Cases in general internal medicine 2 Flashcards
At what level of Hb would you probably see SoB at
Why might you have a raised JVP in COPD
Below 80
Because of right heart failure secondary to pulmonary hypertension secondary to COPD
Onset of breathlessness; seconds
- Pneumothorax
- PE
- FB (foreign body! Don’t forget this one)
Onset of breathlessness; mins/hrs
- Airways (inflammation/obstruction)
- Chest infection (pus)
- Acute heart failure (fluid)
Onset of breathlessness; days/weeks
These(chronic/not resolving):
- Airways (inflammation/obstruction)
- Chest infection (pus)
- Acute heart failure (fluid)
AND:
- Interstitial lung disease
- Malignancy/ Large pleural effusion
- Neuromuscular
- Anaemia/ Thyrotoxicosis
What is a primary pneumothorax
A primary spontaneous pneumothorax is one that occurs without an apparent cause and in the absence of significant lung disease
What is the management of primary pneumothorax
< 2 cm:
– Discharge, repeat CXR
> 2 cm OR THEY HAVE SOB:
– Aspiration
– If unsuccessful: chest drain
What is management of secondary pneumothorax
< 2 cm:
– Aspiration
> 2 cm:
– Chest drain
What could cause breathlessness after a chest drain insertion
Re-expansion pulmonary oedema
What is are lung bullae
A bulla is a permanent, air-filled space within the lung parenchyma that is at least 1 cm in size and has a thin or poorly defined wall;
NOT to be confused with pneumothorax!
You wouldn’t put a chest drain in for bullae.
Aka vanishing lung disease
When can it be called asbestosis
You can only call it asbestosis when there is pulmonary fibrosis
Asbestos lung disease gives you plaques, but this is not asbestosis
What are the types of opacity on xray and what are their respective DDx
- Interstitial/alveolar shadowing (=fluid, pus, blood)
- Reticulo‐nodular shadowing (fibrosis)
- Homogeneous shadowing (pleural effusion)
- Masses/cavitations
If a patient has a PE what drug do you think about in the first instance
LMWH (e.g. dalteparin)
If the x ray is very white, what can you say about penetration
Too white= underpenetrated
Should you be able to see the left hemidiaphragm behind the heart?
Yes you should! If you can’t, there’s something going on (e..g tumour or consolidation)
Air fluid level on X-ray/CT and reduced BS, hyper-resonant percussion notes
Bullous disease. Do not put drain in
……….
…….
……..
………
……….
………
……….
………
………..
………..
………..
………
ABDO…..
……..
Causes of hepatomegaly
• Cancer (primary or secondary deposits) • Cirrhosis (early, usually alcoholic) • Cardiac: – Congestive cardiac failure – Constrictive pericarditis
Infiltration
Give examples of infiltration causing hepatomegaly
Fatty infiltration, haemochromatosis, amyloidosis,
sarcoidosis, lymphoproliferative diseases
Causes of liver disease
Alcohol • Autoimmune • Drugs • Viral • Biliary disease
Causes of splenomegaly
H (portal Hypertension)
H (Haematological)
Infection
Inflammation
- 75 year old man
- Epigastric pain
- Back pain
- PR: 130 bpm
- BP: 80/50 mm Hg
Likely diagnosis?
A. Peptic ulcer B. Pancreatitis C. Gastritis D. GORD E. Ruptured aortic aneurysm
E. Ruptured aortic aneurysm
Endo causes of acute abdominal pain
DKA
Addison’s
Epigastric pain DDx
Peptic ulcer
Gastritis
GORD
Malignancy
Acute pancreatitis
MI
ALSO:
• Above (heart) – MI • Below (Aorta) – ruptured aortic aneurysm • Right: (liver/gall bladder) – Cholecystitis – Hepatitis
What things point to acute pancreatitis
- Pain
* High amylase
What is the test for chronic pancreatitis
Normal amylase Faecal elastase (so need a stool sample)
What things point toward chronic pancreatitis
Pain, wt loss
• Loss of exocrine function
• Loss of endocrine function
5 causes RUQ
Gall bladder:
– Cholecystitis
– Cholangitis
– Gallstones
Liver:
• Hepatitis
• Abscess
Above (lungs) – Basal pneumonia Below (appendix) – Appendicitis Left (Stomach, pancreas) – Peptic ulcer, Pancreatitis Right: (kidney) – pyelonephritis
When ballotting the kidney you need to put your hand right under the back and press on the right upper quadrant
…..
RIF pain
GI – Appendicitis – Mesenteric adenitis – Colitis (IBD) – Malignancy
Gynae
– Ovarian cyst rupture, twist, bleed
– Ectopic pregnancy
Suprapubic pain
- Cystitis
* Urinary retention
LIF pain
GI
Diverticulitis
Colitis (IBD)
Malignancy
Gynaecological
Ovarian cyst rupture, twist, bleed
Ectopic pregnancy
Causes of diffuse abdo pain
Obstruction
Infection: Peritonitis, Gastroenteritis
Inflammation: IBD
Ischaemia: Mesenteric ischaemia
Medical causes DKA Addison’s Hypercalacemia Porphyria Lead poisoning
…..
……
…….
……
…….
…….
Ascites with cells greater than what is consistent with SBP
> 250 cells/mm3
3 causes of abdo distension
- Fluid (ascites- shifting dullness + signs of chronic liver disease)
- Flatus (obstruction)
- Fat, faeces, fetus
Signs of obstruction
Nausea, vomiting Not opened bowel High-pitched tinkling BS ?Previous surgery (adhesions) ?Tender irreducible femoral hernia in the groin
Types of ascites
Transudate
Exudate
Types of transudate ascites
Cirrhosis
Cardiac failure
Nephrotic syndrome
Types of exudate ascites
Remember this is calculated using SAAG
Malignancy (abdominal, pelvic, peritoneal mesothelioma)
Infection: e.g. TB, pyogenic
EXCEPTIONS (these are due to low serum albumin rather than high ascites alubimin)
Budd–Chiari syndrome (hepatic vein thrombosis), portal vein thrombosis
Classify jaundice with causes of each
Pre-hepatic
-Haemolysis, defective conjugation
Hepatic
-Hepatitis
Post hepatic
-CBD Obstruction
…….
…….
……..
……..
Investigation to do for bloody diarroeah?
MSC of the stools to look for the bacteria below
Blood diarroea causes
Infective colitis
Inflammatory colitis
Ischaemic colitis
Diverticulitis, Malignancy
Bacteria causing infective colitis
Campylobacter Haemorrhagic E coli Entamoeba histolytica Salmonella Shigella
Who is inflammatoy colitis (IBD) common in, and who is it more common in
Young, Extra-GI manifestations
Who is ischaemic colitis present in
Elderly
Obsructed bowel what blood markers could be high
Lactate and CK
Management of acute GI bleeds
What if you find it is a variceal bleed
When do you give antibiotics
ABC IV access Fluids G&S, X-match blood OGD
Variceal bleed
- Antibiotics
- Terlipressin
Investigations for acute abdomen
FBC, U&Es, LFTs, CRP, Clotting, G&S, X-match
Erect CXR
CT
Management of acute abdomen
NBM Fluids Analgesic Anti-emetics Antibiotics Monitor vitals & UO
Investigation for jaundice
Bloods: FBC, LFTs, CRP
Abdominal USS
after a fast (gallstones better visualized in a distended, bile-filled gallbladder)
Investigations for dysphagia and weight loss
OGD & Biopsy
Investigations for PR bleed and wt loss
Colonoscopy
Management of ascites
Diuretics (spironolactone ± furosemide)
Dietary sodium restriction
Fluid restriction in patients with hyponatraemia
Monitor wt daily
Therapeutic paracentesis (with IV human albumin)
What calculation should you do for ascites and what can it tell you
The gradient
Serum albumin-ascites albumin:
> 11g/L:
Cirrhosis, Cardiac failure
<11 g/L:
TB, Cancer, (Nephrotic syndrome)
Why will the gradient between serum albumin and ascites albumin be low in nephrotic syndrome
Becuse the serum albulin is low because you leak proteins into the urine
How do you manage encephalopathy
Lactulose
Phosphate enemas
Avoid sedation
Treat infections
Exclude a GI bleed
Why would you want to exclude a GI bleed in encephalopathy
Because someone with chronic liver disease is prone to a GI bleed, and the blood will act as a substate for bacteria in the GI tract to metabolise and produce toxins from
Why do you give lactulose in encephalopathy
To reduce transit time so that there is less time for bacteria to make toxins
Post-op care complications in abdo surgery
Wound infection
Anastomotic leak
Pelvic abscess
e.g. post-appendectomy
What are the featres of wound infection
Erythematosus
Discharge
What are the features of an anastomotic leak
Diffuse abdo tenderness
Guarding, rigidity
Hypotensive/tachycardic
What are the features of pelvic abscess (e.g. post-appendectomy)
Pain, fever, sweats, mucus diarrhoea
Presentation and treatment of a perianal abscess
Tender, red swelling
Incision & drainage
Presentation and treatment of an anal fissure
Rectal pain (defaecation)
Stool coated with blood
Advice re diet (fluids, fibre)
GTN cream
Presentation of IBS
Recurrent abdo pain, bloating
Improves with defecation
Change in the frequency/form of stool
What red flags might be seen with IBS
No PR bleed, anaemia, wt loss or nocturnal symptoms, exclude Coeliac
A good question to ask somebody you suspect to have IBS/IBD
Is there nocturnal symptoms
IBD have them IBS don’t
Treatment for IBS
Diet & Lifestyle modification
Symptomatic treatment:
- Abdo pain: antispasmodics
- Laxatives for constipation
- Anti-diarrhoeals
Respiratory assocaited symptoms to ask about?
WBC:
Wheeze, breathlessness, cough (then leads you onto… ) sputum, haemoptysis, weight loss
Chest pain
What is ciclosporine main side effect
Use as immunosuppresant following renal trasplant
Cause gum hypertrophy
Retrosternal pain with high alcohol consumption
Gastritis
