Handbook Section 1 Flashcards
DxT Acute diarrhoea + colicky abdominal pain ± vomiting
gastroenteritis
DxT (Young adult) diarrhoea ± blood and mucus + abdominal cramps
inflammatory bowel disease (UC/Crohn)
DxT Pale bulky offensive stools, difficult to flush, weight loss
malabsorption
DxT (Young adult) diarrhoea ± blood and mucus + abdominal cramps
DxT As above + constitutional symptoms ± eyes/joints
Crohn disease
DxT Fatigue + weight loss + iron deficiency
coeliac disease
DxT Failure to thrive (child) + recurrent chest infections
cystic fibrosis
DxT Altered bowel habit: diarrhoea ± constipation ± rectal bleeding ± abdominal discomfort
colorectal carcinoma
DxT Diarrhoea (fluid/incontinent) + constipation +++ abdominal discomfort + anorexia/nausea
faecal impaction
DxT Profuse watery diarrhoea + abdominal cramps and increasing distension (on antibiotics)
pseudomembranous colitis (Girotra’s triad)
DxT Variable diarrhoea/constipation + abdominal discomfort + mucus PR + flatulence ++
irritable bowel syndrome
Basic Diarrhoea management
In Australia most infective cases are viral. The basic principle therefore is to achieve and maintain adequate hydration until the illness resolves. In adults and children oral rehydration is indicated unless there is evidence of impending circulatory ‘shock’ demanding intravenous
therapy. Oral rehydration solution containing sodium, potassium and glucose should be considered for patients with mild to moderate dehydration. Adults should drink 2 to 3 L of the solution in 24 hours. Normal food intake may start after rehydration.
Cause pseudomembranous colitis
This potentially fatal colitis can be caused by the use of any antibiotic, especially clindamycin, lincomycin, ampicillin and the cephalosporins (an exception is vancomycin). It is usually due to an overgrowth of C. difficile, which produces a toxin that causes specific inflammatory lesions, sometimes with a pseudomembrane.
Pseudomembranous colitis is diagnosed by
Diagnosed by characteristic lesions on sigmoidoscopy and a tissue culture assay and/or PCR for C. difficile toxin.
Pseudomembranous colitis, treated by
Cease antibiotic
Need hygiene measures to prevent spread
Mild to moderate: metronidazole 400 mg (o) tds for 10 days
Severe: vancomycin 125 mg (o) qid for 10 days
(in consultation with specialist). Beware of toxic megacolon.
Molluscum Contangiosum, diagnosed by
Molluscum is usually diagnosed by its distinct pink pearly appearance and central punctum. It is very common in
children. The rash lasts weeks to months, or occasionally a couple of years.
Molluscum rarely leaves tiny pit-like scars.
Molluscum Contangiosum, spread by
direct contact, sharing towels and bath toys, or through water (e.g. sharing baths or swimming).
Molluscum Contangiosum, treated by
The most common approach in children is to leave the rash alone and wait for it to clear. Treatments designed to irritate the lesion can make the rash clear more quickly (see CHAPTER 124 ) but can be distressing to the child and so are not normally done.
Molluscum Contangiosum, caused by
Pox virus
Acute inflammatory polyradiculoneuropathy (Guillain–Barré syndrome), definition
Guillain–Barré syndrome, which is a rapidly progressive and treatable cause of PN or ascending radiculopathy, is potentially fatal. Early diagnosis of this serious disease by the family doctor is crucial as respiratory paralysis may lead to death. The underlying pathology is segmental demyelination of the peripheral nerves and nerve roots.
Acute inflammatory polyradiculoneuropathy (Guillain–Barré syndrome), clinical feature
Weakness in the limbs (usually symmetrical)
Paraesthesia or pain in the limbs (less common)
Both proximal and distal muscles affected, usually starts peripherally
and moves proximally
Reflexes depressed or absent
Within 3–4 weeks the motor neuropathy, which is the main feature, progresses to a maximum disability, possibly with complete quadriparesis and respiratory paralysis.
Acute inflammatory polyradiculoneuropathy (Guillain–Barré syndrome), investigation
CSF protein is elevated; cells are usually normal.
Motor nerve conduction studies are abnormal.
Acute inflammatory polyradiculoneuropathy (Guillain–Barré syndrome), management
Admit to hospital.
Respiratory function (vital capacity) should be measured regularly (2–4 hours at first).
Tracheostomy and artificial ventilation may be necessary.
Physiotherapy to prevent foot and wrist drop and other general care
Treatment is with plasma exchange or IV immunoglobulin (0.4g/kg/day for 5 days), which may need to be continued monthly.
Inguinal hernias, presentation
These usually present in the first 3 to 4 months with an incidence of 1 in 50 males and 1 in 500 females
Inguinal and femoral hernias should be referred urgently as early surgery is advisable to avoid the high risk of bowel incarceration or strangulation and ovarian entrapment and ischaemia in females.
Inguinal hernias, when to refer
ASAP, infants and irreducible hernias
Reducible hernias: the ‘6–2’ rule
Birth–6 weeks: surgery within 2 days
6 weeks–6 months: surgery within 2 weeks
Over 6 months: surgery within 2 months
Indirect inguinal hernia, definition
a hernia emerging through the deep inguinal ring,
originating lateral to the inferior epigastric vessels, following the path of the spermatic cord, and which can traverse the whole length of the inguinal canal and can descend into the scrotum, high risk of strangulation
Direct inguinal hernia, definition
Originates medial to the inferior epigastric vessels and protrudes through the posterior wall of the inguinal canal,
and is therefore separate from the spermatic cord. It is
almost always seen in men and rarely descends into the scrotum. Due to a wider neck, strangulation and obstruction are most unusual.
Femoral hernia, definition
Herniates through the femoral ring (also known as the
femoral canal), which is the medial component of the femoral sheath. The hernia tends to bulge forward and then upwards as it becomes larger. The neck is lateral to the pubic tubercle. Femoral hernias are often small, usually occur in females and may be unnoticed by the patient. They are particularly liable to produce bowel obstruction or strangulation.
Symptoms and signs of hernial obstruction
Colicky abdominal pain
Nausea and vomiting
Constipation and failure to pass flatus
Abdominal distension
High-pitched tinkling bowel sounds
Local tenderness and swelling of the hernia
No expansile cough impulse
General hernia treatment
All symptomatic hernias require repair. Those patients who are not symptomatic and who are medically fit
should also be offered surgery because most patients usually become symptomatic eventually and a watch-and-wait approach delays rather than prevents surgery. Obstructed and strangulated hernias require urgent surgery. The risk of strangulation is greatest with femoral hernias.
Major causes of low back ± leg pain presenting in
the author’s general practice (Murtagh)
Vertebral dysfunction (non-specific back pain) (71.8%)
Lumbar spondylosis
Depression
Urinary tract infection
Spondylolisthesis
Spondyloarthropathies
Musculoligamentous strains/tears
Malignant disease
Arterial occlusive disease
Gas gangrene (clostridial myonecrosis), caused by
Several clostridia organisms, for example, Clostridium perfringens, into devitalised tissue, such as exists following severe trauma to a leg.
Gas gangrene (clostridial myonecrosis), clinical features of
Sudden onset of pain and swelling in the contaminated wound
Brownish serous exudate
Gas in the tissue on palpation or X-ray
Prostration and systemic toxicity
Circulatory failure (‘shock’)
Gas gangrene (clostridial myonecrosis), treated by
Surgical centre for debridement (most important)
Benzylpenicillin 2.4 g IV, 4 hourly + clindamycin (initial treatment)
Hyperbaric oxygen if available
Acute appendicitis, clinical features
Acute appendicitis features a characteristic ‘march’ of symptoms:
pain → anorexia, nausea → vomiting
In children, vomiting occurs in at least 80% and diarrhoea in about 20%. The temperature is usually only slightly elevated but in about 5% of cases it exceeds 39°C.
Breast cancer screening, Average risk
Mammography should be performed at least every 2 years on women aged 50–74 years.
Women aged 40–49 years may also choose to have a mammogram.
Mammography must not be used alone to exclude cancer
if a lump is palpable. Such lesions require a complete appraisal since, mammography still has a false-negative rate of at least 10%.
Genetic testing should be considered in those at risk.
Common causes of breast mass (Murtagh)
Fibrocystic disease (32%)
Fibroadenoma (23%)
Cancer (22%)
Cysts (10%)
Breast abscess/periareolar inflammation
Lactation cyst (galactocele)
Investigation of breast lumps, triple test
1 History and clinical breast examination
2 Imaging—mammography and/or ultrasound ± MRI
(more than 40yrs - mammogram, less than 40yrs - ultrasound)
3 Fine-needle aspiration cytology and/or core biopsy
Important tell-tale symptoms of breast cancer
Lump
Skin dimpling
Inverted nipple
Bloody nipple discharge
Peau d’orange
Eczema of nipple (Paget discharge)
Types of nipple discharge
Bloodstained:
— intraduct papilloma (commonest)
— intraduct carcinoma
— fibrocystic breasts
Green–grey:
— fibrocystic breasts
— mammary duct ectasia
Yellow:
— fibrocystic breasts
— intraduct carcinoma (serous)
— breast abscess (pus)
Milky white (galactorrhoea):
— lactation cysts
— lactation
— hyperprolactinaemia
— drugs (e.g. antipsychotic, cocaine)
Indications for biopsy or excision of breast lump
The cyst fluid is bloodstained.
The lump does not disappear completely with aspiration.
The swelling recurs within 1 month.
Breast cancer treatment
Tumour excision followed by whole breast irradiation was the most
preferred local therapy for most women with stage I or II cancer.
Total mastectomy and breast-conservation surgery had an equivalent
effect on survival.
Total mastectomy is preferred for a large tumour, multifocal disease,
previous irradiation and extensive tumour on mammography.
Recommendations for radiotherapy after mastectomy are:
tumours >4 cm, axillary node involvement of >3 nodes, positive or close tumour margins
Cytotoxic chemotherapy has an important place, especially in young, healthy women with E receptor negative and have visceral spread.
Adjuvant hormonal therapy by the anti-oestrogen agent tamoxifen 20
mg (o) daily if E receptor +ve, which is a specific modulating agent, is
widely used and is most suitable in postmenopausal women.
Pseudohyponatraemia, causes
• Normal plasma osmolality
– hyperlipidaemia
– hyperproteinaemia
• Increased plasma osmolality
– hyperglycaemia
– mannitol
Hypoosmolar hyponatraemia, causes
• Primary sodium loss (secondary water gain)
– integumentary sodium loss: sweating, burns
– gastrointestinal loss: vomiting, fistula, obstruction, diarrhoea
– renal loss: diuretics, hypoaldosteronism, salt wasting nephropathy, postobstructive diuresis
• primary water gain (secondary sodium loss)
– primary polydipsia
– decreased solute intake (beer potomania)
– ADH release due to pain, nausea, drugs
– syndrome of inappropriate ADH secretion
– glucocorticoid deficiency
– hypothyroidism
– chronic renal insufficiency
• primary sodium gain (exceeded by secondary water gain)
– heart failure
– hepatic cirrhosis
– nephrotic syndrome
Female Puberty, landmarks
Stage One – ages 8-11
Ovaries enlarge and hormone production begins.
Stage Two – ages 8-14
Breast buds usually develop first.
Pubic hair might start, height and weight may increase, curvier body.
Stage Three – ages 9-15
Vaginal discharge may start.
Stage Four – ages 10-16
Menarche (first menstruation) and ovulation usually starts now.
Stage Five – ages 12-19
Full development with regular menses.
Puberty stages for boys
Stage One - ages 9-12
Hormone production has begun
Stage Two - ages 9-15
Growth spurt begins, body shape changes, muscles and pubic hair begins. The testicles and scrotum get darker and bigger.
Stage Three - ages 11-16
Penis grows longer and more frequent erections occur. Voices may start to break.
Stage Four - ages 11-17
Penis grows wider and its texture becomes more adult-like. Facial hair also starts to grow. Skin gets oilier.
Stage Five - ages 14-18
Full height is reached. Pubic hair and genitals look like an adult. Chest hair is growing and shaving may begin.
Low back pain, red flag
Age >50 years or <20 years
History of cancer
Temperature >37.8°C
Constant pain—day and night esp. severe night pain
Unexplained weight loss
Symptoms in other systems
Significant trauma
Features of spondyloarthropathy, and cauda equina
Neurological deficit
Drug or alcohol abuse especially IV drug use
Use of anticoagulants
Use of corticosteroids
No improvement over 1 month
Carbon monoxide, clinical effects by blood percentage
< 2.5 % - No significant health effects Physiological background level in the body
2.5 – 5 % - Exacerbation of existing cardiovascular disease
5 – 10 % - Subtle neurobehavioral symptoms
10 – 20 % - lethal with coronary artery disease.
Headache (“frontal tightness”), shortness of breath during exertion in healthy adult population.
20 – 30 % throbbing headache, nausea, flushing
30 – 40 % Severe headache, dizziness, nausea, rapid breathing
>40 % Collapse, coma, convulsion, death
Carbon monoxide, common clinical manifestations
headache, nausea and vomiting, skin flushing, muscle pain, weakness, shortness of breath, dizziness, coordination difficulties, confusion, or chest pain.
Symptoms can be mistaken for flu-like illness or food poisoning.
Very high levels of carbon monoxide can cause loss of consciousness, seizures and death.
Long-term exposure to low levels of carbon monoxide can also lead to impaired thinking and concentration, emotional lability, irritability and impulsiveness.
Carbon monoxide, diagnosis
history and examination, in conjunction with an elevated carboxyhaemoglobin level
Measure carboxyhaemoglobin levels in any case of suspected carbon monoxide poisoning when the patient is first seen.
Exercise a high level of suspicion of carbon monoxide poisoning if:
- Symptoms are related with the use of a gas/wood heater, or other gas/petroleum fuelled item, in an enclosed space.
- Symptoms also occur in other occupants
- Symptoms improve when outside the house.
- There are concerns about an appliance – faulty or have not been maintained, newly installed
Severe anxiety or panic attacks typically cause
lightheadedness with other somatic symptoms include palpitations, sweating, inability to swallow, headache, breathlessness and manifestations of hyperventilation.
A panic attack is defined as a
Discrete period of intense fear or discomfort in which four (or more) symptoms which develop abruptly and reach a peak within 10 minutes
Panic attack, management
Mainstay: Reassurance, explanation and support
Immediate intervention: breathing techniques, Relaxation techniques, Rebreathing into a paper bag is rarely indicated
Longterm: Cognitive behaviour therapy (CBT)
The most common way people become infected with hepatitis C in Australia is by
sharing injecting equipment such as needles, syringes, spoons and tourniquets.
Hepatitis C is spread through
blood-to-blood contact when blood from a person with hepatitis C enters another person’s bloodstream.
In Australia, hepatitis B in adults is spread most commonly through
unprotected sex and unsterile injecting of illicit drugs.
Hepatocellular carcinoma, risk factors
- chronic liver disease, and cirrhosis (85–90%)
- Male incidence is three to four times that of females
- hepatitis B and C virus [HCV] infection
- alcohol‐related liver disease
- fatty liver disease
- Born overseas (50%)
Hepatocellular carcinoma, monitored by
Liver ultrasound, the primary tool recommended for HCC surveillance.
Serum α‐fetoprotein improves earlier detection of HCC compared with ultrasound alone.
Recommend surveillance with a combination of ultrasound and serum α‐fetoprotein levels every 6 months.
Pulmonary Embolism should be suspected in
All patients who present with new or worsening dyspnoea, chest pain or hypotension without alternative cause
Pulmonary Embolism, investigation
D-dimer - is a degradation product of cross-linked fibrin (high sensitivity but low specificity)
Computed tomography pulmonary angiography (CTPA) - preferred as a negative scan excludes PE and it may provide the alternative diagnosis
Ventilation/perfusion (V/Q) scan - for patients with renal impairment or pregnant women
Lower limb doppler ultrasonography - high positive predictive value but low sensitivity and low negative predictive value
Pulmonary Embolism, management
Anticoagulation is indicated in almost all cases of PE. (DOAC - first line, Warfarin - severely obese or renally impaired, LMWH - pregnant, breastfeeding, GIT/GUT cancer)
Haematologist or respiratory physician be involved in the decision making.
Imaging at the end of the initial 3–6-month treatment period is performed to establish a new baseline for the patient.
