GP Companion 1st edition — update 2012

GP Companion
1st edition — 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 GPRA’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.
RETURN TO CONTENTS
3
Contents
5: Contraception and pregnancy
49
1: About your GP Companion
3
Contraception50
Antenatal care
66
2: Maximising your GP rotation
9
6: Paediatrics
How to get the most from your
GP rotation
10
3: General practice resources at
your fingertips
15
Resources in general practice
Common medical abbreviations
Pathological sieves
16
24
35
4: Preventive health
37
Men’s preventive health checks
Men’s health – PSA
Women’s preventive health checks
38
43
44
71
Paediatric developmental milestones
72
National immunisation program schedule 77
Normal parameters for paediatric
82
vital signs
7: Dermatology
83
Dermatological assessment
Dermatitis and psoriasis
Skin cancer differentiations
84
88
90
8: Diabetes and endocrinology
93
Glucose testing – diabetes diagnosis
and management
94
Contents
4
1: About your GP Companion
Endocrinology reference ranges
(excluding glucose)
99
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
126
Spirometry131
CXR interpretation
136
Smoking cessation
138
Immunohaematology157
Coagulation studies
162
Renal function tests – urinalysis, UEC
and GFR estimation
166
173
Liver function tests
Ca, Mg, PO4 and urate
178
Lipids183
186
Arterial blood gases
Assessing arterial blood gases –
acid-base balance
188
12: Drug information
191
Therapeutic drug intervals
192
11: Other tests – Haematology and
biochemistry141
Haematology142
Acute phase reactants
154
Contents
1: About your GP Companion
5
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 – 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.
©2011 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
9
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
10
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»» 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
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11
»» 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.
12
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
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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
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13
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
[email protected]
3: General practice resources at your fingertips
15
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
16
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
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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
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17
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
18
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
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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 Australia’s most eminent and respected
experts, with input from an extensive network of
general practitioners and other users.
Therapeutic Guidelines is published in print format
as a series of pocket-sized books, and also in
electronic formats suitable for both personal and
handheld computers.
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
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19
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.
20
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
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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 O’Dowd
This book is great for students who like colour
diagrams, shiny pages and easy-to-read language.
It demonstrates the importance of evidencebased medicine and also discusses conditions in a
general practice context as opposed to the usual
hospital-based orientation of medical textbooks.
Churchill’s Pocketbook of General Practice
This concise handbook addresses common
conditions according to diagnosis and
management and also has highlighted boxes to
demonstrate the important points to the reader.
A Textbook of General Practice
by Anne Stephenson
This text encompasses many of the factors about
general practice that other books leave out,
such as how to talk to patients, how to handle
Resources in general practice
3: General practice at your finger tips
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21
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.
22
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
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3: General practice at your finger tips
women’s health, children and young people,
mental health, acute serious illness, aged care
and chronic conditions.
Aimed at both experienced GPs and GP
registrars, the program is accredited for CPD
points, however it is also interesting and beneficial
for medical students. A free trial is available. Go to
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- 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
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23
Common medical
abbreviations
A
AAA
abdominal aortic aneurysm
AAL
anterior axillary line
ABG
arterial blood gases
ABI
ankle brachial index
ABL
Australian bat lyssavirus
ACacromioclavicular
ac before meals
ACA
anterior cerebral artery
ACE
angiotensin-converting enzyme
angiotensin-converting enzyme inhibitors
ACEI
ACIR
Australian Childhood
Immunisation Register
ACL
anterior cruciate ligament
albumin creatinine ratio
ACR
24
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
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3: General practice at your finger tips
AR
aortic regurgitation
ARC
AIDS-related complex
acute respiratory distress syndrome
ARDS
AS
aortic stenosis
ASA
acetylsalicylic acid
atrial septal defect
ASD
ASIS
anterior superior iliac spine
aspartate aminotransferase
AST
AVatrioventricular
B
BCC
basal cell carcinoma
bacillus of Calmette and Guérin
BCG
(TB vaccination)
BhCG
beta human chorionic gonadotrophin
bowel movement
BM
body mass index
BMI
BP
blood pressure
BPH
BPPV
benign prostatic hyperplasia
benign paroxysmal positional vertigo
C
CABG
coronary artery bypass grafting
CAD
coronary artery disease
CBT
cognitive behaviour therapy
calcium channel blocker
CCB
CCF
congestive cardiac failure
CDT
combined diphtheria/tetanus vaccine
CF
cystic fibrosis
CHD
coronary heart disease
CIcontraindications
creatinine kinase
CK
CLL
chronic lymphocytic leukaemia
CMCcarpometacarpal
CMVcytomegalovirus
cranial nerve
CN
CO
cardiac output
Common medical abbreviations
3: General practice at your finger tips
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25
COPD
chronic obstructive pulmonary disease
COXcyclo-oxygenase
CPAP
continuous positive airway pressure
CPK
creatinine phosphokinase
CRFM
chloroquine-resistant falciparum malaria
CSF
cerebrospinal fluid
CSFM
chloroquine-sensitive falciparum malaria
computerised tomography
CT
CTD
connective tissue disorder
CTS
carpal tunnel syndrome
CVA
cerebral vascular accident
CVP
central venous pressure
cardiovascular system
CVS
chest X-ray
CXR
D
D&C
D&V
DBP
26
dilation and curettage
diarrhoea and vomiting
diastolic blood pressure
DDST
Denver Developmental Screening Test
DIPJ
distal interphalangeal joint
DM
diabetes mellitus
DNR
do not resuscitate
DRE
digital rectal examination
dsDNA double-stranded deoxyribonucleic acid
DTaP
diphtheria, tetanus, acellular pertussis
deep tendon reflexes
DTR
DUB
dysfunctional uterine bleeding
DVT
deep vein thrombosis
Dxdiagnosis
E
evidence-based medicine
EBM
EBV
Epstein-Barr virus (glandular fever)
extracellular fluid
ECF
ECGelectrocardiogram
estimated glomerular filtration rate
eGFR
ELISA
enzyme-linked immunosorbent assay
Common medical abbreviations
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3: General practice at your finger tips
EOM
extraocular eye movement
ER
external rotation
EtOHalcohol
ESR
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
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27
H
HAV
hepatitis A virus
Hbhaemoglobin
HBcAb
hepatitis B core antibody
(testing for past contact)
HBcAg
hepatitis B core antigen
(testing for current virus)
hepatitis B surface antigen
HBsAg
(testing for current virus)
HBsAb
hepatitis B surface antibody
(testing for immunity or past contact)
HBV
hepatitis B virus
human chorionic gonadotrophin
HCG
hepatitis C virus
HCV
health care worker
HCW
high density lipoprotein
HDL
Hib
Haemophilus influenzae type b
HIV
human immunodeficiency virus
HLA-B27 human leukocyte antigen (B27)
28
HMGhydroxymethyl-glutaryl
HPV
human papillomavirus
HR
heart rate
HRT
hormone replacement therapy
HTNhypertension
Hxhistory
I
IAintra-articular
IBD
inflammatory bowel disease
IBS
irritable bowel syndrome
ICH
intracranial haemorrhage
intracranial pressure
ICP
intercostal space
ICS
IHD
ischaemic heart disease
IMintramuscular
intramuscular injection
IMI
international normalised ratio
INR
IOFB
intraocular foreign body
Common medical abbreviations
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3: General practice at your finger tips
IPJ
interphalangeal joint
IPV
inactivated polio vaccine
internal rotation
IR
ITP
idiopathic thrombocytopenia purpura
IU
international units
IUCD
intrauterine contraceptive device
IUD
intrauterine device
IVintravenous
IVC
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
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29
M
MAL
midaxillary line
MAOI
monoamine oxidase inhibitor
MCA
middle cerebral artery
MCL
medial collateral ligament
MCPJ
metacarpophalangeal joint
MCU
microscopy and culture of urine
microscopy, culture and sensitive
MCS
Metsmetastasis
MI
myocardial infarction
mm Hg millimeteres of mercury
MMR
measles, mumps, rubella vaccine
mitral regurgitation
MR
magnetic resonance imaging
MRI
MS
multiple sclerosis
MSKmusculoskeletal
mid-stream urine
MSU
mitral valve prolapse
MVP
30
N
NAD
no abnormalities detected
NESB
non-English speaking background
NH
nursing home
NHL
non-Hodgkin’s lymphoma
NIP
National Immunisation Program
NOF
neck of femur
neck of humerus
NOH
NR
normal range
NSAIDs non-steroidal anti-inflammatory drugs
NSTEMI non-ST segment elevation myocardial infarction
normal spontaneous vaginal delivery
NSVD
non-specific urethritis
NSU
N/Vnausea/vomiting
Common medical abbreviations
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3: General practice at your finger tips
O
(o)
taken orally
OAosteoarthritis
OCD
obsessive compulsive disorder
OCP
oral contraceptive pill
O/C/P
ova, cysts and parasites
O/E
on examination
otitis media
OM
OPV
oral poliomyelitis vaccine (no longer in use)
over the counter
OTC
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
RETURN TO CONTENTS
31
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)
32
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
RETURN TO CONTENTS
3: General practice at your finger tips
SCC
squamous cell carcinoma
SD
standard deviation
socioeconomic status
SES
SGA
small for gestational age
SH
social history
SIsacroiliac
SIADH
syndrome of inappropriate ADH
sudden infant death syndrome
SIDS
SLsublingual
SLE
systemic lupus erythematosus
SOB
shortness of breath
SOL
space occupying lesion
selective serotonin reuptake inhibitors
SSRI
staphylococcal scalded skin syndrome
SSSS
ST segment elevation myocardial STEMI
infarction
sexually transmitted infection
STI
slipped upper femoral epiphysis
SUFE
SVC
superior vena cava
supraventricular tachycardia
SVT
T
TA
temporal arteritis
TBtuberculosis
TC
total cholesterol
TCA
tricyclic antidepressants
TENS
transcutaneous electrical nerve stimulation
thyroid function test
TFT
TGtriglyceride
TGA
Therapeutic Goods Administration
TIA
transient ischaemic attack
TIBC
total iron binding capacity
tympanic membrane
TM
temporomandibular joint
TMJ
termination of pregnancy
TOP
TORCH toxoplasmosis, rubella, cytomegalovirus, herpes virus
thyroid stimulating hormone
TSH
T3tri-iodothyronine
T 4
thyroxine (free)
Common medical abbreviations
3: General practice at your finger tips
RETURN TO CONTENTS
33
U
UC
ulcerative colitis
UEC
urea, electrolytes, creatinine
UGI
upper gastrointestinal
UMNL
upper motor neuron lesion
upper respiratory tract infection
URTI
U/Sultrasound
urinary tract infection
UTI
V
VAPP
vaccine-associated paralytic poliomyelitis
ventricular fibrillation
VF
Venereal Disease Research VRDL
Laboratory test (for syphilis)
ventral septal defect
VSD
varicella-zoster virus
VZV
34
W
WCC
WHO
WPW
white cell count
World Health Organisation
Wolff-Parkinson-White syndrome
+vepositive
–ve negative
↑increase
↓decrease
♀female
♂male

leading to
with or without
+/-
Common medical abbreviations
RETURN TO CONTENTS
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
RETURN TO CONTENTS
35
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)
36
Pathological sieves
RETURN TO CONTENTS
3: General practice at your finger tips
4: Preventive health
37
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+
38
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
RETURN TO CONTENTS
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
RETURN TO CONTENTS
39
Test/assessment
Colorectal Ca
Frequency
Every 2 yrs
How
FOBT
PSA and DRE
Absolute
CVS risk
Every 2 yrs
Blood pressure
Every 2 yrs
40
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
RETURN TO CONTENTS
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
RETURN TO CONTENTS
41
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?
42
Men’s preventive health checks
RETURN TO CONTENTS
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
RETURN TO CONTENTS
43
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+
44
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
RETURN TO CONTENTS
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
RETURN TO CONTENTS
45
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+
46
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
RETURN TO CONTENTS
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
RETURN TO CONTENTS
47
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)
48
Women’s preventive health checks
RETURN TO CONTENTS
4: Preventive health
5: Contraception and pregnancy
49
Contraception
Contraception is defined as the prevention of fertilisation and/or implantation of the ovum, thus
preventing pregnancy.
Method of action
Advantages
»» Predicting time of
maximum fertility
(ie ovulation)
»» Free
»» Acceptable for
religious groups
»» No side effects
Disadvantages
Natural methods
Rhythm
method
50
•Menstrual calendar
•Charting body temp
(↑ at ovulation)
•Thickening
of mucus
•Ovulation
predictor kits
»» Relies on
regular cycle
»» Lengthy
instruction
»» ↑ commitment
required
»» High failure rate
Contraception
RETURN TO CONTENTS
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
RETURN TO CONTENTS
51
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
52
Contraception
RETURN TO CONTENTS
5: Contraception and pregnancy
Method of action
Advantages
Disadvantages
Hormonal methods Note: Contraindications to combined OCP listed on page 64*
Combined
»» Inhibits ovulation
»» Inhibits FSH release
oral
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
RETURN TO CONTENTS
53
Method of action
Progesterone »» Inhibits ovulation in
only pill
50 - 60% of cycles
»» Alters
endometrium
»» Alters cervical
mucus
»» ↓ tubal motility
54
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
RETURN TO CONTENTS
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
RETURN TO CONTENTS
55
Implanon
56
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
RETURN TO CONTENTS
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
RETURN TO CONTENTS
57
Method of action
Emergency
»» High doses of
contraceptive
oestrodiol and
progestogen
pill
»» Makes
endometrium
unfavourable for
implantation
»» Interference with
corpus luteum
function
58
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
RETURN TO CONTENTS
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
RETURN TO CONTENTS
59
Mirena
60
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
RETURN TO CONTENTS
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
RETURN TO CONTENTS
61
Method of action
Female
62
»» 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
RETURN TO CONTENTS
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
RETURN TO CONTENTS
63
* 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
64
»» 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
RETURN TO CONTENTS
5: Contraception and pregnancy
General Practice Students Network (GPSN)
GPSN is a national student-run program that provides medical
students with access to information, networking opportunities,
events and other resources to foster an interest in general practice.
To find out more and get your
FREE GPSN membership
visit gpsn.org.au
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.
66
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
RETURN TO CONTENTS
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)
14/40
»» FBC
»» Blood group and antibody screen
»» Antenatal serology
»» MSU
»» Discuss choices of care
»» Childbirth education information
15-16/40
»» Amniocentesis if indicated
15-20/40
»» Maternal serum screening
18-20/40
»» Obstetric ultrasound
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
RETURN TO CONTENTS
67
»» Assess foetal and maternal wellbeing
»» Discuss feeding plans
Primigravida
Multigravida
32/40
»» Wellbeing and foetal growth check
36
40
32
36
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
28
38 and 40/40
»» Progress review
»» Wellbeing and foetal growth check
»» Discuss induction of labour at 40/40
32
28
24
24
20
16
12
20
16
12
Adapted from health.sa.gov.au, rcpa.edu.au and
FMC Antenatal Schedule for clinics
68
Antenatal care
RETURN TO CONTENTS
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
RETURN TO CONTENTS
69
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6: Paediatrics
71
Paediatric developmental milestones
Gross motor
Fine motor
6 wks
»» Moro
response
»» Good head
control when
pulled
»» Not able to assess
»» Coos
»» Startles at
loud noise
»» 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
72
Speech and language
Social skills
Paediatric developmental milestones
RETURN TO CONTENTS
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: Paediatrics73
RETURN TO CONTENTS
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
74
»» 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
RETURN TO CONTENTS
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: Paediatrics75
RETURN TO CONTENTS
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
76
Paediatric developmental milestones
RETURN TO CONTENTS
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: Paediatrics77
RETURN TO CONTENTS
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
78
National Immunisation Program Schedule
RETURN TO CONTENTS
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 i
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: Paediatrics79
RETURN TO CONTENTS
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.
80
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
RETURN TO CONTENTS
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: Paediatrics81
RETURN TO CONTENTS
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
80 -160
70 -120
60 - 90
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
36.5 - 37.5
36.0 - 37.2
36.0 - 37.2
36.0 - 37.2
36.0 - 37.2
82
Normal parameters for paediatric vital signs
RETURN TO CONTENTS
6: Paediatrics
7: Dermatology
83
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
84
Dermatological assessment
RETURN TO CONTENTS
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: Dermatology85
RETURN TO CONTENTS
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
86
Dermatological assessment
RETURN TO CONTENTS
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
88
Dermatitis and psoriasis
RETURN TO CONTENTS
7: Dermatology
Contact Dermatitis
Atopic Dermatitis
(Eczema)
Shape/border
»» Asymmetrical
»» Depends on type of
contact
»» Asymmetrical
»» Ill-demarcated border
Colour
»» Red with white scales »» Red with white scales
Psoriasis
»» Symmetrical
»» Well-demarcated
border
»» Pink plaques
surrounded by
silvery scale
Secondary Sites
Secondary site
»» Face, wrists, forearms
»» Nails
Dermatitis and psoriasis
7: Dermatology89
RETURN TO CONTENTS
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
»» Sunlight exposure
»» Sunlight exposure
Associated findings
»» Sun-damaged skin
»» Actinic keratosis
»» Sun-damaged skin
»» Actinic keratosis
»» Sun-damaged skin
»» Any change in
lesion needs review
90
Skin cancer differentiations
RETURN TO CONTENTS
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:
Aappearance
asymmetry
Bborder
Ccolour
Ddiameter
distribution
Eevolution
Skin cancer differentiations
7: Dermatology91
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8: Diabetes and endocrinology
93
Glucose testing – diabetes diagnosis and management
Serum glucose is used to detect hyperglycaemia
and hypoglycaemia, as well as detection of diabetes
mellitus and monitoring of glycaemic control.
Serum Glucose
Fasting Glucose
4.0 - 6.0 mmol/L
Random (> 2 hrs post-prandial) 3.0 - 7.7mmol/L
Diagnostic of Diabetes Mellitus Equivocal for Diabetes Mellitus
»» Symptoms of diabetes mellitus
AND
»» Fasting Glucose > 7.0 mmol/L
on 2 occasions OR
»» Fasting Glucose between
5.6 - 6.8 mmol/L
OR
»» Random Glucose between
7.8 -11.0 mmol/L
Unlikely Diabetes Mellitus
»» Fasting Glucose < 5.5 mmol/L
AND/OR
»» Random Glucose < 7.8 mmol/L
»» Random Glucose > 11.1mmol/L
(> 2 hrs post-prandial) on
2 occasions
ÆÆ No Oral Glucose Tolerance
Test (GTT) required
ÆÆ Conduct an Oral GTT
ÆÆ No Oral GTT indicated
Note: Fasting means the only intake is water for 8 hrs before the sample is collected
94
Glucose testing – diabetes diagnosis and management
RETURN TO CONTENTS
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
RETURN TO CONTENTS
95
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)
Before meals – fasting
After meals – 2 hrs
Post-Prandial
HbA1C %
Ideal
Acceptable
Suboptimal
< 5.5
5.5 - 7.0
> 7.7
<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
96
Glucose testing – diabetes diagnosis and management
RETURN TO CONTENTS
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
2
Monitor glycaemic control
3
4
For those unable to take Metformin
Start sulphonylurea
If inadequate control, increase dosage
If still inadequate control, consider:
»» Adding a sulphonylurea, +/- glitazone or
arcarbose
»» Insulin
If still inadequate control, consider:
»» Glitazone or arcarbose
»» Insulin
Glucose testing – diabetes diagnosis and management
8: Diabetes and endrocrinology
RETURN TO CONTENTS
97
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
< 130/80 mm/Hg
Without proteinuria
With proteinuria (1g/day)
< 125/75 mm/Hg
BMI
< 25
Urinary Albumin excretion
Timed overnight collection
< 20µg/min
< 20 mg/L
Spot collection
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
Albumin: Creatinine ratio
Men
< 2.5 mg/mmol
< 3.5 mg/mmol
Women
Cigarette consumptionNil
98
Glucose testing – diabetes diagnosis and management
RETURN TO CONTENTS
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
RETURN TO CONTENTS
99
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
100
10 - 30
Highest levels
of the cycle
Endocrinology reference ranges (excluding glucose)
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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
LH
»» 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
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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
102
Pathological
»» Prolactinomas
»» Pituitary tumours
»» Hypothalamic disorders associated with
amenorrhoea-galactorrhoea syndrome
»» Some medications
• Phenothiazines
• Metoclopramide
• Oestrogens
Endocrinology reference ranges (excluding glucose)
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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)
Before Pregnancy
0
Conception to
12 Weeks
1- 28
7- 47
Week 3
7
0 -50
Week 4
14 (next period due)
5 - 425
Week 5
21
20 - 7,000
Week 6
28
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
Progesterone levels
for single foetus
(nmol/L)
17 -146
13,000 - 250,000
Endocrinology reference ranges (excluding glucose)
8: Diabetes and endrocrinology
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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
104
Endocrinology reference ranges (excluding glucose)
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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
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105
TSH
Free T3
Free T4
↑
Normal - ↓
↓
Normal or ↓
Normal - ↓
↓
↓
↑
↑
Normal - ↓
Normal - ↓
Normal - ↓
Hypothyroidism
»» Primary
»» Secondary (pituitary dysfunction)
Hyperthyroidism
Sick Euthyroid
Note: Elevations in the above are seen in such disorders as pancreatitis and alcohol abuse
The table above has been adapted from Murtagh’s General Practice
All reference ranges obtained from rcpamanual.edu.au unless otherwise stated
Endocrinology reference ranges (excluding glucose)
106
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8: Diabetes and endocrinology
Going Places Network
The Going Places Network is a junior doctor network that allows
members to explore the world of general practice through
information, networking
opportunities, events and
other resources.
To find out more and get
your FREE Going Places
Network membership
visit gpaustralia.org.au
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
110
Follow-up
Reassess within 1 - 7 days2
HTN classification and management
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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
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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
112
HTN classification and management
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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
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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
114
HTN classification and management
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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
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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
116
HTN classification and management
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9: Cardiovascular medicine
ECG interpretation
ECG – Leads and orientation
Right Arm
2
150
3
100
4
75
5
60
6
50
+
L+
-aV
-60°
-30°
180°
0°
150°
120°
LA
-
30°
90°
60°
II
300
-120°
-90°
-150°
I
1
-
d1
Heart rate –
beats/min
VR
Lea
Large squares
between R-R interval
+a
d1
-
Left Arm
Lead 1
Lea
RA
-
+aVF-
ECG – Establishing rate
If regular – 300 divided by the number of large
squares (R-R interval)
+
LL
+
ECG interpretation
9: Cardiovascular medicine
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117
Orientation
Region of Heart
(Dysfunction)
Corresponding
Leads
Anterior region
V3 - V4
Inferior region
II, III and aVF
Lateral region
I, aVL, V5 -V
6
Septal region
V1 and V2
118
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
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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
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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
120
Cardiac enzymes
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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
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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
122
Peripheral vascular disease
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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
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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
– to exclude
»» Allergic rhinitis indications
other causes if
»» Speech rate to assess severity (sentences
– mild, words – moderate, single words
indicated
only – severe disease)
»» Specialist testing:
»» Respiratory rate
• Challenge tests
»» Presence of cyanosis
• Allergy testing
126
Diagnostic testing
Asthma diagnosis and management
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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
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127
Relievers – Have a direct bronchodilator effect and relieve symptoms of asthma. Mainstay treatment
for acute asthma. Stimulation of beta2 receptors (mainly bronchial), thus relaxation of the bronchial
smooth muscle.
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
128
Asthma diagnosis and management
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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
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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
Council’s Asthma Management Handbook.
Adapted from nationalasthma.org.au
130
Asthma diagnosis and management
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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
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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) – FEV1 (baseline)
% improvement =
FEV1 (baseline)
Spirometry flow volume curves
10
FEV25%
FEV1
6
Expiration
2
0
Inspiration
132
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]
8
Vol [l]
2
4
6
4
FIV75% 6
FIV50%
8
10
Spirometr y
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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
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
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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
134
d) restrictive lung disease
(eg pulmonary fibrosis)
Flow
c) severe obstructive disease
(eg emphysema)
Flow
Volume
b) obstructive airway disease
(eg asthma)
Flow
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
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10: Respirator y medicine
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.
Spirometr y
10: Respirator y medicine
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135
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:
AAirways
»» Trachea and mainstream bronchi
• Pneumothorax – deviates towards
opposite side
• Pleural effusion – deviates towards
opposite side
136
BBreathing
»» 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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10: Respirator y medicine
CCirculation
»» Vasculature in the lungs
»» Pulmonary artery and aortic knuckle
»» L) ventricle and heart size
»» Hilar – lymph nodes, tumour, vasculature –
pulmonary HTN
»» oracic s
Soft tissues and skeleton
S
»» 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
CXR interpretation
10: Respirator y medicine
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137
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
138
Smoking cessation
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10: Respirator y medicine
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 – [email protected])
Smoking cessation
10: Respirator y medicine
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139
Let Erik the e-Rep
service your sample cupboard
Visit http://www.aspenpharma.com.au
and login with the Physician password
‘healthy’ to request samples.
Aspen Australia is a group of companies including Aspen Pharmacare Australia Pty Ltd (ABN 51 096 236 985)
34-36 Chandos Street St Leonards NSW 2065 Tel. +61 2 8436 8300 Email. [email protected]
11.Other tests – Haematology and biochemistry
141
Haematology
Full blood count and Erythrocyte Sedimentation Rate (ESR)
Indices
Haemoglobin (Hb)
Red Cell Count (RCC)
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
142
Haematology
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11: Other tests – Haematology and biochemistr y
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)
Haematology
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143
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
< 0.1
< 0.2
< 0.2
144
Haematology
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11: Other tests – Haematology and biochemistr y
Anaemia is low Hb concentration
Classification of anaemia
Microcytic Anaemia
(MCV < 80 fL)
Normocytic Anaemia
(MCV 80 - 95 fL)
Macrocytic Anaemia
(MCV > 95 fL)
»» Iron deficiency
»» Thalassaemia
»» Acute phase response
»» Sideroblastic anaemia
»» Basophils
»» Acute blood loss
»» Anaemia of chronic disease
»» Hypoproduction of RBC
• Renal failure
• Bone marrow failure
»» Pregnancy
»» Hypothyroidism
Megaloblastic bone marrow
»» B12 and/or folate deficiency
»» DNA synthesis affecting
medications – eg phenytoin)
Non-Megaloblastic bone marrow
»» Liver disease
»» Alcohol abuse
»» Hypothyroid and hypopituitary
»» Hypoplastic anaemia
»» Accelerated erythropoiesis
Haematology
11: Other tests – Haematology and biochemistr y
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145
Iron studies
Iron
Adult
10 - 30µmol/L
Iron Binding Capacity (TIBC)
45 - 80µmol/L
Transferrin
1.7 - 3.0 g/L
Transferrin saturation
0.15 - 0.45 (15 - 45%)
Ferritin
Male
30 - 300µg/L
Female
15 - 200µg/L
Vitamin B12
Folate
146
120 - 680 pmol/L
RBC folate
360 -1,400 nmol/L
Serum folate
7- 45 nmol/L
Haematology
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11: Other tests – Haematology and biochemistr y
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 ↓
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
Haematology
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147
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
148
Haematology
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11: Other tests – Haematology and biochemistr y
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
Haematology
11: Other tests – Haematology and biochemistr y
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149
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
150
Haematology
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11: Other tests – Haematology and biochemistr y
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
Haematology
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151
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
152
Haematology
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11: Other tests – Haematology and biochemistr y
Monocytosis
Normal Morphology
Abnormal Morphology
»» Acute/chronic bacterial infection
• Especially TB
»» Carcinoma
»» Hodgkin’s disease
»» Recovery from agranulocytosis
»» Cytokines
»» Hyposplenism
• Atrophy
• Splenectomy
• Trauma
»» Myelodysplasia
• Chronic myelomonocytic leukaemia
»» Acute myelomonocytic leukaemia
Adapted from rcpamanual.edu.au
Haematology
11: Other tests – Haematology and biochemistr y
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153
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
154
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
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11: Other tests – Haematology and biochemistr y
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
Acute phase reactants
11: Other tests – Haematology and biochemistr y
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155
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
156
Acute phase reactants
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11: Other tests – Haematology and biochemistr y
Immunohaematology
Blood group and antibody screen
For all blood grouping and antibody screens it is imperative that both the request form and the
collection tube must have patient’s first name and surname in full; record number; date of birth; date
and time of collection; signature or initials of the collector.
The ABO System and Rh(D) of red blood cell antigens are the main components of blood grouping.
Unlike most antibodies, the ABO antibodies develop within the plasma without previous exposure to
the antigen.
Red cell antigens and plasma antibodies
Red blood cell antigens
Corresponding antibodies in plasma
A
Anti-B
B
Anti-A
AB
Nil
O
Anti-A and Anti-B
Immunohaematology
11: Other tests – Haematology and biochemistr y
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157
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.
158
Immunohaematology
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11: Other tests – Haematology and biochemistr y
Blood grouping
Forward group
Against
Blood group
Anti-A
Anti-B
Anti-D
Patient serum
+
-
+
-
A Pos
Patient cells
+
-
-
-
A Neg
-
+
+
-
B Pos
-
+
-
-
B Neg
+
+
+
-
AB Pos
+
+
-
-
AB Neg
-
-
+
-
O Pos
-
-
-
-
O Neg
Immunohaematology
11: Other tests – Haematology and biochemistr y
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159
Blood grouping
Reverse group
Against
Patient serum
Blood group
A1 cells
B cells
Patient cells
-
+
-
A
+
-
-
B
-
-
-
AB
+
+
-
O
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.
160
Immunohaematology
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11: Other tests – Haematology and biochemistr y
Direct Antiglobulin Test (DAT)
Washed patient’s red blood cells are placed
with a polyspecific anti-human globulin serum
to determine if antibodies and/or complement
are bound to the red blood cells. A positive
result brings about agglutination of the patient
cells. Monospecific antisera for IgG, IgM and
complement can be used to further investigate a
positive DAT.
Positive results seen in:
»» Autoimmune haemolysis
»» HDNB
»» Drug-induced immune haemolysis
(eg G6PD, etc)
»» Incompatible blood transfusions
Immunohaematology
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161
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
162
Coagulation studies
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11: Other tests – Haematology and biochemistr y
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
PT
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
Coagulation studies
11: Other tests – Haematology and biochemistr y
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163
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
164
Coagulation studies
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11: Other tests – Haematology and biochemistr y
Prolonged APTT
Normal PT
Normal TT
Prolonged PT
Normal APTT
Normal TT
Prolonged APTT
Prolonged PT
Normal TT
Prolonged APTT
Prolonged PT
Prolonged TT
Factor VIII, IX or XI
deficiency
Factor VII deficiency
Factor II, V or X
deficiency
Fibrinogen (I) deficiency
Lupus inhibitor
Combined factor II, VII
and X deficiency
»» Vitamin K deficiency
»» Warfarin treatment or
»» Liver disease
Combined factor II, VII
and X deficiency
»» Vitamin K deficiency
»» Warfarin treatment or
»» Liver disease
Prolong PT > APTT
Impaired conversion of
fibrinogen to fibrin
»» Heparin treatment
»» FDP
»» Dysfibronogenaemia
Factor VIII or IX
inhibitor
Lupus inhibitor
Prolong APTT > PT
Adapted from rcpamanual.edu.au and gpnotebook.com
Coagulation studies
11: Other tests – Haematology and biochemistr y
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165
Renal function tests – urinalysis, UEC and GFR estimation
Urinalysis
Should be conducted within four hours of collection
Application
Interpretation
pH
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
166
Renal function tests – urinalysis, UEC and GFR estimation
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11: Other tests – Haematology and biochemistr y
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
Renal function tests – urinalysis, UEC and GFR estimation
11: Other tests – Haematology and biochemistr y
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167
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
168
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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11: Other tests – Haematology and biochemistr y
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
Renal function tests – urinalysis, UEC and GFR estimation
11: Other tests – Haematology and biochemistr y
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169
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
8 -16 mmol/L
Anion Gap
(Na + K) –
(Cl + HCO3).
Creatinine
170
»» 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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11: Other tests – Haematology and biochemistr y
Estimated Glomerular filtration rate:
Cockcroft-Gault formula:
Estimated Creatinine clearance (mL/min):
{(140 – age in yrs) x (weight in kgs) x 1.23 constant}
Plasma Creatinine in µmol/L
Note: Remember to convert mmol/L to µmol/L by x 1000
Multiply by 1 for males, multiply by 0.85 for females
Interpretations
Normal Creatinine clearance
Mild impairment Creatinine clearance
Moderate impairment Creatinine clearance
Severe impairment Creatinine clearance
> 50 mL/min
25 - 50 mL/min
10 - 25 mL/min
< 10 mL/min
MDRD formula – modification of diet in renal disease formula
GRF(mL/min/1.73m2) = 186 x (Plasma Creatinine in µmol/L / 88.4)-1.154 x (age in yrs)-0.203
Multiply by 0.742 if female
Renal function tests – urinalysis, UEC and GFR estimation
11: Other tests – Haematology and biochemistr y
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171
Staging for chronic kidney disease
Stage 1
90 mL/min/1.73 m2 with proteinuria or haematuria
60 - 90 mL/min/1.73 m2
Stage 2 (Mild)
Stage 3 (Moderate)
30 - 60 mL/min/1.73 m2
Stage 4 (Severe)
15 - 30 mL/min/1.73 m2
< 15 mL/min/1.73 m2
Stage 5 (End-stage)
Adapted from rcpamanual.edu.au and kidney.org.au
172
Renal function tests – urinalysis, UEC and GFR estimation
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11: Other tests – Haematology and biochemistr y
Liver function tests
Total protein
Neonate
Adult
Interpretation
40 -75g/L
62 - 80g/L
Increased:
»» Dehydration
»» Acute phase response
»» Hyperalbuminaemia
»» Hyperglobulonaemia
Decreased:
»» Overhydration
»» Chronic liver disease
»» Burns
»» Malnutrition
»» Protein losing disorders
Liver function tests
11: Other tests – Haematology and biochemistr y
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173
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
174
< 200µmol/L
Total:
< 20µmol/L
Direct:
< 7µmol/L
Increased:
»» Hepatocellular disease
»» Biliary disease
»» Haemolysis
»» Megaloblastic anaemia
Liver function tests
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11: Other tests – Haematology and biochemistr y
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
Liver function tests
11: Other tests – Haematology and biochemistr y
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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
176
ALP: Alkaline phosphatase
GGT: Gamma glutamyl transferase
Liver function tests
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11: Other tests – Haematology and biochemistr y
Patterns
Disease process
Acute inflammatory process
ALT
AST
ALP
GGT
↑↑
↑↑
↑AST < ↑↑ALT
↑
↑
↑↑
↑↑
↑↑
↑↑
↓
↓
Acute obstruction
Chronic obstruction
↑
↑
Advanced alcoholic liver
↑
↑↑
↑↑ AST > ↑ALT
End-stage liver disease
↓
↓
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
Liver function tests
11: Other tests – Haematology and biochemistr y
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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.
178
Ca, Mg, PO 4 and urate
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11: Other tests – Haematology and biochemistr y
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
Ca, Mg, PO 4 and urate
11: Other tests – Haematology and biochemistr y
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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
180
Ca, Mg, PO 4 and urate
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11: Other tests – Haematology and biochemistr y
Magnesium:
Reference Range:
Neonates:
0.6 - 0.9 mmol/L
Adults:
0.8 -1.0 mmol/L
Possible interpretations
Hypomagnaesaemia
Hypermagnesaemia
»» Cardiac arrhythmias
»» Neuromuscular disorders
»» Refractory hypocalcaemia
»» Increased renal or GIT loss
»» Decreased intake
»» Renal failure – assessment rarely required
Ca, Mg, PO 4 and urate
11: Other tests – Haematology and biochemistr y
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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
182
Ca, Mg, PO 4 and urate
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11: Other tests – Haematology and biochemistr y
Lipids
Analyte
Reference
range
Interpretations
Considerations
Total
Cholesterol
< 4.0 mmol/L
»» Increased risk of coronary
artery disease
• Genetic:
–– Familial
hypercholesterolaemia
• Secondary:
–– Biliary obstruction
–– Hypothyroidism
–– Nephrotic syndrome
»» Should be assessed in
conjunction with HDL/LDL
and triglycerides
»» Levels falsely reduced up to
8/52 after an acute illness
»» Levels should be assessed
in fasting state and
not immediately postcardiovascular exercise
High Density
Lipid (HDL)
Population RR:
0.9 - 2.2 mmol/L
Therapeutic RR:
> 1.0 mmol/L
“The Good”
Lipids
11: Other tests – Haematology and biochemistr y
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183
Analyte
Reference
range
Interpretations
Considerations
Low Density
Lipid (LDL)
“The Bad”
Population RR:
2.0 - 3.4 mmol/L Therapeutic RR:
< 2.5 mmol/L
»» LDL is calculated via
Friedwald equation:
LDL = TC – HDL –
Triglyceride/2.2
»» Unreliable when
triglycerides > 4.5 mmol/L
»» Prolonged tourniquet can
artificially elevate LDL up
to 20%
Triglyceride
< 1.7 mmol/L
»» Increased risk for coronary
artery disease
• Primary hypertriglycerideamia
• Secondary:
–– Nephritic syndrome
–– Hypothyroidism
–– Pancreatitis
–– Diabetes mellitus
–– Alcoholism
–– OCP use
–– Corticosteroid use
Adapted from heartfoundation.org.au and rcpamanual.edu.au
184
Lipids
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11: Other tests – Haematology and biochemistr y
R-cubed
R-cubed provides GP registrars, medical students and prevocational
doctors with real strategies to build resilience in busy times.
An initiative of General Practice Registrars Australia (GPRA),
R-cubed offers excellent online resources to help you to stay well.
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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
186
Ar terial blood gases
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11: Other tests – Haematology and biochemistr y
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: T he patient’s temperature and FiO2 should be known to effectively calculate and interpret ABG
Adapted from rcpamanual.edu.au
Ar terial blood gases
11: Other tests – Haematology and biochemistr y
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187
Assessing ar terial blood gases – acid-base balance
↓ pH
Is the primary change in CO2?
Yes
No
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
188
No
»» No change
»» Opposite change
Compensatory
change
Yes
Is the change in keeping with the pH (ie ↓ HCO3)?
Yes
No
Metabolic acidosis
Compensatory
change
↓ pH and ↓ HCO3↑ Anion gap
Underlying cause is due to
↑ production and HCO3fails to buffer
↓ pH and ↓ HCO3Norm anion gap
Underlying cause is loss
of HCO3 ions or ingestion
of H+ ions
Ar terial blood gases – acid base balance
RETURN TO CONTENTS
11: Other tests – Haematology and biochemistr y
↑ pH
Assess the pH
Is the primary change in CO2?
Yes
No
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
No
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
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189
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Check out our earnings calculators:
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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
192
Therapeutic drug inter vals
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12: Drug information
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