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F1 notes > Basics in Presentations for clerking and Mx plan > Flashcards

Basics in Presentations for clerking and Mx plan Flashcards

1
Q

What should be asked about a patients background with joint pain?

A
  1. age and sex
    * e.g men > women with gout, & women with RA
    * younger sexual causes of septic arthritis
  2. Immunodeficiency
  3. IVDU - increase risk of septic arthritis
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2
Q

Differentials for joint pain

A

Acute - SA, trauma, gout, pseudogout
Chronic - RA, Osteoarthritis, PA

RA - symmetrical
PG - knee
OA - likely knee + hand
PA - asymmetrical oligoarthritis, distal phlangeal, arthritis mutilans, psoriatic spondylitis

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3
Q

What does a SOCRATES of joint pain tell you?

A

S - small joint vs large joint
O - acute vs chronic causes
C - stiff - OA, RA,PA, - Intense - G, PG, SA
R - confined
A - fever (SA), psoriasis, fatigue (RA)
T - mane (ra), activity (oa), persistent think acute
E - ra not worse on movement
S - Acute more severe

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4
Q

Red flags of SA

A

Fever, systemically unwell, acute, prothetic joint
* red hot swollen, increasing tender with limited range of movement

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5
Q

Obs to monitor in Joint pain

A

Temp, sepsis signs

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6
Q

Examination things to look for in joint exams

A
  • surgical scars
  • limited range of movement
  • red hot swollen
  • heberdens (distal) and bouchard (proximal) nodes
  • swan neck & boutonniere (flexed proximal, hyperextended distal - can see in ehlers danlos)
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7
Q

SA mx and ix

A
  1. Infection of joint space that can cause rapid joint destruction
  2. Joint aspirate to microscopy needle -ve and rhomboid +ve for the gouts
  3. FBC & CRP & BCs before treatment
  4. XR - for trauma
  5. ABs - cluster in cocci = s.aureus
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8
Q

SA antibiotics

A

2 week IV abs
4 week oral abs

ortho for arthrocentesis if prosthetic joint

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9
Q

What should be asked about a patients background with cough?

A
  • Older - cancer, copd, ild
  • young - postnasal drip, asthma
  • drugs - acei, methotrexate
  • smoking
  • occupation - ild, eaa, pneumoconiosis
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10
Q

Causes of cough

A
  • u airway - post nasal drip (mucus from nasal mucosa drips along nasopharynx into larynx)
  • l airway - pneumonia, copd, asthma, lung cancer (red flags), bronchiectasis (recurrent chest infections with blood)
  • parenchyma - ild (occupation), pulmonary oedema (hf)
  • drugs
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11
Q

Red flags with cough

A
  • haemoptysis
  • weight loss
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12
Q

Assessment of cough

A
  • observe for tachypnoeic and saturations - acute
  • in chronic cases - sats may need to be scale 2
  • fever
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13
Q

Examination of cough

A
  • lung cancer - cachetic, monophonic wheeze
  • polyphonic wheeze for a, copd, bronchiectasis - multiple sounds at once
  • ild - fine inspiratory crackles
  • clubbing - cancer, bronchiectasis, ild
  • pneumonia - coarse crackles, bronchial breathing sounds
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14
Q

Ix Lung cancer

A
  • FBC - haemoptysis
  • CXR
  • CT scan
  • biopsy, bronchoscopy, image guided techniques
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15
Q

Mx Lung cancer

A
  • chemo + radio + lobectomy
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16
Q

What should be asked about a patients background with diarrhoea?

A
  • young - IBD / Coeliac
  • chronic change in elderly - cancer
  • lifestyle - takeaways
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17
Q

Differentials for diarrhoea

A
  • acute- food poisoning, gastroenteritis, infectious colitis
  • talk about close contacts / travel
  • IBS = younger - flucuating with constipation / bloating
  • hyperthyroidism - increase MR increase motility - anxiety, sweting, tremor, heat intolerance, diarrhoea
  • colorectal - ida
  • fp - after food
  • gastroenteritis - close contact
  • infectious colitis - watery in elderly completed course of ABs, e.g. clindamycin, ciprofloxacin, co-amoxiclav and cephalosporins
  • IBD - RIF pain, UC - rectal bleeding
  • coeliac - wont flush away (steatorrhoea and weight loss), rash on exxtensors (dermatitis herptiformis), fhx
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18
Q

Red flags diarrhoea

A
  • PR Bleeding if chronic
  • acute - ischaemic colitis, ibd, infection
  • IBD increases around 50-60 as well
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19
Q

How to assess diarrhoea

A
  • assess for dehydration - tachycardia, hypotension
  • fever
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20
Q

Examination for diarrhoea

A
  • gloves and gowns
  • generalised discomfort might be ibd
  • tumour may be palpable
21
Q

Mx of gastroenteritis

A
  • inflammation of stomach and small bwoel due to viral infection
  • ischaemic colitis is the colon
  • Ix - stool culture and pcr, u&e - check pre renal AKI
  • resolve, fluids, if bacterial e.g. campylobacter consider antibiotics such as clarithomycin (macrolide)
22
Q

How do macrolide act

A
  • binding to the 50S ribosomal subunit of bacteria, which stops bacterial protein synthesis
23
Q

What should be asked about a patients background with iliac fossa pain?

A
  • sex - e.g. female reproduction
  • ask about trans if needed
  • ask about heavy bleeding / fibroid history
  • previous surgical history
24
Q

Differentials for iliac fossa pain

A
  • appendicitis, inguinal hernia, ibd, bowel obstruction, intestinal ischaemia
  • ectopic, ovarian cyst, PID
  • urinary tract calculi, uti
25
Q

SOCRATES for IF pain

A
  • S - right (appendicitis), left (diver), either (everything else
  • O - sudden = torsion, calculi, ischaemia, cyst, incarcerated hernia - gradual = appen, ibd, diver, obstruction, pid, ectopic, uti
  • C - intense - torsion, calculi, dull - appen, ibd, diver, ectopic, uti, bowel obstruction, ischaemia
  • R - loin - calculi, umbili to right - appen
  • A - discharge / irregular bleeding- PID, ectopic preg, dysuria - uti, calculi - diarrhoea / pr bleeding - IBD, diver, intestinal ischaemia
  • Timing - wax and wane - calculi, perisistent = everything else
  • E - sex - PID, eating - intestinal ischaemia
  • S - Calculi and torsion = worst pain

A - vomiting + fever

inguinal hernia - not reduce, vomit, not able to pass faeces or flatus

ischaemia - acute = sudden with hypotension, previous abdo surgery
- chronic - after eating due to gut claudication
- colitis = left sided with bleeding
- urine smell for uti / sti

26
Q

Red flags for IF pain

A
  • absolute constipation with pain and vomiting - SBO
  • fever
  • sudden onset of pain
  • rectal bleeding / vaginal bleeding
27
Q

Assessment and examination of IF pain

A
  • looking for fever, tachycardia, tachypnoea
  • surgical scars, distended abdomen with no bowel sounds
  • guarding (voluntary contraction of muscles) / rebound tenderness (stab of pain when abdomen pushed slowly down then released suddenly) - peritonism
28
Q

Torsion ovarian Mx and Ix

A
  • ovary rotates among vascular pedicle
  • urinalysis and pregnancy test
  • speculum examination
  • serum hCG
  • clotting screen
  • G&S
  • transvaginal ultrasound scan - whirlpool sign
  • iv fluids, detortion, salpingo-oophorectomy
29
Q

What should be asked about a patients background with dysuria?

A
  • gender - women = uti, older men - bigger prostate, youth - sti
30
Q

Differentials of dysuria

A
  • Lower UTI - cystitis, sti, genitourinary syndrom (atrophic vaginitis), BPH, prostatitis
  • Upper - calculi, pyelonephritis
  • older - urinary retention - could be caused by BPH or constipation
  • urine usually smells, look for discharge, dryness of vagina / dyspareunia
  • BPH - voiding symtpoms - hesitancy, incomplete emptying, poor stream, straining + storage (frequency, urgency, nocturia, dysuria)
  • pain on defecation - prostatitis
  • fevers
31
Q

Red flags of dysuria

A
  • frank haematuria and weight loss usually painless
  • rigor and fever + organ hypoperfusion lead to sepsis and AKI
32
Q

assessment and examination of dysuria

A
  • look out for fever, hypotension, tachycardia
  • lower abdo discomfort, renal angle tenderness where kidney and 12th rib meet
  • enlarge bladder
  • dry and inflammed genitals
33
Q

Mx of Genitourinary syndrome

A
  • low oestorgen levels leading to thin and fragile vaginal mucosa leading to dyspareunia, post menopausal bleeding and dysuria
  • urinalysis - leucocytes and nitrites
  • post void bladder scan
  • FBC for any bleeding
  • ultrasound with any postmenopausal bleeding
  • mx - lubricants, moisturisers, topical and systemic oestrogens
34
Q

What should be asked about a patients background with right upper quadrant pain?

A
  • age and sex - gallstone overweight, obese, over 40
  • alcohol - hepatitis, increased risk of pancreatitis
  • NSAID - ulcers
35
Q

Differentials of RUQ pain

A
  • hepatic - viral, autoimmune and hepatic hepatitis - subacute ruq pain - screen endemic, sex, ivdu
  • bilary - gallstones, intermittent pain worse after fatty meal, presence = cholecystitis - blocks flow of common bile duct = ruq, jaundice and fever - charcots triad
  • pancreatitis - gallstone can cause that + alcohol
  • pneumonia, PE if also resp disease signs tachypnoea and cough
  • righ kidney - colic and pyelonephritis
36
Q

SOCRATES of RUQ pain

A
  • S - if flanks = calculi
  • O - rapid - calculi, subacute - hepatitis, gallstone, pud, pancreatitis, lower lobe pneumonia, pyelonephritis
  • C - dull pain, pleuritic pain
  • R - shoulder - hepatitis, cholecystitis, acute cholangitis, back - pancreatitis, groin - calculi
  • A - bowel - gallstone (steatorrhoea), PUD (melaena), jaundice (hepatitis and gallstone), sob pneumonia, dysuria calclui and pyelonephritis
  • T - persistent - hep, chole, cholangitis, lower lobe pneumonia, pyelonephritis, wax and wan - uti, bilary colic, intermittent -PUD
  • E - after meals - colic, PUD - gastric worse after eating
  • S - colic and pancreatitis
37
Q

Red flags of RUQ pain

A
  • acute cholangitis - sepsis
  • radiates to back - pancreatitis
  • tachypnoeic - sepsis
  • haematemesis and melaena - perforated peptic ulcer
38
Q

Assessment an examination of RUQ pain

A
  • fever, tachycardia, hypotension
  • hypoxia
  • murphys sign - pain on deep inspiration
  • visibly icteric (jaundice)
  • rigid, tender abdomen - perforated ulcer
  • renal angle tenderness
  • haemorrhagic pancreatitis - grey and cullens signs
  • basal crepitations
39
Q

Mx and Ix of acute cholangitis

A
  • biliary system infection not just gallbladder
  • usually due to obstructing gall stone
  • urinalysis - negative urobilinogen, bile not flowing to intestines
  • vbg - lactic acidosis and bilirubin = severe infection
  • fbc and crp and lft
  • alp and ggt raised. = obstructive pattern
  • blood cultures
  • clotting screen and g&s
  • amylase for pancreatitis
  • abdo ultrasound = dilated bile duct
  • ctap
  • mrcp - mri that visualises bilary tree and ercp - is scope in - dye into tree and remove obstructing stone

sepsis 6 is needed - ercp, percutaneous bilary drainage or cholecystostomy

40
Q

What should be asked about a patients background with confusion?

A
  • age - old - infections
  • young - drugs
  • cognitive baseline / impairment
  • frailty score
  • alcohol excess, wernickes encephalopathy and subdural
41
Q

Differentials for confusion

A
  • older - delirium - acute confusional state caused by an acute health problem
  • dementia
  • subdural in elderly
  • intoxication, CNS inflammation - seizures and reduced CNS
  • brain tumours
  • metabolic disturbances - hypoglycaemia, hyponatraemia, hypercalcaemia
    *
42
Q

Red flags with confusion

A
  • altered gcs
  • seizures
  • focal neurology
  • loss of consciousness - airway
  • fever - sepsis - intracranial
  • head injury
43
Q

Assessment and examination of confusion

A

fever - intracranial infection
* cushings triad - bradycardia, hypertension, irregular bleeding - increase intracranial pressure
* lateralising neurology e.g. unequal pupils, highly suggestive of intracranial
* brudzinskis and kernig signs
* brud - hips and knees flex involuntarily after their neck is passively flexed.
* kernig - experiences pain or is unable to extend their knee past 135 degrees when their hip is flexed to 90 degrees.

44
Q

Mx and Ix Encephalitis

A
  • inflammation of brain parenchyma due to infection or autoimmune attack
  • confusion, seizures, drowsiness
  • HSV
  • GCS, 4AT
  • VBG
  • FBC & CRP
  • Blood cultures
  • Ct head
  • Mri head
  • lumbar puncture
  • EEG
  • iv aciclovir
  • strep pneumoniae, neisseria and listeria can be treated with ceftriaxone
  • autoimmune encephalitis - steroids, ivig, plasmapheresis, immunomodulating drugs
  • seizures - anticonvulsants
45
Q

What should be asked about a patients background with N&V?

A
  • previous surgery - bowel obstruction
  • changes to medications
  • recreational drug use e.g. cannabis
46
Q

Differentials for N&V

A

GI - abdo pain / change in bowel habits - gastroenteritis, ibd etc - bo - absolute bowel obstruction

CNS - headache - tumour, migraine, infection

ENT - hearing changes, vertiginous symptoms - posterior stroke - HINTS

Metabolic - DKA - hyperosmolar hyperglycaemic state

Adrenal insufficiency - fatigue
postural hypotension / skin pigmentation
with hyperkalaemia and hyponatraemia

47
Q

Red flags for vomiting

A
  • absolute constipation
  • abdominal distension
  • previous abdominal surgery
  • headache, drowsiness, confusion, seizures
48
Q

Assessment and Ix of Vomiting

A
  • dehydrated - tachycardic, hypotensive
  • fever - infection
  • check aspiration sigsn - tachypnoea, desaturation
  • abdominal tenderness
  • distension with vomiting = BO
  • absent bowel sounds
  • reduced GCS
  • nystagmus
49
Q

Mx and Ix of BO

A
  • disrpution of normal passage through bowels due to mechanical obstruction
  • DRE - confirm rectum is empty
  • VBG - lactic acidosis
  • e.g. tissue hypoxia in bowel obstruction
  • U&E, bone profile and magnesium
  • axr - CT abdomen and pelvis with contrast e.g. tumour
  • Drip and suck with a ryles tube, decompress system
    • iV fluids
  • gastrograffin follow through
  • emergency laparotomy
  • adhesiolysis
  • hernia repair if needed
  • flatus for large bowel

F1 notes (3 decks)

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