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Introduction to Management & Consulting

Michelle Papandony - General Practice Notes

Patient Management Sequence


1. Tell the patient the diagnosis
2. Establish patient knowledge of the diagnosis
3. Establish patient attitude towards diagnosis and management
4. Educate the patient
5. Develop management plan with the patient immediate, long term, preventative
6. Other preventative opportunities
7. Reinforce
8. Take away information
9. Evaluate
10. Arrange follow up

Flu Pandemic Protection


Phases of spread
- Contain, sustain, control, recover, protect
Influenza Virus
- Type A/B/C
- Transmission droplet, direct/ indirect, airborne
- Survival of the virus
o 30 minutes on hands
o 48 hours on a dry, non porous surface
o 12 hours on paper/ tissue
- Criteria
o Fever >38 degrees
o Cough (non phlegm)
o Sore throat
H1N1
- Contagious 1 day before and 7 days after symptom onset
Infection control
- Hand hygiene
- Case isolation
- Immunization
- Cough etiquette
o Cough into arm
o Dispose of tissue
o Wear surgical mask when having symptoms
- Cleaning contaminations
o Virus/ bacteria cannot survive on a clean, dry surface (they require heat and humidity)
Detergent vs. Disinfectant
- Detergent cleans
- Disinfectant removes infection (alkaline, non abrasive)

The Face as a Mirror of Disease


Case 1: 46 year old salesman with plethora, rosacea, greasy oedematous puffy skin, suffused
conjunctivae, telangiectasiae, parotid enlargement
- Alcohol Abuse
Case 2: 20 year old student with general roundness and uniform fatness of the face
- Obesity

Michelle Papandony - General Practice Notes

Case 3: 20 year old student with enlarged moon like face, erythema (plethoric appearance), acne,
hirsutism
- Cushings Disease (due to pituitary disease) excess ACTH from the Pituitary gland
- Cushings Syndrome (iatrogenic) excess cortisone from the adrenal gland
- Investigations
o Dexamethasone Suppression test
o Serum ACTH, Cortisol
o Urine cortisol
o BSL
o Image pituitary/ adrenal
Case 4: 19 year old student with inflammatory papules and nodules on the face. Also present on
shoulders, upper chest and back
- Acne vulgaris

Case 5: 32 year old housewife with erythema, papules and pustules on the cheeks, forehead (central)
nose and chin. The periorbital and perioral areas are spared
- Rosacea (form of acne)
- Related to spicy food and alcohol
- Treatment Tetracyclines (long term)
Case 6: 23 year old waitress with erythematous rash with sharp borders, affecting nose and cheeks
symmetrically in a butterfly pattern. No pustules or adherent scale.
- SLE
- Investigations
o ANA
o Ra Factor
o Double stranded DNA
o Extracted Nuclear Antibodies (ENA)
o X ray if arthritis
Case 7: 25 year old secretary with multiple small red pustules and papules on background of erythema
and scaling around mouth and on chin. Began at nasolabial folds. Spares adjacent perioral area
- Seborrhaic dermatitis (perioral dermatitis)
- Treatment Tetracyclines (4 weeks) + Antifungal agent
Case 8: 52 year old housewife with several linear skin excoriations on her face. The ulcers are at various
stages of healing with some old scars.
- Neurotic excoriations (diagnosis if patient admits to it)
- Dermatitis artifacta (if patient doesnt admit it)
Case 9: 22 year old student with increased brown blotchy pigmentation mainly on cheeks and forehead.
- Cloasma or Molasma
- Due to excess oestrogen (pregnany, OCP)
Case 10: 22 year old secretary with 3 months of a red itchy rash on her upper eyelids with occasional
swelling
- Contact dermatitis
- Upper eyelid is very sensitive
Case 11: 5 year old child with a flushed face, fever, malaise and red rash on the arms
- Erythema infectiousum (slap cheek syndrome)
- Due to parvovirus
- Usually benign however if a pregnant woman becomes infected it can cause fetal problems and
spontaneous abortion

Michelle Papandony - General Practice Notes

Case 12: 68 year old woman with an apathetic look and broadening and prodginess of the face. Pallor,
coarse and dry skin, thin coarse listless hair, enlarged tongue and change in voice
- Hypothyroidism
- Investigations
o TSH high
o T4 low
Case 13: 40 year old woman with thin face, a frightened expression (the thyroid stare) and prominent
eyes (sclera not covered by the lower eyelid)
- Thyrotoxicosis
- Graves disease
- Investigations
o TSH low
o T4 high
Case 14: 48 year old swimming instructor with 6 months fatigue, anorexia and nausea, dizziness and
vague abdominal pains
- Addisons disease
- Can also have hyperpigmentation
o Hyperpigmentation can also be due to haemachromatosis
- Signs
o Hyponatraemia
o Hyperkalaemia
o Uraemia
- Due to increased plasma ACTH
- Investigations
o Plasma cortisol
o Short synactatnon stimulation test
o Electrolytes
o Low BSL
- Treatment mineralocorticoid + Glucocorticoid replacement

Case 15: 54 year old housewife with enlarged face and large supra orbital ridge, broad nose and
prominent square lower jaw. Enlarged tongue and soft tissue swelling of the nose, lips and ears. Goitre.
- Acromegaly (Adult)
- Gigantism (child)
- Investigations
o Insulin like growth factor
o Plasma GH
o Image pituitary
Case 16: 52 year old health food proprietor with 12 months tiredness, headaches, faintness, palpitations
and dysponoea on exertion
- Pernicious anaemia
- Causes: B12 deficiency, autoimmune
- Investigations
o Serum B12 and Folate
o MCV
Case 17: 67 year old farmer with fatigue, arthritis of hands, polyuria and polydipsia, loss of libido and
tanning of skin
- Haemachromatosis (bronze diabetes)
- Investigations
o Iron studies (transferring sat increased)
o Liver biopsy or MRI

Michelle Papandony - General Practice Notes

Case 18: 68 year old man with a fixed flat facial expression and a fixed unblinking stare. There is
immobility of the facial muscles
- Parkinsons disease
o Triad Resting tremor, bradykinesia, ridgidity, postural instability
Case 19: 33 year old housewife with a sudden onset of paralysis of right half of face. No sensory loss.
- Bells Palsy
Case 20: 76 year old man with recent onset deafness, skull enlargement of frontal and parietal areas
the hat doesnt fit anymore feature. Increased bone warmth and painful legs.
- Pagets disease
- Investigations
o Increased serum ALP
o Xray
Case 21: 46 year old woman with an expressionless tired looking face with bilateral ptosis
- Myasthenia Gravis
- Investigations
o Serum acetylcholine receptor antibody test
o Scan for thymoma (CXR)
Case 22: 29 year old nurse with sudden onset swelling of face especially eye lids. Oedema mainly at
junction of skin and mucous membranes.
- Angioedema due to allergy
Case 23: 60 year old fisherman with rapidly spreading painful red skin problem starting at nose as bright
as red spot. Associated with malaise, fever and chills. Note well defined edge.
- Eyisipelis (usually beta hemolytic strep)
- Due to strep infection
- Treatment Penicillin
Case 24: 45 year old farmer with tiredness, short of breath, hypertension, headaches and erectile
dysfunction
- Alcohol abuse
Case 25: 2 year old child with URTI, malaise, fever, sore eyes, swelling of eyes especially right eye
- Periorbital cellulitis
- Can be fatal if it spreads to brain
Case 26: 56 year old shop assistant with polyarthritis and discolouration of the hands, tightening of the
lips, bird like facies and difficulty swallowing
- Scleroderma
- CREST syndrome
- Investigations
o DNA studies (anticentrome antibody)
Case 27: 37 year old truck driver with malaise, fever, painful face and sudden swelling of left face
especially maxillary region
- Dental abscess
Case 28: 6 year old boy with facial trauma especially with bruising of the forehead plus legs and forearms
- Trauma

A Diagnostic Medical Model

Michelle Papandony - General Practice Notes

Traditional Diagnostic Model


- Full History + physical examination = diagnostic hypothesis + Investigations = revision of
hypothesis
Typical General Practice Model
- Previous knowledge inc medical record
- Cues from history
- Spot examination inc physiognomy
- Hypothesis search (further cues, physical exam, office tests) provisional diagnosis
A diagnostic strategy model
- What is the probability of diagnosis?
- What serious disorders must not be missed? (Red Flags)
- What are the pitfalls? (often missed)
- Could it be a masquerade?
- Is the patient trying to tell me something? (Yellow Flags)
Not to be missed conditions
- Vascular
- Infection
- Cancer
Deadly Vascular Conditions
- Arterial
o Acute coronary syndromes
o Cerebral TIAs, stroke, SAH
o Aneurysms Aortic, cerebral
- Venous
o DVT, PE
o Axillary venous thrombosis
- Arteritis
o Giant Cell Arteritis/ temporal arteritis
o Vasculidities
- Bleeding
o Ectopic
o Anticoagulants
Deadly Infection
- Meningo-encephalitis
- Septicaemia
- Meningococcus
- HIV infection
- Infective endocarditis
- Avian flu/ SARS/ Prion
- Clostridia infections tetanus, pseudomembranous colitis
- Pneumonia
Malignancy
- Major primaries colon, lung, breast, melanoma, kidney, prostate
- Occult ovary, pancreas, caecum, lung, kidney, lymphomas, leukaemias, cervix
- Metastatic colon, lung, breast, melanoma
- Paraneoplastic effects lung, kidney, pancreas, hepatoma
Red Flags
- Age >50
- Sudden onset
- History of cancer
- Fever >37.8
- Weight loss
- Drug or alcohol abuse
- Travel esp overseas
- Neurological deficit
- Vomiting

- Altered cognition or consciousness


- Failure to improve
- Use of anticoagulants, biologicals, steroids
Signs Red Flags
- Pallor
- Cyanosis
- Altered conscious state
- Cold extremities
- Tachypnoea
- Tachycardia
- Fever >38
- Poor capillary refill >2secs
Vital Signs Know your normal values
- Fever
o Oral >37.2; rectal/otic > 37.7
o Add 0.6 for evening
<6 months
6 mo 3 years
Pulse
120 140
110
Resps
45
30
BP
90/60
90/60

Michelle Papandony - General Practice Notes

3 12 years
80 100
20
100/70

Adult
60 100
14
<130/85

The 7 first line masquerades


The 7 other masquerades
- Depression
- Malignant disease
- Diabetes
- Chronic kidney failure
- Drugs iatrogenic, self abuse, OTC
- HIV infection
- Anaemia
- Baffling bacterial infections
- Thyroid and other endocrine
- Baffling viral and protozoal infections
- Spinal dysfunction
- Neurological dilemmas
- Urinary infection
- CTDs and vasculitidies
Classic Pitfalls (red faces)
- Abscess (hidden)
- Haemochromatosis
- Allergies
- Malnutrition
- Chronic fatigue syndrome
- Menopause syndrome
- Celiac disease
- Migraine
- Domestic abuse inc children
- Pagets disease
- Drugs
- Pregnancy
- Herpes zoster
- Sarcoidosis
- Faecal impaction
- Seizure disorders
- Foreign bodies
- Tourettes syndrome
- Giardiasis
Headache
- Probability diagnosis tension headache
- Often missed migraine variants, eye, neck, sleep, nutrition, sinus, exertion
- Masquerades depression, drugs, UTI anaemia, endocrine, spinal dysfunction
- Psychogenic stress, perfectionism
- Not to be missed
Vascular

Infective

Sub arachnoid haemorrhage


Stroke/ TIA
Temporal arteritis
Central venous thrombosis
Enlarging aneurysm
Dissection carotid/ vertebral artery
Subdural/ extradural haematoma
Meningitis
Encephalitis

Michelle Papandony - General Practice Notes

Malignancy/ Tumour
Other

Intracranial abscess
Orbital cellulites
Severe sinusitis
Primary cerebral, pituitary
Metastasis
Acute glaucoma

The sick febrile child


Vascular
Acute myocarditis
Infective
Meningitis
Meningococcal infection
Septicaemia
Viral encephalitis
Pneumonia
Bronchiolitis
Severe gastroenteritis
Epiglottitis
LTB (croup)
Appendicitis/ peritonitis
Urinary infection
Red Flags
- Observations well outside normal range
for the age
- Neonate > 38
- Pulse > 140
- BP < 90/60
- Respiration > 40
- Increased work of breathing
- Noisy breathing
- Chest wall/ sternal retraction

Pallor
Cold extremities
Capillary refill < 2 secs
Rash fine maculopapular > purpuric
Sunken eyes
Inactive, lying quietly, disinterested
Drowsiness
Reduced mental state
Seizure

A Preventative Care Initiative for At-Risk Groups


Background
- 70% GP consultations are for chronic conditions
- Majority of older people remain in good health until a relatively short period before their death
- Most older people with chronic disease have mild/ mod disability and are independent
- Our population is aging
Older people with chronic illness and severe disability
- Have large impact on health and welfare systems
- Especially
o Dementias, depression, CVAs and progressive neurological disorders
o Ischaemic heart disease
o Cancers
o Respiratory disease
Primary Prevention
- Reducing the chance of disease occurring
- Targets risk groups and risk factors
- Interventions education, immunization, health promotion
Secondary Prevention
- Early detection of disease before it is symptomatic
- Targets risk groups and risk factors
- Interventions Pap smears, BP check, Lipids, Mammograms, PSA, Skin ca (screening)
Tertiary Prevention
- Minimize effect of established disease
- Targets chronic illness and disability

- Interventions Rehabilitation, Maintenance, Supports


Health Assessments
Why do health assessments?
- Financial incentives
- Patient satisfaction
- Doctor and nurse satisfaction
- A learning exercise for students and registrars
- NOT
o Lower morbidity
o Lower mortality
o Less frequent use of hospital
o Less frequent re-admission to hospital
o Reductions in falls
o Improved quality of life
o Less frequent admissions to nursing homes
Older People (ASTI and non ASTI)
- 4 main areas to assess:
o Medical
o Physical functioning activities of daily living, falls
o Psychological functioning cognition, mood
o Social functioning supports, carer status
- Medical history
- A standard systems review
o General mood, energy, sleep
o Respiratory
o Cardiovascular
o GIT inc diet and weight change
- Medical examination
o BP, pulse, rhythm
o CVS
o Respiratory
o Abdominal
o Endocrine
o Renal
o Neurological
- Some tips/ traps
o Check carotids
o Check for AAA and hernias
o Check for lyphadenopathy
o Check urine
o Check peripheral circulation and neurology
o Mobility and risk of falls assessment
Physical Functioning
- Activities of Daily Living (ADLs)
o Bathing and toileting
o Dressing
o Getting, preparing and eating meals
o Mobility walking, stairs, bending
- Falls last 6 months
- Home safety check
Psychological Functioning
- Cognition MMSE
- Mood Geriatric depression scale
Social Functioning

Michelle Papandony - General Practice Notes

o
o

G/U esp incontinence and sexual


health
Musculoskeletal
Cognition

o
o
o
o
o
o

Gait
Coordination
Dentition
Feet
Vision
Hearing

Michelle Papandony - General Practice Notes

- Adequacy of supports (availability and affordability)


- Carer (carer for someone else or does someone care for this person?)
ATSI > 55yo
- These people may consider age irrelevant or not know so accept stated age on face value
- Health assessment same as for non ATSI > 75yo
A 45 year old health check
- Preventative care for patients who are at risk of chronic disease (aged 45 49 yo)
- People at risk:
o Current condition > 6 months
Asthma, diabetes, cancer, IHD, mental health condition, arthritis
o Lifestyle risks
Smoking, alcohol abuse, lack of exercise
o Biomedical risk
High cholesterol, high BP, Family history
Components of the > 45 yo health check
- History past and present
- Include alcohol, rec drugs, smoking
- Family history
- Sexual history
- Examination
- Investigations
- Assessment of risks currently known
- Interventions needed
- Referrals needed
- Advice and information for patient
Health Assessment Intellectual Disability
- IQ more than 2SD below the average IQ +
- Fam history
requires help with ADLs
- Lifestyle factors
- List of HCWs
- Allergies
- List of carers
- Current treatment
- Current problems
- Immunisations
- Past medical history
- Day program
- Level of IQ
- Social activities
- Autism
- ADLs
- Community living skills
- Communication skills
- Behavior
- Has there been any change in any of these in the last 12 months
Physical Examination
- Dental check every 6 months
- Hearing check every 5 years
- Vision check every 5 years
Other Aspects
- Nutrition and development
- Dysphagia and swallowing
- Bowel and bladder
- Mobility
- Exercise
- Osteoporosis
- Epilepsy
- Mental health
- Genetic counseling
- Sexual health
- Abuse

Michelle Papandony - General Practice Notes

Health screens pap, mammogram, Vit D, lipids, fasting gluc, prostate, thyroid, testicular exam,
colorectal ca

Family Violence
Golden Rules
- ASK break the silence
- Safety of women and children first priority
- There are NO excuses for violence and it is a crime
- Violence is about use and abuse of power and control
- It is the perpetrators responsibility to stop
Crimes (Family Violence) Act 1987
- Main purpose is to provide for intervention orders in cases of family violence
- The court has to make the order if on the balance of probabilities
o The person has assaulted or caused damage to property of a family member and is likely to
do so again
o The person has threatened to do so, and is likely to do so again
o The person has harassed, molested or behaved in an offensive manner towards a family
member and is likely to do so again
Mandatory Reporting
- Doctors
- Child care proprietors
- Psychologists
- Youth, social and welfare workers
- Nurses
- Police
- Teachers
- Probation officers
- Qualified child care workers
- Youth parole officers
- These professionals are required to report when in the course of practicing their profession, they
form the belief based on reasonable grounds, that a child is in need of protection as a result of
physical, sexual abuse or neglect. The mandated professional must notify Child Protection Victoria
of that belief as soon as possible after forming the belief and/ or after each occasion on which they
become aware of any further reasonable grounds for that belief.
How to ask
- Woman
o Have you ever been afraid at home?
o Has anyone ever hurt you?
o Did someone do this?
o Has there ever been any violence?
o Have you ever been frightened of your partner?
o Does your partner hit?
o Does your partner put you down?
o What happens when your partner gets angry?
- Man
o What happens when you and your partner have an argument?
o What happens when you get angry? What do you do?
o Do you think she is ever frightened, scared or intimidated by you?
Taking a History
- History onset, pattern, type of abuse, worst fear
- Esteem sense of self worth, sense of control
- Life situation are she and her children safe
- Praise her efforts and she is not to blame
Management
- Talk to the victim alone
- Ask direct questions
- Summarize and reflect
- Explore the options together
- Support the womans choices
Examination
- Check current injury

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Michelle Papandony - General Practice Notes

- Check for co-existent injury: abdo and chest; teeth and jaw; perforated ear drum; genital injury
- General health
- Mental state
Agent of change
- Advise her of her rights and services available
- Encourage her to contact services
- Assure her the violence is not her fault
- Advise her that she cannot make her partner change if he doesnt want to
Reporting
- If children are at risk MUST REPORT
- Consider an intervention order for an abused partner

Definition of Domestic violence


- Power and control
- Anger is the feeling, violence is the behavior
Characteristics of men who perpetrate violence and abuse at home
All walks of life
- Rarely recognized in a social group
- Most men are normal
- X6 more likely if dad was violent
- Incidence increases with income and levels of education
Presentations
- Present after a crisis/ to save the marriage
- Men rarely present
- Depression
- Communication problems at home
- Problems with the children
- Partner has disclosed
Working with the man
- Safety first DO NO HARM
o No confidentiality for the man
o Confidentiality for the woman
Golden Rules For Stopping Mens Violence
- The safety of women and children is always rule number one
- No excuses for violence ever
- If you cant challenge the silence and secrecy about violence, you cant beat violence
- Violence is a crime
- Violence is a choice
- Violence is about using power and control, not about being out of control
- If you want to say no to violence, you have to say no to patriarchal thinking
- Its the mans responsibility to stop his violence and abuse
- Violence and abuse are no laughing matter
- If you are responsible you have the strength to take no for an answer
- When you are learning responsibility the women and children judge your progress
- If you want to be responsible, you have to give up trying to use force and power as a way to get
what you want in relationships
Giving up violence means giving up power and control

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