Page 324 - TNFlipTest

FM26 Family Medicine
Common Presenting Problems Toronto Notes 2019
• associatedsymptoms
■ neurologic (central)
◆ transient diplopia, dysphagia, dysarthria, ataxia (TIA, VBI, migraine)
◆ persistent headache, alterations in level of consciousness, sensory and/or motor deficits (CNS) ■ audiologic (peripheral)
◆ hearing loss, tinnitus, otalgia, aural fullness ■ others
◆ N/V (peripheral vestibular disorders)
◆ SOB, palpitations (hyperventilation, cardiac problem) • generalmedicalhistory
■ HTN, DM, heart disease, fainting spells, seizures, cerebrovascular disease, migraines
■ ototoxic drugs: aminoglycosides (gentamicin, streptomycin, tobramycin), erythromycin, ASA,
antimalarials
■ hypotension (secondary to diuresis): furosemide, caffeine, alcohol
■ depression/anxiety: can present with light-headedness
Physical Exam/Investigations
• syncopal
■ cardiac (orthostatic changes in vitals), peripheral vascular, and neurologic exams
■ blood work, ECG, 24 h Holter, treadmill stress test, loop ECG, tilt table testing, carotid, and
vertebral doppler, EEG • vertiginous
■ ENT and neurologic exams
■ Dix-Hallpike, consider audiometry and MRI if indicated • non-syncopal, non-vertiginous
■ assess gait, vision and test for neuropathy
■ cardiac and neurologic exams
■ 3 min hyperventilation trial (patient is coached to hyperventilate until patient becomes dizzy to
identify if symptoms are reproducible and confirm that hyperventilation is the etiology of the
symptoms), ECG, EEG
■ Romberg test: test for disequilibrium (patient sways towards the side of vestibular dysfunction)
Treatment
• guidedbyhistory,physicalexam,andinvestigations
• includeeducation,lifestylemodification,physicalmaneuvers(e.g.EpleyforBPPV),symptomatic
management (e.g. antiemetics), pharmacotherapy, and surgery
• referwhensignificantcentraldiseaseissuspected,whenvertigoofperipheraloriginispersistent
(lasting >2-4 wk), or if atypical presentation
Domestic Violence/Elder Abuse
INTIMATE PARTNER VIOLENCE Definition
• includesphysical,sexual,emotional,psychological,andfinancialabuse(seeEmergencyMedicine,ER27)
Epidemiology
• lifetimeprevalenceofintimatepartnerviolenceagainstwomenisbetween25-30%
• womenwhoexperienceabusehaveincreasedratesofinjury,death,andhealthconsequencesincluding
50-70% increase in gynecological, central nervous system, stress-related problems
• occurs in all socioeconomic, educational, and cultural groups with increased incidence in pregnancy,
disabled women, and 18-24 age group
• 25-50%chanceofchildabuseorneglectinfamilieswherepartnerabuseoccurs • physicianrecognitionratesaslowas5%
Presentation
• multiplevisitswithvague,ill-definedcomplaintssuchas:headaches,gastrointestinalsymptoms, insomnia, chronic pain, hyperventilation
• mayalsopresentwithinjuriesinconsistentwithhistory
Management
• screenALLpatients
■ always have a high index of suspicion
■ asking about abuse is the strongest predictor of disclosure
■ several screening tools (see sidebar) exist to identify victims of partner violence
■ make sure to determine the victim’s level of immediate and long-term danger and ask if there are
weapons in the house • ensurepatientsafety
■ victim most at risk for homicide when attempting to leave home or following separation
Dix-Hallpike Test
• Have the patient seated with legs extended and head at 45° rotation
• Rapidly shift patient to supine position with head fully supported in slight extension (for 45 s)
• Observe for rotatory nystagmus and ask about sensation of vertigo
Screening Instruments for Domestic Violence
A) Woman Abuse Screening Tool
(WAST)-SHORT
1. In general how would you describe your relationship? a. A lot of tension
b. Some tension
c. No tension
2. Do you and your partner work out
arguments with . . .? a. Great difficulty
b. Some difficulty
c. No difficulty
Endorsing either question 1 (“a lot of tension”) or question 2 (“great difficulty”) makes intimate partner violence exposure likely
B) HITS
How often does your partner: 1. Physically hurt you?
2. Insult you?
3. Threaten you with harm? 4. Scream or curse at you?
Each question on HITS to be answered on a 5 point scale ranging from 1
(= never) to 5 (= frequently)
A total score of 10.5 is significant