Histories Flashcards
LUTS
Differentials:
Infective - UTI/prostatitis/in setting of stone
Benign - BPH/Stricture, constipation, Medications (Diuretics), Diabetes insipidus
Malignant - Prostate cancer / Bladder cancer (primarily trigone lesions)
Neurological - MS/Parkinson’s
History questions:
Storage
- If frequency - caffeine + water intake
Voiding
Acuity of symptoms
Dysuria/Flank pain
Fevers/Rigors/Sweats
Haematuria
- If yes –> smoking, occupational exposures, past pelvic radiotherapy
FmHx urological/breast/ovarian, bony pain, fatigue
Altered bowel habit
New medications, recent surgery
Any new weakness / change in sensation / parasthesia’s / PmHx/FmHx neurological disease or Diabetes
Previous UTI’s / Previous pelvic trauma / Previous STI’s
Investigations:
Bedside - urine dipstick, DRE, PVR, uroflow, Bladder diary
Urine MCS
Lab - PSA (if no concern of infection), FBC, Coags (if haematuria), eGFR (determine whether can do CT IVP if haematuria), CRP (if concern of infection)
Imaging - RTUS to size prostate vs CT non-con/IVP depending on Hx, MRI prostate
Treatment
Abx - 4 weeks cipro for prostatitis, 7/7 for UTI in male
Medical management - Duodart vs Tamsulosin (if concern for ED)
Operation
- Consider flexi if haematuria/microhaematuria or significant symptoms of urgency/UUI w/ risk factors of TCC (suggestive of trigonal tumour) or as part of UTI workup for younger male or if concern that there is a stricture (can also do RGUG in this case).
- Consider TURP/GLL/HOLEP/Urolift if refractory to medical management / patient preference (urolift doesn’t have retrograde ejaculation)
- TP Biopsy –> PSMA PET –> prostatectomy vs EBRT vs active surveillance vs watchful waiting vs ADT + novel hormonal agent
Headache/SAH
- Sudden collapsed, headache + vomiting in 31M
Differentials:
Intracerebral haemorrhage 2ndary to AVM, hypertensive haemorrhage, trauma
Intracranial infection - Meningitis,
Venous sinus thrombosis
Other things but not this situation:
Tumour
Carotid/Vertebral artery dissection
Giant cell arteritis - Temporal artery
Other benign causes of headache -
History:
SOCRATES
Acuity of onset of symptoms
Trigger of symptoms - before, during, after
Signs of meningism - neck stiffness, photophobia
Trauma -
Visual disturbances - brainstem compression
Weaknesses / sensory changes
Fevers/rigors/sweats
Hx of smoking / drug use / aneurysm / seizures
FmHx/PHx connective tissue disorder / PCKD
Vaccinations - meningitis/covid (venous sinus thrombosis)
Recent surgery / medical presentation / immunosuppression
Exam:
Vitals
Consciousness
GCS
Head trauma
Cranial nerve - pupillary size + reactivity + EOM –> brainstem compression
Signs of meningeal irritation
Limb weakness / sensory changes - Full neurological
Treatment:
Endovascular coiling vs Craniotomy + surgical clipping
- Coiling more favourable with narrow neck
- Coiling more favourable for posterior circulation aneurysms as difficult to access
- Coiling more favourable when active vasospasm and swelling (retracting hazardous)
Risk of vasospasm for 3 weeks following aneurysm (peaks at 7-10)
- Electrolytes, no medical complications etc. important
- Give nimodipine as per local guidelines
CSW syndrome vs SIADH
- CSW –> ANP –> reduced urinary sodium + water through kidneys (Urine Na»_space;> Normal in CSF AND evidence of clinical and biochemical hypovolaemia (CVP and HCT)
CSW –> sodium and volume replacement
SIADH –> Fluid restriction
If in doubt better to treat as per CSW
Risk factors:
Prior aneurysm, smoking, cocaine, HTN, FmHx aneurysms and connective tissue disorder (e.g. Marfan)
Neck Lump
- 58M with 6/12 hx of neck swelling (not painful)
This one likely thyroid as elevates on swallowing (thyroid swellings elevate because they are enveloped by pretracheal fascia which attaches thyroid to laryngopharynx)
Thyroid Ddx:
MNG - colloid, hyperplastic, adenomatous)
Solitary nodule
- Cystic degeneration colloid
- Follicular adenoma
- Thyroid carcinoma - papillary/follicular/medullary/anaplastic
- Focal area of nodularity within Hashimoto’s
Other Ddx:
Infective
- Reactive lymphadenopathy – increase in size of the cervical lymph nodes in response to infection
- Sialadenitis
Neoplastic
- Lymphoma – a haematological malignancy that commonly causes lymphadenopathy
- Head and Neck Cancer or Salivary Gland Tumour
- Metastatic disease spread
- Skin lump, ranging from benign (e.g. lipoma) to malignant (skin cancer)
Vascular - Carotid body tumour (see below)
Inflammatory - Sarcoidosis
Traumatic - Haematoma
Autoimmune - Thyroid disease, such as Graves’ disease
Congenital
- Cystic hygroma (see below)
- Thyroglossal cyst (see below)
- Branchial cyst (see below)
- Dermoid cyst – a cystic type teratoma, form along the lines of embryological fusion, can present as midline painless lumps, more common in children and young adults
History:
SOCRATES
Duration of onset
How it has changed over time and recently
Painful/painless
Precipitating factors - recent infection
Lumps or bumps elsewhere
Dysphagia/dysphonia/dyspnoea/noisy breathing/hoarseness/haemoptysis
Fevers/rigors/sweats/unintentional loss of weight
Signs of thyroid - temperature, bowels, periods, appetite, weight gain vs loss
- HYPER - Appetite, weight loss, palpitations, bowel habit (diarrhoea), heat intolerance, tremor, nervousness, muscle weakness, anxiety, sweating
- HYPO - Cold intolerance, constipation, tiredness, poor appetite, weight gain, forgetfulness, dryness of skin, menorrhagia, anaemia, carpal tunnel
Opthalmic history - diplopia and grittiness
Smoker/alcohol/FmHx head and neck cancer/Radiation exposure (ionising radiation for acne, tonsillitis, excessive facial hair, thymic enlargement)
Immunosuppressive conditions
Change in bowel habit / nausea / vomiting
OE:
ENT
Cranial nerves
Thyroid (front, laterally and behind)
- Thrill/bruit
- Venous distension
- Pemberton + Horner
- How does it move withs wallowing
- Diffuse goitre or one side
- How does thyroid feel
- Tracheal deviation
- Lymphadenopathy
- Retrosternal extension
- Stigmata of thyroid disease
- Assess swallowing, cough, phonation
Rest of body - proximal myopathy, pre-tibial myxoedema, carpal tunnel, reflexes, thyroid acropathy, thyroid eye exam (ophthalmoplegia, lid lag, proptosis, exophthalmos, chemosis, conjunctivitis)
Ix:
TFT - TSH, T4
Thyroid anti-bodies - Thyroid peroxidase, Anti-thyroglobulin, TSH receptor antibodies
CMP
Nuclear scanning of thyroid nodule - limited role
USS +/- FNA (low false negative for FNA, non-diagnostic 5-10%)
- Irregular margin, micro-calcification, solid rather than cystic, vascularity centrally
- Lymph nodes
If FNA shows follicular lesions that are indeterminate –> hemithyroidectomy for tissue diagnosis –> proceed to total if required (10-20% malignant from tissue diagnosis)
If papillary or medullary –> total thyroidectomy w radioactive iodine ablation and suppressive thyroxine (most tumours are TSH dependent)
Risks
- Bleeding, infection, pain
- Damage to RLN, EBSLN, trachea
- Hypocalcaemia rare (2 functioning glands in each side of neck)
Prognosis
- Follicular 85% 10 year survival - check with nuclear scanning, USS, and Thyroglobulin levels
- Papillary -
- Anaplastic -
- Medullary -
NOF
- 85yo post fall
Ddx:
Fracture - pelvis or hip
Haematoma alone
Muscle tear
Ligament / tendone
Intra-abdominal
History:
SOCRATES
MIST
Before, during, after
- Rule out cardiac causes if required
Loss of consciousness / head strike
Able to mobilise after
Cuts - tetanus
Any witnesses
Previous injuries to that area
Other injuries or places where it hurts
Any recent illnesses
Change in neurology
PmHx - OP, cancer, etc.
Fasting
Ix:
CT
Tx:
Fascia-iliaca / femoral nerve block
Analgesia - multi-modal
Usually operative management - arthroplasty
Delirium preventative measures
Laxatives
RLQ Pain
Ddx:
Bowel - Meckel’s, Appendicitis, malignancy constipation, IBD, hernia, bowel obstruction, ileitis
Gallbladder/Liver possible
Urinary- Renal colic, other kidney pathologies
Gynae - Ovarian cyst rupture, ectopic pregnancy, other gynae pathology
Vascular - Mesenteric infarct
MSK - Abdominal strain
Other - mesenteric adenitis
Hx:
For each of the systems as above
Ix:
Beta-HCG, urine dipstick + MCS
Bloods - FBC, UEC, CRP, LFT
CT -
Portal Hypertension
Portal hypertension DDx
Liver related:
Pre-hepatic - Right sided heart failure, constrictive pericarditis
Hepatic - Cirrhosis vs non cirrhosis causes (schistosomiasis, sarcoid, granulomatous), Portal vein thrombosis, Budd-Chiari
Post-hepatic - Splenic vein thrombosis, biliary pathology
Systemic related:
Coagulopathy
Drugs
Nodular hyperplasia
Hx:
SOCRATES
Acute vs chronic
Yellowing of skin and eyes
Encephalopathy, infection, vomiting blood
Swelling in legs or tummy
Easy bruising or bleeding
Unintentional weight loss
Fevers/rigors/sweats
FmHx liver disease/clotting issues
Full after eating
Alcohol, hepatitis, autoimmune disease, fatty liver, iron, copper
Travel/Live to Africa or recent other travel
Issues with heart
Sexual and drug history
Ix:
FBC, UEC, CRP, LFT, Coag - could consider thrombophilia panel, could also consider AFP
Need USS
CT may be required
EUS or MRI
AAA
Pain, hypotension, pulsatile mass
Ddx:
Renal colic
diverticulitis
bowel ischaemia
Degenerative disc disease
Ovarian torsion
Abdominal / back pain - pain radiating to back
- How long for
- Any sudden change
Any evidence of leg pain on walking distances
Ulcers / infections / blockages on legs
Hx of hypertension, smoking, FmHx of aneurysm, lipids, diabetes
Marfan’s, ehler’s danlos - joint dislocations, hyperextensivity, issues with eyes, collapsed lung
Other vascular - heart disease, carotid disease etc.
Previous staph, syphilis infections
Think about AMPLE
Exam:
Looking for marfanoid appearance, pulsating abdomen, obviously ischaemic legs, sweating, pain
Observations - would want to make sure not in shock
Go straight to abdomen - will do rest of body after
Inspect - no pulsatile mass
General palpation
Two hands to see if can palpate in inspiration if fat for the aorta
Then do aorta and iliac bruits
Going to legs then heart and face
Femoral artery palpation, popliteal, DP, PT, CRT, observe for any ischaemic ulcers, make sure nil stigmata distal emboli
Heart , pectus excavatum/carinatum
Neck - carotid, carotid bruit
Ischaemic limb:
Ddx
Vascular causes
ALI - embolisim, thrombosis, trauma
CLI - atherosclerosis, vasculitis, vasculopathy from radiation
Non-vascular causes
Compartment syndrome
Nec fasc / cellulitis
DVT causing venous gangrene
Spinal cord pathology
Vasospastic disorder
Cold exposure / frostbite
Gout
Septic arthritis
Hx:
Pain where
Any other regions
Is it on walking and relieved by rest
How long walking
Any night pain, specifically anything that wakes you up from sleep
- If calf pain but no foot pain potentially not ischaemic pain (worst supplied regions should be painful)
If night pain - relieved by standing up and going for walk or hanging leg off bed
Any fevers/rigors/sweats
Any smoking history
Diabetes, lipids, HTN, heart disease/stroke
Pax FmHx - renal failure, hypothyroidism, gout
Other medical conditions
Anaesthetic history
Drug history and allergies
Social history - related to rehab
Ask questions about neurological causes
Ask about mechanical causes
EXAMINE + ABI of not CLI
Ix:
BSL at bedside, prudent ECG as well if vasculopathic
FBC, UEC, CRP, Coag
CT angiography / Doppler USS / Angiogram+/-plasty
Groin lump
Should The Children Ever Find Lumps Readily
Size/site/shape/surface/skin changes/symmetry/scars
Temperature/tenderness/transillumanability
Colour/Consistency/Compressibility
Edge/Expansility and pulsatility
Fluctuation/Flud thrill/Fixation
Lymph nodes/Lumps elsewhere
Resonance/Relations/Neurovascular status
Ambulance Handover
IMIST + AMPLE
Identity of patient
Mechanism and time
- speed, what hit, anyone else
Injuries
Signs and symptoms and how they are faring
- A, B, C, D, all obs
- Any LOC, self-extrication, walking on scene
Treatment they have done
AMPLE / AMBO
Dysphagia
Ddx:
Mechanical vs coordination
Intra-luminal, luminal, extra
motility vs neuro
Intra - Foreign body, oesophageal web, plummer vinson
Luminal - Cancer, oesophagi’s, barrett’s, benign stricture, chemical stricture
Extra - Retrosternal goitre, lung cancer, pharyngeal pouch, head and neck cancer
motility - spasm, achalasia
neuro - MG, bulbar palsy, cerebrovascular accident - 9, 10, 12 or coordination difficulty
Hx:
Liquids, solids, both - which started first
Sudden vs gradual, how long
Does it get stuck, does it feel like difficult to swallow - where is the difficulty
Regurgitate?
Full meal?
Where does it feel like food gets stuck
Any pain or painless (if pain cancer vs infection/ulcer)
GORD/reflux
Weight loss or chest infection?
Thyroid disease symptoms or previously
Any auto-immune / allergy related conditions
Any radiation / surgery / endoscopy / smoking
FmHx
Investigations:
FBC - eosinophils, WCC
EUC - baseline b4 PPI, sometimes electrolyte abnormalities
TFT if suspicion thyroid
Iron studies - if anaemic / plummer vinson
CRP - If infection
CMP - Para-neoplastic - also b4 PPI
Barium swallow, FNE, Endoscopy
CT oral contrast depending on presentation
More
H pylori infection
Haematemesis
Ddx
PUD
Variceal bleeding
- Other bleeding from rectum, ascites, jaundice, etc.
Tumour
- Constitutional symptoms
Mallory weiss - N+V excessive
Systemic cause of bleeding
Ensure not haemoptysis!!!
Prior to vomiting blood were they vomiting at all / nauseous
Do they normally have dyspepsia / chest pain before or after eating
Any malaena or change in bowel habit
Any recurrent use of NSAIDS or aspirin
Any diagnosed liver disease, have they ever noticed they were yellow
Any haemorrhoids, distended abdomen, easy bruising
Immunisations / needle use / alcohol intake / smoking
Any fevers/rigors/sweats/weight loss
Previous medical history, anaesthetic risk, allergies
Social and family history
If they are confused more likely hepatic encephalopathy as ammonia from urea not being metabolised adequately
Terlipressin for splanchnic vasoconstriction reduce flow through portosystemic shunt
Code blue and call on call endoscopist
ABCDE - need to intubate urgently to protect airway
Oxygen +++
Massive haemorrhage protocol, 2 wide bore IV, terlipressin, try and avoid over filling –> raises portal pressure and promotes further bleeding (better to give blood itself and aim for CVP 6-10, Pulse <100, Systolic >100 / MAP 65
May need to consider lactulose etc. if encephalopathic - keep monitoring
IDC for fluid status monitoring, ensure doesn’t become coagulapathic from massive haemrrhage
Must commence IvAbx as this prevents late septic complications
Sepsis may even sometimes (from SBP) lead to increased portal venous flow and lead to the variceal bleeding
When stable - focussed assessment including chart review, history, examination and then formulate plan
IR can consider TIPPS / embolisation if EBL not helpful
Hoarseness of voice
Consider - Oesophageal mass, Lung mass, otherwise could be primary throat/RLN issue from neck mass or thyroid mass
Could also be haematological or iatrogenic
Ddx
Infectious - Laryngitis, Croup, Laryngeal TB, Candida
Structural - Vocal cord nodule, HPV, Trauma, Paralysis of cord
Neurological - RLN palsy, Vagus nerve lesion (stroke, tumour), Parkinson’s disease, MG, ALS
Malignant - Cancer of larynx, thyroid, lung and oesopaghus
GI - Reflux, functional dysphonia
Endocrine - Hypothyroidism
Hx:
SOCRATES
Acute vs chronic
Intermittent or persistent
Dysphagia, dysphonia, SOB, Cough
Coughing up blood, progressive worsening
Lump
Fevers/rigors/sweats/unintentional loss of weight
Alcohol, smoking
Vaccinations, recent infection, TB previously
Reflux
Trauma
Weaknes/changee in sensation - FmHx neurological disease or cancer of larynx, thyroid or parathyroid, head and neck, oesophagus, blood
Heat/cold sensitivity, fatigue, weight gain, loss of hair, dry skin, palpitations or tremor
Easy bruising, lots of infections, anaemia
Immunosuppressed
EXAMINE
Ix:
FBC, UEC/CMP, TFT, CRP
USS if lump +/- FNA etc.
Could do CXR
Endoscopy/Laryngoscopy
CT for staging
Varicose veins + venous ulcer
Hx:
Previous DVT
Recurrent varicose veins / previous treatment
Stroke with weakness, neuromuscular disease
MSK injury of the area
Any abdominal pain, PR bleeding, PV bleeding
Any abdominal congestion, fevers/rigors/sweats
KTW syndrome PW syndrome
Raynauds
Ddx BADCAT
Blood disorders (polycythaemia), arterial drugs (BB, OCP), connective tissue disorders (RA, SLE, Scleroderma), Trauma
Thyroid history
Hyper
Increased appetite with loss of weight
Preference for cold
Increased sweating
Proximal myopathy with wasting and weakness
Diarrhoea + Frequency
Thacycardia + AF
Ameno/oligomenorrhea
Nervousness/irritability
Fine tremor
Hypo:
Weight gain and decreased appetite
Preference for hot weather
Dry skin, loss of hair
Muscle fatigue
Constipation
Bradycardia
Menorrhagia
Slow thought, depression, dementia
Symptoms of carpal tunnel syndrome
Causes of ptosis
Unilateral -
3rd nerve palsy
Horner’s - partial
Syphilis
Bilateral
Congenital ptosis
Myopathies - MG, dystrophia myotonica
Syphilis
Salivary gland tumour
Ddx
Benign - pleomorphic adenoma, warthog’s tumour, basal cell adenoma,
Malignant - Mucoepidermoid, adenoids cystic, acidic cell, carcinoma ex pleomorphic adenoma, SCC, lymphoma, metastatic
Mimicers - Sialadenitis, sialolithiasis, sjogren’s, IGG4 related disease, Sarcoidosis
Hx:
How quickly growth and pain
Any pain with eating
Any warmth or hot skin
Hard consistency vs soft
Fixed to skin
Weakness in muscles of face
Sensation near ear (greater auricular nerve) or face
Pus?
Dry mouth, dry eyes
Autoimmune diseases or connective tissue disease (RA, SLE)
Fevers/rigors/sweats/unintentional weight loss
Smoking history
Radiation
Other past medical history
Immunisations
Bruising/infections/known other cancer
Skin cancers - history of being in the sun a lot
What is Sjogren’s syndrome?
* Autoimmune condition - 90% occur in women at an average age of 50 years
* Intermittent or constant swelling of one or all of the salivary glands
* Clinical diagnosis if at least two of the following triad is present:
Keratoconjuctivitis sicca (dry eyes)
* Xerostomia (dry mouth)
* Associated connective tissue disorders
such as rheumatoid arthritis (50% of cases), scleroderma, systemic lupus erythematosus, polymyositis or polyarteritis nodosa
* If no associated connective tissue disorders are present, this is known as primary Sjbgren’s disease (note that Mikulicz syndrome is enlargement of the salivary and lacrimal glands secondary to sarcoidosis, lymphoma or tuberculosis, associated with dry mouth and dry eyes, but no arthritis)
* Pathology is lymphocyte-mediated destruction of the exocrine glands secondary to 8-cell hyper-reactivity and associated loss of suppressor T-cell activity
* Patients are at 40x increased risk of developing lymphoma, usually 8-cell non-Hodgkin’s type
* Several antibodies present, e.g. anti-salivary antibodies, rheumatoid factor, but two specific antibodies present - anti-SSA-Ro and anti-SSS-La
EXAMINE
Ix:
USS +/- FNA
CT/MRI for staging or to check facial nerve involvement
Autoimmune panel if Sjogren’s (ANA, Anti-RO/LA) + IGG4
Swab culture
FBC, CRP
Digital clubbing
Ddx
Gastro - cirrhosis, IBD, Malabsorption, lymphoma
Resp - Bronchial SCC, Lung disease (CF), Fibrosing alveoli’s, Mesothelioma
Cardiac - Cyanotic congenital heart disease, IE, Atrial myxoma
Rare - Familial
Cause - Multifactorial - TNF, Vagus affected, increased growth hormone, vasodilatation of nail-bed vessels secondary to unidentified factor which normally inactivated in lung, platelet precursors fragmented within pulmonary circulation - trapped in peripheral vasculature
Surgical jaundice
Pre, hepatic, post
Ddx; post op
Haemolysis from transfusion
Hepatic- anaesthetics, sepsis, intra/post operative hypotension
Post - bile duct injury
How long have you been yellow for
Any weight loss/appeitite/back pain
Fevers/rigors/sweats
Immunisations
Stool/urine
Pruritus
Foreign travel, recent blood transfusion
Alcohol
OCP/Phenothiazines
Drug use
Previous surgery - gallstones
Acuity of symptoms onset and then
Start with - any pain at all or any pain around meal-times
Any fevers/rigors/sweats
Previous gall bladder surgery or gall stones
Any change in bowel habit, PR bleeding
Any dark urine at all
Any itching
Any fatigue and unexplained loss of weight
Have you got any known liver disease or disease of the blood
Any recent blood loss or blood transfusion
Then ask about travel, IVDU, alcohol, sick contacts, unsafe sexual practices, tattooing or body piercing, recent illness, recent new medications
Any autoimmune diseases
Smoking, Pmhx, allergies, social history and family history
Ix:
At a minimum
Urine if dark urine make sure not haematuria
FBC - platelets, wbc
UEC - hepatorenal, urea, baseline
LFT - differentiate between cause
CRP - inflamattory/infective
Liver USS
Can do serology, AFP, other tumour markers, liver screen etc. depending on Hx
CT also depending on Hx including quad phase
Duputreyns
(a) What i s your differential diagnosis?
The differential diagnosis includes:
* Skin contracture - look for scar from previous wound
* Tendon contracture - thickened area, which moves on passive flexion of involved finger
* Congenital contracture of the little finger - affects PIPJ
* Ulnar nerve palsy - ring and little fingers are hyperextended at MCPJ and flexed at PIPJ.
Describe any tethering or pitting of the skin on the palmar aspect of the hand, and also note the appearance of any visible cords Look for scars from previous surgery
*
* Describe any flexion deformities at the metacarpophalangeal and proximal interphalangeal joints (MCPJ and PIPJ) of the involved fingers
- Look for involvement of the thumb and the first web space (a sign of more aggressive disease)
- Ask the patient to turn his hands over to look for Garrod’s pads (thickening of the subcutaneous tissues) over the PIPJ.
Feel - Palpate the swelling, particularly noting its fixation to skin
- Does the other palm have similar thickening? Move
- Assess the range of motion in the involved fingers
- Note the presence of fixed deformities by passively moving the involved joints.
(b) What conditions are associated with
Oupuytren’s contracture?
We have found the following mnemonic helpful to remember the associations - DEAFEST PAIL:
Diabetes mellitus Epilepsy
Age (positive correlation) Family history (autosomal
dominant)/Fibromatoses*
Epileptic medication (e.g. phenobarbitone) Smoking
Trauma and heavy manual labour Peyronie’s disease (fibrosis of the corpus
cavernosum - seen in 3% of patients with
Dupuytren’s)
AIDS
Idiopathic (most common)
Liver disease (secondary to alcohol).
(a) What i s the underlying pathophysiology of the condition?
Local microvessel ischaemia is thought to result in increased activity of xanthine oxidase, resulting in superoxide free radical production that in turn stimulates myofibroblast proliferation and type Ill collagen formation. Specific platelet-derived and fibroblast growth factors also play a role in the aetiology. Allopurinol, which inhibits xanthine oxidase, may help to reduce symptoms.
The process of chronic inflammation is thought to be essential to the subsequent fibrosis (see Further reading).
Carpal tunnel
DDx
* Anatomical abnormalities:
* Bone - previous wrist fractures, e.g.
Calles fracture, acromegaly
* Soft tissues - lipomas, ganglia
* Physiological abnormalities:
* Inflammatory conditions - rheumatoid arthritis, gout
* Alterations of fluid balance - pregnancy, menopause, hypothyroidism, obesity, amyloidosis, renal failure
* Neuropathic conditions - diabetes mellitus, alcoholism.
*Overuse / idiopathic
(b) Name one investigation you might perform before offering this lady treatment?
Nerve conduction studies:
* Symptoms of carpal tunnel syndrome can be mimicked by higher (more proximal) lesions of the median nerve. These high lesions are characterized by loss of sensation over the thenar eminence due to involvement of
the palmar cutaneous branch, and loss of the relevant forearm flexors (especially flexor pollicis longus)
* Symptoms may also be due to cervical nerve root lesions (e.g. secondary to a cervical disc herniation) or thoracic outlet syndrome
* Nerve conduction studies also assist in determining the severity of the lesion.
Lumbar disc
- Age
- Occupation
- Features of the pain, especially site,
radiation, any history of injury, and relieving
and exacerbating factors - Neurological symptoms (e.g. weakness, numbness and paraesthesia) and their distribution
- Sphincter disturbance - bladder and bowel symptoms (unlikely in patients used for examination purposes)
- Effect on patient’s lifestyle, e.g. work, sleep
- Previous treatments, e.g. use of analgesia, physiotherapy, caudal epidurals, operative
intervention
Explore other causes of back pain, e.g. diseases of the pancreas, abdominal aortic aneurysm, loin pain from renal causes.
Breast Lump
DDx
Benign - Fibroadenoma, breast cyst, fibrocystic change, lactational adenoma, lipoma, phyllodes tumour, hamartoma
Malignant - Ductal carcinoma, lobular, inflammatory breast cancer, paget’s disease of the nipple, phyloddes
Inflammatory - Mastitis, abscess, necrosis, mondor’s disease, granulomatous mastitis
Hx
SOCRATES
Lump history, lymph node history
Nipple discharge
Skin changes to breast
Risk factors
Menstruation early, late menopause, late age of first pregnancy or no pregnancy
HRT
Family history - BRCA? other cancers?
Fevers rigors sweats
Weight loss, back pain, shortness of breath
Autoimmune/Inflammatory diseases
Trauma, irritation, cream, allergy of skin anywhere else
Other health issues, allergies
Previous surgeries, anaesthetic risk
Social history, profession, requirement for reconstruction
Triple - Exam, USS +/- FNA, Mammogram —> Core biopsy/excisional biopsy –> definitive treatment +/- hormonal treatment
Mammography concerning features =
Mass of increased density
Ill defined margins
Speculated stellate architecture
Miicrocalcifications
Distortion of breast anatomy
extensive DCIS component, multi-focal disease, patient preference reasons for not sparing breast procedure, previous collagen vascular disorders
Burn history
IMIST from ambulance
What burnt patient - fire, electricity, oil, gas
Duration of contact
Ignition of clothing?
Closed environment?
ALOC
VIolent movement / trauma associated when falling
What PPE worn
AMPLE
ABCDE - EMST
Want to do secondary survey + assess which burns are deep dermal or full thickness, or partial derma
Capillary vasodilatation and recruitment closed capillary loops –> major extravasation of plasma to all interstitial tissues –> persists in areas under burn –> shock
Deep tissue death + vascular thrombosis = worsens this
Compartment syndrome highly likely
Without skin = rapid cooling with exposure –> raise room temperature + glad wrap
Bicarbonate to alkalinise urine making pigments water soluble (haemochromogens)
4thj degree = deep to subcutaneous fat
Watch for ARF and sepsis
PR Bleeding
Ddx
Lower GI
- Haemorrhoids, fissure, diverticular, CRC, angiodysplasia, proctitis (radiation, IBD, infection), ischaemic colitis
Upper GI
- PUD, varices, fistula
Small bowel
- Crohn’s, Meckel’s, GIST/Carcinoid/Adenocarcinoma
Vascular
- Coagulopathy, thrombocytopenia, HHT
Hx:
SOCRATES
Where when how often blood
Painful/painless/colour
Chronicitity
Mucous/pus
Diarrhoea/frrequency
Constipation before episode
Symptoms better or worse after food
Fevers/rigors/sweats/suspicious food/unintentional weight loss
Recent travel
Fatigue/Dizziness on sitting or standing/Palpiations
FmHx auto-immune/IBD/Cancer
FOBT/Colonoscopy
Recent NSAID or anticoagulant use
Radiation/SMoking/Alcohol
Liver disease/yellow skin
H pylori/dyspepsia/
Easy bruising/bleeding elsewhere/petechiae
Skin lesions
Systems review
MUST EXAMINE INCLUDING DRE
Ix:
FBC, UEC - urea, iron studies, LFT, CRP
Colonoscopy
CT angiography
Capsule endoscopy
How to differentiate between ulcers
DDx
Arterial
Neuropathic
Pressure
Venous
Other Ddx same as leg laceration
Hx:
SOCRATES
Location, pain
Leg swelling, aching, heaviness, itching
Varicose veins, DVT, obesity, prolonged standing, previous venous surgery
Severe pain worsening with elevation, claudication, rest pain, cold feet
Smoking, diabetes, hypertension, dyslipidaemia, PVD,
Painless, numbness, tingling, burning
Diabetes, alcoholism, spinal cord disease
Fevers/rigors/sweats
Immobility, malnutrition, sensory loss
Exam:
Location
Margins, exudate
Surrounding skin
Peripheral pulses
Capillary refill
Complete neurological exam - monofilament and vibration testing
Confirmatory tests
Doppler USS
ABI
CT angiography
HBA1c
May require imaging to rule out deep infection such as CT
