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2021 > Abdo > Flashcards

Abdo Flashcards

1
Q

Abdo Schpiel

A

Today I examined ___ abdomen and my main findings were ___ mass consistent with spleen/kidney/liver or multiple.

Given these findings I went to complete a renal/GI/haematological examination and my peripheral findings were ____.

This is consistent with a diagnosis of ____. But my differentials are ____.

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2
Q

Causes of Massive Hepatomegaly

A
  • MF
  • MDS
  • Liver mets/HCC
  • CLD/ETOH with fatty infiltration
  • TR (pulsatile)

*If CLD but liver big = hepatoma, haemochromotosis

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3
Q

Causes of Moderate Hepatomegaly

A
  • Haemochromotosis
  • MDS
  • CML, CLL
  • Lymphoma
  • NAFLD
  • Infiltration
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4
Q

Causes of marked splenomegaly (>7cm)

A
  • Primary myelofibrosis
  • CML
  • MDS
  • Myelofibrosis
  • Malaria
  • Kala azar
  • Splenic lymphoma
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5
Q

Causes of moderate splenomegaly (3-7cm)

A
  • Lymphoma
  • CLL
  • PRV
  • Portal Hypertension (with CLD but liver may be small)
  • Leukaemia
  • Thalassaemia
  • Storage Disease
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6
Q

Causes of mild splenomegaly (1-2cm) - *spleen has to be 2-3x its normal size to be palpable.

A
  • PRV, ET
  • Haemolytic anaemia, ITP, Thalassemia, Sickle cell disease
  • Infection
  • CTD
  • Infiltration: Sarcoidosis, amyloidosis
  • Portal Hypertension (with signs of CLD)
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7
Q

Causes of hepato-splenomegaly

A
  • CLD - fatty liver/NAFLD, ETOH
  • Hepatitis
  • Haemochromotosis
  • HCC or infiltration
  • Infiltration - lymphoma, amyloid, CTD
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8
Q

Causes of massive hepato-splenomegaly

A
  • MF
  • MDS
  • CML/CMML
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9
Q

Causes of moderate hepato-splenomegaly

A
  • CLL

- Lymphoma

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10
Q

Abdo likely cases:

A

GIT:

  • CLD +/- portal HTN (21%)
  • Hepatomegaly undefined
  • Splenomegaly
  • Hepatomegaly metastatic disease
  • Hepatosplenomegaly (others)
  • Abdominal Mass (pancreatic cancer)
# Renal:
- PCKD +/- Renal transplant (32%)

Haematology:

  • Chronic Lymphocytic Leukaemia/Lymphoma (17%)
  • Myelofibrosis/CML (16%)
  • PRV (4%)
  • Others (HIV, isolated splenomegaly, sarcoidosis)
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11
Q

Abdo Inspection (10 things):

A

1) Patient’s age
2) Patient’s face (PCV, jaundice, drowsiness)
3) The rest of the body (does the patient look malnourished, cachectic)
4) Flanks
5) Umbilicus
6) Organs, liver, spleen, kidney’s
7) Scars (renal Tx)
8) Veins
9) Masses
10) Tubes/lines

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12
Q

8 things to mention about the liver:

A

1) Span (MCL)
2) Shape/map out the edge (left vs right lobes)
3) Tender, non-tender
4) Consistency/feel, firm, hard, soft
5) Edge: regular, irregular, nodular
6) Surface: smooth, nodular
7) Pulsatile or non-pulsatile
8) Rubs or bruits

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13
Q

Why spleen and not kidney? (5)

A

1) Comes down & medially with respiration
2) Has a notch
3) Can’t get above it
4) Dull over it & in Traub’s area
5) Not ballottable

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14
Q

Spleen characteristics:

A

1) Why is it a spleen and not kidney
2) How big is it?
3) Consistency, firm
4) Tender, non-tender
5) Any rubs?

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15
Q

Unilateral RIF mass with a scar?

A

Transplanted kidney…

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16
Q

PCK (12) things to look for

A

1) Bilateral, maybe asymmetrical
2) Span of each, ability to get above mass
3) Surface, border
4) Tender or non-tender
5) Auscultation
6) Movement with respiration
7) Ballottable or non ballottable
8) Any differentials
9) Is there a current fistula - or an old one
10) Is there a renal Tx?
11) Are there signs of CKD?
12) Blood pressure

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17
Q

*Must leave abdomen by 5 minutes!

A

*Must leave abdomen by 5 minutes!

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18
Q

Abdo Gastro additional things you’d like to do:

A
  • Temperature chart
  • LNs (including inguinal)
  • PN, cerebellar signs (ETOH, B12)
  • Testes - atrophy
  • CVS - CM
  • Urine analysis (Urobilinogen)
  • DRE
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19
Q

Liver problem signs (4)

A
  • Small liver - mild-moderate spleen
  • Ascites
  • Signs of CLD
  • Dupytron’s, parotidomegaly
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20
Q

Haematological problem signs (6)

A
  • Splenomegaly only, hepatosplenomegaly, lymphadenopathy
  • Pallor
  • Jaundice (Haemolysis)
  • Bruises
  • Petechiae
  • Pleural effusions
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21
Q

Renal disease signs (5)

A
  • PCK, renal Tx
  • Finger urochrome stains
  • Gouty Tophi
  • AVF - ask for blood pressure (lying & standing)
  • JVP - fluid status
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22
Q

PCKD extra-renal manifestations:

A
  • hepatomegaly/cysts
  • MVP
  • MCA aneurysm - CN 3, 4 and 6
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23
Q

Abdo:

A
  • inspect
  • palpate
  • percuss
  • auscultate
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24
Q

Liver

A
  • can’t get above it
  • moves inferiorly with inspiration
  • dull (no overlying bowel)
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25
Q

Kidneys

A
  • can get above

- bimanually palpate

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26
Q

Spleen

A
  • can’t get above it
  • notch
  • moves inferiorly with inspiration
  • not bimanually palpable
  • dull
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27
Q

Mild hepatomegaly causes

A
  • hepatitis
  • biliary obstruction
  • hydatid disease
  • HIV infection
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28
Q

Hepato-splenomegaly causes:

A
  • CLD with portal HTN
  • Myeloproliferative disease, lymphoma, leukaemia, pernious anaemia, sickle cell anaemia
  • Infection - acute viral hepatitis, infectious mononucleosis, CMV
  • Infiltration - amyloidosis, sarcoid
  • CTD
  • Acromegaly
  • Thyrotoxicosis
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29
Q

Hands (abdo) signs:

A
  • Leuconychia, clubbing
  • Palmar erythema
  • Dupytren’s contracture (ETOH)
  • Arthropathy (CTD, haemochromotosis, Felty’s sydnrome)
  • Hepatic flap
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30
Q

Face (abdo) signs:

A
  • Eyes: jaundice, anaemia, iritis, Kayser-Fleischer rings
  • Parotids: (ETOH)
  • Breath fetor hepaticus
  • Lips: stomatitis, leukoplakia, ulceration, localised pigmentation, telangiectasia
  • Gums: gingivitis, bleeding, hypertrophy, pigmentation
  • Tongue: atrophic glossitis, leukoplakia, ulceration
  • Tonsils
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31
Q

Legs (abdo) signs:

A
  • Bruising
  • Oedema - note this could be liver disease / hypoalbuminaemia / heart failure or obstruction from LNs
  • Neurological signs (ETOH)
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32
Q

Myeloproliferative signs and causes:

A
  • Splenomegaly
  • +/- Hepatomegaly
  • No nodes
  • Leukonychia, conjunctival pallor, bruising
  • DDx: CML/CMML, myelofibrosis, PV, ET
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33
Q

Lymphoproliferative signs and causes:

A
  • As for myeloproliferative plus nodes. May be associated with tophaceous gout
    DDx: CLL, lymphoma, infection (CMV, EBV, viral hepatitis, HIV, syphilis)
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34
Q

Cirrhosis causes

A
  • ETOH
  • Viral - HBV, HCV
  • AI: PBC, PSC, auto immune hepatitis
  • Metabolic: NASH, haemochromotosis, alpha-1 AT deficiency, Wilson’s disease, CF
  • Drugs: MTX, Isoniazid, Amiodarone
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35
Q

ETOH misuse signs:

A
  • Cachexia
  • Tremor
  • Parotid enlargement
  • Dupuytren’s contracture
  • Cerebellar syndrome
  • Peripheral neuropathy
  • Myopathy
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36
Q

Portal HTN consequences:

A
  • Oesophageal varices
  • Ascites
  • Hyersplenism/thrombocytopenia
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37
Q

Liver dysfunction consequences:

A
  • Coagulopathy
  • Encephalopathy
  • Jaundice
  • Hypoalbuminaemia
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38
Q

Causes of decompensation in cirrhosis:

A
  • Infection
  • SBP
  • Hypokalaemia
  • GI bleed
  • Sedatives
  • HCC
39
Q

Hepatic encephalopathy severity grades

A

Grade 1: insomnia/reversal of day-night sleep pattern
Grade 2: lethargy/disorientation
Grade 3: Confusion/somnolescence
Grade 4: Coma

40
Q

Most common causes of ascites:

A
  • Cirrhosis
  • Malignancy
  • Heart failure
  • TB
  • Pancreatitis
41
Q

SA-AG

A
  • Serum albumin - ascitic fluid albumin
  • > 11g/L suggests transudative ascites
  • < 11g/L suggests exudative ascites
42
Q

Causes of hepatomegaly:

A

Malignancy

  • Cirrhosis:
  • ETOH
  • NAFLD
  • PBC
  • Hepatic congestion
  • RHF
  • Constrictive pericarditis
  • Restrictive cardiomyopathy

*ETOH hepatitis

  • Infectious disease:
  • Viral hepatitis
  • Toxoplasmosis
  • Hydatid disease
  • Pyogenic liver abscess
  • Amoebic liver abscess
  • Infiltration:
  • Amyloidosis
  • Sarcoidosis
  • Vascular liver disease:
  • Budd-Chiari syndrome

Polycystic liver disease

43
Q

Splenomegaly + anaemia without lymphadenopathy is most likely to be a myeloproliferative condition such as chronic myeloid leukaemia (CML).

A

Splenomegaly + anaemia without lymphadenopathy is most likely to be a myeloproliferative condition such as chronic myeloid leukaemia (CML).

44
Q

Splenomegaly and lymphadenopathy is most likely to be a lymphoproliferative condition such as lymphoma or chronic lymphocytic leukaemia.

A

Splenomegaly and lymphadenopathy is most likely to be a lymphoproliferative condition such as lymphoma or chronic lymphocytic leukaemia.

45
Q

Spleen characteristics

A
  • enlarges towards the RIF
  • possesses a medial notch
  • is dull to percussion
  • one cannot palpate ‘above’ a spleen
  • the spleen is not balltoable
46
Q

Causes of splenomegaly

A
  • Portal HTN - 33%
  • Haematological malignancy - 27%
  • Infection - HIV, IE - 23%
  • Congestion or inflammation - cardiac failure - 8%
  • Primary splenic disease (splenic vein thrombosis - 4%
47
Q

Renal Tx steps:

A
  • Palpate the margins - often smooth
  • Estimate the size (usually 8cm x 5cm)
  • Comment on whether it is tender or non-tender
  • Comment on consistency (often a firm mass)
  • Percuss over the mass (usually a dull percussion note)
  • Auscultate for bruits
48
Q

Adequacy of RRT

A
  • assess for fluid status
  • clinical signs of uraemia:
  • altered mental status
  • asterixis (metabolic encephalopathy)
  • excoriation marks (secondary to pruritis)
  • tachypnoea (metabolic acidosis with respiratory compensation)
  • pericardial rub (uraemic pericarditis)
49
Q

Abdo immunosuppression consequences:

A

1) Infection stigmata
2) Presence of skin lesions (benign or malignant)

3) Complications relating to specific drugs:

Cyclosporin: gum hypertrophy, hirsutism, coarse tremor, hypertension, diabetes

Steroids: purpura, cushingoid features, diabetes

Tacrolimus: diabetes mellitus, tremor

50
Q

Cause of renal failure:

A
  • Diabetes - FPT, lipodystrophy, diabetic retinopathy
  • HTN - BP
  • Vasculitis - skin lesions, stigmata of rheumatological disease
  • PCKD - palpable kidnies, nephrectomy scars

Alport’s syndrome - hearing aid
Tuberous sclerosis - subungal fibromas
Membranoproliferative GN

51
Q

Add ons to renal tx presentation:

A
  • measure the BP
  • check urinalysis - glycosuria, haematuria and proteinuria
  • auscultate the heart for a pericardial rub (uraemic pericarditis)
52
Q

Common cause of CKD

A
  • Diabetes
  • GN
  • HTN
  • PCKD
  • Reflux nephropathy
  • Analgesic nephropahy
53
Q

PCKD extra steps:

A
  • BP
  • CVS: MVP, AR, LV heave
  • Neuro: old stroke, CN 3 palsy/Berry aneurysm
54
Q

Other causes of renal cysts:

A
  • Multiple simple cysts
  • Tuberous sclerosis
  • Von Hippel Lindau Syndrome
55
Q

Single palpable kidney ddx:

A
  • PCKD with only 1 palpable kidney
  • Hydronephrosis
  • Hypertrophy of a single functioning kidney
  • Renal cell carcinoma
56
Q

Double palpable kidney ddx:

A
  • Bilateral renal cysts
  • Bilateral hydronephrosis
  • Amyloidosis
  • Bilateral RCC - VHL
57
Q

Extra-renal manifestations of ADPKD:

A
  • Cerebral aneurysms
  • Liver cysts
  • Pancreatic, splenic cysts
  • Valvular heart disease: MVP, AR
58
Q

Abdo Mass features:

A
  • Size
  • Consistency
  • Border - inspection, percussion, palpation
  • Tender/non-tender
  • Attached to abdominal wall
  • Movement with respiration
  • Pulsastile
  • Ballotable
  • Percussion note: solid masses with a firm consistency will give a dull percussion note
  • Auscultatory findings
59
Q

*It is not possible to palpate above the liver or spleen.

A

*It is not possible to palpate above the liver or spleen.

60
Q

Generalised lymphadenopathy causes (6):

A
  • Lymphoma (rubbery and firm)
  • Leukemia (CLL, ALL)
  • Infections (CMV, EBV, HIV, TB, Syphilis, Toxo)
  • CTD (RA, SLE)
  • Infiltration (Sarcoidosis)
  • Drugs (Phenytoin)
61
Q

Localised lymphadenopathy causes (3):

A
  • Local acute or chronic infection
  • Metastases from carcinoma or other solid tumour
  • Lymphoma (especially Hodgkin’s lymphoma)
62
Q

Liver disease: Chronicity not required

A
  • Jaundice
  • Ascites
  • Coagulopathy
  • Encephalopathy

*All may acute liver failure

62
Q

Liver disease: Chronicity NOT required

A
  • Jaundice
  • Ascites
  • Coagulopathy
  • Encephalopathy

*All may acute liver failure

63
Q

Liver disease: Chronicity REQUIRED

A
  • Cachexia
  • Spiders
  • Gynaecomastia
  • Most portal HTN
  • Caput
  • Clubbing
  • Palmar erythema
  • Testicular atrophy
64
Q

High SA-AG causes (>11) - (4):

A

*Portal Hypertension: pre/intra/post hepatic:
- Cirrhosis
- ETOH hepatitis
- Cardiac ascites
- Budd-chiari

65
Q

APKD NAILED:

A
  • Polycystic kidney - may be massive
  • Hepatic cysts, rare splenic cysts - may cause confusion
  • Transplanted kidney (can be tricky)
  • Look for a fistula
  • BP - 75% hypertensive
  • Anaemia (CRF, polycythaemia from high EPO) *Hb higher than expected for degree of renal failure
  • CN3 palsy
  • Listen to heart for MVP - may also have AR/LVH
  • Urine - haematuria (haemorrhage into the cyst) and proteinuria (<2g/day)
66
Q

Thrombophilia screen (unprovoked VTE, if young, recurrent, FHx, porto/hepatic/cerebral/mesenteric)

A
  • APLS - LAC, ACL, B2 glycoprotein
  • Factor 5 Leiden
  • PT Gene mutation
  • Protein C/S deficiency
  • Anti-thrombin III deficiency
  • MPN - JAK2/PNH
67
Q

Complications of CKD

A
  • Anaemia - Stage 3
  • Electrolyte disturbance
  • Bone health
  • Malnutrition
  • Oedema - Stage 4
  • Lethargy/pruritis
  • Uraemia
  • CV risk
68
Q

Complications of dialysis

A
  • Sudden cardiac death
  • Vascular disease
  • Extravascular calcification
  • Amyloidosis
69
Q

Indications for dialysis

A
  • A - acidosis (metabolic) - pH <7.1
  • E - electrolytes - refractory - K>6.5
  • I - intoxications - Salicylates, Lithium, Isopropanol, Methanol, Ethylene glycol
  • O - overload - refractory to diuresis
  • U - uraemia - pericarditis, encephalopathy, neuropathy, bleeding
70
Q

Post renal transplant issues

A
  • Diabetes
  • HTN
  • Cancer
  • CVD
  • Infections: CMV, BK, PJP, fungal
  • OP
  • Hchol
71
Q

Abdominal distension (6 F’s)

A
  • Fat
  • Fluid
  • Flatus
  • Faeces
  • Fibroids
  • Fetus
72
Q

Extra-intestinal manifestations of UC (5)

A
  • Liver - PSC, fatty liver, cirrhosis, carcinoma, amyloidosis
  • Blood - VTE, anaemia
  • Enteropathic arthropathy
  • Skin - ulcers, pyoderma, EN
  • Ocular - Uveitis, conjunctivitis, episcleritis
73
Q

DDx colitis (7)

A
  • IBD
  • Infectious - pseudomembranous
  • Radiation
  • Ischemic colitis
  • Microscopic/collagenous
  • Toxic exposure
  • Lymphocytic
74
Q

Colitis infection ddx (9)

A
  • Shigella
  • Salmonella
  • Yersinia
  • E. coli 0157:H7
  • Campylobacter
  • CDT
  • STI
  • IC - herpes, CMV, cryptosporidium
  • TB
75
Q

Goals of management of CD (3)

A
  • Induce remission
  • Maintain remission
  • Preventing/treating complications
76
Q

MTx side effects (4)

A
  • Hepatotoxic
  • BM suppression
  • Teratogenic
  • Interstitial pneuomonitis
77
Q

MTx side effects (4)

A
  • Hepatotoxic
  • BM suppression
  • Teratogenic
  • Interstitial pneumonitis
78
Q

TTP (5)

A
  • Fever
  • Anaemia (MAHA)
  • Thrombocytopenia
  • Renal failure
  • Neuro abnormalities
79
Q

Splenectomy (4)

A
  • Vaccinate: pneumococcus, Hib, group C meningococcus, flu vax, COVID 2-3/52 before splenectomy
  • Booster every 5 years, annual flu, COVID
  • Consider prophylactic penicillin V 250mg BD
  • Alert braclet
80
Q

Cx post renal Tx - 1-12 weeks (4)

A
  • Acute rejection
  • CNI toxicity
  • Infection: CMV/BK virus
  • Recurrence of disease
81
Q

Cx post renal Tx - 12-52 weeks (6)

A
  • Acute rejection
  • CNI toxicity
  • Infection CMV
  • Recurrence of primary disease
  • Chronic rejection
  • BK
82
Q

Cx post renal Tx - >1 year (7)

A
  • IF-TA - chronic allograft nephropathy
  • CVD
  • Malignancy
  • Infection
  • BK
  • Hypertensive nephrosclerosis
  • Recurrence of disease
  • Infection from over IS
83
Q

Elevated Cr post Tx (6)

A
  • Re-check
  • Urine m/c/s
  • Tac (CNI) level
  • Medication adherence, hydration status
  • USS renal tx doppler
  • Biopsy
84
Q

Cx post renal Tx (general) - (5)

A
  • NODAT
  • Increased malignancy risk - yearly skin, scopes every 2 years, PSA yearly, mamograms, cervical smear
  • Infection risk: CMV, BK (usually after 6/12)
  • CV risk - REMAINS - still have CKD
  • CKD-MBD
85
Q

SAAG <11 (4)

A
  • Peritoneal carcinomatosis
  • Peritoneal TB
  • Pancreatitis
  • Nephrotic syndrome
86
Q

HBV Phases (4)

A
  • Immune tolerance (monitor)
  • Immune clearance (inflammation) - EAg+ to EAg- *Treat!
  • Immune control - EAb+, low VL, normal LFTs - Monitor
  • Immune escape - High VL, abnormal ALT -*Treat!
87
Q

Cirrhosis Rx (5)

A
  1. Rx cause of CLD
  2. Prevent superimposed insults: vaccinate, avoid hepatotoxic drugs - e.g., statin
  3. Rx and prevent Cx:
    - nutrition, ETOH, low salt, FR, protein 1.5g/kg/d, adequate energy (counteract catabolism)
    - hepatoma surveillance - USS + aFP every 6/12, all cirrhotics, or HBV
    - ascites, varices, SBP, encephalopathy
  4. Tx - at decompensation or MELD >10, <65YO, no major CI
  5. general health maintenance: CVRF, exercise program, bone health, ACP
88
Q

Ascites Rx (7)

A
  1. Salt restriction
  2. FR
  3. diuretics: spiro (100-400mg), fruse 40-160mg)
  4. LV paracentesis if Sx
  5. Umbilical hernia repair
  6. TIPPS but encephalopathy
  7. Tx
89
Q

Long Term post OLTx Rx (10)

A
  • Infection risk
  • Return to occupation (often <3 months)
  • Post Tx renal failure
  • Post Tx diabetes
  • CV RF
  • Bone health
  • Malignancy risk - PTLD
  • Disease recurrence
  • Chronic rejection
  • 90% 10-year survival
90
Q

CKD-MBD - Ix/Rx (5)

A
  • Ca/PO4/PTH/ALP
  • PO4 binder
  • Calcitriol
  • Secondary/Tertiary PTH
  • Cinacalcet
91
Q

ESKD diet (6)

A
  • Low K
  • Low PO4
  • Low Na
  • Dietician
  • Nutrition
  • Adherence
92
Q

Life on dialysis (5)

A
  • Sleep - RLS/CTS/IDA
  • Fertility/sexual fn
  • Edu, employment, financial, logistics, travel
  • Mood/depression/cognition
  • QOL, impact on self, others, support

2021 (34 decks)

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