2. Interactive Cases in General Internal Medicine 1 Flashcards
Complication of COPD
Pulmonary Hypertension (Hypoxia -> vasoconstriction)
Breathlessness DDx
By onset…
Acute: Pneumothorax PE Foreign Body Anxiety Anaphylaxis
Sub-acute: Airways (inflammation/obstruction) Chest infection (pus) Acute heart failure (fluid) Pulmonary Hemorrhage (blood)
Chronic: All of above (chronic/unresolving) Interstitial Lung Disease Malignancy Large Pleural Effusion Neuromuscular Anaemia/Thyrotoxicosis
60 yr old man SOB Sudden onset PMH COPD DH Symbicort and Tiotropium HR 110 Raised JVP Decreased breath sounds, scattered wheeze and creps (R) Peripheral oedema Sats 80% air FBC: HB 85 WCC 12 plt 300
Most likely diagnosis?
Treatment?
Pneumothorax
Chest Drain
CPAP
Continuous Positive Airway Pressure
CPAP improves oxygenation
Used in Type 1 Resp Failure
Management of Pneumothorax
Primary:
- <2cm: Discharge, repeat CXR 1 wk
- > 2cm or SOB: Pleural aspiration, if unsuccessful: chest drain
Secondary:
- <2cm: Pleural aspiration
- > 2cm: Chest drain
ALSO don’t forget regular, adequate analgesia!
What to tell patient with Chest Drain in
Underwater seal must always be below the waistline
Pneumothorax
Improved after Chest Drain insertion.
Recurrent SOB after 2hrs
Potential cause of recurrent SOB?
Re-expansion pulmonary oedema (one lung!)
47 yr old woman Acute SOB Pleuritic Chest Pain PMH DVT O2 Sat 78% air PR 110 BP 120/80 Raised JVP Vesicular Breath Sounds
Cause and management
PE
LMWH
RBBB and Right axis deviation signs of…
Right sided heart strain
S1, Q3, T3
ECG PE finding
S wave in I
Q wave and T wave inversion in III
Suspected PE (120/80 BP) Management
- LMWH
- CTPA
- If PE confirmed, start Warfarin and continue LMWH
Indication for BiPAP
Respiratory Acidosis/High CO2
e.g. COPD
Suspected PE; why do we need to continue BOTH LMWH and Warfarin together for a few days?
Warfarin has a paradoxical PROCOAGULANT effect initially. LMWH covers them during this period - when INR comes back up, stop LMWH
–> (inhibition of Protein C and Protein S causes their levels to drop faster than procoagulation proteins such as Factor II/VII/IX/X)
Suspected PE (60/30 BP) Management
Thrombolysis
Primary Pneumothorax,Greater than 2cm
Management
Pleural Aspiration
If unsuccessful: Chest Drain
Primary Pneumothorax, SOB
Management
Pleural Aspiration
If unsuccessful: Chest Drain
Primary Pneumothorax, Less than 2cm
Management
Discharge, repeat CXR
Secondary Pneumothorax, Less than 2cm
Management
Pleural Aspiration
Secondary Pneumothorax, Greater than 2cm
Management
Chest Drain
FEV1/FVC ratio > 70%
Restrictive Lung disease
FEV1/FVC ratio < 70%
Obstructive Lung Disease
50 yr old female Progressive SOB Dry Cough Clubbing FEV1/FVC ratio > 70%
DDx?
Idiopathic fibrosing alveolitis
Connective tissue disease, RA
Drugs (e.g. methotrexate)
Asbestosis
Asbestosis
Pulmonary Fibrosis due to Asbestos exposure.
If you have some plaques, not enough for diagnosis of Asbestosis.
CXR Interpretation
This is a PA/AP CXR of…
- Name and DOB
- Taken on (Date)
- At (Time)
Quality of film: RIP
Rotation
Inspiration
Penetration (under/over)
Opacities on CXR
Interstitial/Alveolar shadowing ('Fluffy') - fluid or pus Reticulo-nodular shadowing (fibrosis) Homogeneous shadowing (e.g. pleural effusion) Masses/Cavitations
Lung lobe affected if Interstitial/Alveolar shadowing obscuring Right border of heart
Right middle lobe
If unable to follow left hemi-diaphragm behind heart?
Collapsed lung
Tracheal deviation Collapsed lung vs Pleural effusion
Collapse pulls trachea towards it, Effusion pushes away.
Summary of CXR analysis
Compare L vs R upper/mid/lower zones:
- alveolar/interstitial shadowing
- reticulonodular shadowing
- homogeneous shadowing
Follow the periphery:
- pneumothorax
- pleural thickness
- costophrenic angles
- diaphragm
- heart
- mediastinum
Type 1 Resp Failure
Low level of oxygen in the blood without an increased level of carbon dioxide in the blood.
Typically caused by Ventilation/Perfusion mismatch, e.g. high altitude/PE/pneumonia)
Type 2 Resp Failure
Low level of oxygen in the blood with increased level of carbon dioxide in the blood.
Caused by inadequate alveolar ventilation; both oxygen and carbon dioxide are affected.
E.g. COPD/asthma/reduced breathing effort/chronic bronchitis/neuromuscular problems
Abdominal General Inspection Findings
Feeding Tube/Stoma Bag/Drain Agitated/In Pain/Confused Obese/Low BMI/ Cachectic Scars: Midline (laparotomy) RIF (appendectomy) R Subcostal (Cholecystectomy) Jaundice (cirrhosis/hepatitis) Anaemia (obvious pallor suggests significant anaemia (e.g. GI Bleeding) Abdo. Distension (ascites/bowel distension/masses) Masses (malignancy/organomegaly) Dressings Needle track marks (HIV/Hepatitis) Excoriations - pruritus (cholestasis)
Abdominal Hand and Arms Inspection Findings
Asterixis (liver flap) Bruising Clubbing Dupuytren's contracture Erythema (palmar) Leuconychia (hypoalbuminaemia due to liver failure) ABCDEL
+ AV fistulae
Abdominal Head and Neck Findings
Anaemia Jaundice Excoriation marks Spider Naevi Oral exam: Pigmentation Gum hypertrophy (ciclosporine after renal transplant)
Abdominal Chest Findings
Gynaecomastia
Hair loss
Spider naevi
Excoriation marks
Close Abdominal Inspection Findings
Distension
Caput Medusae (distended superficial abdominal veins, direction of flow in the veins below the umbilicus is towards the legs)
Scars
Causes of Hepatomegaly
Cancer (primary or secondary deposits) Cirrhosis (early, usually alcoholic) Cardiac: -congestive cardiac failure -constrictie pericarditis
Infiltration
-fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases
Summary of liver disease
Alcohol Autoimmune Drugs Viral Biliary Disease
Causes of splenomegaly
H’s - Portal Hypertension, Haematological (e.g. lymphoma/haemolytical anaemia/leukaemia)
I’s - Infection, Inflammation
Symptoms of chronic liver disease
Asterixis (decompensated) Bruising (decompensated) Clubbing Dupuytren's contracture Erythema Fetor Hepaticus Gynaecomastia Hair Loss Icterus/Jaundice (decompensated)
Also: Leukonychia Parotid enlargement Spider Naevi Scratch marks Ascites Hepatomegaly Testicular atrophy Caput medusae Splenomegaly Encephalopathy (decompensated)
Infections that can cause splenomegaly
Malaria Schistosomiasis Leishmaniasis TB Infective Endocarditis Infectious Mononucleiosis
Presenting Complaint of Following Conditions?
Peptic Ulcer Pancreatitis Pancreatic Cancer Cholecystitis Hepatitis Chronic Liver Disease Appendicitis Diverticulitis Ruptured Aortic Aneurysm IBD Coeliac
Peptic Ulcer:
Dyspepsia/Bleeding
Pancreatitis:
Abdominal Pain if acute
Pancreatic Cancer:
Painless Jaundice
Cholecystitis:
Pain RUQ
Hepatitis:
Jaundice
Chronic Liver Disease:
A-J
Appendicitis: Abdominal Pain (mid->RLQ)
Diverticulitis:
LLQ pain
Ruptured Aortic Aneurysm:
Patient in Shock
IBD: Pain/Diarrhoea/Bleeding
Coeliac:
Diarrhoea/Pain/Bloating/Anaemia
75 yr old man Epigastric Pain Back Pain PR 130bpm BP 80/50
Dx?
Ruptured Aortic Aneurysm
Epigastric Pain DDx
Stomach: Peptic Ulcer (?NSAIDs) GORD (better w antacids) Gastritis (retrosternal, ETOH) Malignancy
Pancreas: Acute Pancreatitis (?Gallstones, high amylase)
Above (heart):
MI
Below (aorta):
Ruptured Aortic Aneurysm
Right (liver/gall bladder):
Cholecystitis
Hepatitis
Pancreatitis: Acute vs Chronic
Acute:
Pain
High Amylase
Chronic:
Pain
Weight Loss
Loss of endocrine function (can’t produce insulin ->diabetic?)
Loss of exocrine function (can’t digest food -> lose weight, steatorrhoea)
Normal amylase
-> Low faecal elastase! is diagnostic test, NOT AMYLASE
RUQ Pain DDx
Gall Bladder:
Cholecystitis
Cholangitis
Gallstones
Liver:
Hepatitis
Abscess
Above (lungs):
Basal Pneumonia
Below (appendix):
Appendicitis
Left (stomach/pancreas):
Peptic Ulcer
Pancreatitis
Right (kidney):
Pyelonephritis
Charcot’s Cholangitis Triad
RUQ colicky pain
Jaundice
Fever
Cholecystitis Signs and Symptoms
Raised WCC Raised CRP Tender Abdominal Pain RUQ Fever Murphy's Sign
Murphy’s Sign
A sign of gallbladder disease consisting of pain on taking a deep breath when the examiner’s fingers are on the approximate location of the gallbladder
Cholangitis Signs and Symptoms
Jaundice
Fever
Rigor
RIF Pain DDx
GI: Appendicitis Mesenteric adenitis Colitis (IBD) Malignancy
Gynaecological:
Ovarian cyst rupture/twist/bleed
Ectopic Pregnancy
Suprapubic Pain DDx
Cystitis
Urinary Retention/UTI
LIF Pain DDx
GI:
Diverticulitis
Colitis (IBD)
Malignancy
Gynaecological:
Ovarian Cyst Rupture/Bleed/Twist
Ectopic Pregnancy
Diffuse Abdominal Pain DDx
Obstruction
Infection: Peritonitis, Gastroenteritis
Inflammation: IBD
Ischaemia: Mesenteric Ischaemia
Medical Causes: DKA Addison's Hypercalcaemia Porphyria Lead Poisoning
Mesenteric Arteries
Celiac: Stomach Spleen Liver Gallbladder Duodenum
Superior Mesenteric:
Small intestine
Right Colon
Inferior Mesenteric:
Left Colon
+Ileomesenteric arcade -> rectum
65 yr old man AAA repair 2 days ago Diffuse abdominal pain PR 120 bpm RR 30
Blood tests likely to show…?
High amylase (due to abdo pain)
Spontaneous Bacterial Peritonitis
Ascites, neutrophils greater than or equal to 250 cells/mm^3
Compensated -> Decompensated Liver Disease
Ascites, Bruising, Jaundice or Encephalopathy
Abdominal Distension
Fluid or Flatus?
Ascites:
Shifting dullness
Features of Liver disease
Obstruction: Nausea, vomiting Not opened bowel High pitched tinkling BS ?Previous surgery (adhesions) ?Tender irreducible femoral hernia in groin
Fat, Faeces, Fetus
Ascites Classifications
Albumin gradient = serum albumin - ascitic albumin
High Albumin Gradient: >11g/L Portal Hypertension Constrictive Pericarditis Cardiac Failure (acute and chronic) Cirrhosis
(Increased hydrostatic pressure pushes fluid out of vasculature -> higher relative level of albumin in serum)
Low Albumin Gradient: <11g/L Nephrotic Syndrome TB Pancreatitis (acute and chronic) Cancer Peritonitis
50 yr old man Jaundice RUQ pain Dark urine Pale stool
Cause of pale stool?
- Post-hepatic (obstruction to flow of bile)
caused by CBD obstruction -> Low stercobilinogen (conjugated BR does not reach into bowel where it can be converted into stercobilinogen)
Dark urine caused by conjugated bilirubin leakage from liver
Jaundice Framework
Pre-hepatic:
Haemolysis,
Defective Conjugation (Gilbert’s syndrome)
Hepatic:
Hepatitis (Alcohol, autoimmune, viral, drugs)
Post hepatic: CBD Obstruction (gallstones, stricture, Ca of head of pancreas)
Bilirubin Pathway
Red blood cells -> Unconjugated Bilirubin in Spleen -> Conjugated bilirubin in liver by Glucuronyltransferase -> secreted in bile -> converted to urobilinogen + stercobilinogen (BROWN)
Clinical difference between obstructive jaundice and hepatocellular jaundice?
Obstructive -> pale stool due to stercobilinogen not being formed (bile blockage)
Abnormal Blood tests in Pancreatic Cancer
High Alkaline Phosphatase
High Gamma GT
Ca19-9 (tumour marker for panc. cancer)
Blood Diarrhoea DDx
–> loss of epithelial integrity
1. Infective Colitis (CHESS): Campylobacter Haemorrhagic E. Coli Entamoeba Histolytica Salmonella Shigella
2.Inflammatory Colitis:
Young, Extra-GI manifestations (eyes/skin)
- Ischaemic Colitis:
Elderly - Diverticulitis
- Malignancy
Obstructive Lung Disease
Respiratory Disease characterised by airway obstruction.
Can result from narrowing of the smaller bronchi and bronchioles, often because of excessive contraction of the smooth muscle itself.
Characterised by easily collapsible and inflamed airways, obstruction to airflow.
Types of Obstructive Lung Disease
Chronic Bronchitis
Bronchiolitis
(inflammation of bronchioles - most often viral cause)
Bronchiectasis
(Abnormal and irreversible dilatation of the bronchi caused by destructive and inflammatory changes)
Asthma
Cystic Fibrosis
Restrictive Lung Disease
Problem with lung expansion, usually stifness in lungs themselves. Can also be stiffness of chest wall/weak muscles/damaged nerves.
Types of Restrictive Lung Disease
Interstitial Lung Disease e.g. idiopathic pulmonary fibrosis
Sarcoidosis
Obesity
Scoliosis
Neuromuscular disease
Complication of (impacted) faecal loading
Overflow (spurious) diarrhoea
Confusion, often in elderly
Management of Acute GI Bleed
e.g. Variceal Bleed
ABC IV access Fluids G+S, X-match blood OGD
…e.g. Variceal Bleed
Antibiotics (due to bacterial translocation)
Terlipressin (causes splanchnic vasoconstriction)
Investigations and Management of Acute Abdomen
Investigations:
Bloods: FBC U+Es LFTs CRP Clotting G+S X-match
Erect CXR (looking for air under diaphragm)
CT
Managment:
NBM Fluids Analgesic Anti-emetics Antibiotics Monitor Vitals + Urine Output
Dysphagia + weight loss. Investigations?
OGD + Biopsy
Management of Ascites
Diuretics (spironolactone +/- furosemide)
Dietary sodium restriction
Fluid restriction in patients with hyponatraemia
Monitor wt daily
Therapeutic paracentesis (with IV human albumin)
Management of Encephalopathy
Lactulose
Phosphate enemas
Avoid sedation
Treat infections
Exclude a GI bleed
Post-op Care
Wound infection
Anastomotic leak
Pelvic abscess
Wound Infection:
Erythematosus
Discharge
Anastomotic leak:
Diffuse abdo tenderness (peritonitis)
Guarding, rigidity
Hypotensive/tachycardic
Pelvic abscess, e.g. post appendectomy: Pain Fever Sweats Mucus diarrhoea
Perianal Disease
Presentation?
Treatment?
Perianal abscess:
Tender red swelling
Incision + Drainage
Anal fissure: Rectal pain (defaecation) Stool coated with blood Advice re diet (fluids, fibre) GTN cream
Irritable Bowel Syndrome
Presentation?
Presentation: Recurrent Abdo pain Bloating Improves with defecation Change in frequency/form of stool
NO…
- PR bleed
- Anaemia
- wt loss
- nocturnal symptoms
- exclude Coeliac
Irritable Bowel Syndrome
Treatment?
Diet and Lifestyle modification Symptomatic treatment: -Abdo pain: antispasmodics -Laxatives for constipation -Anti-diarrhoeals
Management of Hyperkalaemia
Calcium Gluconate
10mls of 10%
Insulin
Dextrose
Jaundice investigations?
Jaundice:
Bloods (FBC, LFTs, CRP)
Abdominal USS –> after a fast; gallstones better visualised in a distended, bile-filled gallbladder)
PR Bleed, wt loss. Investigations?
Colonoscopy