alkalosis

7.36 - 7.44

»» Overall alkalosis

»» Overall acidosis

The pH determines the primary acid-base imbalance (either respiratory or metabolic underlying cause) ie acidosis or alkalosis Base Excess

-3 to 3 mmol/L

»» Metabolic alkalosis »» Compensatory respiratory acidosis

AlveolarArterial pO2 Difference

< 25 mmHg (if FiO2 = 0.21)

»» In all cases of hypoxia except hypoventilation

»» Metabolic acidosis »» Compensatory respiratory alkalosis

Note: T he patient’s temperature and FiO2 should be known to effectively calculate and interpret ABG Adapted from www.rcpamanual.edu.au

Ar terial Blood Gases 11: Other Tests – Haematology and Biochemistr y

Assessing Ar terial Blood Gases – Acid-Base Balance ↑ pH (next page)

Assess the pH

↓ pH Is the primary change in CO2? Yes

Is the change in keeping with the pH (ie ↑ CO2)?

Is the primary change in HCO3?

Yes

Respiratory acidosis ↓ pH and ↑ CO2

Respiratory failure If ↓O2  ? need for O2 Take care with O2 if cause is COPD as it may worsen patient’s condition

No »» No change »» Opposite change Compensatory change

Yes Is the change in keeping with the pH (ie ↓ HCO3)? Yes

Metabolic acidosis

Compensatory change

↓ pH and ↓ HCO3↑ Anion gap

Underlying cause is due to ↑ production and HCO3fails to buffer

↓ pH and ↓ HCO3Norm anion gap

Underlying cause is loss of HCO3 ions or ingestion of H+ ions

Assessing Ar terial Blood Gases – Acid-Base Balance 11: Other Tests – Haematology and Biochemistr y

↓ pH (previous page)

Assess the pH

↑ pH Is the primary change in CO2? Yes

Is the change in keeping with the pH (ie ↓ CO2)?

Is the primary change in HCO3?

Yes

Respiratory alkalosis

No »» No change »» Opposite change Compensatory change

↑ pH and ↓ CO2

Underlying cause brings about hyperventilation, which causes the respiratory alkalosis

Yes Is the change in keeping with the pH (ie ↑ HCO3)? Yes

Metabolic alkalosis

Compensatory change

↑ pH and ↑ HCO3-

Underlying cause is loss of H+ ions or ingestion of base

Assessing Ar terial Blood Gases – Acid-Base Balance 11: Other Tests – Haematology and Biochemistr y

12: Drug Information

Therapeutic Drug Inter vals Medication

Therapeutic Range

Amitriptyline

150 - 900 nmol/L

Nortriptyline

200 - 650 nmol/L

Lithium

0.6 -1.2 mmol/L

Carbamazepine

20 - 40 mmol/L

Phenobarbitone

65 -170 mmol/L

Phenytoin

40 - 80 mmol/L

Valproate

350 -700 mmol/L

Digoxin

0.6 - 2.3 nmol/L

Theophyline

Neonate: 33 - 66 mmol/L

Child/adult: 55 -110 mmol/L

Gentamicin

Pre: < 2.0µg/mL

Post: < 12.0µg/mL

Adapted from www.rcpamanual.edu.au

Therapeutic Drug Inter vals 12: Drug Information

9 780980 867206

ISBN 978 0 9808672 0 6 AU$15.00 www.gpra.org.au