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Internal Medicine General > Deck 1 > Flashcards

Deck 1 Flashcards

1
Q

What is a mnemonic for the causes of clubbing?

A

CLUBBING ABCDEF

Cyanotic heart disease
Lung disease
UC + Crohn's 
Biliary Cirrhosis
Birth defects
Infective Endocarditis
Neoplasm
GI malabsorption syndrome (celiac)
Abscess
Bronchiectasis 
Cystic Fibrosis
DONT SAY COPD
Empyema
Fibrosis
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2
Q

DDx lower GI bleeding

A 
Colorectal cancer or polyps
Diverticulosis 
Angiodysplasia 
Anorectal disease
Enterocolitis
Brisk bleeding from upper GI
Rectal trauma

**pay particular attention to the hemodynamics lily unstable patient

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3
Q

DDx upper GI bleed

A
  1. Ulcerative or erosive processes–> PUD, esophagitis, gastritis
  2. Portal HTN
  3. Trauma (I.e Mallory Weiss tear)
  4. Tumours
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4
Q

DDx hemoptysis

A
  1. Airway disease–> inflammatory (bronchiectasis, bronchitis); neoplasms (bronchogenic carcinoma); other (foreign body, trauma)
  2. Pulmonary parenchymal disease–> infectious (TB, necrotizing pneumonia); inflammatory/immune (vasculitis); other (coagulopathy)
  3. Cardiac/vascular–> PE with infarction; elevated capillary pressure (mitral stenosis, LV failure); AV malformation
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5
Q

DDx abdominal distension

A
  1. Ascites–> low serum to ascites albumin ratio = exudative (peritoneal carcinomatosis); high serum to ascites albumin ratio = transudative (portal HTN)
  2. Bowel dilation–> mechanical obstruction (adhesions, volvulus); Paralytic (toxic megacolon, neuropathy)
  3. Other–> abdominal mass, IBS, organomegaly (hepatomegaly), pelvic mass (I.e ovarian cancer or others)
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6
Q

DDx hematuria

A
  1. Glomerular disease–> SLE, hemolytic uremic syndrome, vasculitis
  2. Post renal–> stones, bladder tumour, BPH, cystitis
  3. Haematological–> coagulopathy, sickle hemoglobinopathy
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7
Q

DDx cardiac arrest

A

CAD
Cardiac conduction abnormalities
Myocardial abnormalities
Non cardiac (I.e PE)

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8
Q

DDx chest pain

A
  1. Cardiac
    - -A. Ischemic –> ACS, stable angina pectoris
    - -B. Non-ischemic–> aortic aneurysm, pericarditis
  2. Pulmonary or mediastinal
    - -PE or pulmonary infarct
    - -Pleuritis
    - -Pneumothorax
    - -Malignancy
  3. GI
    - -esophageal spasm or esophagitis
    - -PUD
    - -Mallory Weiss syndrome
    - -biliary disease or pancreatitis
  4. Anxiety disorders
  5. Chest wall pain (I.e costochondritis)
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9
Q

DDx dyspnea

A
  1. Cardiac
    - myocardial dysfunction (I.e ischemic cardiomyopathy)
    - valvular heart disease
    - pericardial disease (I.e tamponade)
    - increased cardiac output (I.e anemia)
    - arrhythmia
  2. Pulmonary
    - upper airway (foreign body, anaphylaxis)
    - chest wall and pleura (pleural effusion)
    - lower airway (asthma, COPD)
    - alveolar (pneumonia)
  3. Central (metabolic acidosis, anxiety)
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10
Q

DDx lymphadenopathy

A
  1. Localized
    - Reactive (I.e tonsillitis)
    - Neoplasticism (metastatic cancer)
  2. Diffuse
    - infectious (I.e viral)
    - inflammatory (I.e sarcoidosis)
    - neoplastic (I.e lymphoma)
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11
Q

DDx pleural effusion

A
  1. Transudative–> I.e CHF, nephrotic syndrome, cirrhosis
  2. Exudative–>
    - A. Infectious (parapneumonic, empyema, TB)
    - B. Neoplastic (primary, mets, mesothelioma)
    - C. Cardiac/vascular (I.e PE, collagen vascular disease)
    - D. GI (I.e ruptured esophagus, pancreatitis, chylothorax)
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12
Q

DDx hyperkalemia

A
  1. Increased intake (usually associated with low excretion)
  2. Redistribution
    - A. Decreased entry into cells–> I.e insulin deficiency, beta 2 blockade
    - B. Increased exit from cells–> I.e metabolic acidosis, rhabdomyolysis
  3. Reduced urinary excretion
    - A. Decreased glomerular filtration rate–>I.e acute or chronic kidney disease
    - B. Decreased secretion–> I.e aldosterone deficiency, drugs (I.e spironolactone)
    * *dont forget to order and ECG to look for changes! (“T waves you wouldn’t want to sit on”)
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13
Q

DDx hypokalemia

A
  1. Decreased intake (I.e anorexia nervosa)
  2. Redistribution (I.e alkalemia, insulin, beta 2 adrenergic stimulating drugs)
  3. Increased losses, either renal or GI (I.e vomiting/diarrhea)
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14
Q

DDx weight loss

A
  1. Decreased nutritional intake–> psychiatric disease (anorexia, bulimia, depression), medical disease (chronic illness, esophageal cancer), illicit drugs or meds (alcohol, opiates, cocaine, amphetamines, anti cancer drugs)
  2. Increased energy expenditure–> hormonal (I.e hyperthyroid), chronic illness (COPD, HF), malignancy, infection, excessive physical activity (I.e runners)
  3. Caloric loss–> malabsorption (I.e diarrhea), diabetes
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15
Q

Define heart failure

A

Occurs when the hearts function as a pump is inadequate to maintain adequate perfusion, or the heart is only able to do so at HIGHER FILLING PRESSURES

SYNDROME not a diagnosis –>must determine underlying etiology

CLINICAL dx, do not need to wait for an echo to diagnose (though an echo can give further info on the underlying pathology behind the clinical presentation of heart failure)

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16
Q

What are the two key questions to ask yourself about HF?

A
  1. What type of HF is it

2. What is the etiology

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17
Q

what should you ask on history for an upper GI bleed?

A
  1. blood–> hematemesis, coffee ground emesis, melena, hematochezia (if brisk)
  2. abdominal pain
  3. hx of gerd
  4. medications
  5. EtOH consumption
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18
Q

what to look for specifically on physical exam for an upper GI bleed

A
  1. vitals–> tachy? hypotension or HTN?
  2. signs of anemia
  3. signs of liver disease
  4. FOB
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19
Q

investigations for upper GI bleed

A 
CBC and diff
chem-7
LFTs and lipase 
INR, PTT, group and screen 
urea breath test
serology
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20
Q

how would you manage an upper GI bleed?

A
  1. keep patient NPO–> send for EGD–> can be either diagnostic only or therapeutic i.e bleeding control with epinephrine/thermal hemostasis, endoclips, hemospray
  2. pantoloc 80 mg IV bolus then 8mg/hr thereafter
  3. variceal bleeds require octreotide
  4. consider iron supplements and fluids–> transfusion if hemoglobin drops and/or symptomatic and/or large bleed
  5. advise patient of lifestyle changes
  6. hold offending meds i.e NSAIDs, bisphosphonates, anticoagulants
  7. if H. Pylori is a factor–> triple therapy: PPI +amoxicillin + clarithromycin // quadruple therapy: PPI + bismuth + tetracycline +metronidazole
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21
Q

DDx for lower GI bleed

A 
Common:
diverticulosis--> CT to assess
ischemic bowel--> lactate and CT angio
infectious--> SECSY bacteria 
hemorrhoids, fissure

Less common:
brisk UGIB
IBD (UC>CD)
CRC or bleeding polyps

Other: coagulopathy/thrombocytopenia, post surgical bleed

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22
Q

what to ask on history for a LGIB

A

characterization of blood

abdominal pain

PMHX–cancer, IBD, diverticulosis

medications–anticoagulants, NSAIDs

anemia sx

B symptoms

infection sx

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23
Q

what to look for on physical for LGIB

A

are they hemodynamically stable?–vitals
signs of anemia
abdominal tenderness/masses
rectal exam

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24
Q

investigations for a LGIB

A

CBC and diff
chem 7
PTT, INR, group and screen, lactate
liver panel
stool C+S, FOB
colonoscopy, consider and EGD if suspect UGI etiology
consider angiography if suspect ischemic bowel or vasculitis

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25
Q

treatment for LGIB

A

IV fluids–> transfuse if necessary
hold anti hypertensives and diuretics
consider vitamin K, FFP if needed

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26
Q

DDx of chronic/recurrent abdominal pain

A
  1. inflammatory
    - PUD
    - biliary colic
    - IBD
    - chronic pancreatitis
  2. neoplastic or vascular
    - recurrent bowel obstruction
    - mesenteric ischemia
    - sicke cell anemia
  3. toxin
    - lead poisoning
  4. other
    - mittleschmertz
    - endometriosis
    - porphyria
    - IBS
    - radiculopathy
    - abdominal wall pain syndrome
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27
Q

what should you make sure to rule out in acute upper abdo pain?

A

make sure you rule out thoracic sources like MI, pneumonia, dissecting aneurysm

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28
Q

DDx for acute inflammatory diarrhea

A
  1. bacterial
    - shigella
    - salmonella
    - campylobacter
    - yersinia
    - E. coli (hemorrhagic)
    - C. diff
  2. protozoal
    - entamoeba histolytica
    - strongyloides
  3. others
    - NSAIDs
    - IBD
    - ischemic
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29
Q

define inflammatory diarrha

A

when there is damage to the mucosal lining or brush border which leads to passive loss of protein rich fluids and a decreased ability to absorb these lost fluids

**blood only found in inflammatory diarrhea

diarrhea may be perfuse or very small in volume

often associated with abdominal pain and fevers/chills

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30
Q

define non inflammatory diarrhea

A

no damage to the mucosal lining… N/V may be present

NOT present: fevers, chills, blood in stool, severe abdo pain or tenderness

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31
Q

DDx non inflammatory diarrhea

A
  1. bacterial
    - S. aureus
    - C. perfringens
    - B. cereus
    - E coli (ETEC and EPEC)
    - salmonella enteritidis
    - vibrio cholera
  2. protozoal
    - giardia
  3. viral
    - rotavirus
    - norwalk
    - CMV
  4. drugs
    - antibiotics
    - colchicine
    - laxatives
    - antacids (magnesium)
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32
Q

what should you rule out first when patients present with bloody diarrhea

A

IBD

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33
Q

DDx chronic diarrhea

A
  1. inflammatory
    - IBD
    - infectious (TB, Cdiff, CMV, HSV)
    - ischemic bowel
    - radiation colitis
    - neoplasia
  2. secretory
    - stimulant laxatives
    - post ileal resection/cholescystectomy
    - bacterial toxins
    - vasculitis
    - neoplasia
    - addison’s disease
    - congenital syndromes
  3. steatorrheic
    - giardia
    - celiac sprue
    - chronic pancreatitis
    - chronis cholestasis
  4. osmotic
    - osmotic laxatives
    - lactose intolerance
    - chewing gum
  5. functional
    - IBS
    - constipation (overflow diarrhea)
    - anal sphincter dysfunction
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34
Q

DDx nausea/vomiting with abdominal pain and relieved by vomiting

A

gastric outlet obstruction
small bowel obstruction
GERD (regurg)

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35
Q

DDx nausea/vomiting with abdominal pain and NOT relieved by vomiting

A 
gallbladder disease
pancreatitis
MI
hepatitis 
infectious
gastroenteritis
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36
Q

DDx nausea/vomiting without abdominal pain and associated with headache/dizziness

A

cerebral tumor
migraine
vestibular disease
increased ICP

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37
Q

DDx nausea/vomiting without abdominal pain and with no other symptoms

A 
drugs
uremia
pregnancy
metabolic (hypercalcemia)
gastroparesis (i.e diabetes)
ketoacidosis
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38
Q

DDx abdominal distension with FLUID

A
  1. with portal HTN
    - cirrhosis
    - cardiac failure
    - hepatic vein thrombosis
  2. with normal portal pressure
    - cancer (especially OVARIAN)
    - pancreatitis
    - TB
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39
Q

DDx abdominal distension with flatulence

A 
functional bowel disease (IBS)
fibre
lactose intolerance 
chewing gum (sorbitol, mannitol)
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40
Q

DDx abdominal distension with reduced feces output

A

constipation
colonic obstruction
dysmotility

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41
Q

DDx abdominal distension–other

A

pregnancy
obesity
blood
large tumors

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42
Q

what is a mnemonic to remember a DDx for abdo distension

A 
the 6 Fs
Fat
Feces
Fetus
Flatus
Fluid
Fatal growth (large tumors)
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43
Q

DDx for jaundice with high UNconjugated bilirubin

A
  1. overproduction
    - hemolysis
    - ineffective erythropoeisis (i.e in megaloblastic anemias)
  2. decreased hepatic intake
    - gilbert’s syndrome
    - drugs (i.e rifampin)
  3. decreased conjugation
    - drug inhibition
    - Crigler-Nair syndromes type I and II
    - Gilbert’s syndrome
    - neonatal jaundice
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44
Q

DDx for jaundice with CONjugated bilirubin

A 
-common:
drugs
cirrhosis
inflammation (hepatitis of any cause)
infiltrative (i.e hemochromatosis)
familial disorders (dubin-johnson etc)
PBC
PSC
sepsis 
post op/TPN

-less common:
1. intraductal obstruction
gallstones
biliary stricture
parasites
malignancy (cholangioca)
sclerosing cholangitis
2. extraductal obstruction
malignancy (i.e pancreatic cancer or lymphoma)
mets in peri portal notes
3. inflammation

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45
Q

foods/substances that aggravate GERD sx

A 
EtOH
caffeine
tobacco
fatty/fried foods
chocolate
peppermint
spicy foods 
citrus fruits
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46
Q

typical symptoms of GERD

A 
heartburn 
acid regurd
sour regurg
water brash
sensation of lump in throat (globus sensation)
frequent belching

non-esophageal sx are poor predictors of reflux
i.e chronic cough, wheezing, sore throat, hoarseness, dental erosions

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47
Q

indications for gastroscopy in GERD

A

heartburn with red flags like bleeding and weight loss

persistent reflux sx or prior severe erosive esophagitis after therapeutic trial of 4-8 weeks of PPI 2x daily

history of esophageal stricture with persistent dysphagia

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48
Q

treatment for reflux

A

PPIs are most effective, relief in 80% of cases –usually need to be continued as maintenance

can use antacids, H2 blockers for on demand relief

diet helps the symptoms not the disease–avoid aggravating foods

the only beneficial lifestyle change is weight loss if obese and elevating the head of the bed at night if having nocturnal symptoms

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49
Q

complications of GERd

A

esophageal stricture disease
ulcer
bleeding
barretts esophagus/esophageal carcinoma

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50
Q

red flags of dyspepsia that raise suspicion of gastric malignancy

A 
unintended weight loss
persistent vomiting 
progressive dysphagia
odynophagia
unexplained anemia or iron deficiency
hematemesis
jaundice
palpable abdominal massor lymphadenopathy
family history of GI cancer 
previous gastric surgery
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51
Q

what is Carnetts sign

A

during exam for dyspepsia—indicates an abdominal wall muscle problem

pain increases during muscle contraction (i.e sit up)

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52
Q

how is gastritis defined

A

histologically–inflammation of the stomach mucosa

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53
Q

define PUD

A

focal defects in the mucosa that penetrate the muscularis mucosa of the stomach or duodenum resulting in scarring

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54
Q

etiology of PUD

A 
h pylori infection 
NSAIDs
physiologic stress induced 
ZE syndrome
idiopathic
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55
Q

6 classical features of duodenal ulcers

A 
epigastric pain
burning
develops 1-3 hours after meal
relieved by eating and antacids
interrupts sleep
periodicity 
*duodenal ulcers are rarely malignant

*gastric ulcers have more atypical symptoms and a biopsy is necessary to exclude malignancy

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56
Q

investigations for PUD

A

endoscopy
upper GI series
h pylori tests
fasting serum gastrin measurement if ZE suspected

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57
Q

approach to PUD

A

stop NSAIDs
acid neutralization
h pylori eradication
quit smoking

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58
Q

management of bleeding peptic ulcers

A

EGD to explore upper GI tract
IV panto drip
estbalish risk of rebleeding or continuous bleed since most stop bleeding spontaneously
–increased age above 60, history of PUD, comorbid disease, hemodynamically unstable or endoscopic signs of recurrent bleeding
if high risk for rebleed consider ICU admission

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59
Q

how do NSAIDs cause PUD

A

direct–> erosions/petechiae via local effect of drug on gastric mucosa

indirect–> systemic NSAID effect–> inhibits mucosal COX leading to decrease synthesis of protective prostaglandins and thus leading to ulcers

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60
Q

risk factors for stress induced gastric ulceration

A 
mechanical ventilation
anticoagulation
multiorgan failure
speticemia
severe surgery or trauma
CNS injury ("cushings ulcers")
burns involving more that 35% of body surface
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61
Q

What does stroke volume depend on?

A

Preload, after load and contractility

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62
Q

What determines cardiac output

A

Heart rate and stroke volume

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63
Q

Why is there reduced cardiac output in HF?

A

Either:

  1. Impaired ventricular filling–> diastolic failure
  2. Impaired ventricular ejection–> systolic failure
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64
Q

What is systolic heart failure?

A

HFrEF–>reduced ejection fraction

Decreased myocardial contractility which results in low EF

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65
Q

What is diastolic heart failure

A

HFpEF–> preserved contractility and EF but with impaired cardiac compliance

Higher filling pressures for a given LV volume–> increased filling pressures reflect back into the pulmonary and systemic circulations which results in overload sx
The ventricle can’t fill adequately and thus you get decreased preload and thus decreased CO–> fatigue, lethargy, ischemia
If the echo is normal with clinical signs of HF you have HFpEF

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66
Q

How do you distinguish between “forward failure” and “backward failure” in heart failure?

A
  1. Forward failure = COLD failure
    - -usually requires CCU admission as it is more severe
    - -heart is not pumping enough blood to meet organs needs–> under perfusion of brain, kidneys, periphery
    - -can’t diurese these patients without pressor support
  2. Backwards failure = WET failure
    - -fluid backs up because heart “can’t keep up”
    - -volume overload–> pulm edema, SOB, peripheral edema
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67
Q

What are the two defining characteristics of systolic dysfunction? With these in mind, what can cause systolic dysfunction?

A
  1. Impaired contractility–> myocardial ischemia/infarction, chronic volume overload, dilated cardiomyopathy
  2. Increased after load–> aortic/pulm stenosis, HTN
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68
Q

What are the two defining characteristics of diastolic dysfunction? With this in mind, what can cause it?

A
  1. Impaired relaxation–> LVH, HOCM, restrictive cardiomyopathy, MI
  2. Obstruction to filling–> mitral/tricuspid stenosis, pericardial constriction, tamponade
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69
Q

What is the pathophysiology behind CHF?

A

Decreased CO leads to activation of the RAAS and sympathetic systems, which further exacerbates CHF

CHF is a disorder of neurohormonal dysregulation

Sympathetic stimulation–> vasoconstriction–> increased after load

RAAS stimulation–> fluid retention–> volume overload

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70
Q

What are some causes of restrictive cardiomyopathy?

A

Sarcoidosis, amyloidosis, hemochromatosis

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71
Q

What are the different classes that make up the NYHA classification system for heart failure?

A

I–sx with extraordinary activity
II–sx with ordinary activity
III–sx at less than ordinary activity
IV–sx at rest

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72
Q

What is a mnemonic for causes of acute CHF exacerbation?

A

FAILED

Failed to take meds
Anemia, arrhythmia 
Ischemia, infection, infarction
Lifestyle indiscretion--increased salt or fluid intake
Endocrine (TSH), EtOH
Drugs (NSAIDs, steroids)
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73
Q

What types of things should you ask on history for heart failure?

A
  1. Characterize the symptoms
    - -dyspnea, Orthopnea, PND
    - -pedal edema, ascites, RUQ pain (liver congestion)
    - -fatigue
  2. Investigate the cause
    - -Hx of HTN, CAD, valvular disease, arrhythmias
    - -cardiac risk factors
    - -Hx of anemia, thyroid disease, pregnancy
    - -recent flu–?myocarditis
    - -EtOH
    - -family history of dilated or hypertrophic cardiomyopathy or of hemochromatosis
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74
Q

What should you be looking for in particular on a physical exam for HF?

A
  1. ABCs/general/vitals
    - -BP, tachy/Brady, hypoxia
    - -WOB, cyanosis
  2. Respiratory
    - -crackles, wheezes
  3. CVS
    - -volume assessment (JVP, peripheral edema)
    - -apex (may be dilated or displaced in a dilated cardiomyopathy, may be sustained in hypertrophic cardiomyopathy)
    - -S3, S4, murmurs
  4. Abdo
    - -ascites, hepatomegaly
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75
Q

What labs would be appropriate to order in the setting of heart failure?

A

CBC–anemia causes high output HF
Lytes, BUN, Cr–baseline before giving diuretics, ACEi
LFTs–elevated with hepatic congestion
If you suspect infiltrative disease:
–calcium level (elevated in sarcoidosis, MM)
–SPEP/UPEP (MM)
–iron studies (hemochromatosis)
TSH is suspect hyper or hypothyroid
BNP–elevated in CHF (also elevated in PE, pulm HTN, LVH, Afib, ACS, renal failure)

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76
Q

What might you be looking for on ECG in the context of heart failure?

A

Active ischemia or arrhythmia
Old ischemia or conduction disease
LVH, atrial enlargement

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77
Q

What mighty you look for on CXR in the context of heart failure?

A
  1. Cephalization of vasculature
  2. Effusions
  3. Cardiomegaly
  4. Kerley B lines
  5. Bat winging–perihilar fullness
  6. Peri-bronchial cuffing
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78
Q

What imaging tests may be appropriate to order beyond a CXR in HF?

A
  1. Echo–EXAM
    - -looks at EF, relaxation
    - -chamber sizes, valve anatomy
    - -pericardium
  2. MIBI
  3. Cardiac MRI
  4. PET
  5. Coronary angio for CAD
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79
Q

What are the best indices for CHF dx as per the JAMA article?

A
  1. HX of CHF
  2. Clinical gestalt
  3. S3
  4. Elevated JVP
  5. Pulmonary edema on CXR
  6. Afib
  7. BNP <100 RULES CHF OUT
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80
Q

What is the acute management of CHF?

A 
L(M)NOP
Loop diuretic--lasix 
(Morphine--no longer recommended)
Nitroglycerin--vasodilator
O2 above 90%
Position upright
Positive pressure ventilation (BiPAP--decreases need for intubation and ICU)
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81
Q

What orders should you write for a patient presenting in CHF?

A 
Diet--restrict salt to less than 2g/day and fluid <1.5L/day
Frequent vitals
Maintain O2 above 90%
Daily weights
Fluids in and out
Furosemide IV BID--reassess daily
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82
Q

What are the goals of chronic CHF management

A

Decrease mortality, morbidity and hospitalizations

Improve quality of life

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83
Q

What lifestyle elements can help in the chronic management of CHF

A

Diet–restrict salt and fluid
Quit smoking and drinking alcohol
Exercise–cardiac rehab program

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84
Q

What drugs should be used in the chronic treatment of CHF

A
  1. ACEi
    - -improve survival
    - -improve NYHA class, slow progression of disease
    - -attenuate LV remodelling
    - -SEs = cough, angio edema, hyperkalemia and elevated Cr–> check writhing 3-5 days of starting
  2. ARBs
    - -as effective as ACEi for patients who cannot tolerate ACEi
  3. Beta blockers
    - -NOT for acute HF because they suppress the tachy that is compensating for decreased heart function
    - -improve survival (metoprolol, bishop roll, carvedilol)
    - -improve NYHA and slow progression
    - -SEs = Brady, heart block, bronchoconstriction, initial worsening of CHF, hypotension, fatigue, sexual dysfunction
    - -metoprolol 100 mg PO BID
    - -carvedilol 25-50 mg PO BID
    - -bishop roll 10mg PO daily
    * *start at 1/4 dose and titration up
  4. Aldosterone antagonists–> spironolactone
    - -improves survival
    - -indicated for NYHA III-IV, EF <40%
    - -improves NYHA
    - -SEs = gynecomastia, breast tenderness, AKI, hyperkalemia
    - -spironolactone 25-50 mg PO daily
  5. Digoxin
    - -NO survival benefit
    - -decreases hospitalizations
    - -SEs = cardiac arrhythmias, GI disturbance, neutron changes (visual)
  6. Loop diuretics
    - -NO survival benefit–used only for chronic treatment if chronically volume overloaded
    - -symptomatic benefit
    - -SEs = hypotension, volume depletion, hypokalemia, elevated Cr
    - -furosemide 20-40 PO BID
  7. Vasodilators
    - -hydralazine + nitrate combo for after load reduction if ACEi or ARB intolerable (I.e renal impairment)
    - -mortality benefit ESPECIALLY IN AFRICAN AMERICANS
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85
Q

Which drugs used on the management of chronic CHF have survival benefit?

A 
ACEi/ARB
Beta blockers (not in acute)
Spironolactone (aldosterone antagonists)
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86
Q

Which drugs used in the management of chronic CHF have no survival benefit?

A

Digoxin–decreases hospitalizations

Loop diuretics–symptoms management if volume overloaded

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87
Q

What are the three principles of diastolic heart failure management

A

Treat comorbidities
Rate control Afib
BP control HTN

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88
Q

What are some non-drug therapies to manage CHF?

A
  1. Implantable defibrillators (AICD)
    - -survival benefit for Class III-IV on maximal medical therapy
  2. Cardiac resynchronization therapy (CRT)
    - -survival benefit for class III-IV with WIDE QRS on maximal medical therapy
  3. Heart transplant
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89
Q

What defines anemia in men and women

A

Men less than 130

Women less than 120

90
Q

What is a mnemonic to remember the Ddx for microcytic anemia?

A 
TAILS
Thalassemia
Anemia of chronic disease
Iron deficiency
Lead poisoning 
Sideroblastic anemia
91
Q

What is the Ddx for a normocytic anemia with a HIGH reticulocyte count?

A
  1. Bleeding–GI, GU
  2. Hemolysis
    - -inherited–> SCD, thalassemia, spherocytosis
    - -acquired–> MAHA (DIC, HUS, TTP), AIHA
92
Q

What is a Ddx for a normocytic anemia with a LOW reticulocyte count?

A
  1. Pancytopenia–> leukaemia, MDS, myelofibrosis, aplastic anemia, chemo, infiltrative disease (TB, amyloid, sarcoidosis)
  2. Non-pancytopenia–> anemia of chronic disease
  3. Mixed picture–> B12 + iron deficiency
93
Q

What is the ABCD approach to macrocytic anemias?

A 
Alcoholism
B12/folate deficiency
Chronic disease--> liver, TSH
Compensatory reticulocytosis 
Dysplasia
Drugs
94
Q

What is a Ddx for megaloblastic macrocytic anemia?

A

B12/folate deficiency

Meds I.e chemo or methotrexate

95
Q

What is a Ddx for non-megaloblastic macrocytic anemia?

A

Alcoholism
Hypothyroidism
Reticuocytosis
Myelodysplasia

96
Q

What things in particular should you elicit on the history of a patient presenting with anemia?

A
  1. Possible causes
    - -family history of anemia
    - -bleeding (GI, GU, menorrhagia)
    - -diet (iron, B12, folate, Pica)
    - -PMHx of autoimmune disease
    - -Pancytopenia sx (bleeding, bruising, infection)
    - -meds (chemo, anti coagulation)
    - -PMHx hypothyroid or liver disease or symptoms of these
  2. Possible consequences
    - -fatigue, headache, lightheadedness/syncope, malaise, weakness
    - -exercise intolerance, dyspnea, palpitations, chest pain
    - -dizziness, tinnitus
    - -dark urine
97
Q

What things in particular should you look for on the physical exam of a patient with anemia?

A
  1. HEENT–>
    pallor in mucous membranes, conjunctiva
    LAD
2. Cardiac--> 
Tachy
Orthostatic hypotension
Systolic flow murmur 
Signs of CHF
  1. Derm–>
    Palmar crease pallor
    Jaundice
    Nail changes (koilonychia due to iron deficiency)
    Brittle hair
    Signs of ecchymoses, retro peritoneal bleeding, etc
    Gingival bleeding
  2. Abdo
    DRE with FOB
    Pelvic exam–look for blood
    Splenomegaly
98
Q

What investigations should you order when you are working up a patient for anemia?

A

CBC + diff, lutes, BUN, Cr, glucose

Reticulocyte count

Peripheral smear (look for schistocytes)

Iron panel–in iron deficiency, expect low ferritin, low serum iron, high TIBC and low serum sat. In chronic disease, see elevated ferritin, low serum iron and low TIBC

B12, TSH if macrocytic

Bone marrow aspirate/biopsy, SPEP, UPEP

Hemolysis panel–elevated reticulocytes, elevated unconjugated bilirubins, elevated LDH, low haptoglobin, schistocytes on peripheral smear

Coombs test for AIHA

Hgb electrophoresis if suspect hemoglobinopathy

Liver panel if suspect liver disease

INR, PTT, group and screen

99
Q

How do you treat anemia from iron deficiency?

A

Oral supplementation-ferrous fulmar ate 300 mg TID x3-6 months
IV supplementation is alternative
If bleed is suspected, consider a scope

100
Q

How do you treat anemia caused by renal failure?

101
Q

How do you treat anemia caused by thalassemias?

A
  1. Beta major–> transfusions + iron chelation to avoid iron overload, bone marrow transplant
  2. Alpha–> similar
102
Q

How do you treat anemia caused by sickle cell disease?

A
  1. Hydroxyl rhea
  2. Folate supplementation
  3. Penicillin prophylaxis and vaccines
  4. Bone marrow transplant
  5. Treat crises with analgesia, oxygen, hydration
103
Q

How do you treat anemia caused by B12 deficiency?

A

Monthly IM injections or PO supplementation

104
Q

What is a Ddx for fever?

A
  1. Infection–> bacterial, viral (HIV), TB
    - -can be in various sites I.e sepsis, meningitis, pneumonia, IE, pyelonephritis, septic joint
  2. Neoplastic–> leukaemia, lymphoma, other malignancies
  3. Autoimmune–> SLE, RA, vasculitis
  4. Medications–> antihistamines, heparin, phenytoin
  5. Other–> VTE
105
Q

What types of things should you elicit on a history of fever?

A
  1. Fever itself–> measured or unmeasured, time of day, response to antipyretic a
  2. Systemic symptoms–weight loss, fatigue, rash, arthralgia, night sweats
  3. Symptoms of possible source–> infection source or meds, PE/DVT sx, Hx of cancer, rheum disease
  4. Infectious contacts–> travel history, TB contact, food borne or animal contacts, HIV risk factors, immunizations
106
Q

Symptoms of UTI/pyelonephritis

A

Dysuria, frequency, flank Pai

107
Q

Symptoms of pneumonia

A

Cough

Pleuritic chest pain

108
Q

Symptoms of URTI

A

Cough
Coryza
Ear pain

109
Q

Symptoms of meningitis

A

HA
Confusion
Nuchal rigidity
Rash

110
Q

Symptoms of osteomyelitis

111
Q

Symptoms of skin infection

A

Purulence
Redness
Discharge
Warmth

112
Q

Symptoms of PID

A

Discharge
Dyspareunia
Lower abdo pain

113
Q

Symptoms of gastroenteritis

A

Abdo pain
Diarrhea
BRBPR
Vomitus

114
Q

define SIRS

A

Tachycardia
Tachypnea
Elevated or low WBC
Febrile or low temp

115
Q

Define Sepsis

A

SIRS + likely source of infection

116
Q

Define septic shock

A

Sepsis + hypotension and inability to resuscitate with fluids

117
Q

What should you look for on physical exam in a patient with fever?

A
  1. Vitals–SIRS/Sepsis/shock
  2. General–mental status changes, diaphoresis, rigours
  3. HEENT–oral ulcers, malar/discoid rash, LAD, Nuchal rigidity
  4. Cardio/resp/abdo–murmurs, crackles, RUQ pain, hepatomegaly, murphys, splenomegaly, CVA tenderness
  5. Derm–rashes, joint pain or swelling
118
Q

What investigations should you consider in a patient with fever?

A

CBC + diff, lutes, BUN, Cr, glucose, liver panel, LDH, lactate

ESR/CRP

ANA, ENA, RF, ANCA

UA

Pan cultures (blood, urine, sputum, stool) + gram stain

CT before LP

Serologies for HIV, hepatitis, monospot (EBV), CMV

Imaging–> CXR, echo (IE), consider PET, consider ECG

TB skin test

Biopsy of tissue identified

119
Q

How do you manage fever

A 
IVF
Cold compresses
Acetaminophen/ibuprofen as antipyretic 
Treat underlying cause
If unstable, start broad spectrum abx and narrow upon sensitivities
120
Q

What can cause a systolic murmur?

A 
Aortic sclerosis/stenosis
HOCM
Flow murmur (anemia, sepsis, thyrotoxicosis)
Pulmonary stenosis
MR
TR

“Can be caused by increased flow in a high output state like anemia or sepsis or thyrotoxicosis or by abnormal cardiac structures”

121
Q

What types of things might you comment on for general appearance when assessing for a systolic murmur?

A

Cyanosis
Distress
Diaphoresis
Increased work of breathing (accessory muscle use, tripoding, full sentences, tachypnea etc)

122
Q

What types of things give you your “clinical gestalt” when assessing a systolic murmur?

A 
Airway
Breathing
Circulation 
General appearance 
Vitals--look for signs of sepsis
Volume exam (cap refill, skin turgor, JVP, dry axilla, tears, mucous membranes, postural vitals)
123
Q

What types of things would you look for on extra cardiac exam when assessing for systolic murmur?

A 
Pallor (anemia)
Edema (volume)
Peripheral pulses 
Brachioradial delay (Astenosis)
Apical carotid delay (Astenosis)
Carotid artery palpating--rate, rise, volume
JVP
124
Q

Describe the general cardiac exam

A

Inspection–chest wall deformities, scars, pacemaker?
Palpation–heaves, thrills, PMI (displaced or sustained?)
Auscultation–comment on S1, S2, EHS, then murmurs

125
Q

How would you characterize a systolic murmur on exam?

A
  1. Timing–> use carotid pulse to distinguish S1 and S2. Identify location in systole or diastole or continuous or both.
  2. Pattern–> crescendo-decrescendo, pan systolic.
  3. Radiation–> axilla, carotid arteries, clavicles.
  4. Pitch–> high (louder with diaphragm) or low (louder with bell)
  5. Intensity–> grade I to VI
  6. Maneuvers (see another card)
126
Q

What types of maneuvers can be done on exam to examine a systolic murmur more closely?

A
  1. Quiet inspiration/sustained abdo pressure–> increases venous return and therefore increases R sided murmurs
  2. Transient arterial occlusion–> inflate BP cuffs bilaterally to 20-40 > sBP which increases systemic vascular resistance and therefore increases L sided murmurs (except for HOCM, should decrease this murmur)
  3. Stand to Squat/Passive leg elevation–> increases venous return and SVR, decreases murmurs of HOCM and MVP
  4. Valsalva–> decreases venous return and increases SVR and thus decreases Astenosis intensity
127
Q

Describe specific characteristics of an aortic stenosis murmur

A
  1. Decreased carotid volume and slow rise of carotid pulse–> pulsus parvus et tardus
  2. Loudest at RUSB
  3. Decreased/absent S2
  4. valve calcification on CXR
  5. Radiates to carotids and/or clavicles
  6. Sustained apical impulse
  7. Bradioradial delay
128
Q

Describe the specific characteristics of a mitral regurgitation murmur

A
  1. Pan systolic
  2. Loudest at apex
  3. Radiates to axilla/left subscapular area
  4. Displaces/enlarged apex beat
  5. Left parasternal movement
  6. S3
129
Q

Describe the specific characteristics of a pulmonary stenosis murmur

A
  1. Pre cordial lift due to RVH
  2. Right sided S4
  3. JVP prominent wave
  4. Wide splitting S2
130
Q

Describe the specific characteristics of a tricuspid regurgitation murmur

A
  1. Increased with inspiration/abdominal pressure
  2. Usually pan systolic
  3. Low pitched
  4. LLSB
  5. Raised JVP
  6. Pulsatile liver
  7. Ascites
  8. Peripheral edema
131
Q

Describe the specific characteristics of HOCM murmur

A
  1. Harsh, mid systolic murmur LSB
  2. Louder with valsalva
  3. Decreased with stand–> squat
  4. Decreases with leg elevation
  5. Softer with isometric hand grip
  6. Sustained apex beat
  7. S4
132
Q

What types of findings would you expect to see in a patient with CHF?

A

Crackles on lung exam
Pulsatile liver and/or ascites on abdo exam
S3 (maybe S4 if stiffened ventricle depending on etiology)

133
Q

What types of things are you looking for on the extra cardiac exam when you are examining a patient for CHF?

A
  1. Signs of the cause of the CHF/underlying etiology
    - -Evidence of vascular disease–>PVD, atherosclerosis
    - -Atrial fibrillation
  2. Consequences of CHF
    - -peripheral pulses, skin temperature
    - -EDEMA (pedal, sacral)
    - -dullness to percussion (pleural effusion)
    - -crackles or decreased breath sounds on ausculation
    - -enlarged, tender liver (may or may not be pulsatile) which may indicate hepatic congestion
134
Q

How would you examine the JVP?

A

Position HOB 30-45 degrees
Tangential lighting
Stand at foot
Look between two heads of the SCM
Biphasic, changes with respiration, non palpable, non occludable
Comment on the height (normal is less than 3 cm)
AJR–> positive if sustained elevated JVP after two respiratory cycles or 10 seconds

135
Q

What should you look for on pre cordial exam when you are assessing CHF?

A

Inspect for chest wall deformities, scars, pacemakers
Palpate for thrills, heaves, PMI
Auscultation for normal heart sounds, S3, S4, then any murmurs

136
Q

What types of things should you comment on in your assessment of a patient with CHF

A

Right sided versus left sided?
What investigations would you do? BNP, ECG, CXR, maybe echo
History? Causes can include HTN, CAD, T2DM, smoking, MI, valvular disease
Consequences? SOBOE, blocks, PND, Orthopnea, weight gain

137
Q

Describe very briefly the flow of the physical exam for CHF

A 
Formalities of introduction 
ABCs
General appearance
Vitals
Examine for possible causes of CHF
Examine for consequences of CHF
JVP
Pre cordial exam
Decide whether R or L sided
Comment on investigations, history, consequences
138
Q

What might you see as soon as you walk in the exam room in a patient with pericarditis?

A

They may be sitting up and leaning forward, as this reduces pressure on the parietal pericardium

139
Q

What findings might you expect when examining the heart of someone with pericarditis?

A

Pericardial friction rub (high pitched)

140
Q

What must you rule out when you are assessing for possible pericarditis

A 
Tamponade (beck's triad, pulsus paradoxus)
MI
Aortic dissection
Pulmonary embolism
Esophageal rupture
141
Q

What might lymphadenopathy suggest in the setting of pericarditis?

142
Q

What should you look for in the extra cardiac exam when examining a patient for pericarditis?

A
  1. Causes of the pericarditis
    - -signs of trauma to the chest
    - -lymphadenopathy (cancer)
    - -rheumatic disease
    - -systemic signs of sepsis
  2. Consequences of the pericarditis
    - -TAMPONADE
    - -peripheral pulses, skin temp
    - -edema (pedal and sacral)
    - -Auscultation lungs
    - -abdo exam
143
Q

What are the signs of cardiac tamponade?

A

Beck’s triad:

  • -low arterial BP
  • -distended neck veins
  • -distant, muffled heart sounds

Pulsus paradoxus–> abnormally large decrease in sBP > 10mmHg on inspiration
Pericardial rub
Hypotension

144
Q

What exam finding is highly specific for pericarditis?

A

Pericardial friction rub

Best heard with diaphragm
Scratchy or squeaky
Intensity increases with leaning forward

145
Q

What investigations might you order in suspected pericarditis?

A 
CBC and diff
BNP
ECG (widespread ST elevation or PR depression)
CXR
Echo
146
Q

What can cause pericarditis?

A 
Prior infection 
Radiation to heat
Trauma
Drugs/toxins
Kidney failure 
Cancer 
Rheumatological history 
IBD
147
Q

What is the major consequence of concern with pericarditis?

148
Q

How do you diagnose pericarditis?

A 
At least two of:
Typical chest pain
Pericardial friction rub
ECG changes 
New or worsening pericardial effusion
149
Q

What do you expect to see in the vitals of someone with Afib?

A

Tachy
HTN
Pulse irregularity

150
Q

What should you examine for on the extra cardiac exam of someone with Afib?

A
  1. Causes
    COPD
    CHF
    Focal neuro signs (stroke?)
2. Consequences
Evidence of heart failure
Peripheral pulses
Diaphoresis
Volume exam
151
Q

What can cause Afib? (Mnemonic)

A 
PIRATES
Pulmonary disease
Ischemia
Rheumatic disease
Anemia (high output state)
Trauma 
Electrolytes 
Sepsis and other high stress states

Holiday heart (EtOH)

152
Q

What are symptoms of Afib?

A 
Palpitations
Fatigue
Weakness
Dizziness
Lightheadedness
Decreased exercise capacity 
Dyspnea
Angina
Syncope
153
Q

What are some precipitants of Afib?

A

Exercise

Alcohol

154
Q

What investigations might you order in the patient with Afib?

A 
BNP
CBC and diff
ECG (look at LA size, is there a thrombus, valves, LV function, pericardium)
CXR
Echo
K
Mg
155
Q

What must you rule out in a patient with Afib?

156
Q

Describe very briefly the organization of an exam of a patient with Afib

A

Formalities
ABCs
General appearance–diaphoresis, breathing
Vitals–tachy, HTN, pulse irregular
JVP
Pre cordial exam–inspection, palpation, auscultation
Comment on causes, symptoms, precipitants, investigations, rule out MI

157
Q

What might you expect to see in the vitals of someone with pneumonia?

A

Low O2 sat

Look for signs of SIRS–> fever, high RR, high HR, elevated WBC

158
Q

What are the important parts of the extra pulmonary exam when assessing for pneumonia?

A

Volume exam
Mental status
N/V/diarrhea
Cardiac exam, abdo exam, skin inspection

159
Q

Describe the general pulmonary exam briefly

A

Inspection–> increased WOB, cyanosis, stridor or wheeze, chest deformity, breathing movements, AP diameter
Palpation–> chest excursion, trachea midline?
Percussion–> resonant? Dull? Hyperresonant?
Auscultation–> all lung fields

160
Q

What aspects of the pulmonary exam should be of specific note in pneumonia?

A
  1. Inspect for cough, sputum production, chills, rigours
  2. Palpation for increased tactile fremitus
  3. Percuss expecting decreased resonance over areas of consolidation
  4. Auscultation for crackles
161
Q

What organisms most likely cause community acquired pneumonia?

A 
S. Pneumo
Mycoplasma 
Chlamydia
Viral
H. Influenza
M. Catarrhalis 
Legionella
162
Q

What organisms most commonly cause HAP?

A 
GNR--> 
Pseudomonas
Klebsiella 
Ecoli 
MRSA
163
Q

What are the symptoms of pneumonia

A 
Cough
Fever
Sputum
Chest pain
N/V/D
Dyspnea
164
Q

What investigations might you order in someone with suspected pneumonia?

A

CBCD
Blood CX
Sputum CX and gram stain
CXR

165
Q

Describe very briefly an approach to the clinical exam for pneumonia

A

Formalities
ABCs
General appearance–> cyanosis, distress, diaphoresis, WOB, cough, tachypnea etc
Vitals–> O2 sat, SIRS?–temp, RR, HR, WBC count
Extra pulmonary exam–> volume status, mental status, N/V/D, cardiac, abdo, skin exam
General resp exam–> note features expected in pneumonia
Comment on causes/likely to etiology, symptoms, investigations

166
Q

Name 4 special tests/signs used in the examination of COPD

A

Blow test
Match test
T-L height
Barrel chest

167
Q

What might you expect to find on the vitals of someone with COPD

A

Low O2 sat
Tachypnea
Tachycardia
Pulsus paradoxus

168
Q

What might you look for on the fingers of someone with COPD?

A

Nicotine staining

169
Q

What would you look for on extra pulmonary exam in a patient with COPD?

A 
NOT CLUBBING (COPD alone doesn't cause clubbing... You would have to have bronchiectasis or lung cancer or some other process as well)
Volume exam
Lymph nodes (especially cervical)
170
Q

What should you look for on the pulmonary exam that is specific to COPD?

A
  1. Inspection–> barrel chest with an AP diameter greater than or equal to chest width, PURSED LIP breathing
  2. Palpation–> laryngeal height less than 4 cm, decreased expansion, RV heave due to pulm HTN
  3. Percussion–> hyper resonant; resonant over cardiac area
  4. Auscultation–> decreased breath sounds, wheeze
171
Q

How long would you expect the forced expiratory time to be in a patient with COPD

A

More than 9s

172
Q

How do you examine for pulsus paradoxus in a COPD patient

A

Inflate the cuff until no sounds are heard as you normally would

Slowly decrease the cuff pressure until you hear sounds on expiration but not inspiration–note this reading

Slowly continue decreasing the cuff pressure until you hear sounds throughout the respiratory cycle–note this reading

If the pressure difference between the two readings is more than 10mmHg then this is pulsus paradoxus

173
Q

What would help you rule in COPD?

A

Smoking history more than 40 pack years… Or just ever
Sputum
SOBOE
Subjective wheeze

174
Q

What are causes other than COPD for pulsus paradoxus?

A

Asthma
Cardiac tamponade
Constrictive pericarditis
Big PE

175
Q

Describe very briefly an approach to the exam of a COPD patient

A
  1. Formalities
  2. ABCs
  3. General appearance–>pursed lip breathing?
  4. Nicotine staining?
  5. Vitals–> O2 sat, tachypnea, tachy, pulsus paradoxus
  6. Extra pulm–> hands for clubbing (not caused by COPD), volume exam, lymph nodes
  7. General pulm exam–> specific COPD findings
  8. Special tests–> match test, blow test, pulsus paradoxus
  9. Comment on what would help you rule in COPD
176
Q

What two conditions in particular should you be examining for in a patient with e CXR suggesting effusion?

A

CHF and cirrhosis

177
Q

What sign on General appearance can sometimes be seen in patients with CXR suggesting effusion?

178
Q

What are you looking for in particular on vitals in a patient with a CXR suggesting effusion?

A

Tachypnea

Fever

179
Q

What are you examining for on the extra pulmonary exam of a patient with a CXR suggesting effusion?

A
  1. Hands–> clubbing? (Lung cancer)
  2. Volume exam
  3. Lymph nodes, especially cervical (lung, GI cancer)
  4. Signs of CHF
  5. Signs of liver cirrhosis
  6. Signs of pericarditis
180
Q

Describe a general pulm exam you would do in a patient presenting with CXR suggestive of effusion?

A
  1. Inspection–increased WOB, cyanosis, stridor or wheeze, chest deformity, breathing movements, AP diameter
  2. Palpation–chest excursion, tactile fremitus, trachea
  3. Percussion–resonant? Dull? Hyper resonant?
  4. Auscultation–all lung fields
181
Q

What signs on pulmonary exam should you look for in particular in a patient with CXR suggestive of effusion?

A
  1. Inspection–inspiration pain
  2. Palpation–DECREASED tactile fremitus
  3. Percussion–decreased resonance over effusion
  4. Auscultation–decreased breath sounds
182
Q

What may cause a transudative pleural effusion?

A 
Systemic (I.e decreased oncotic pressure, increased hydrostatic pressure) 
CHF
Constrictive pericarditis 
Cirrhosis
Nephrotic syndrome
183
Q

What are some causes of exudative pleural effusion?

A 
Lung parenchymal infection
Malignancy
PE
Collagen vascular disease
GI disease
Hemothorax
Chylothorax
184
Q

What is a chylothorax

A

Pleural effusion
Results from lymph formed in the digestive system (chyle) accumulating the pleural cavity due to disruption or obstruction of the thoracic duct

185
Q

How do you diagnose the cause of a pleural effusion?

A

Thoracocentesis for all pleural effusions more than 1 cm in the decubitus view

186
Q

What exam should you always do in patients presenting with abdo pain?

187
Q

What is your DDx for RLQ abdo pain

A

Appendicitis–4 tests
Pyelonephritis–CVA tenderness
Gyne–pelvic exam
IBD–4 tests

188
Q

What are you paying most attention to on General appearance in the patient with RLQ pain

A 
Comfort, colour (jaundice, tan)
Cachectic?
Muscle wasting?
Chills?
N/V/D?
189
Q

What are you paying most attention to in vitals for the patient with RLQ pain?

190
Q

What are you looking for on extra abdominal exam in the patient with RLQ pain?

A

Lymph nodes–sister may Joseph’s, virchows, Irish
Special tests for appendicitis, IBD, Pyelonephritis, Tyne
DRE!!!

191
Q

What is sister Mary Joseph node?

A

Palpable nodule bulging into the umbilicus as a result of mets of malignant cancer in the pelvis or abdomen

Suggesting of CANCER, GI most likely then gyne, rarely from appendix

192
Q

What is the Irish lymph node?

A

Left anterior axillary enlarged lymph node, often involved in metastatic gastric cancer

193
Q

What is virchows node?

A

Lymph node in the LEFT supraclavicular fossa
Gets its lymph supply from vessels in the abdominal cavity
Finding of enlarged, hard node is strongly indicative of the presence of abdo cancer especially gastric spread through lymph

194
Q

Describe the general abdominal exam

A
  1. Inspection–scars and lesions, skin wall abnormalities (striae), abdominal contours (scaphoid, bulging flanks, protuberant), visible peristalsis, pulsations or masses
  2. Auscultation–bowel sounds, Bruits (aortic, iliac, femoral, renal)
  3. Percussion–normal tympany? Gas? Fluid? Dullness? Pain?
  4. Palpation–light palpation (look for guarding or tenderness) and deep palpation (look for rebound tenderness, enlarged organs, costovertebral tenderness)
195
Q

What are the special tests for appendicitis?

A

McBurney’s point tenderness–one third of the way from ASIS to umbilicus

Rovsings sign–palpation of left lower quadrant increases pain in RLQ

Psoas sign–indicates an inflamed appendix that is retrocecal; passively extend the thigh of a patient lying on his side with knees extended or ask patient to actively flex thigh at hip (if causes abdo pain sign is positive)

Obturator sign–pain on internal rotation with hip and knee flex ion

196
Q

Special tests for pyelonephritis

A

CVA tenderness

Fever

197
Q

Special tests for Crohn’s

A

Peri-anal disease

Arthritis

Eyes–uveitis, iritis, episcleritis

Erythema nodosum, pyoderma gangrenosum

198
Q

What special test would you do for possible gyne cause of abdo pain?

A

Pelvic exam

199
Q

What test should you always do in patient with RLQ pain

200
Q

What are some causes of RLQ pain?

A 
Appendicitis
Pyelonephritis 
Crohn's disease/IBD
Cancer 
Gallstone ileus
201
Q

What are some causes of diffuse abdo pain

A 
AAA
Ischemia bowel
Bowel obstruction
Gastroenteritis 
Metabolic disturbance
IBS
202
Q

What are some gyne causes of RLQ/abdo pain?

A

Ectopic pregnancy
Ruptured ovarian cyst
PID
Endometriosis

203
Q

What in particular would you look for when examining a patient for portal HTN

A

Stigmata of chronic liver disease

Venous hum (due to increased collaterals circulation in cirrhosis)

Systolic bruit (AAA)

Friction rub over liver (tumour)

DRE (haemorrhoids)

Ascites

204
Q

What would you look for on the hands in the extra pulmonary exam for portal HTN

A 
Clubbing
Palmar erythema
Thenar, hypothenar, interosseous wasting 
Contractures
Leukonychia 
Asterixis
205
Q

What would you look for on the head in the extra abdominal exam for portal HTN

A

Parotid enlargement
Jaundice
Fetor hepaticus
Temporal wasting

206
Q

What would you look for on the body on the extra abdominal exam of a patient with portal HTN

A 
Gynecomastia
Testicular atrophy
Spider angiomas 
Edema 
Needle tracks
Tattoos
207
Q

What would you be looking for in particular on the abdominal exam of a patient with portal HTN

A
  1. Inspection–caput medusae
  2. Auscultation–Bruits, rubs, venous hums around a ?palpable liver mass
  3. Percussion–percuss liver span, percuss for spleen–> nixon’s test, traube’s space, castelle’s sign
  4. Palpation–liver edge, RUQ tendereness, splenomegaly, ascites
208
Q

How do you assess Traube’s space?

A

Bounded by the left anterior axillary line, the 6th rib and the costal margin
Should be resonant on percussion
Dullness indicates splenomegaly possibly

209
Q

How do you assess Castelle’s sign

A

Percuss in the lowest left intercostal space in the anterior axillary line

Should remain resonant during full inspiration

Dullness suggests possible splenic enlargement

210
Q

What is nixons test

A

Place left hand under patients left posterior chest and pull upwards

With right hand, begin palpation in RLQ

Direct patients breathing by telling them when to take a deep breath and when to exhale

While proceeding diagonally towards the LUQ, try to palpable the spleen edge during each inspiration phase

211
Q

What test should you do in the exam of the patient with portal HTN?

A

DRE–haemorrhoids

212
Q

How do you assess ascites?

A

Shifting dullness–percuss abdo midline (tympanic)…percussion moved progressively more lateral away from examiner until dull. Keep one finger on dull side and one on tympanic side–ask patient to lean towards examiner (right side)…wait for fluid to shift…dull position (on left) should now be resonant

Fluid wave

Bulging flanks

213
Q

What are the causes of cirrhosis

A 
Alcoholic liver disease
Chronic hep B or C
Acetaminophen
Methotrexate 
Autoimmune
PBC
Hematochromatosis 
Wilsons 
RSHF
A1AT deficiency
NASH
Hepatic veno occlusive disease
214
Q

What are signs of portal HTN

A 
Ascites
Edema
Splenomegaly 
Varicosity 
Haemorrhoids 
Caput medusa
215
Q

What are the signs of chronic liver failure?

A 
VARICES
Varices
Ascites 
Renal 
Icterus
Coagulopathy 
Encephalopathy 
Splenomegaly
216
Q

What would you look for especially on vitals in a patient with LGIB

A

Orthostatic vitals

+ if drop in HRmore than 30 or drop in sBP more than 20mmHg or drop in dBP more than 10mmHg

217
Q

What are three really important exams for assessing a patient with LGIB

A

Vitals–orthostatic
Volume exam
DRE/FOB

218
Q

What constitutes a volume exam

A 
Cap refill
Skin turgor
Dry axilla 
JVP
Tears
Mucous membranes
Postural vitals
219
Q

What are you looking for on the extra abdo exam for a patient with LGIB

A

Hands–clubbing
Lymphadenopathy–Anguilla, sister Mary Joseph, Irish, Virchow
Constitutional–fever, weight loss, night sweats
Syncope

220
Q

What are possible causes of LGIB

A 
Anatomical--diverticulosis (painless)
Vascular--angio dysphasia (painless)
Ischemic
Radiation induced
Inflammatory--IBD, infectious (painful)
Neoplastic 
Haemorrhoids
221
Q

Risk factors for diverticula the bleeding (arterial)

A 
Aspirin/NSAID use
Advanced age
Obesity
HTN
Hyperlypidemia
222
Q

Investigations to do in a patient with a LGIB

A 
CBC 
Type and cross match
Platelet count
INR
PTT
Endoscopy

Internal Medicine General (4 decks)

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