GP Companion 2011 by GPRA Publications

GP Companion

1st edition â&#x20AC;&#x201D; update 2012 General Practice Registrars Australia RRP $29.95

General Practice Students Network RRP$15.00

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1: About your GP Companion This is an update to the first edition of GP Companion, which was prepared by the General Practice Students Network (GPSN) as a handy pocket reference to help students get the most out of their general practice rotations. GPSN is administered by General Practice Registrars Australia (GPRA), which is the peak national representative body for GP registrars. Following feedback about the usefulness of the GP Companion, it will now be distributed to GPRAâ&#x20AC;&#x2122;s registrar and junior doctor networks, in addition to medical students. GPRA also administers the Going Places Network, which provides information to junior doctors interested in general practice.

Contents

5: Contraception and pregnancy

1: About your GP Companion

Contraception Antenatal care

50 66

2: Maximising your GP rotation

6: Paediatrics

How to get the most from your GP rotation

3: General practice resources at your fingertips

Resources in general practice Common medical abbreviations Pathological sieves

16 24 35

4: Preventive health

Men’s preventive health checks Men’s health – PSA Women’s preventive health checks

38 43 44

Paediatric developmental milestones 72 National immunisation program schedule 77 Normal parameters for paediatric vital signs 82 7: Dermatology

Dermatological assessment Dermatitis and psoriasis Skin cancer differentiations

84 88 90

8: Diabetes and endocrinology

Glucose testing – diabetes diagnosis and management

94 Contents

1: About your GP Companion

Endocrinology reference ranges (excluding glucose)

9: Cardiovascular medicine

109

HTN classification and management ECG interpretation Cardiac enzymes Peripheral vascular disease

110 117 120 122

10: Respiratory medicine

125

Asthma diagnosis and management Spirometry CXR interpretation Smoking cessation

126 131 136 138

11: Other tests – Haematology and biochemistry

141

Haematology Acute phase reactants

142 154

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

157 162

12: Drug information

191

Therapeutic drug intervals 13: Notes

192

166 173 178 183 186 188

193

Contents 1: About your GP Companion

With you on your journey Students

At General Practice Registrars Australia (GPRA), we support our members throughout their general practice journey. We are with them through medical school and their hospital internship, right up until when they negotiate their first employment contract. We then provide resources to help them make the most out of their career and be resilient GPs.

General Practice Students Network gpsn.org.au

Junior doctors

Registrars

GPs

Going Places Network gpaustralia.org.au

General Practice Registrars Australia gpra.org.au

R-cubed â&#x20AC;&#x201C; wellbeing for doctors rcubed.org.au

Produced with funding support from General Practice Education and Training Limited

Medical editors: Dr Abhi Varshney and Kerry Summerscales. 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 Victoria 3001 Information contained in this publication was correct at the time of printing and published in good faith. GPRA does not accept liability for the use of information within this publication. ÂŠ2011 GPRA. No part of this publication may be reproduced without prior permission and full acknowledgement of the source: GP Companion, a publication of General Practice Registrars Australia. ISBN 978 0 9808672 0 6 gpra.org.au

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 • Write referrals to specialists • Order investigations at the local pathology and radiology services • Fill out prescriptions • Bill 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 How to get the most from your GP rotation 2: Maximising your GP rotation

–– 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

How to get the most from your GP rotation 2: Maximising your GP rotation

»» 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 »» 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 How to get the most from your GP rotation

2: Maximising your GP rotation

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

SUPPORTING YOUNG DOCTORS IN GENERAL PRACTICE At Healthscope, our greatest asset is the relationship we have with our highly qualified and respected Medical Practitioners. Healthscope Medical Centres currently operates 66 medical and specialist facilities across Australia, encompassing a vast network of over 440 Practitioners, all supported by our unparalleled dedication to quality clinical care and administrative support. Our centres are also focused on the career development and education of young Practitioners. Through ongoing clinical training initiatives and education opportunities, our young doctors are encouraged to pursue areas of special interest to foster their professional growth.

To find out more about the benefits of joining a Healthscope Medical Centre please contact Lachlan McBride on 0417 574 401 or lachlan.mcbride@healthscope.com.au

3: General practice resources at your fingertips

Resources in general practice Databases 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. PubMed Free search for any journal articles, links to full text articles and other resources, over 17 million citations, 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, cochrane.org ProQuest Available free for RACGP members at racgp.org.au UpToDate The latest information, members only site, uptodate.com MD Consult Offers a free 30 day trial, see mdconsult.com

Resources in general practice

3: General practice at your finger tips

Journals 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. British Medical Journal Offers reputable articles on all medical topics at bmj.com There is also a student version at studentbmj.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 racgp.org.au American Academy of Family Physicians Similar to the Australian Family Physician, available online at aafp.org/afp

The Lancet The be all and end all of high quality medical journals, thelancet.com

Resources in general practice 3: General practice at your finger tips

Websites 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, healthinsite.gov.au The Merck Manual Easy-to-read information on what a disease is, what causes it, how to examine, diagnose and treat patients, and what the prognoses are, merck.com

MedlinePlus Basic health information on many conditions from the National Library of Medicine in the United States, 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, 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, australiandoctor.com.au

Resources in general practice

3: General practice at your finger tips

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 Australiaâ&#x20AC;&#x2122;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. tg.org.au

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 immunise.health.gov.au Child Health Record The Department of Education and Early Childhood Development (DEECD) website contains growth charts, health and development assessments and child health information for parents and practitioners. 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. mja.com.au/public/guides/guides.html

Resources in general practice 3: General practice at your finger tips

RACGP guidelines The Royal Australian College of General Practitioners endorses a variety of guidelines for general practitioners on their easy-to-navigate website racgp.org.au/guidelines

Guidelines »» Management of Stroke Guidelines »» Physical Activity with CVD Guidelines

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

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.

Books

It also includes clinical pearls used by the author himself, including easy-to-remember triads for diagnosing a condition based on three key Resources in general practice

3: General practice at your finger tips

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 Oâ&#x20AC;&#x2122;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. Churchillâ&#x20AC;&#x2122;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

Resources in general practice 3: General practice at your finger tips

home visits and 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 eight-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 racgp.org.au Self-Education gplearning gplearning is an online tool developed by the RACGP and available free to members. It contains about 200 learning activities including Resources in general practice

3: General practice at your finger tips

womenâ&#x20AC;&#x2122;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 gplearning.com.au Rural and Remote Medical Education Online (RRMEO) Available free to Australian College of Rural and Remote Medicine members (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. 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 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-â&#x20AC;&#x2030;month subscription is available free when you sign up as an RACGP member. Current and past issues are also available for sale from racgp.org.au/check

Resources in general practice 3: General practice at your finger tips

Common medical abbreviations A AAA AAL ABG ABI ABL AC ac ACA ACE ACEI ACIR ACL ACR

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

ACS ACTH ADH ADL ADT AF AFB AFP AGA AIDS ALP ALT AMI AML ANA ANCA AOM AP APTT

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 Common medical abbreviations

3: General practice at your finger tips

AR ARC ARDS AS ASA ASD ASIS AST AV

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

basal cell carcinoma bacillus of Calmette and GuĂŠrin (TB vaccination) beta human chorionic gonadotrophin bowel movement body mass index blood pressure

BPH BPPV

benign prostatic hyperplasia benign paroxysmal positional vertigo

C CABG CAD CBT CCB CCF CDT CF CHD CI CK CLL CMC CMV CN CO

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

Common medical abbreviations 3: General practice at your finger tips

COPD COX CPAP CPK CRFM CSF CSFM CT CTD CTS CVA CVP CVS CXR

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

D D&C D&V DBP

dilation and curettage diarrhoea and vomiting diastolic blood pressure

DDST DIPJ DM DNR DRE dsDNA DTaP DTR DUB DVT Dx

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

evidence-based medicine Epstein-Barr virus (glandular fever) extracellular fluid electrocardiogram estimated glomerular filtration rate enzyme-linked immunosorbent assay Common medical abbreviations

3: General practice at your finger tips

EOM ER EtOH ESR

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

group A betahaemolytic streptococcus 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

Common medical abbreviations 3: General practice at your finger tips

H HAV Hb HBcAb HBcAg HBsAg HBsAb HBV HCG HCV HCW HDL Hib HIV HLA-B27

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)

HMG HPV HR HRT HTN Hx

hydroxymethyl-glutaryl human papillomavirus heart rate hormone replacement therapy hypertension history

I IA IBD IBS ICH ICP ICS IHD IM IMI INR IOFB

intra-articular inflammatory bowel disease irritable bowel syndrome intracranial haemorrhage intracranial pressure intercostal space ischaemic heart disease intramuscular intramuscular injection international normalised ratio intraocular foreign body Common medical abbreviations

3: General practice at your finger tips

IPJ IPV IR ITP IU IUCD IUD IV IVC

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

local anaesthetic long-acting beta agonist left atrial pressure lactate dehydrogenase low density lipoprotein

LFTs LGA LH LHRH LIF LLL LLQ LMNL LMP LOC LP LRTI LSCS LUL LUQ LUT LV LVF LVH

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 left ventricular failure left ventricular hypertrophy

Common medical abbreviations 3: General practice at your finger tips

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

Common medical abbreviations

3: General practice at your finger tips

O (o) OA OCD OCP O/C/P O/E OM OPV OTC

taken orally osteoarthritis obsessive compulsive disorder oral contraceptive pill ova, cysts and parasites on examination otitis media oral poliomyelitis vaccine (no longer in use) over the counter

P PA Pap smear PAT PCL PCOS PE

posterior anterior Papanicolaou smear paroxysmal atrial tachycardia posterior cruciate ligament polycystic ovary syndrome pulmonary embolism

PEF PHN PID PIH PIPJ PKU PMH PMR PMS PND PO POF POP PPH PPI PR PRL PROM PSA

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

Common medical abbreviations 3: General practice at your finger tips

PSH PSIS PSVT Pt PTH PTSD PUD PV PVC PVD

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

rheumatoid arthritis red blood cell respiratory distress syndrome respiratory function tests rest, ice, compression, elevation right iliac fossa right lower lobe (lung)

RML RN ROM ROS RR RRV RSI RSV RUL RUQ RVF RVH

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

short-acting beta agonist subarachnoid haemorrhage sudden acute respiratory syndrome systolic blood pressure subcutaneous Common medical abbreviations

3: General practice at your finger tips

SCC SD SES SGA SH SI SIADH SIDS SL SLE SOB SOL SSRI SSSS STEMI STI SUFE SVC SVT

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 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)

Common medical abbreviations 3: General practice at your finger tips

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 at your finger tips

Pathological sieves

“VINDICATES” – for differential diagnosis:

There are numerous diagnostic sieve mnemonics around. The following systematic approaches to diagnosis are commonly used in general practice.

V – vascular I – inflammatory or infectious N – neoplastic or neurological 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

“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)

Pathological sieves 3: General practice at your finger tips

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 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 138

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+

Opportunistically if other risk factors or behavioural issues. Recommendations are 2 alcohol free days a week, not more than 4 drinks on average on drinking days, and no more than 6 drinks on any one drinking day

Men’s preventive health checks

4; Preventive health

Test/assessment

Frequency

How

Additional information

Age

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

15 - 25 Consider up to 3/12 for high risk Give sun protection advice

30 - 65+

Men’s preventive health checks 4: Preventive health

Test/assessment Colorectal Ca

Frequency Every 2 yrs

How FOBT

PSA and DRE

Absolute CVS risk

Every 2 yrs

Blood pressure

Every 2 yrs

Measure

Additional information

Age

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 43 for further information Always use in conjunction with DRE

50 - 65+

More often if change of treatment indicated

45 - 65+

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+

Men’s preventive health checks

4; Preventive health

Test/assessment

Frequency

How

Additional information

Age

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

Annually if HTN, DM or history of renal disease

50 - 65+ ATSI: 45 - 65+

Urinary dipstick and U&E

Men’s preventive health checks 4: Preventive health

Test/assessment

Frequency

Osteoporosis

How

Additional information

Age

Assess risk

Bone mineral densitometry if indicated

Variable

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 – 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 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

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.

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 138

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+

Opportunistically if other risk factors or behavioural issues. Recommendations are 2 alcohol free days a week, not more than 2 drinks on average on drinking days, and no more than 4 drinks on any one day

Women’s preventive health checks

4: Preventive health

Test/assessment

Frequency

How

Additional information

Age

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

Women’s preventive health checks 4: Preventive health

Test/assessment

Frequency

How

Additional information

Age

Pap smear

Every 2 yrs

Speculum Pap smear collection

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 intake

Give advice on high folate 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+

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

18 - 70

Women’s preventive health checks

4: Preventive health

Test/assessment

Frequency

Colorectal Ca

Every 2 yrs

Absolute CVS risk

Every 2 yrs

Blood pressure

Every 2 yrs

How FOBT

Measure

Additional information

Age

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+

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+

Women’s preventive health checks 4: Preventive health

Test/assessment

Frequency

How

Additional information

Age

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

Annually if HTN, DM or history of renal disease

50 - 65+ ATSI: 45 - 65+

Urinary dipstick and U&E

Adapted from RACGP – Preventative Activities over the Lifecycle – Adults and RACGP Red Book – racgp.org.au * CAGE questions for alcohol consumption (see page 42)

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

Natural methods Rhythm method

»» Predicting time of maximum fertility (ie ovulation) • Menstrual calendar • Charting body temp (↑ at ovulation) • Thickening of mucus • Ovulation predictor kits

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

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

Contraception

5: Contraception and pregnancy

Method of action Coitus interruptus

»» Not ejaculating inside the ♀

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

Advantages

Disadvantages

»» 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

Contraception 5: Contraception and pregnancy

Method of action

Advantages

Disadvantages

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

Hormonal methods Note: Contraindications to combined OCP listed on page 64* Combined »» Inhibits ovulation oral »» Inhibits FSH release contraceptive »» Prevents follicular pill ripening »» 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: • Weight gain • Acne • ↓ libido • Breast discomfort • Mood disturbances • Breakthrough bleeding • Headache • HTN

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

Contraception 5: Contraception and pregnancy

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

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

Disadvantages »» Must be taken same time every day »» Prescription only »» Side effects may include: • Irregular bleeding • Weight gain • Moodiness • Acne

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

Contraception

5: Contraception and pregnancy

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

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

Disadvantages »» Prescription only »» Side effects may include:

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

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:

0.0 - 1.0

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

Contraception

5: Contraception and pregnancy

Vaginal ring

Method of action

Advantages

Disadvantages

»» 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

Contraception 5: Contraception and pregnancy

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

Advantages

Disadvantages

»» 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

Contraception

5: Contraception and pregnancy

Method of action

Advantages

Disadvantages

Intrauterine devices Note: Contraindications to IUCD listed on page 64** IUCD »» Device inserted (Intrauterine into the uterus contraceptive »» Prevention device) of blastocyst 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

Contraception 5: Contraception and pregnancy

Mirena

Method of action

Advantages

Disadvantages

»» 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

Sterilisation 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

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

0.0 - 0.5

Contraception 5: Contraception and pregnancy

Method of action 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)

Advantages

Disadvantages

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

0.0 - 0.4

Contraception

5: Contraception and pregnancy

Method of action 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

Advantages »» Reliable

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

Not applicable

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

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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 Antenatal care

5: Contraception and pregnancy

• 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) 14/20 »» 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 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

Antenatal care 5: Contraception and pregnancy

»» Assess foetal and maternal wellbeing »» Discuss feeding plans

Primigravida

Multigravida

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

32 28

20 16 12

Adapted from health.sa.gov.au, rcpa.edu.au and FMC Antenatal Schedule for clinics

Antenatal care

5: Contraception and pregnancy

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

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6: Paediatrics

Paediatric developmental milestones Gross motor

Fine motor

Speech and language

Social skills

6 wks

»» Moro response »» Good head control when pulled

»» Not able to assess

»» Coos »» Startles at loud noise

»» Smiles in response

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

Paediatric developmental milestones

6: Paediatrics

Gross motor

Fine motor

Speech and language

Social skills

9 mths

»» Crawling »» Pull to stand

»» Reaches for toys »» Mama, Dada, »» Palmar to fingerimitates one word thumb 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

Paediatric developmental milestones 6: Paediatrics

Gross motor

Fine motor

Speech and language

Social skills

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

3 yrs

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

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

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

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

Paediatric developmental milestones

6: Paediatrics

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

Paediatric developmental milestones 6: Paediatrics

Red flag developmental signs 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

Please refer to page 80 for footnotes

National Immunisation Program Schedule 6: Paediatrics

Age

Vaccine

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)

Please refer to page 80 for footnotes

National Immunisation Program Schedule

6: Paediatrics

Age

Vaccine

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

Diphtheria, tetanus and acellular pertussis (dTpa)

15 - 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 80 for footnotes

National Immunisation Program Schedule 6: Paediatrics

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.

National Immunisation Program Schedule

6: Paediatrics

i j

These vaccines are for one cohort only within this age range. Contact your state or territory health department for details. 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 months. The Australian Immunisation Handbook -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

Dermatological assessment

7: Dermatology

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 healthinsite.gov.au, virtualskincentre.com and various other sources

Dermatological assessment

7: Dermatology

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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

»» Erythematous lesions »» Vesicles

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

»» Plaques »» Vesicles »» Pustules

Characteristics Type of lesions

Dermatitis and psoriasis

7: Dermatology

Contact Dermatitis

Atopic Dermatitis (Eczema)

Shape/border

»» Asymmetrical »» Depends on type of contact

Colour

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

»» Asymmetrical »» Ill-demarcated border

Psoriasis »» Symmetrical »» Well-demarcated border »» Pink plaques surrounded by silvery scale

Secondary Sites Secondary site

»» Face, wrists, forearms

»» Nails

Dermatitis and psoriasis 7: Dermatology

Skin cancer differentiations SCC

BCC

Melanoma

Morphology

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

»» 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

Skin cancer differentiations

7: Dermatology

SCC Epidemiology

»» Less common »» Usually > 50 yrs

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

Melanoma »» 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

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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

Unlikely Diabetes Mellitus

»» Symptoms of diabetes mellitus »» Fasting Glucose between AND 5.6 - 6.8 mmol/L »» Fasting Glucose > 7.0 mmol/L OR on 2 occasions »» Random Glucose between OR 7.8 -11.0 mmol/L »» Random Glucose > 11.1mmol/L (> 2 hrs post-prandial) on 2 occasions

»» Fasting Glucose < 5.5 mmol/L

ÆÆ No Oral Glucose Tolerance Test (GTT) required

ÆÆ No Oral GTT indicated

ÆÆ Conduct an Oral GTT

AND/OR

»» Random Glucose < 7.8 mmol/L

Note: Fasting means the only intake is water for 8 hrs before the sample is collected Glucose testing – diabetes diagnosis and management

8: Diabetes and endocrinology

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.

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

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 Glucose testing – diabetes diagnosis and management 8: Diabetes and endrocrinology

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

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 Glucose testing – diabetes diagnosis and management

8: Diabetes and endocrinology

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

Start sulphonylurea Monitor glycaemic control

3 4

For those unable to take Metformin

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 endrocrinology

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 Women Cigarette consumption

Alcohol intake Men Women Exercise

� 2 standard drinks/day (� 20g/day) � 1 standard drink/day (� 10g/day) At least 30 mins moderate exercise 5 or more times a week (total 150 mins wk)

Adapted from Murtagh’s General Practice, rcpa.edu.au, health.gov.au, diabetesaustralia.com.au and racgp.org.au

< 2.5 mg/mmol < 3.5 mg/mmol Nil

Glucose testing – diabetes diagnosis and management

8: Diabetes and endocrinology

Endocrinology reference ranges (excluding glucose) Testosterone Male Pre-pubertal Free Testosterone (pmol/L)

Female Adult

Pre-pubertal

170 - 510

Total Testosterone (nmol/L)

< 0.5

Dihydrotestosterone (nmol/L)

8 - 35

Adult < 4.0

< 0.5

< 4.0

1- 2.5

Possible Interpretations Male Increased

»» Precocious puberty

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

Endocrinology reference ranges (excluding glucose) 8: Diabetes and endrocrinology

Male Decreased

Female

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

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

1.0 - 8.0

2 -15

Early Follicular Phase

100 - 200

2.0 - 4.5

Pre-Ovulatory Phase

500 -1,700

Ovulation

10 - 30

Highest levels of the cycle Endocrinology reference ranges (excluding glucose)

100

8: Diabetes and endocrinology

Follicle stimulating hormone IU/L

Luteinising hormone IU/L

Luteal Phase Post-Menopausal

>18

15 -100

Oestadiol (pmol/L)

Progesterone (nmol/L)

500 - 900

7.0 - 70.0

70 - 200

Possible Interpretations Increased

Decreased

FSH

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

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

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

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

Endocrinology reference ranges (excluding glucose) 8: Diabetes and endrocrinology

101

Increased Oestrodiol

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

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

Pathological »» Prolactinomas »» Pituitary tumours »» Hypothalamic disorders associated with amenorrhoea-galactorrhoea syndrome »» Some medications • Phenothiazines • Metoclopramide • Oestrogens Endocrinology reference ranges (excluding glucose)

102

8: Diabetes and endocrinology

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

Days after conception

BhCG levels for single foetus (IU/L)

Progesterone levels for single foetus (nmol/L)

1- 28

Before Pregnancy Conception to 12 Weeks

7- 47

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

Weeks 12 - 28 Week 13 - 16

17 -146 13,000 - 250,000

Endocrinology reference ranges (excluding glucose) 8: Diabetes and endrocrinology

103

Gestational age wks post-LMP

Days after conception

BhCG levels for single foetus (IU/L)

Week 17 - 24

4,000 - 165,000

Weeks 25 - Birth

3,640 -117,000

4 - 6 Weeks Post-Birth

Less than 5

Progesterone levels for single foetus (nmol/L) 55 - 200

Notes: Conception to 12 weeks 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 Weeks 12-28 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 Endocrinology reference ranges (excluding glucose)

104

8: Diabetes and endocrinology

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 imvs.com.au and 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

Endocrinology reference ranges (excluding glucose) 8: Diabetes and endrocrinology

105

TSH

Free T3

Free T4

↑

Normal - ↓

↓

Normal or ↓

Normal - ↓

↓

Hypothyroidism »» Primary »» Secondary (pituitary dysfunction) Hyperthyroidism Sick Euthyroid

↓

↑

Normal - ↓

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 rcpamanual.edu.au unless otherwise stated

Endocrinology reference ranges (excluding glucose)

106

8: Diabetes and endocrinology

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9: Cardiovascular medicine

109

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

≥ 180

≥ 110

Normal

Grade 3 (severe) hypertension

Follow-up

Reassess within 1 - 7 days2

HTN classification and management

110

9: Cardiovascular medicine

Diagnostic category1 Isolated systolic hypertension

Systolic (mmHg)

Diastolic (mmHg)

≥ 140

< 90

Follow-up As for category corresponding to systolic BP

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 113 Lifestyle factors that can decrease BP and decrease cardiac risk S – Smoking N – Nutrition A – Alcohol P – Physical activity

HTN classification and management 9: Cardiovascular medicine

111

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

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

HTN classification and management

112

9: Cardiovascular medicine

SNAP factors to assist in decreasing BP 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

HTN classification and management 9: Cardiovascular medicine

113

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

114

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

HTN classification and management 9: Cardiovascular medicine

115

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 maximum doses Consider adding other antihypertensive agents, eg moxonidine, alpha blockers or centrally acting agents such as clonidine or methyldopa

Goals not achieved

Refer for specialist assistance

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

HTN classification and management

116

9: Cardiovascular medicine

ECG interpretation

ECG – Leads and orientation

Right Arm

150

100

-90°

L+

-aV

-60°

-30°

180°

0°

150° 120°

30°

90°

60°

300

-120°

-150°

Heart rate – beats/min

Lea

Large squares between R-R interval

Lea

Left Arm Lead 1

+aVF-

ECG – Establishing rate If regular – 300 divided by the number of large squares (R-R interval)

ECG interpretation 9: Cardiovascular medicine

117

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

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

118

9: Cardiovascular medicine

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

ECG interpretation 9: Cardiovascular medicine

119

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

Cardiac enzymes

120

9: Cardiovascular medicine

Analyte

Reference range

Timeframe of elevation post-MI

Comments

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

»» 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

AST

12 - 72 hrs post-MI

Also elevated in hepatocellular disease and skeletal muscle damage

< 40 U/L

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

Cardiac enzymes 9: Cardiovascular medicine

121

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 Peripheral vascular disease

122

9: Cardiovascular medicine

Arterial insufficiency

Venous insufficiency

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

123

10: Respiratory medicine

125

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

»» 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 »» Crackles on auscultation  other on page 131) diagnosis (or concurrent diagnosis) »» Chest X-ray »» Allergic rhinitis indications – to exclude »» Speech rate to assess severity (sentences other causes if – mild, words – moderate, single words indicated only – severe disease) »» Specialist testing: »» Respiratory rate • Challenge tests »» Presence of cyanosis • Allergy testing

Diagnostic testing

Asthma diagnosis and management

126

10: Respirator y medicine

Asthma medications Preventers – Anti-inflammatory agents that reduce symptoms and exacerbations of asthma – prophylactic agents. Alvesco Flixotide Qvar

Ciclesonide 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

127

Relievers â&#x20AC;&#x201C; 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. Airomir

Salbutamol

Asmol Epaq

SABA

Ventolin

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

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

Asthma diagnosis and management

128

10: Respirator y medicine

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

Asthma diagnosis and management 10: Respirator y medicine

129

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 nationalasthma.org.au and National Asthma Councilâ&#x20AC;&#x2122;s Asthma Management Handbook. Adapted from nationalasthma.org.au

Asthma diagnosis and management

130

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

Spirometr y 10: Respirator y medicine

131

One of the key features of diagnosis of asthma is respiratory obstruction that is significantly improved via use of a bronchodilator (usually salbutamol). 100 x FEV1(post-bronchodilator) â&#x20AC;&#x201C; FEV1 (baseline)

% improvement =

FEV1 (baseline)

Spirometry flow volume curves 10

FEV25%

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

Flow [l/sec]

Vol [l] 2

FIV75% 6 FIV50% 8 10

Spirometr y

132

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

Volume

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 nationalasthma.org.au/images/ stories/manage/pdf/spirometer_ handbook_naca.pdf

Spirometr y 10: Respirator y medicine

133

Adapted from page 12 of Spirometry: The Measurement and Interpretation of Ventilatory Function in Clinical Practice at 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

134

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Respiratory function tables For childhood and adolescent respiratory function charts, see pages 123 -126 of Asthma Handbook 2006 at 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 based on age and height. Contact your local lung function laboratory for advice about predicted values, including lower limits of normal and the effect of ethnicity.

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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 borderLower 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

CXR interpretation

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

»» oracic s

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) Normal chest X-ray in a healthy female

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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

Smoking cessation

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Smoking cessation – 5As 5As

Explanation

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 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)

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Haematology Full blood count and Erythrocyte Sedimentation Rate (ESR) Indices Haemoglobin (Hb)

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

Red Cell Count (RCC)

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Indices

Reference range

Leucocyte count – White Cell Count (WCC)

4.0 -11.0 x 109/L

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%)

Platelet count ESR

150 - 400 x 109/L 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)

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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

< 0.2 Haematology

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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

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Iron studies Iron

Adult

10 - 30µmol/L

Iron Binding Capacity (TIBC)

45 - 80µmol/L

Transferrin

1.7 - 3.0 g/L

Transferrin saturation Ferritin

0.15 - 0.45 (15 - 45%) Male

30 - 300µg/L

Female

15 - 200µg/L

Vitamin B12 Folate

120 - 680 pmol/L RBC folate

360 -1,400 nmol/L

Serum folate

7- 45 nmol/L

Haematology

146

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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

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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

Acute blood loss

Myeloproliferatives

Hyposplenism »» Atrophy »» Splenectomy »» Trauma

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

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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

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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

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

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

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

*More pancytopaenia noted than just neutropaenia Haematology

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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

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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

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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 rcpamanual.edu.au

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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 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.

Acute phase reactants

154

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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. 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

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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

156

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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 patientâ&#x20AC;&#x2122;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

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Red cell antigens and plasma antibodies Red blood cell antigens

Corresponding antibodies in plasma

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.

Immunohaematology

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Blood grouping Forward group Against

Blood group

Anti-A

Anti-B

Anti-D

Patient serum

A Pos

A Neg

B Pos

B Neg

AB Pos

AB Neg

O Pos

O Neg

Patient cells

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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.

Immunohaematology

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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

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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

Coagulation studies

162

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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 on page 164

Fibrinogen

1.5 - 4.0g/L

D-Dimer

< 500 mg/mL

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

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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

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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 rcpamanual.edu.au and gpnotebook.com

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Renal function tests – urinalysis, UEC and GFR estimation Urinalysis Should be conducted within four hours 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

Renal function tests – urinalysis, UEC and GFR estimation

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Application

Interpretation

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

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Application

Interpretation

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

UEC – Urea, Electrolytes and Creatinine Urea

Reference range

Elevated in

Decreased in

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

Renal function tests – urinalysis, UEC and GFR estimation

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Reference range

Elevated in

Decreased in

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

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Sodium

Reference range

Elevated in

Decreased in

135 -145 mmol/L

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

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

Anion Gap 8 -16 mmol/L (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

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Estimated Glomerular filtration rate: Cockcroft-Gault formula: {(140 – age in yrs) x (weight in kgs) x 1.23 constant} Estimated Creatinine clearance (mL/min): 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 Renal function tests – urinalysis, UEC and GFR estimation 11: Other tests – Haematology and biochemistr y

171

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 rcpamanual.edu.au and kidney.org.au

Renal function tests – urinalysis, UEC and GFR estimation

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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

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Albumin

Neonate

Adult

Interpretation

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

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

Liver function tests

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Neonate

Adult

Interpretation

< 50 U/L

< 35U/L

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

ALK PHOS (ALP) 50 - 300 U/L

25 -100 U/L

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

AST

< 40 U/L

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

ALT

< 40 U/L

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175

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

Liver function tests

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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 rcpamanual.edu.au

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177

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.

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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

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179

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

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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

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181

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

182

11: Other tests – Haematol ogy and biochemis tr 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 Good”

Lipids 11: Other tests – Haematology and biochemistr y

183

Analyte

Reference range

Interpretations

Considerations

Low Density Lipid (LDL) “The Bad”

Population RR: »» LDL is calculated via 2.0 - 3.4 mmol/L Friedwald equation: Therapeutic RR: LDL = TC – HDL – < 2.5 mmol/L Triglyceride/2.2

Triglyceride

< 1.7 mmol/L

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

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

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

Lipids

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11: Other tests – Haematology and biochemistr y

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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

Ar terial blood gases

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Reference intervals pH

7.36 - 7.44

Interpretation Increased

Decreased

»» 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: The patient’s temperature and FiO2 should be known to effectively calculate and interpret ABG Adapted from rcpamanual.edu.au

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187

Assessing ar terial blood gases – acid-base balance ↓ 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 HCO3- fails to buffer

↓ pH and ↓ HCO3Norm anion gap

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

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↑ pH

Assess the 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

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 acidosis

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

189

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12: Drug information

191

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 rcpamanual.edu.au

Therapeutic drug inter vals

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12: Drug information

13: Notes

193

NOTES

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