Common presentations NOS Flashcards
How do u assess pt p/w PR bleeding?
- Sx: nature of bleeding (blood mixed in with stool often higher up, bright red fresh often lower down), quantity pt has noticed, WL, change in bowel habit (frequency + consistency), tenesmus (e.g. in fissures), anal sx (sore/pain in fissures, itch in haemorrhoids)
- FH of bowel Ca/polyposis, PMH, DH e.g. aspirin
- Examination: pallor, CV shock, obvious WL, abdo masses, hepatomegaly,
- Stool: blood mixed with stool (darker, often left colon/transverse colon from cancer or IBD), shiny black/plum coloured (melaena, higher bleeding), bright red (suggests rectum/anus, if clearly separate from stool usually anal), blood on surface of stool (may be anal or may be rectum/DC lesion)
- DRE: usually needed to confirm blood in rectum + exclude rectal masses, essential if referring to secondary care
Causes of PR bleeding
Common: o Diverticular disease inflammation o Colon polyps or carcinoma, or anal cancer o Haemorrhoids o Anal fissure, fistula-in-ano o IBD – CD, UC (younger)
Less common:
oAngiodysplasia (common in elderly, AV malformation)
o Infectious gastroenteritis
o Massive upper GI bleeding
o Radiation proctitis
o Ischaemic colitis – mesenteric vascular insufficiency
o Solitary rectal ulcer
o Dieulafoy’s lesion – submucosal bigger artery in GIT, brisk bleeding with little/no ulceration, most common in stomach but can be anywhere, pain uncommon
o Endometriosis
o Meckel’s diverticulum (children more common than adults)
o Rectal varices
o Trauma e.g. sexual abuse
o STI
What are haemorrhoids and what causes them?
Anal mucosal pads become enlarged + congested, can cause anal pain, pruritis ani + bright PR bleeding
May be related to constipation, prolonged straining, increased anal sphincter tone and obstructed venous flow (e.g. in pregnancy)
Types of haemorrhoid
Internal (usually painless, origin above dentate line)
External (origin below dentate line). Grade I no prolapse, grade II prolapse on defecation then reduce, grade III need manual reduction, grade IV can’t be reduced
Sx of haemorrhoids
bleeding after defecation (paper or in faeces or may be lots in pan), soiling, mucus discharge, pruritis ani, sometimes pain (e.g. thrombosis), rectal mass, tenesmus
Differentials for a pt with ‘haemorrhoids’
perianal haematoma (covered by skin, whereas haemorrhoids mucosal-covered), rectal prolapse, anal fissure, anal polyp, IBD, rectal Ca
Haemorrhoid infarction
cushions get engorged – severe pain, local swelling, looks black/blue, local oedema. Bed rest, analgesia, stool softeners. Most resolve with time
How are haemorrhoids managed?
dry + wash perineum after defecation, digital replacement to relieve sx, local anaesthetic creams, treatment to reduce spasm of internal sphincter (GTN ointment [unlicensed], botulinum toxin injection). Can also have some surgical management. Prevent with more fibre in diet or bulking agents
Features of bladder outflow obstruction
Voiding/obstructive sx: weak/intermittent stream, straining, hesitancy, terminal dribbling, incomplete emptying
Storage/irritative sx: urgency, frequency, urge incontinence, nocturia
Post-micturition sx: dribbling
Haematuria unusual but may be due to rupture of veins over an enlarged prostate, or obstructing bladder tumour
BPH
unusual before 50, transitional zone affected which compresses prostatic urethra.
Medical treatment if bothersome LUTS – alpha blocker (doxazosin, alfuzosin, tamsulosin, terazosin), or 5-alpha reductase inhibitor if high risk of progression/v big prostate (e.g. finasteride). Poss also anticholinergic if still storage issues
Prostate Cancer
RF are age, black African/Caribbean origin, FH, BRCA1/2 mutation, possible link to diet, smoking
CF: LUTS, urinary retention, haematuria/haematospermia, pain (back, perineal, testicular), constipation, anuria, uraemia, SUI, bone pain/#/hypercalculaemia/MSCC, lung mets, liver mets pain/jaundice, brain-fits, pelvic LN causing swollen legs/scrotal oedema
GP Ix are DRE, PSA, U+E (renal), LFT (raised LFTs – liver mets), bone profile
Ix that may be done at referral include MRI and TRUS with biopsy
Bladder neck dysfunction
younger men, bladder neck doesn’t open properly when voiding. Urodynamics diagnosis. Can try alpha blockers, or a cystoscopic bladder neck incision
Urethral strictures
leads to backflow. May be congenital, or acquired through catheterisation, radiotherapy, trauma, infective, neoplastic from prostate/TCC/SCC. Can do urethral dilatation, or an actual surgery
Blepharitis
Inflammation of lid margins +/- lashes/lash follicles. Can lead to styes or chalazions. May be meibomian gland dysfunction, seborrhoea or S aureus (i.e. usually not infectious but can be).
CF: asymptomatic, or itchy burning eyes due to unstable tear film. Crusty scaly deposits on lashes, may see meibomian glands plugged with secretions, or lid may swell if block. Pt often c/o eye feeling dry, but it may actually be watering
M: lid hygiene to reduce bacteria + unblock MGs (this involves clean warm compresses, lid massage, mixing baby shampoo with warm water and using cotton bud on lid margin). If chronic topical chloramphenicol/fusidic acid may be needed, or oral doxycycline if severe
Tinea capitis
Scalp ringworm
children > adults. Dermatophyte scalp infection. Can be spread through hairbrushes, clothing, towels.
Presentation – dry scaling, moth-eaten hair loss, black dots (hairs broken off at scalp surface), smooth areas of hair loss, kerion (very inflamed mass), favus (yellow crust, matted hair) or carrier state. May get swollen LNs
M: adv soften crusts with moistened dressings, discard/disinfect things like hairbrushes/scarves/pillows, don’t share towels, treat any pets. Give oral antifungal if there is positive skin + sample – usually griseofulvin for 4-8w. Consider also topical antifungal
Comps – secondary cellulitis or impetigo
