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FM14 Family Medicine
Common Presenting Problems
Toronto Notes 2019
Abdominal Pain Red Flags
• Severe pain
• Signs of shock
• Peritoneal signs
• Abdominal distention
• Pain out of proportion to clinical findings
• New onset pain, change in pain, or altered
bowel habits in elderly
• Weight loss
• Blood per rectum/melena
• Anemia
• Supraclavicular nodes
• Family history of serious bowel disease
In patients >50, keep a high index of suspicion for AAA – its presentation may mimic renal colic or diverticulitis
Pathophysiology
• typeofpain
■ somatic pain: sharp, localized pain ■ visceral pain: dull, generalized pain
• locationofpain
■ epigastric (foregut): distal esophagus, stomach, proximal duodenum, biliary tree, pancreas, liver
Differential Diagnosis
• Acute viral infection • Vasomotor rhinitis • Deviated septum
• Nasal polyps
• Acute/chronic sinusitis • Drug-induced rhinitis
Rhinitis Medicamentosa
Rebound nasal congestion. Occurs with prolonged use (>5-7 d) of vasoconstrictive intranasal medications. Patient may become dependent, requiring more frequent dosing to achieve the same decongestant effect
Investigations
• guidedbyfindingsonhistoryandphysical
• possiblebloodwork:CBC,electrolytes,BUN,Cr,amylase,lipase,AST,ALT,ALP,bilirubin,glucose,
INR/PTT, toxicology screen, β-hCG
• imaging
■ CXR (for free air under the diaphragm) in setting of perforation in surgical abdomen
■ abdominal x-ray, KUB (consider: gas pattern, free air, kidney stones, constipation)
■ ultrasound (renal stones, gallbladder disease, gynecological problems, liver disease, pancreatitis,
diverticular disease, appendicitis)
■ CT scan (AAA, appendicitis), non-contrast helical CT-Scan (first choice for renal stones)
• othertests
■ urinalysis
■ endoscopy (for peptic ulcers, gastritis, tumours, etc.) ■ H. pylori testing (urea breath test, serology, biopsy)
Allergic Rhinitis
• seeOtolaryngology,OT23
Definition
• inflammationofthenasalmucosathatistriggeredbyanallergicreaction • classification
■ seasonal
◆ symptoms during a specific time of the year
◆ common allergens: trees, grass and weed pollens, airborne moulds
■ perennial
◆ symptoms throughout the year with variation in severity ◆ common allergens: dust mites, animal dander, moulds
• persistentallergicrhinitismayleadtochronicrhinosinusitis
Epidemiology
• affectsapproximately40%ofchildrenand20-30%ofadults
• prevalencehasincreasedindevelopedcountries,particularlyinthepasttwodecades • associatedwithasthma,eczema,sinusitis,andotitismedia
Etiology
• increasedIgElevelstocertainallergens→excessivedegranulationofmastcells→releaseof inflammatory mediators (e.g. histamine) and cytokines → local inflammatory reaction
Assessment
• identifyallergens
• takeanenvironmental/occupationalhistory
• askaboutrelatedconditions(e.g.atopicdermatitis,asthma,sinusitis,andfamilyhistory)
Management
• conservative
■ minimize exposure to allergens
◆ most important aspect of management, often sufficient (may take months) ■ maintain hygiene, saline nasal rinses
• pharmacologicagents
■ oral antihistamines – first line therapy for mild symptoms
◆ e.g. cetirizine (Reactine®), fexofenadine (Allegra®), loratadine (Claritin®)
■ intranasal corticosteroids for moderate/severe or persistent symptoms (>1 mo of consistent use to
see results)
■ intranasal decongestants (use must be limited to <5 d to avoid rhinitis medicamentosa)
■ ■
■
◆ RUQ: biliary, hepatic, colonic, pulmonary, renal
◆ LUQ: cardiac, gastric, pancreatic, renal, vascular
periumbilical (midgut): distal duodenum to proximal 2/3 of transverse colon hypogastric (hindgut): distal 1/3 of transverse colon to rectosigmoid region
◆ RLQ: colonic, appendix, gynecologic, renal
◆ LLQ: colonic, gynecologic, renal
any location: aneurysm, dissection, ischemia, zoster, muscle strain, hernia, bowel obstruction, ischemia, peritonitis, porphyria, DKA