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
high amylase
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
What are causes of abdominal distension?
5 F
Fluid
Flatus
Fat
Faeces
Fetus
What are clues that would point you towards ascites ?
FLUID
- Shifting dullness
- features of liver disease
- Asterixis
- Bruising
- Clubbing
- Dupytren
- Erythema
- Leukonychia
- Asterixis
What features would point you towards obstruction?
Obstruction
- Nausea, vomiting
- Not opened bowel
- High-pitched tinkling BS
- ?Previous surgery (adhesions)
- ?Tender irreducible femoral hernia in the groin
how do you classify ascites?
What are the causes?
Transudate
- Cirrhosis
- Cardiac failure
- Nephrotic syndrome
Exudate
- Malignancy (abdominal, pelvic, peritoneal mesothelioma)
- Infection: e.g. TB, pyogenic
- Budd–Chiari syndrome (hepatic vein thrombosis), portal vein thrombosis
50 year old man • Jaundice • RUQ pain • Dark urine • Pale stool
What is the cause of his pale stool?
A. Low biliverdin
B. High unconjugated bilirubin
C. High conjugated bilirubin
D. Low urobilinogen
E. Low stercobilinogen
E. Low stercobilinogen
how do you classify jaundice?
What are the cuases of jaundice within those classicifications?
Pre-hepatic
- Haemolysis, defective conjugation
Hepatic
- Hepatitis
Post hepatic
- CBD Obstruction
Describe the metabolism of billirubin and what can go wrong in pre hepatic janudice?
RBC are lysed - unconjugated bilirubin - becomes conjugated in liver by Glucuronyltransferase.
Haemolytic anaemia - increased unconjugated billirubin enzyme saturated
Gilbert’s syndrome- decreased amount of Glucuronyltransferase
Describe the metabolism of billirubin and what can go wrong in hepatic janudice?
Hepatitis
- Alcohol
- Autoimmune
- Drugs
- Viruses
Hepatocytes are damaged and therefore have difficulty conjugating the billirubin
Describe the metabolism of billirubin and what can go wrong in post hepatic jaundice?
- Gallstones in CBD
- Stricture
- Ca of head of pancreas
Dark urine and pale stools
Why do you get pale stools in post hepatic jaundice
low stercobillinogen
50 year old man • Painless Jaundice • Wt loss • Dark urine • Pale stool • O/E
His blood tests are most likely to show elevated:
A. ALP, CA19-9
B. AST, CA 125
C. ALP, alfa-fetoprotein
D. ALT, alfa-fetoprotein
E. ALP, CEA
A. ALP, CA19-9
Why do you get blood diarrhaea (desentry)?
(loss of epithelial integrity
What are differentials for bloody diarrhoea?
Infective colitis
Inflammatory colitis
Ischaemic colitis
Diverticulitis, Malignancy
What feature in the history would point you towards an inflammatory colitis?
young person
extra- GI manifestation: ask about joint problems, eye problems
What is you typical patient with ischaemic colitis?
elderly
previous cardiovascular incidents
What are the organisms that cause infective collitis?
CHESS organisms
Campylobacter
Haemorrhagic E coli
Entamoeba histolytica
Salmonella
Shigella
What does this abdominal X ray show?
thumb printing - inflammation- thickening of bowel wall
What does this abdominal x ray show?
UC
What does this abdominal x ray show?
toxic megacolon
This patient presented with diarrhoea
What does this abdominal X ray show?
Overflow (spurious) diarrhoea due to faecal loading
What is the management of a patient with acute GI bleeding?
- ABC
- IV access
- Fluids
- G&S, X-match blood
- OGD
How do you treat a variceal bleed?
Variceal bleed
Antibiotics
Terlipressin
How do you manage an acute abdomen?
- NMB
- Fluids
- Analgesic
- Anti-emetics
- Antibiotics
- Monitor vitals & UO
What are investigations you would like to do in an acute abdomen?
- FBC, U&Es, LFTs, CRP, Clotting, G&S, X-match
- Erect CXR
- CT
Someone presents with jaundice what investigations would you like to do?
- Bloods: FBC, LFTs, CRP
- Abdominal USS
- after a fast (gallstones better visualized in a distended, bilefilled gallbladder)
Someone presents with dysphagia and weight loss
what investigations would you like to do?
OGD & Biopsy
Someone presents with PR bleed and weight loss
What investigation would you like to do?
Colonoscopy
How do you treat a patient with Ascites?
Conservative: dietary sodium restrictions, fluid restrict (only in patients with hyponatraemia), monitor weight
Medical: Diuretics (spironolactone +/- furosemide)
Surgical: Therapeutic paracentesis (with IV human albumin)
What does the Serum Albumin - Ascites albumin tell you about the cause of ascites?
>11g/L: – Cirrhosis, Cardiac failure
<11 g/L: – TB, Cancer, (Nephrotic syndrome)
How do you treat hepatic Encephalopathy?
Lactulose
Phosphate enemas
(because increase the GI motility so less time things (e.g. toxin) toxin can be absorbed - and doesn’t overwhelm cirrhotic liver) - NOT ON SLIDES
Avoid sedation
Treat infections
Exclude a GI bleed
Someone is coming out of surgery and they have
- Erythematosus
- Discharge
What is the complication?
wound infection
Someone is coming out of bowel surgery and they have
- Diffuse abdo tenderness
- Guarding, rigidity
- Hypotensive/tachycardic
What does this indicate?
Anastomotic leak
Someone is coming out of bowel surgery and they have
• Pain, fever, sweats, mucus diarrhoea
What is this indicative?
Pelvic abscess
e.g. post-appendectomy
What are feature to be expected in a post patient with a wound infections
Erythematosus • Discharge
What are feature to be expected in a post patient with a anastomotic leak?
- Diffuse abdo tenderness
- Guarding, rigidity
- Hypotensive/tachycardic
What are feature to be expected in a post patient with a pelvic abscess?
Pain, fever, sweats, mucus diarrhoea
What are post op complication that can happen in bowel surgery?
wound infection
anastomotic leak
pelvic abscess
What are presentation and treatment of perianal abcesses?
Presentation: Tender, red swelling
Treatment: Incision & drainage
What are presenting feature and treatment of anal fissures
Presentation:
- Rectal pain (defaecation)
- Stool coated with blood
Treatment:
Conservative: Advice re diet (fluids, fibre)
Medical: GTN cream, botox injections into the sphincter
Surgical: cutting some of the anal sphincter muscles
What is the pathology?
What is the treatment?
Perianal abscess
Incision & drainage
What is this pathology?
what is the treatment?
ANAL Fissures
Treatment:
Conservative: Advice re diet (fluids, fibre)
Medical: GTN cream, botox injections into the sphincter
Surgical: cutting some of the anal sphincter muscles
How do IBS present?
What feature are not usually presentß
What do you need to exclude?
What is the treatment?
How do IBS present?
- Recurrent abdo pain, bloating
- Improves with defecation
- Change in the frequency/form of stool
What feature are not usually present?
- No PR bleed, anaemia, wt loss or nocturnal symptoms,
What do you need to exclude?
exclude Coeliac
What is the treatment?
Conservative: Diet & Lifestyle modification
Medical: Symptomatic treatment:
- Abdo pain: antispasmodics
- Laxatives for constipation
- Anti-diarrhoeals
What liver enzymes go up in an obstructive picture?
ALP, GGT
What enzymes go up in a hepatitic picture
AST, ALT
If someone has diarrhea, what do you always do ?
send off a stool sample for C diff for MCSU
In what condition do you get a rasied ca 125?
gynecological cancers
what blood test would be abnormal in an ischaemic bowel?
lactate and CK
if someone has deranged LFT’s what investigation do you request?
abdominal ultrasound
How do you differentiate between IBS and IBD in the history?
IBS will not wake up at night to go to the toilet
