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General Practice > Emergency presentations + paeds > Flashcards

Emergency presentations + paeds Flashcards

1
Q

What does acute abdomen mean?

A

rapid onset severe abdominal sx (usually with pain) that may indicate life-threatening intra-abdo pathology

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2
Q

How do you assess a pt p/w ?acute abdomen?

A
  • Ask about pain, vomiting (bilious, undigested food, faeculent, haematemesis), melaena/bright bleeding/other stool changes, urinary changes, lumps in abdo/groin, whether they’re eating + drinking, bowels, feeling faint/dizzy/palps, fever/rigors, rash/itching, weight loss
  • Check for signs of sepsis, dehydration
  • Examine abdomen for jaundice, distension, bruising (around umbilicus Cullen’s sign of haemorrhagic pancreatits/ectopic pregnancy/flanks Grey Turner’s sign of retroperitoneal haematoma), bowel sounds, aortic/iliac bruits, ascites, tenderness, shifting dullness, fluid thrill, organomegaly, guarding, rebound tenderness, bladder distension
  • Groin for herniae, DRE
  • Men – scrotum, women – DVE if needed
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3
Q

Differentials for the acute abdomen

A

SURGICAL:
*Upper GI: cholecystitis, pancreatitis, peptic ulcer disease, gastroenteritis, GI haemorrhage, splenic rupture
*Lower GI: appendicitis, diverticulitis, Meckel’s diverticulum, SBO/LBO, acute intestinal ischaemia, vasculitis, lower GI haemorrhage, AAA
Mesenteric adenitis – dispute as to whether is an actual diagnosis
*Strangulated hernia
*Renal: acute retention, renal colic, pyelonephritis
*Psoas abscess
*Testicular torsion
*Ectopic pregnancy rupture
*PID, tubo-ovarian abscess
*Ovarian torsion, ovarian cyst torsion/rupture

MEDICAL:

  • MI, pericarditis, pneumonia
  • Sickle crisis
  • Hepatitis, IBD exacerbation
  • Opiate withdrawal
  • Acute intermittent porphyria
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4
Q

Normal observations in children (RR, HR)

A 
<1y - 30-40; 110-160
1-2y- 25-35; 100-150
2-5y-20-30; 95-140
5-12y-15-20; 80-12-
>12y-12-16, 60-100
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5
Q

Causes of breathing difficulty in a child

A
  • Lower airway obstruction: bronchiolitis, asthma, pneumonia, foreign body, viral-induced wheeze, whooping cough
  • Upper airway obstruction: anaphylaxis, croup, epiglottitis, bacterial tracheitis, peritonsillar abscess, foreign body
  • Cardiac: acute heart failure, SVT
  • Panic disorders
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6
Q

What is a fever in a child?

A

Generally if temp 38C or higher, often hard to define and reported parental perception of fever should be accepted. In young children usually indicates an infection, with fever a natural response to this

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7
Q

Causes of fever in kids

A
  • Serious infections like sepsis, meningitis, pyelonephritis, peritonitis, pneumonia, encephalitis
  • Less serious infections like URTIs, EBV
  • Fever without obvious source e.g. HPB infections, osteomyelitis, septic arthritis, abscess, pericarditis
  • Travel-related like parasitic infections, TB, rheumatic fever, malaria
  • Drug fever
  • Kawasaki disease
  • Malignancy – ALL, AML, lymphoma B symptoms
  • Autoimmune – mixed connective tissue disease, RA, IBD, hyperthyroidism
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8
Q

What is the relevance of red and amber flags for fever in kids?

A
  • If any red flags arrange emergency transfer for suspicion of things like sepsis, meningitis, encephalitis, pneumonia, severe dehydration
  • If amber features see them and see if they need admission. E.g. infant <3m with suspected UTI needs hospital, significant parental anxiety etc
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9
Q

Amber flags in children with fever

A

Pallor of skin/lips/tongue reported by parent

Not responding normally, waking only with prolonged stimulation, reduced activity, not smiling

Nasal flaring
Tachypnoea: 6-12m RR>50, >12m RR >40
Sats 95% OA or less
Crackles on auscultation

Poor feeding in infants, dry MM, CRT >2s, reduced urine output, tachycardia >160 <1y, >150 1-2y, >140 2-5y

Fever for 5 days or more, rigors, temp 39 or more aged 3-6 months, swelling of limb/joint, non weight-bearing/not using a limb

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10
Q

Red flags in children with fever

A

Pale, mottled, ashen or blue skin/lips/tongue

Not responding, appears ill to HCP, unable to rouse/doesn’t stay awake, weak high pitched or continuous crying

Grunting, RR 60 or more, moderate-severe chest indrawing

Reduced skin turgor

Non-blanching rash, bulging fontanelle, neck stiffness, focal neurological signs focal seizures, status epilepticus

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11
Q

Roseola infantum

A

HSV 6/7: sudden onset high fever, coryza/sore throat/mild diarrhoea, then as fever goes down get rash on trunk + neck for couple of days

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12
Q

Slapped cheek syndrome

A

Erythema infectious. (Parvovirus B19): mild prodrome, 2-4d bright erythema on cheeks sparing nose + sparing around eyes/mouth, then erythematous macular-morbilliform eruption on extensor surfaces, then fades as a lacy pattern (reticulated). Children usually fine, can cause arthralgia in adults, can precipitate aplastic crisis

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13
Q

Measles

A

v contagious virus. Cough/coryza/sore red eyes/high fever, Koplik spots in mouth then morbilliform rash (macular, confluent)

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14
Q

Rubella

A

rubella virus
erythematous rash, may have mild constitutional sx or arthralgia in older children. Typically lasts 3 days

in pregnant women if exposed test them. if have rubella then if >20w prob fine, if <10w offer TOP as v high risk CRS, if 11-16w 10-20% chance

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15
Q

Bacterial maculopapular rash + fever

A
  • Scarlet fever: tonsillitis, fine red rough-textured rash, fades and get desquamation, bright red tongue with strawberry appearance
  • Erythema marginatum – rheumatic fever
  • Erythema migrans – Lyme disease. target lesion
  • rose spots of typhoid fever
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16
Q

Kawasaki disease

A

fever 5+ days not controlled with meds, conjunctival injection, rash, lymphadenopathy, red cracked lips/strawberry tongue, red palms/soles/desquamation.

Do Echo

M-high dose aspirin (to protect against coronary arteritis)

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17
Q

Vesicular/bullous rashes

A
  • Viruses: HSV-1 (cold sores, eczema herpeticum), chickenpox (vesicules surrounded by erythematous halo, central umbilication + crusting), hand foot + mouth disease (high fever, coryza. Oral lesions red spots then yellow-grey ulcers, then spots on hands + soles that turn into blisters, lasts 7-10d)
  • Bacterial: boils, impetigo (crusting), staphylococcal scalded skin syndrome, toxic epidermal necrolysis
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18
Q

Petechial + purpuric rashes in children

A
  • Viruses: v common, from most like adenoviruses, enteroviruses
  • Bacterial: meningococcal or other septic infection, may be initially erythematous/maculopapular then petechiae + purpura. Can also get in infective endocarditis
  • HSP – headache/fever/anorexia, then rash on legs + buttocks, abdo pain/vomiting, joint pain (Esp knees + ankles), subcutaneous oedema, haematuria
  • Thrombocytopenia – ITP, ALL
  • Malaria
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19
Q

Complications of head injury

A
  • Primary damage: neural tissue injury (focal contusions, lacerations, diffuse axonal injury), bv injury (extradural, subdural, subarachnoid haemorrhage), penetrating injury
  • Secondary damage: cerebral oedema, hypotension, hypoxia, seizures, hypoglycaemia, later-onset infection
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20
Q

CVS causes of chest pain

A

o ACS (pain lasting >15 mins, a/w N+V/sweating/SOB, haemodynamic instability, new onset/abrupt deterioration; don’t use response to GTN to confirm/exclude)
o Stable angina
o Dissecting thoracic aneurysm (tearing pain, radiation to back, hypertension, different in both arms, inequality in pulses, new diastolic murmur (AR)
o Pericarditis/cardiac tamponade (sharp constant sternal pain, relief sitting forward, may radiate, worse lying on left/on inspiration/swallowing/coughing, may have fever/cough/arthralgia; tamponade may have dysphagia/sob; may hear pericardial friction rub, may have pulsus paradoxus, hypotension, muffled HS, jugular venous distension)
o Acute CCF (ankle swelling, tired, severe sob, orthopnoea, elevated JVP, coughing, gallop rhythm, inspiratory crackles at bases, wheeze)
o Arrythmias (palpitations, sob, syncope/near-syncope, brady or tachy)

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21
Q

Pulmonary causes of chest pain

A

o PE: acute sob, pleuritic CP, cough, haemoptysis, syncope, tachypnoea/tachycardia, signs of DVT, mild pyrexia
o Pneumothorax: acute pleuritic pain + sob, reduced chest wall movements, reduced breath sounds, increased resonance percussion
o CAP: cough and at least one of sputum/wheeze/dyspnoea/pleuritic CP; focal chest signs (dull percussion, bronchial breathing, coarse crackles), temp
o Asthma: wheeze, sob, cough, often triggers
o Lung/lobar collapse: localised CP, sob, cough, reduced chest wall movement, dull percussion, bronchial breathing, reduced BS
o Lung cancer: chest/shoulder pain, haemoptysis, dyspnoea, WL, appetite loss, hoarseness, cough
o Pleural effusion: localised CP, sob

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22
Q

MSK causes of chest pain

A

o Rib #: h/o trauma or coughing. u/l sharp chest pain worse on inspiration
o Costochondritis: u/l sharp anterior chest wall pain, worse with breathing/activity/postural, usually preceded by exercise/URTI, can last for months. Tender over costochondral junction, pain on palpation, tender swelling of costal cartilage at costochondral junction in Tietze’s syndrome
o Spinal disorders – disc prolapse, cervical spondylosis, facet joint dysfunction. Dull aching CP, worse with particular neck movements, radiates down arm/into head/shoulder/scapulae, may have headache/dizziness

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23
Q

GI causes of chest pain

A

o Acute pancreatitis: often h/o gallstones or high alcohol. Sudden onset pain, severe, continuous, boring, epigastric/generalised, may radiate to RUQ/chest/lower abdomen, relieved sitting up + leaning forward, N+V, tenderness, distension, Cullen’s sign (discolouration around umbilicus), Grey-Turner’s sign (discolouration around flank), hypotension
o Oesophageal rupture – CP, sob, odynophagia, h/o procedures/FB ingestion/oesophageal cancer
o PUD, GORD, oesophageal spasm, oesophagitis – substernal pain esp at night/after big meal, radiation to throat from epigastrium, worse bending/flat, acid/food reflux
o Acute cholecystitis – sudden onset severe RUQ pain, anorexia, N+V, sweating, low grade fever, Murphy’s sign (inspiration inhibited by pain on palpation), jaundice (stone in bile duct/external compression)

24
Q

Psychological causes of chest pain

A

no identifiable case, often preceded by stressful event, usually in left sub-mammary position with no radiation, sharp continuous pain, worse with tiredness/stress, may get sx of hyperventilation (tingling extremities) and palps

25
Q

What is precordial catch?

A

brief episodic left-sided CP, a/w bending/posture, relieved by single deep breath/straight posture, no radiation

26
Q

How do you assess a pt p/w CP?

A
  • History: if they currently have it, onset/nature/radiation (acute onset with central or band like CP radiating to jaw/arms/back suggests cardiac; persistent localised pain more likely lung/MSK), R+A factors (exertional CP – angina, pleuritic CP – MSK/pulmonary), sob (cardiac/lung), h/o CP or past ECG, CV risk factors, MSK/GI disorders, previous trauma, anxiety + depression
  • Examination: CV (heart sounds [murmurs/pericardial rub], BP in both arms [aortic dissection], pulse rate + rhythm [shock/arrhythmias], chest wall (palpate for tenderness, does movement reproduce pain, listen to lungs for infection, check sats + RR), general appearance (signs of shock), abdo tenderness (gallstones, pancreatitis, peptic ulcer), neck tenderness/stiffness (cervical spondylosis, OA), leg swelling/tenderness (DVT), skin rashes (shingles), bruising (rib #), temp (infection, pericarditis, pancreatitis)
  • May need admission to hospital
  • Investigations to consider if not needing immediate admission:
    o ECG – ventricular hypertrophy, arrhythmias, PE, stable angina, ACS
    o CV bloods – glucose, lipid profiles, U+E
    o FBC – anaemia may exacerbate stable angina
    o TFTs
    o LFT + amylase – cholecystitis, pancreatitis
    o CRP/ESR for inflammation/infection
    o CXR – signs of HF, pulmonary pathology
27
Q

Acute SOB causes

A
  • Pulmonary: acute asthma, acute COPD, pneumonia, PE, pneumothorax, pleural effusion, bronchiectasis, lung/lobar collapse (bronchial obstruction/compression by cancer/FB/secretions), acute pneumonitis, upper airway obstruction causing stridor
  • Cardiac: acute HF, sudden onset arrhythmia e.g. SVT, IHD (including silent MI), acute valvular dysfunction, tamponade
  • Other: metabolic (aspirin OD, DKA, renal failure), acute blood loss (pallor, tachycardia), thyrotoxicosis, NM e.g. GBS/MG, hyperventilation (hypertension, palpitations, paraesthesia, CP, choking sensation)
28
Q

Signs that SOB is due to a lung issue?

A

wheeze, sputum, hyperinflated chest, purse lip breathing, ankle oedema from RHF, any focal chest sign, fever, signs of DVT, pleuritic CP, cough, haemoptysis, dizziness/syncope

29
Q

Signs that SOB is due to a cardiac issue?

A

general malaise, collapse, upper body discomfort, nausea, abnormal rate pulse, sweating, hypotension, orthopnoea, coughing with frothy blood-stained sputum (acute pulmonary oedema), collapse/pulsus paradoxus/neck vein engorgement (tamponade)

30
Q

Emergency management of pt with SOB in GP (whilst waiting for ambulance(

A

o Sit them up
o If sats 94% or less give O2 and continuously monitor – usually simple face mask at 5-10L/min, or nasal cannulae at 2-6L/min. For COPD/NM disorders/chest wall deformity/morbid obesity use 28% venturi mask at 4L/min
o MI – give aspirin 300mg
o Pulmonary oedema – give an IV diuretic, opioid + anti-emetic, and GTN spray
o SVT – attempt Valsalva/carotid sinus massage one side at a time
o Acute severe asthma/COPD – bronchodilator like neb/MDI salbutamol, oral prednisolone 40-50mg if available
o Tension pneumothorax – if diagnosis certain + life-threatening condition consider large bore

31
Q

What is angio-oedema?

A

swelling of deep dermis, SC or SM tissue of face/genitalia/hands/face, sometimes bowel/airway. Most often occurs with urticaria but may be alone. Skin may look normal/have wheals/anther rash, skin swelling less well defined, assess for resp sx + circulatory collapse

32
Q

What are the causes of angio-oedema?

A

Allergic: mast-cell mediated (usually IgE) and histamine-induced. Almost always a/w urticaria within 1-2h of exposue to the allergen. Likely if there is urticaria

Non-allergic: increased bradykinin. Likely if no urticaria

  • Non-allergic drug reaction: days-months after taking the drug, e.g. ACEi
  • Hereditary angio-oedema: rare inherited issue which causes overproduction of bradykinin. Spontaneous/triggered attacks
  • Acquired angio-oedema: usually due to lymphoma/CT disorder. Presents from 40+ usually
33
Q

How is angio-oedema (without anaphylaxis) managed?

A
  • acutely - IV/IM chlorphenamine + hydrocortisone, arrange admission
  • stable - find cause, stop the drug, non-sedating antihistamine, short course steroids, maybe refer to derm/immunology
34
Q

What is anaphylaxis?

A

severe life-threatening generalised/systemic hypersensitivity reaction with rapidly developing A/B/C problems, usually a/w skin + mucosal problems

35
Q

Features of anaphylaxis

A

o Sudden onset + rapid progression of sx – look + feel unwell, usually occur over minutes. Depends on trigger e.g. stings faster than ingested triggers
o Life-threatening A/B/C problems – airway swelling/difficulty breathing or swallowing/stridor etc, sob/wheeze/tiredness/confusion/low sats/resp arrest, signs of shock/tachycardia/hypotension/reduced GCS/cardiac arrest/myocardial ischaemia
o Skin and/or mucosal changes – often the first features, in >80% of anaphylactic reactions

May also have GI sx

Skin issues without life-threatening ABC usually doesn’t lead to anaphylaxis

36
Q

How do you manage anaphylaxis in primary care?

A

o Call for ambulance + colleagues
o Assess – ABCDE, if not breathing normally + unresponsive do CPR, if don’t need CPR examine chest/pulse/BP/skin/inside mouth
o Sit them up if A+B problems, lie flat if hypotension
o IM adrenaline 1:1000 as per age-related guidelines. Repeat at 5 min intervals if needed
o Remove trigger if possible e.g. remove the stinger from a bee sting
o If possible give high flow O2, obtain IV access, rapid fluid challenge, monitor ECG + pulse oximetry
o Give slow IM/IV chlorphenamine and hydrocortisone, consider neb salbutamol/ipratropium if they are wheezy

37
Q

Causes of the acute painful red eye

A 
Scleritis
Uveitis
Corneal abrasion
Corneal ulcer
Viral keratitis
Acute angle closure glaucoma
Endophthalmitis
Foreign body
Chemical injury
38
Q

Scleritis

A

50% a/w rheum condition, less common from surgery or infection. Urgent ophth will need to treat the cause.

CF: dull boring eye pain, headache, watering eye, painful movements, reduced VA is late. Usually a deep pinkish colour with more dilated brighter vessels superficially

39
Q

Uveitis

A

inflammation of uveal tract, anterior uveitis most common. Usually idiopathic but can be a/w HLA-B27 positive conditions like AS/PA or some infections

CF: photophobic, red, watery, painful eye, VA often mildly reduced. May see hypopyon, irregular pupil (due to posterior synechiae where iris attaches to lens capsule), cloudy view cos of cells in aqueous humor + corneal oedema, circumciliary injection esp around cornea

M: ophth to control inflammation

40
Q

Corneal abrasion

A

Break in the corneal epithelium

CF: v painful red watering eye, photophobia, VA may be mildly reduced if injury is in visual axis.

Stains brightly with fluorescein + blue light.

M: Chloramphenicol ointment reduces risk of bacteria entering + acts as a lubricant, may also use ocular lubricants/oral analgesics to help pain, avoid contact lenses until healed

41
Q

Corneal ulcer

A

Similar sx to abrasion then pain very bad + worsened VA. Usually caused by infected abrasion e.g. extended contact lens wear. If severe need admission

42
Q

Viral keratitis

A

o Pain, watering, photophobia, reduced VA, dendritic epithelial defect
o Herpes simplex e.g. from cold sores – usually in kids, looks like branching ulcer (like HZ) but with terminal bulbs (unlike HZ), patchy iris defect
o Herpes zoster – segmental iris defect, Hutchinson’s sign (rash on nose so is on the cornea as both supplied by nasociliary branch of CNV1)
o Refer to ophth-topical antivirals. Don’t give steroids to undiagnosed red eye as applying it to HSV keratitis can cause a geographic ulcer from impaired immune response

43
Q

What is acute angle closure glaucoma?

A

obstructed anterior chamber (angle between cornea + iris where AH drainage usually takes place) causing a sudden rise in IOP because AH isn’t draining properly, though IOP may be normal, causes progressive optic neuropathy

44
Q

RF for acute angle closure glacuoma

A

Hypermetropes - esp in reduced light

Women

45
Q

CF of acute angle closure glaucoma

A

sudden onset red painful eye, blurred vision, N+V, headache, severe eye pain + tenderness, injection, eye feels hard, hazy cornea, semi-dilated pupil

46
Q

Management of acute closed angle glaucoma

A

IV acetazolamide + pilocarpine drops (constrict pupil so better AH outflow). Analgesia + anti-emetics. Definitive is laser/surgical hole at peripheral of iris

47
Q

Endophthalmitis

A

Overwhelming infection. Severe pain, photophobia, rapidly progressive LoV, hypopyon, injection, corneal oedema

Needs intravitreal ABx. Could lose sight.

48
Q

Foreign bodies in the eye

A

Low speed e.g. gravel - irritation red/watering/FB sensation (even after cleared), may get photophobia/minor visual changes. Remove with LA eye drops + cotton bud, Abx drops for abrasions, lubricants for sx

High speed e.g. metal fragments -o More potential for injury. If having VA changes suggestive of corneal/retinal damage, flashes + floaters may indicate retinal damage. Penetrating injuries may cause blood in AC, visible holes in iris/distortion, plugged wound

49
Q

Chemical injury to the eye

A

whatever it is irrigate + urgent r/v. Alkalis are the worst. Check pH, Abx drops, cytoplegics to help pain by paralysing iris

50
Q

Causes of the acute painless red eye

A

Subconjunctival haemorrhage
Episcleritis
Conjunctivitis
Dry eye

51
Q

Subconjunctival haemorrhage

A

common, usually just red but can feel gritty. Causes include trauma, sudden rise in intrathoracic pressure e.g. heavy lifting, rubbing eye; higher risk with HTN + anticoagulants/antiplatelets.

May give lubricants if feeling gritty but otherwise reassure will resolve in a few weeks (may go a faint yellow first)

52
Q

Episcleritis

A

Uncomfortable not frank pain, sectoral area of hyperaemia + red dilated superficial vessels, blanches with phenylephrine. In 30% there is a systemic autoimmune condition e.g. UC. Self-limiting, adv analgesia + topical lubricants (sometimes top steroid/NSAID)

53
Q

What is conjunctivitis?

A

inflammation over the sclera (bulbar) + inner (tarsal) eyelids. Usually b/l to some extent due to symmetrical pathologies/cross infection.

Causes general discomfort, watering, gritty feeling, DC, crusted eye shut, diffuse injection, chemosis, debris

54
Q

Viral conjunctivitis

A

Viral e.g. adenoviral. V v contagious, eye watering, coryzal sx, pre-auricular LN. M-lubricants, cold compresses, hygiene

55
Q

Bacterial conjunctivitis

A

Normal bacterial: resp pathogens like S pneumoniae. Often worse injection + DC. M – topical chloramphenicol drops/ointment or fusidic acid

Chlamydial: often u/l with serous dc, refer to GUM, may cause scarring. In babies usually a couple of weeks PP

Gonorrhoeal: severe swelling, hyperpurulent DC. Refer to GUM-can cause corneal ulcer. In babies usually within 48h PP

56
Q

Allergic conjunctivitis

A

common esp when h/o atopy. Itchiness, swelling of eyelids/conjunctiva, coryzal sx. Can be seasonal or perennial.

M-cold compress, oral antihistamines, wash face after exposure, topical antihistamines/steroids/mast cell stabilisers for more severe

57
Q

Dry eye

A

b/l ocular irritation worsened with exposure e.g. screen time/wind

May be:
*Evaporative e.g. blepharitis (inflamed eyelid margins – obstructed meibomian glands – tears evaporate more. May have crusting, matted eyelashes, chalazions) *Tear deficiency e.g. Sjogren’s syndrome

M: lid hygiene, warm compresses with lid massage, ocular lubricants (ointments at night)

General Practice (6 decks)

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