Interactive Cases in General Internal Medicine 3 Flashcards
In an abdo examination what do you look for on the hands in liver failure?
Asterixis (liver flap)
Bruising
Clubbing
Dupuytren’s contracture
Erythema (palmar)
Leuconychia
In an abdo examination what do you look for on the forearms?
AV fistulae
Current or previous renal replacement therapy
In an abdominal examination when you look at the head and neck what are you looking out for?
Anaemia
Jaundice
Skin: jaundice, excoriation marks or spider naevi?
Oral examination:
– Pigmentation
– Gum hypertrophy (? On ciclosporine after renal transplant)
in an abdominal examination what do you notice on the inspection of the chest?
Gynaecomastia
Hair loss
Excoriation marks
Spider naevi
in an abdominal examination what do you notice on the inspection of the abdomen?
- Abdominal distension?
- Caput Medusae?
- distended superficial abdominal veins
- direction of flow in the veins below the umbilicus is towards the legs.
- Scars?
What are the names of all these scars?
From what procedure do you get this scar
- Right subcostal (Kocher’s) incision (biliary surgery)
- Mercedes-Benz incision (liver transplant)
- Midline laparotomy incision (GI or any major abdominal surgery)
- McBurney’s (Gridiron) incision (appendicectomy)
- J-shaped/ ‘hockey stick’ incision (renal transplant)
- Low transverse (Pfannenstiel) incision (gynaecological procedures)
- Inguinal incision (hernia repair, vascular access)
- Loin incision (nephrectomy)
What could cause hepatomegaly?
- Cancer (primary or secondary deposits)
- Cirrhosis (early, usually alcoholic)
-
Cardiac:
- Congestive cardiac failure
- Constrictive pericarditis
-
Infiltration
- Fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases
when do you get asterixis?
hepatic encephalopathy
What is the caput medusa a sign of
portal hypertension
What are causes of splenomegaly?
H (portal Hypertension)
H (Haematological)
Infection
Inflammation
what are causes of liver disease?
Alcohol
Autoimmune
Drugs
Viral
Biliary disease
75 year old man • Epigastric pain • Back pain • PR: 130 bpm • BP: 80/50 mm Hg
What is this?
A. Peptic ulcer
B. Pancreatitis
C. Gastritis
D. GORD
E. Ruptured aortic aneurysm
E. Ruptured aortic aneurysm
What type of pain would you have in an inflammed bowel
Constant
What type of pain would you have in an obstruction?
Colicky
How do you classify adominal pain?
Nature: constant, colicky
Location: Epigastic, RUQ, RIF, suprapubic, LIF, general
What are the causes for epigastric pain? What would you ask for to narrow down to this condition?
AND THEN CONSIDER a bit below, above and to the right
Stomach:
- Peptic ulcer (?NSAID use)
- GORD (better with antacids)
- Gastritis (retrosternal, ETOH)
- Malignancy
Pancreas:
- Acute Pancreatitis -(?Gallstones, high amylase)
AND THEN CONSIDER a bit below, above and to the right
Above (heart) – MI
Below (Aorta) – ruptured aortic aneurysm
Right: (liver/gall bladder) – Cholecystitis – Hepatitis
What are abdominal conditions where you would refer to a medical team?
- hypercalcaemia
- Addisonian crisis (ask to take of the bra - darker under the bra)
- DKA- vomitting and abodminal pain
What are feature of acute pancreatitis?
What are investigation results you might see
- Pain
- High amylase
What are feature of chronic pancreatitis?
What are investigation results you might see?
Pain, wt loss
Loss of exocrine function
Loss of endocrine function
Normal amylase
Faecal elastase
What are causes of RUQ pain?
And think a bit above, to the side and below
Gall bladder:
- Cholecystitis
- Cholangitis
- Gallstones
Liver:
- Hepatitis
- Abscess
And think a bit above, to the side and below
- Above (lungs)
- Basal pneumonia
- Below (appendix)
- Appendicitis
- Left (Stomach, pancreas)
- Peptic ulcer, Pancreatitis
- Right: (kidney)
- pyelonephritis
What are causes for RIF pain?
and think a bit above, below and to the side
-
GI
- Appendicitis
- Mesenteric adenitis
- Colitis (IBD)
- Malignancy
-
Gynaecological
- Ovarian cyst rupture, twist, bleed
- Ectopic pregnancy
What are causes for suprapubic pain?
and think a bit above, below and to the side
Cystitis
Urinary retention
What are causes of LIF pain?
- GI
- Diverticulitis
- Colitis (IBD)
- Malignancy
- Gynaecological
- Ovarian cyst rupture, twist, bleed
- Ectopic pregnancy
When does an ovarian cyst become painful?
if it is ruptured
torsion
haemorrhage
Woman comes in with abdominal pain asked to take off her bra.Why?
addison’s hyperpigmentation
What are causes of generalised abdominal pain?
- Obstruction
- Infection: Peritonitis, Gastroenteritis
- Inflammation: IBD
- Ischaemia: Mesenteric ischaemia
-
Medical causes
- DKA
- Addison’s
- Hypercalacemia
- Porphyria
- Lead poisoning
Mesenteric ischaemia:
IF the celiac artery is obstructed which organ might be affected
stomach
spleen
liver
Gallbladder
duodenum
ischaemic mesentric artery:
IF the superior mesenteric artery is obstructed which organ might be affected
small intestine
Right colon
Mesenteric ischaemia:
IF the inferior mesenteric artery is obstructed which organ might be affected
left colon
rectum
History and EXAM
65 year old man • AAA repair 2 days ago • Diffuse abdominal pain • PR: 120 bpm • RR: 30
What are his blood tests likely to show?
A. Normal lactate
B. High amylase
C. High Bicarbonate
D. High sodium
E. High Calcium
55 year old man • Excess ETOH use • Cirrhosis • Confused • Abdominal pain • Abdominal distension • O/E: Ascites, liver flap
Which of the following is consistent with Spontaneus bacterial peritonitis?
A. Ascites neut ≥ 25 cells/mm3
B. Ascites neut ≥ 50 cells/mm3
C. Ascites neut ≥ 100 cells/mm3
D. Ascites neut ≥ 250 cells/mm3
E. Ascites neut ≥ 500 cells/mm3
D. Ascites neut ≥ 250 cells/mm3