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
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
- 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
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
RLQ Pain
Ddx:
Bowel - Meckel’s, Appendicitis, malignancy constipation, IBD, hernia, bowel obstruction, ileitis
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
Portal Hypertension
DDX:
Cirrhosis vs non-cirrhotic (schistosomiasis/PTV thrombosis)
Hx:
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:
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
Gout, septic arthritis
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
Injuries
Signs and symptoms and how they are faring
- A, B, C, D
Treatment they have done
AMPLE
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
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
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
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
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
