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OSCE 2019 > Long Case Differentials/management > Flashcards

Long Case Differentials/management Flashcards

1
Q

Differentials for a neck lump

A
  • branchial cyst
  • salivary gland enlargmeent
  • thyroid (goitre, multinodular goitre, graves, hashimotos, adenoma, carcinoma, subacute thyroiditis)
  • subclavian aneurysm
  • lymph node
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2
Q

symptoms of thyroid malignancy

A

dysphonia

stridor

dysphagia

cough

haemoptysis

weight loss

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3
Q

risk factors to ask for with neck lump?

A
  • family hx: head and neck cancer
  • family hx: thyroid disease
  • smoking
  • alcohol
  • sick contacts: EBV etc.
  • Cat scratch
  • radiation to neck - malignancy
  • other autoimmune disorders - points towards hashimotos
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4
Q

Investigations of thyroid lump

A
  • physical exam - signs of hypo/hyperthyroidism, movement of thyroid on swallowing, movement of thyroid when tongue out
  • bloods- TFTs (T3, T4, TPO, TSH, calcitonin), blood film - for EBV, FBC for infection
  • bedside - ultrasound of thyroid, ECG for arrhythmias
  • Imaging - CT head and neck for malignancy, radionucelotide scan (hot or cold)
  • special tests - Fine needle biopsy - malignancy
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5
Q

management of neck lump

A

Cysts = surgical excision

EBV = supportive

hypothyroid = Levothyroxine

Hyperthyroid = carbamazepine or PTU, beta blocker or thyroidectomy

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6
Q

Differentials for Polyuria

A
  • diabetes mellitus (T1 or T2)
  • diuretics (alcohol, caffeine, medication, lithium)
  • heart failure
  • hypercalcaemia
  • hperthyroid
  • hypokalaemia
  • Diabetes Insipidus
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7
Q

Polyuria specific questions to ask?

A
  1. blood in urine = UTI or stones
  2. fatigue/weight loss = DM
  3. recurrent infections = DM
  4. dribbling = BPH, prolapse
  5. Nocturia = BPH
  6. Increased thirst = DM/DI
  7. vasculitis?? = renal failure
  8. hypertension = Renal failure
  9. autoimmune conditions= Type 1 DM
  10. lithium prescription = DI
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8
Q

What investigations for polyuria?

A
  • Physical exam: PVD signs (T2DM) or peripheral neuropathy, fruity breath (T1DM), signs of dehydration (T2DM), prostate exam
  • Bloods: aldosterone levels (DI), Plasma glucose (DM), sodium levels,
  • U&E: sodium - DI
  • Creatinine = renal failure
  • TFTs = hyperthyroidism
  • urine dipstick = UTI and osmolality
  • Imaging = MRI pituitary - cranial DI
  • special tests = water deprivation test
    *
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9
Q

Management of polyuria

A
  • UTI = antibiotics
  • Cranial DI = removal of tumour, or ADH replacement
  • nephrogenic DI = carbamazepine
  • primary polydipsia = refer to psychiatry and fluid restriction
  • DKA = IV fluids, Insulin therapy
  • DMT1 = insulin
  • DMT2 = diet, exercise, metformin + second line agent like gliclazide
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10
Q

differentials for haematuria/flank pain

A
  • “SWITCH GPS”
  • stones
  • wegener’s vasculitis
  • infection
  • trauma/tumour
  • cryoglobulinaemia
  • HUS
  • glomerulonephritis
  • PCKD
  • sickle cell/SLE
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11
Q

specific questions for haematuria and flank pain?

A
  • colour of urine (orange could be rifampicin, cloudy could indicate UTI)
  • colicky pain?
  • rigors/palpitations = stones or UTI
  • fever
  • history of UTIs
  • dribbling = BPH = retention
  • history of kidney disorders
  • lump in flank?
  • recent rash? SLE or HUS
  • hypercoagulable state?
  • Cough/haemoptysis = wegeners or goodpasture
  • facial swelling = nephritic syndrome
  • oedema/weight gain = nephritic syndrome
  • recent URTI = IgA nephropathy
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12
Q

Investigations for polyuria

A

Physical Exam: ballot kidneys for pain, cacexia (malignancy), dehydration, temperature, prostate exam (retention or mets)

Bloods: CRP/ESR (UTI, infection), FBC (WCC or anaemia), U&E (renal function), Calcium (Renal function), PSA (prostate cancer), Lactate (UTI/sepsis)

Bedside: urine dipstick ( haematuria and UTI), midstream culture = UTI, urine cytology (bladder cancer), renal ultrasound (stones, hydronephrosis, tumour)

Imaging: plain film X ray (stones), non contrast CT (stones, tumour), cystoscopy (bladder cancer), CT tap (staging).

Special Tests: transurethral biopsy (transitional cell cancer)

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13
Q

management flank pain and haematuria

A
  • stones = conservative (increase water), medical (anti-emetic, analgesia, alpha blocker), surgical (sock wave therapy, endoscopic stone retrival)
  • neoplasm = medical (interferon, interleukin), surgical (nephrectomy partial or radial)
  • Lower UTI = increase hydration and give antibiotics according to culture
  • upper UTI = increase hydration, ciprofloxin 7 days
  • nephritic syndrome = steroids + cyclophosphamide, renal transplant
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14
Q

differentials for a breast lump

A
  • Most common
    • fibrocystic change
    • fibroadenoma
    • cyst
    • carcinoma -
      • DCIS
      • LCIS
      • Invasive ductal (most)
      • invasive lobular
      • medullary
      • tubular
  • less common
    • fat necrosis
    • mastitis
    • abscess
    • galactocele
    • phyllodes tumour
    • sarcoma
    • lipoma
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15
Q

what questions to ask about a breast lump?

A
  • painful? Movable?
  • ragged or smooth edges?
  • skin changes
  • changes to nipple
  • discharge - colour or blood
  • back pain
  • fever?
  • History or breast cancer
  • recent trauma?
  • weight loss?
  • age at menarche and menopasue
  • HRT use
  • ovarian cancer hx
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16
Q

Investigations for a breast lump?

A
  • physical exam= symmetry, skin changes, nipple changes
  • bloods = FBC (infection), U&E (renal function baseline), LFT (mets), calcium (mets)
  • bedside = ultrasound of breast (if over 35 in addition to mammogram), ultrasound of liver (staging/liver mets)
  • imaging = mammogram, MRI breast, CT breast (Staging), bone scan for mets
  • Special tests = FNA, needle core biopsy (receptor status, invasiv vs. in situ),
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17
Q

Management of breast lump

A
  • Neoplasm (mostly DCIS)- dependent on receptor positive + chemotherapy + surgical excision (breast conserving or mastectomy + sentinel node)
  • fibroadenoma = excision if symptomatic or >3cm
  • cysts = aspirate if symptomatic
  • reassurance, proper bra fitting, primrose oil help with breast pain,
  • Breast infections/mastitis = antibiotics and aspiration of abscess if present
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18
Q

Differentials for a blackout event

A
  • Non-syncopal = intoxication, metabolic, psychogenic, narcolepsy, epilepsy
  • syncope= vasovagal, cardiac, orthostatic hypotension, cerebrovascular perfusion, arrhythmia
  • epilepsy = lesion cause or non-lesion epilepsy
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19
Q

what questions should you ask about a blackout event?

A
  • ask if someone witnessed the event?
  • did you feel it coming on? Triggered? what was happening immediately before the episode
  • recent head trauma?
  • during episode: length of it, loss of continence, tongue biting, patterened movements
  • after episode: spontaenous recovery? (non-metabolic), tiredness (epilepsy), confusion?
  • risk factors: diabetes, epilepsy, anaemia, alcohol use, arrhythmia, sudden death of a relative, insulin therapy use? medications? blood thinners? beta blockers?
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20
Q

Investigations for a blackout event?

A
  • physical exam: carotid bruit? (stroke), BP standing and lying (orthostatic hypotension), focal neuro signs (stroke)
  • bloods: eletrolytes (seizure) , FBC (anaemia), U&E (dehydration or hyponatraemia), tox screen (intoxication), TFT (arrhythmia), aldosterone levels (BP)
  • bedside: ECG (heart block), glucometer (hypoglycaemia)
  • imaging: CT brain (bleed), Echo, Carotid doppler
  • Special tests: tild test (ANS failure or orthostatic hypotension), holder monider for cardiogenic syncope, EEG for signs of epilepsy
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21
Q

Management of blackout event

A
  • Cardiogenic
    • sleep, diet, exercise limit stress
    • antiarrhythmic medication if appropriate
    • ICD if appropriate or Valve replacement
  • Orthostatic hypotension
    • increase fluid/salt intake
    • avoid alcohol
    • exercise
    • take time when standing up
    • stope medications that potentiate (diuretics etc.)
  • Vasovagal
    • increase fluid and salt
    • SSRI
  • Epilepsy
    • avoid alcohol, stress, sleep deprivation
    • avoid triggers
    • need to bae 6 months seizure free to drive
    • medical: sodium valproate , carbamazepine
      *
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22
Q

Differentials of headache

A
  • sinister cause = VIVID
    • vascular - subarachnoid haemorrhage
    • infective- meningitis
    • Vision - Giant cell arteritis
    • ICP - oedema, hydrocephalus
    • Dissection of carotids
  • Non-sinister cause
    • tension headache
    • micraine
    • sinusitis
    • TMJ pain
    • trigeminal neuralgia
    • cluster headache
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23
Q

what specific questions should you ask about headaches?

A

Red flags

  • decreased consciousness
  • head injury
  • sudden onset
  • seizures
  • focal deficit
  • scalp tenderness
  • worse when lying down or in the mornning
  • neck pain
  • photophobia
  • past malignancy
  • impact on life
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24
Q

Investigations for a headache?

A
  • physical exam: eye movements, pupillary response, focal neuro signs, fundoscopy for papiloedema
  • bloods: CRP for infection and Giant cell arteritis , FBC for infection, blood culture for meningitis
  • bedside: lumbar puncture - meningitis, blood, opening pressure etc.
  • imaging: CT brain - for bleed or space ocupying lesion, MRI
  • Special tests: EEG
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25
Q

management of headache

A
  • haemorrhage = coil insertion surgically
  • migraine = paracetamol
  • sinusitis = antibiotics
  • tumour = chemo, radiation, sometimes ressection
  • hydrocephalus = shunt
  • meningitis = depends on viral or bacterial - steroids and ceftriaxone most common
  • tension headaches = rest
26
Q

Differentials for stroke

A
  • Thrombus stroke
    • large vessel atherosclerosis
    • vasculitis
    • atheroma of perforating arteries (lacunar infarct)
  • emboli
    • Afib
    • valve disease
    • septal defect
    • carotid plaque
  • Dissection
    • carotid
    • vertebral
  • Hypoperfusion
    • hypovolaemic shock
  • haemorhagic
    • hypertensive
    • vascular malformation
    • amyloid angiopathy
    • recreational drugs
    • anti-coagulant/antiplatelet drugs
27
Q

what questions should you ask about a stroke?

A
  • unilateral limb weakness
  • paralysis
  • sensory changes
  • speech abnormality
  • dysphasia?
  • headache?
  • urinary incontinence
  • vertigo?
  • impact on life since stroke?
28
Q

in an acute stroke, what investigations should you do? How about after the acute phase?

A

acute

  • physical exam: eye movements, pupillary response, focal neuro signs
  • bloods: glucose (stroke mimic), coagulation screen (haemorrhagic stroke), FBC
  • bedside: ECG (AFib), Blood pressure (hypertension)
  • imaging: CT brain non-contrast, CT angio for large vessel occlusion, MRI brain

Post acute

  • holter- Afib.
  • Carotid doppler - carotid stenosis/plaque
  • Echo - mural thrombus
29
Q

what is the long term management for stroke?

A

non pharmalogical: smoking cessation, alcohol reduction, diet, weight reduction, exercise

medical: anticoagulated wtih heparin, aspirin therapy, statin, treat diabetes
surgical: carotid endarterectomy if stenosis is present

30
Q

what are the differentials for MS ?

A

Degenerative

  • MS

Infectious

  • lyme
  • syphilis
  • HIV

Neoplastic

  • tumour compressing brain

vascular

  • vasculitis
  • cerebral ischaemia

Inflammation

  • SLE
  • sarcoid
  • vasculitis
31
Q

what questions should you ask if you suspect MS?

A

limb numbness or tingling

visual loss

limb weakness

dyscoordination

worsening with heat?

decreased power?

intention tremor

change in sensation

Risk factors: young adult age, woman, autoimmune history

32
Q

Investigations for suspected MS?

A
  • physical exam
    • increased tone
    • decreased power
    • increased reflexes
    • clonus
    • abnormal sensation
    • intention tremor
    • ataxia - lack of voluntary coordination
    • nystagmus
  • Bloods
    • FBC - rule out infection
    • CRP
  • bedside
    • lumbar puncture
      • oligoclonal bands and high protein
  • imaging: MRI brain
  • Special tests
    • EEG
    • disseminations of lesions in time and space
33
Q

management of MS?

A

acute relapse

  • high dose steroids

Chronic

  • interferons or Natalizumab
34
Q

what are the differentials for movement disorders ?

A
  1. Hypokinesia
    1. parkinson’s
      1. idiopathic
      2. parkinsons + lewy body, multiple system atrophy
      3. drug induced
      4. toxin induced
      5. trauma
  2. hyperkinesia
    1. ataxia
    2. tremor
    3. dyskinesia
35
Q

If someone presents with a resting tremor, what questions shoudl you ask them?

A
  • site, onset character etc.
  • associated symptoms: rigidity, instability, trouble with doorways, shuffling, difficulty turning in bed, slow movement, facial expression changes, blinking less, depression or anxiety, decreased sleep, orthostatic hypotension, bladder dysfunction, hallucinations (LEwy body dimentia)
  • Risk factors: family history, head injury, occupational exposure to pesticides,
36
Q

what investigations should you do for parkinsons?

A
  • physical exam: pill rolling tremor, cogwheel rigidity, changes in posture, shuffling gait, reduced facial expression, vertical gaze palsy
  • Bloods: FBC (inflammatory causes),
  • Bedside : Levodopa administration - look for response
  • imaging: MRI brain (vascular parkinsonism),
37
Q

what is the management for Parkinsons disease?

A

Non-pharmacological: physio, exercise, OT

medical = levodopa + carbidopa

Surgical = Deep brain stimulation

38
Q

what are your differentials for joint pain?

A
  • trauma
    • muscular
    • tendon
    • fracture
  • inflammatory
    • gout
    • pseudogout
    • septic arthritis
    • synovitis
    • osteoarthritis
    • RA
    • bursitis
    • osteomyelitis
    • bone malignancy
  • Neuro
    • nerve entrapment
    • radiculopathy
      *
39
Q

what questions should you ask about joint pain?

A
  • SOCRATES
  • Red flags
    • weakness
    • altered sensation
    • sphincter disturbance
    • urinary retnetion
    • systemic illness
    • night pain
    • trauma
    • cancer history
  • Multiple joints or single?
  • symmetrical?
  • small joint involvement?
  • back pain?
  • pain elsewhere?
  • soreness after waking up?
  • worsens with movement? Improves with rest?
  • onset within hours?
  • insidious onset
  • chronic?
  • relief with painkillers?
  • frequent fractures
  • Effect on life?
    • tie shoes? Walk up stairs? Wash hair etc
  • recent trauma
    • hear a pop/crunch? Tendon rupture
    • blood or exposed bone? risk of infection
    • historical trauma? OA
  • Fall?
    • what happened before, after or during
    • hit head?
    • instability?
  • Recent gonorrhea infection? - reactive arthritis
  • skin changes (Psoriasis)
  • steroid use (predisposed to fracture)
  • mouth ulcers (crohns arthropathy
  • shortness of breath
  • loss of mobility
  • fever, night sweats, malaise)
  • gout risk factors: thiazide diuretics, alcohol, renal failure, chemo
  • septic arthritis risk factors: immune suppression and prosthetic joints
40
Q

investigations for joint pain?

A
  • physical exam: look - swan neck deformity, nodes, etc, feel (heat), move (reduced ROM), special tests
  • Bloods: FBC (septic arthritis), ESR/CRP (inflammation), RF, urate (gout), HLA B27 testing (seronegative spon), PTH *hyperparathyroidism, Vitamin D levels
  • bedside: ultrasound - ligamentous injury or capsular injury
  • Imaging: plain film X ray of joint, MRI for soft tissue damage
  • special tests: Arthrocentesis - for gout, septic arthritis, etc.
41
Q

Management of joint pain?

A
  • Gout = avoid alcohol and red meat, NSAIDS, and allopurinol
  • Septic Arthritis = analgesia, joint aspiration and lavage
  • tendonitis= rest/ice, analgesia
  • reactive arthritis = avoidance of gonorrhea, antibiotics
  • tendon rupture = RICE, physiotherapy, analgesia, tendon repair
  • osteoarthritis = weight loss, physiotherapy, NSAIDS, total replacement, partial replacement
  • RA = smoking cessation, exercise, DMARDS (methotrexate with folic acid), steroids, NSAIDS, joint fusion or replacement
  • seronegative arthritis = smoking cessation, exercise, physio, NSAIDS or methotrexate
  • Osteoporosis = smoking and alcohol cessation, exercise, bisphosphonates,
  • Fracture = rest + immobilize, physio
42
Q

Differential for abdominal pain

A
  • Epigastric
    • peritonitis - radiating to full abdomen, worse on movement, pleuritic pain 10/10
    • perforated peptic ulcer - sudden onset
    • gastritis - from epigastrium to chest - burning pain, self-limiting episode
    • Peptic ulcer disease- burning pain, food alleviates duodenal ulcer but exacerbates a gastric ulcer,
    • MI - can radiate then to jaw, neck, arm etc.
    • ruptured AAA- radiates to back
    • bowel ischaemia
    • gastric cancer (rare)
  • Right upper quadrant
    • biliary colic - self-limiting episode triggered by fatty food
      • cholecystitis - over hours and radiates to the shoulder tip
      • ascending cholangitis - over hours and presents with fever and signs of liver involvement
      • duodenal cancer
      • acute pancreatitis - deep pain radiating to back, relieved by sitting forward
      • ulcer
      • small bowel obstruction (colicky pain)
      • gynae - cholestasis of pregnancy
  • Right iliac fossa pain
    • appendicitis
    • gastroenteritis
    • ureteric colic
    • inguinal hernia
    • orchitis
    • diverticulitis (rare)
    • pyelonephritis
    • ectopic pregnancy
    • PID
    • testicular torsion
    • rupture of ovarian cyst
  • Left iliac fossa pain
    • diverticulitis - 2-3 day history
    • constipation
    • IBD
    • pylonephritis
  • Flank pain
    • stones - unilateral pain
    • UTI
    • muscular
    • ruptured AAA
43
Q

what questions should about abdominal pain?

A
  • associated with foods?
  • NSAID use
  • cough?
  • haematemesis
  • recent vomiting
  • pain getting worse or better?
  • any jaundice
  • any itchiness
  • IBS
  • diarrhea/constipation
  • can you pass gas?
  • risk factor for thromboembolism - ischaemic bowel
  • meckels diverticulum/appendicitis?
  • diverticulitis stuff?
  • skin symptoms = crohns
  • weight loss
  • history of smoking
  • gynae questions
    • ovulation?
    • period?
    • chance of pregnancy
      *
44
Q

Investigations for acute abdominal pain?

A
  • physical exam: guarding/rigidity/ rebound tenderness
    • erythema nodosum (IBD)
    • clubbing
    • abscess
    • pallor
    • ascites
    • jaundice
    • bowel sounds
    • murphys sign
  • bloods:
    • FBC
    • CRP
    • amyase/lipase
    • AST/ALT
    • GGT
    • albumin
    • creatinine
    • glucose - pancreatitis induced lack of insulin
    • troponin - MI
    • bilirubin - elevated conjugated with jaundice
    • pregnancy test
  • bedside
    • ultrasound
    • ECG
    • urinalysis - UTI
  • Imaging
    • erect CXR
    • abdominal X ray
    • CT
  • SPecial tests
    • endoscopy
    • colonoscopy
45
Q

what differentials do you have for haematemesis?

A
  • esophagitis
  • bleeding ulcer
  • esophageal varices
  • mallory weiss tear
  • esophageal cancer
  • gastric cancer
  • trauma
  • aorto-enteric fistula
46
Q

what questions should you ask about haematemesis?

A
  • how much blood
  • any malaena
  • forceful vomiting (mallory weiss tears)
  • weight loss
  • swallowing problems (malignancy)
  • epigastric pain
  • heartburn or reflux
  • aortic repair in the past
  • NSAID use
  • excessive alcohol consumption
  • liver failure symptoms: puffy ankles, easy bruising , distended abdomen, lethargy, methotrexate use, IVDuser(hep c)
47
Q

What investigations would you perform for haematemesis?

A
  • physical exam
    • jaundice, scratch marks, spider naevi, palmar erythema, caput medusae
    • abdominal scar (AA repair)
    • cachectic = cancer
    • any malaena
  • bloods
    • FBC (anaemia)
    • albumin (liver disease)
    • AST/ALT/GGT/ALP - liver function
    • bilirubin
    • INR - raised in liver failure
    • hepatitis and HIV serology
    • glucose
    • tox screen, blood alcohol levels
  • imaging
    • chest X ray
    • ultrasound liver
    • fibro scan - liver cirrhosis
48
Q

Differentials for rectal bleeding?

A
  • anorectal
    • haemorrhoids
    • rectal/anal tumour
    • anal fissure
    • anal fistula
    • rectal varices
    • proctitis
  • colon
    • diverticular diseas
    • colitis
    • IBD
    • tumour
    • C.dif
  • ileum/jejunum
    • meckel’s diverticulum,
    • crohns
    • celiac
    • small bowel tumour
  • upper GI
    • PUD
    • varices
    • gastritis
    • mallory weiss tears
    • aorto-enteric fistula
49
Q

what specific questions should you ask about rectal bleeding?

A
  • color of blood
  • how much blood
  • with a bowel movement
  • mucus (colitis)
  • character of blood
    • haematochezia (fissure and heamorroids)
    • malaena (upper GI)
    • on top of stool (sigmoid, anorectal)
    • mixed in with stool (IBD, colitis, colon tumour)
    • on toilet paper only (haemorrhoids)
    • blood passed after stool (colitis, diverticular diseae, rectal tumour)
  • pain
  • prolapse
  • tenesmus
  • forceful vomiting
  • recent weight loss
  • SOB or fatigue (anaemia)
  • light headedness, syncope (anaemia)
  • recent colonoscopy
  • coagulation disorder
50
Q

what investigations shoudl you perform in rectal bleeding circumstance?

A
  • physical: pulse and BP, anaemia signs, DRE (malaena, frank blood or palpable masses)
  • bloods: FBC (anaemia and platelets), INR (clotting abnormality),
  • imaging: proctoscopy and sigmoidoscopy, colonoscopy, mesenteric angiography , CT angio, upper GI endoscopy, video capsule endoscopy
51
Q

what are your differentials for constipation ?

A
  • lack of fiber
  • dehydration
  • IBS
  • medication induced (opiates)
  • colorectal carcinoma
  • strictures
  • hypothyroid
  • neurologic - diabetic neuropathy, MS, PD
  • haemorrhoids, anal fissure
  • hypercalcaemia
52
Q

what are your differentials for diarrhea?

A
  • infectious
  • inflammatory
    • IBD, crohns, IC
    • diverticular disease
  • Motility
    • hyperthyroid
    • IBS
    • Anxiety
  • malabsorption
    • celiac
  • obstruction overflow
  • medication
    • laxatives
    • meformin
    • antibiotics
    • thiazide diuretics
53
Q

what questions should you ask when patient presents with a change in bowel habit?

A
  • severe/persistent
  • no stool or flatus (obstruction)
  • rectal bleed
  • tenesmus
  • weight loss
  • night sweats
  • hard lumpy (diet), mucoid stool (salmonella), smelly/floating (celiac disease or biliary insufficiency), pale (obstruction of biliary duct),
  • nocturnal diarrhea (IBS)
  • nausea/vomiting (obstruction)
  • pain? relieved by bowel movement = IBS
  • signs of hypothyroidism - reduced appetite, feeling cold
  • signs of hyperthyroidism - anxiety, sweating, palpitations
  • bone pain?
  • recent travel - gastroenteritis or salmonella
    *
54
Q

what investigations would you do for a change in bowel habit?

A
  • physical: clubbing (crohns/UC), erythema nodosum (Crohn’s), dermatitis herpetiforms (celiac), virchows node , anal cancer/fistula, abdominal mass, DRE for a mass
  • bloods: FBC (anaemia), ESR/CRP (crohn’s UC), celiac antibodies, TFTs for thryoid function, glucose (diabetic neuropathy), albumin (chronic diarrhea)
  • bedside - fecal occult blood, feces for culture, feces for C.dif toxin
  • imaging - abdominal x ray, colonoscopy/sigmoidoscopy,
55
Q

What are your differentials for nausea and vomiting?

A
  • Neuro
    • vertigo, pain, raised ICP, meningitis
  • Blood
    • medication, alcohol, hormones/pregnancy, electrolyte imbalance, toxin, poisoning, DKA
  • Viscera
    • GI obstruction, gastroparesis, diaphragm inflammation, liver, pancreas, gallbladder formation, appendicitis, pregnancy
  • Infectious
    • viral, bacterial or parasitic
56
Q

What questions should you ask about nausea/vomiting?

A
  • what does the vomit consist of
  • is it worse in the morning (raised ICP)
  • new onset?
  • during eating hours?
  • early satiety?
  • abdominal discomfort?
  • pain?
  • fever
  • headache
  • visual disturbances
  • vertigo
  • difficulty walking
  • constipation
  • sick contacts
  • foreign ravel
  • new medications
  • alcohol
57
Q

what investigations should you do for nausea/vomiting?

A
  • physical: peritonitis, reduced consciousness, meningism, abdominal distention, jaundice
  • bloods : FBC, CRP, LFT, amylase, glucose, ketones, tox screen
  • bedside: pregnancy test, supine X ray, abdominal CT endoscopy, fundoscopy (signs of raised ICP)
  • imaging: plain X ray, endoscopy, colonoscopy
58
Q

What are your differentials for jaundice?

A

Prehepatic

  • haemolysis
  • G6PDH deficiency
  • artificial heart valve lysis
  • DIC
  • malaria
  • spherocytosis
  • sickle cell

hepatic

  • hepatitis (viral or autoimmune)
  • neoplasia
  • Gilbert’s disease (enzyme insuficiency)
  • paracetamol overdose

post-hepatic

  • CBD obstruction
  • gallstone ileus
  • budd chiari syndrome
59
Q

what specific questions should you ask in a patient presenting with jaundice?

A
  • where are you from?
  • Pregnant?
  • pain/
  • itching?
  • fever?
  • diarrhea
  • steatorrhea
  • dark urine
  • pale stool
  • weight loss
  • night sweats
  • worse with fatty food?
  • tattoos/ IVDU
  • alcohol consumption
  • uprotectd sex
  • foreign travel- malaria and hepatitis
60
Q

what investigations should you perform on someone with jaundice?

A

physical: jaundice, spider naevi, palmar erythema, clubbing, brusiing, ascites

Bloods: FBC, reticulocyte, bilirubin, LFTs, amylase, haptoglobins, LDH, blood film, viral hepatitis screen, CMV screening,

bedside: urinalysis - bilirubin in urine = post-heaptic, pregnancy test, abdominal ultrasound - liver cirrhosis and obstruction

imaging - MRCP

OSCE 2019 (2 decks)

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