2. Interactive Cases in General Internal Medicine 1 Flashcards
1
Q
Complication of COPD
A
Pulmonary Hypertension (Hypoxia -> vasoconstriction)
2
Q
Breathlessness DDx
A
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
3
Q
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?
A
Pneumothorax
Chest Drain
4
Q
CPAP
A
Continuous Positive Airway Pressure
CPAP improves oxygenation
Used in Type 1 Resp Failure
5
Q
Management of Pneumothorax
A
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!
6
Q
What to tell patient with Chest Drain in
A
Underwater seal must always be below the waistline
7
Q
Pneumothorax
Improved after Chest Drain insertion.
Recurrent SOB after 2hrs
Potential cause of recurrent SOB?
A
Re-expansion pulmonary oedema (one lung!)
8
Q
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
A
PE
LMWH
9
Q
RBBB and Right axis deviation signs of…
A
Right sided heart strain
10
Q
S1, Q3, T3
A
ECG PE finding
S wave in I
Q wave and T wave inversion in III
11
Q
Suspected PE (120/80 BP) Management
A
- LMWH
- CTPA
- If PE confirmed, start Warfarin and continue LMWH
12
Q
Indication for BiPAP
A
Respiratory Acidosis/High CO2
e.g. COPD
13
Q
Suspected PE; why do we need to continue BOTH LMWH and Warfarin together for a few days?
A
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)
14
Q
Suspected PE (60/30 BP) Management
A
Thrombolysis
15
Q
Primary Pneumothorax,Greater than 2cm
Management
A
Pleural Aspiration
If unsuccessful: Chest Drain
16
Q
Primary Pneumothorax, SOB
Management
A
Pleural Aspiration
If unsuccessful: Chest Drain
17
Q
Primary Pneumothorax, Less than 2cm
Management
A
Discharge, repeat CXR
18
Q
Secondary Pneumothorax, Less than 2cm
Management
A
Pleural Aspiration
19
Q
Secondary Pneumothorax, Greater than 2cm
Management
A
Chest Drain
20
Q
FEV1/FVC ratio > 70%
A
Restrictive Lung disease
21
Q
FEV1/FVC ratio < 70%
A
Obstructive Lung Disease
22
Q
50 yr old female Progressive SOB Dry Cough Clubbing FEV1/FVC ratio > 70%
DDx?
A
Idiopathic fibrosing alveolitis
Connective tissue disease, RA
Drugs (e.g. methotrexate)
Asbestosis
23
Q
Asbestosis
A
Pulmonary Fibrosis due to Asbestos exposure.
If you have some plaques, not enough for diagnosis of Asbestosis.
24
Q
CXR Interpretation
A
This is a PA/AP CXR of…
- Name and DOB
- Taken on (Date)
- At (Time)
Quality of film: RIP
Rotation
Inspiration
Penetration (under/over)
25
Opacities on CXR
```
Interstitial/Alveolar shadowing ('Fluffy') - fluid or pus
Reticulo-nodular shadowing (fibrosis)
Homogeneous shadowing (e.g. pleural effusion)
Masses/Cavitations
```
26
Lung lobe affected if Interstitial/Alveolar shadowing obscuring Right border of heart
Right middle lobe
27
If unable to follow left hemi-diaphragm behind heart?
Collapsed lung
28
Tracheal deviation Collapsed lung vs Pleural effusion
Collapse pulls trachea towards it, Effusion pushes away.
29
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
30
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)
31
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
32
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)
```
33
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
34
Abdominal Head and Neck Findings
```
Anaemia
Jaundice
Excoriation marks
Spider Naevi
Oral exam:
Pigmentation
Gum hypertrophy (ciclosporine after renal transplant)
```
35
Abdominal Chest Findings
Gynaecomastia
Hair loss
Spider naevi
Excoriation marks
36
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
37
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
38
Summary of liver disease
```
Alcohol
Autoimmune
Drugs
Viral
Biliary Disease
```
39
Causes of splenomegaly
H's - Portal Hypertension, Haematological (e.g. lymphoma/haemolytical anaemia/leukaemia)
I's - Infection, Inflammation
40
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)
```
41
Infections that can cause splenomegaly
```
Malaria
Schistosomiasis
Leishmaniasis
TB
Infective Endocarditis
Infectious Mononucleiosis
```
42
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
43
```
75 yr old man
Epigastric Pain
Back Pain
PR 130bpm
BP 80/50
```
Dx?
Ruptured Aortic Aneurysm
44
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
45
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
46
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
47
Charcot's Cholangitis Triad
RUQ colicky pain
Jaundice
Fever
48
Cholecystitis Signs and Symptoms
```
Raised WCC
Raised CRP
Tender
Abdominal Pain RUQ
Fever
Murphy's Sign
```
49
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
50
Cholangitis Signs and Symptoms
Jaundice
Fever
Rigor
51
RIF Pain DDx
```
GI:
Appendicitis
Mesenteric adenitis
Colitis (IBD)
Malignancy
```
Gynaecological:
Ovarian cyst rupture/twist/bleed
Ectopic Pregnancy
52
Suprapubic Pain DDx
Cystitis
| Urinary Retention/UTI
53
LIF Pain DDx
GI:
Diverticulitis
Colitis (IBD)
Malignancy
Gynaecological:
Ovarian Cyst Rupture/Bleed/Twist
Ectopic Pregnancy
54
Diffuse Abdominal Pain DDx
Obstruction
Infection: Peritonitis, Gastroenteritis
Inflammation: IBD
Ischaemia: Mesenteric Ischaemia
```
Medical Causes:
DKA
Addison's
Hypercalcaemia
Porphyria
Lead Poisoning
```
55
Mesenteric Arteries
```
Celiac:
Stomach
Spleen
Liver
Gallbladder
Duodenum
```
Superior Mesenteric:
Small intestine
Right Colon
Inferior Mesenteric:
Left Colon
+Ileomesenteric arcade -> rectum
56
```
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)
57
Spontaneous Bacterial Peritonitis
Ascites, neutrophils greater than or equal to 250 cells/mm^3
58
Compensated -> Decompensated Liver Disease
Ascites, Bruising, Jaundice or Encephalopathy
59
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
60
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
```
61
```
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
62
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)
```
63
Bilirubin Pathway
Red blood cells -> Unconjugated Bilirubin in Spleen -> Conjugated bilirubin in liver by Glucuronyltransferase -> secreted in bile -> converted to urobilinogen + stercobilinogen (BROWN)
64
Clinical difference between obstructive jaundice and hepatocellular jaundice?
Obstructive -> pale stool due to stercobilinogen not being formed (bile blockage)
65
Abnormal Blood tests in Pancreatic Cancer
High Alkaline Phosphatase
High Gamma GT
Ca19-9 (tumour marker for panc. cancer)
66
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)
3. Ischaemic Colitis:
Elderly
4. Diverticulitis
5. Malignancy
67
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.
68
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
69
Restrictive Lung Disease
Problem with lung expansion, usually stifness in lungs themselves. Can also be stiffness of chest wall/weak muscles/damaged nerves.
70
Types of Restrictive Lung Disease
Interstitial Lung Disease e.g. idiopathic pulmonary fibrosis
Sarcoidosis
Obesity
Scoliosis
Neuromuscular disease
71
Complication of (impacted) faecal loading
Overflow (spurious) diarrhoea
Confusion, often in elderly
72
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)
73
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
```
74
Dysphagia + weight loss. Investigations?
OGD + Biopsy
75
Management of Ascites
Diuretics (spironolactone +/- furosemide)
Dietary sodium restriction
Fluid restriction in patients with hyponatraemia
Monitor wt daily
Therapeutic paracentesis (with IV human albumin)
76
Management of Encephalopathy
Lactulose
Phosphate enemas
Avoid sedation
Treat infections
Exclude a GI bleed
77
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
```
78
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
```
79
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
80
Irritable Bowel Syndrome
Treatment?
```
Diet and Lifestyle modification
Symptomatic treatment:
-Abdo pain: antispasmodics
-Laxatives for constipation
-Anti-diarrhoeals
```
81
Management of Hyperkalaemia
Calcium Gluconate
10mls of 10%
Insulin
Dextrose
82
Jaundice investigations?
Jaundice:
Bloods (FBC, LFTs, CRP)
Abdominal USS --> after a fast; gallstones better visualised in a distended, bile-filled gallbladder)
83
PR Bleed, wt loss. Investigations?
Colonoscopy
