2019 Flashcards
58F PC: 6/12 PR bleeding (mixed) + dull abdo pain No FLAWS FH: brother Colorectal Ca What will you include in your assessment i.e. history and exam (not Ix)?
1) Nature of bleeding - duration, frequency, colour of the bleeding, relation to stool and defecation 2) Associated symptoms - pain (especially association with defaecation), haematemesis, PR mucus, or previous episodes 3) Family history of bowel cancer or inflammatory bowel disease 4) PR examination is essential for every patient presenting with haemotochezia, allowing assessment for any rectal masses or anal fissures
58F PC: 6/12 PR bleeding (mixed) + dull abdo pain No FLAWS FH: brother Colorectal Ca Differentials?
DDx for painless lower GI bleed: Malignant - colorectal malignancy Benign/structural- Haemorrhoids, Diverticulosis (painless), angiodysplasis Other DDx for lower GI bleeds: Infective - shigella, entamoeba histolytica Inflammatory - IBD, Diverticulitis (painful) Vascular - ischaemic colitis, Iatrogenic - radiation proctitis Upper V Lower Upper: Lower:
58F 6/12 PR bleeding (mixed) + dull abdo pain No FLAWS FHx brother Colorectal Ca Investigations?
1) Bloods - incl FBC/U&E/LFT/Coag/G&D 2) Stool sample - infective 3) Flexi sigmoidoscopy, if inconclusive -> Full colonoscopy +/- OGD +/- MRI small bowel +/- Biopsy! 3b) If HD unstable -> Urgent CT angiogram +/- embolisation
58F 6/12 PR bleeding (mixed) + dull abdo pain No FLAWS FHx brother Colorectal Ca Management?
Acute large rectal bleeding = upper GI bleed until proven otherwise! Lower GI 1) A-E Resuscitation 95% settle spontaneously 2) Ix as outpatient OR if old/co-morbid Ix as inpatient 5% non-resolving/HD unstable 1) Endoscopic haemostasis Inj (Adrenaline injection), thermal ( bipolar electrocoagulation/argon plasma co-agulation), mechanical (clips/band) 2) Angiography +/- arterial embolisation 3) Surgical intervention
Day 5 post Left colectomy PC: Peritonitic abdo pain How will you assess this patient?
A-E incl abdo exam and wound assessment Review of notes + Op note + results (whilst awaiting results from A-E Ix)
Day 5 post Left colectomy PC: Peritonitic abdo pain Vitals/Bloods suggestive of sepsis Immediate management?
A-E Incl sepsis 6: lactate, culture, catheter, fluid, ABx, O2 (if required) Imaging: CT Abdo pelvis
Day 5 post Left colectomy PC: Peritonitic abdo pain Differential diagnosis for high NEWS/post op abdo pain
Specific post op complication: Anastomotic leak, internal bleeding, General post op complication: hospital acquired infection e.g. pneumonia/UTI, PE/DVT, wound infection, constipation
Management of anastomotic leak
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Management of post operative intra-abdominal collection
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Management of post operative abdominal pain
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Management of colorectal Ca
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Aortic Valve
Patients with this congentital abnormaltiy are at risk of ___ . What is the pathogenesis?
At risk of: Aortic Stenosis + Aortic dilation (and infective endocarditis)
Pathogenesis: Higher pressure outflow causes haemodynamic stress + turbulence = continuous trauma -> chronic inflammation
-> fibrosis & calcification = rigidity & stiffening of the aortic valve with stenosis of aortic orifice
(Calcified aortic valve = surface for bacterial -> IE)
-> aortic medical degeneration -> aortic dilation
Cause of sudden death in a patient with bicuspid valve?
MI (secondary to AS)
Aortic Dissection (secondary to ADilation)
Causes of Aortic Stenosis
Senile calcification e.g. aging (commonest), Congenital e.g. bicuspid valve, williams syndrome, Rheumatic
Symptoms of Aortic Stenosis
Triad: Angina, dyspnoea, syncope ON EXERTION
Arrhythmias
If LVF: PND, orthopnoea
If IE: Systemic emboli
Signs of AS
Slow rising pulse
Narrow pulse pressure
Aortic thrill
Apex: Forceful, non-displaced (pressure)
HS: Quiet A2, S4 (forceful contraction vs hypertrophied ventricle), paradoxical split S2
ESM with click is pliable young valve - accentuated by sitting forward in end expiration, radiates to carotids
Displaced apex beat
Aortic Stenosis V Aortic Slerosis
In a patient with aortic stenosis, what might an ECG show
1) LVH
2) LV strain: Tall R, ST depression, T inversion in V4-6
3) LBBB or complete AV block (due to septal calcification)
4) AF
Complications of Aortic Stenosis
Angina, Syncope, Heart Failure, Pulmonary oedema, Arrythmia, Cardiac arrest, Infective endocarditis, Pulmonary hypertension, Atrial fibrillation
Management of aortic stenosis
Medical management:
- Optimise RF; statins, anti-HTN, DM
- Monitor with Echo
- Angina; beta blockers
- HF: ACEi, diuretics
- Avoid nitrates
Surgical AVR: If severe symptomatic AS, severe asymptomatic with reduced EF, sever AD undergoing CABG/orther valve op
- Mechanical - requires AC (young)
- Bioprosthetic - does not require AC (old)
Transcatheter Aortic Valve Implanation: high peri-op risk of stroke!
What oganism commonly causes IE?
Cardiac valves develop vegetations composed of bacteria and platelet-fibrin thrombus.
Strep. Viridans
Staph. Aureus
(S.bovid, S Epidermidis, Enterococci, Pseudomonas / Haemophilus, actinobacillus, Cardiobacterium, Eikenella, Kingella, Coxiella, Chlamydia/ SLE, marantic)
What type of anticoagulation is used post valve replacement?
Warfarin -
prevents reduction of Vit K Epoxide to active Vit K
inhibitting Vit K’s co-factor role in the activation of 2, 7, 9, 10 + Protein S/C/Z
delaying thrombin generation
i.e. prevents activation of extrinsic and common pathway via vit K
How is warfarin reversed?
No bleeding and…
- INR<8 = Hold wararin until INR therapeutic
- INR>8 give PO Vit K and repeat INR @24hrs
Bleeding:
- Major = V Vit K (phytomenadione) + Prothrombin complex (II, VII, IX, X) or FFP (all clotting factors, fibrinogen, protein C&S, AT III)
- INR>5 and minor bleeding = IV Vit K and repeat INR @24hrs
Note Cryoprecipitate contains - Factor VIII, XIII, Fibrinogen, vWF
