Mcleaods Flashcards
Gen obs
BMI Hydration Fever Distress, pain Musc wasting
Hands
Clubbing
Koilonychia
Leukonychia
Palmar erythema
Face
Pallor
Jaund
Spider naevi
Parotid swelling
Mouth
Angular stomatitis
Glossitis
Neck
Lymphadenopathy
Abdo inspec
Scars
Swelling
Distended Vs
Abdo palp
Hepatomeg Splenomeg Mass Kidn Bladder Tenderness
Abdo percuss
Ascites
Abdo ausc
Bowel sounds
Bruit
Rectum
Skin tags
Haemorrhoids
Bleeding
Faecal occult blood
Scrotum
Mass
Swelling
Liver locat
Upper border 5th R ICS on full expirat
Lower costal margin mid clavic on full inspirat
Panc locat
Neck at L1
Tail above and R
Spleen locat
L ribs 9-11
Post to mid axillary line
Kidn levels
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mouth pain
Aphthous ulcer Candiasis Dental sepsis HSV Coxsackie A Trauma Leukoplakia Drug allergy eg sulphonamide Iron, folate, vit B12, vit C defic Leucopenia, leukaemia Reactive arth IBD Coeliac Lichen planus
GORD vs CP
Burning
Upward radiat
Occur when lie falt or bend forw
Waterbrash
Dyspepsia- upper abdo discomfort
Reflux like- HB
Ulcer like- relieved by food, antacid
Dysmotility like- naus, belch, bloat, satiety
May be pointing sign or fat intol.
Abdo pain
Visc pain- distens, traction, sm contrac. SNS splanchnic Ns.
Somatic pain- parietal perit and abdo wall, localised, IC spinal Ns.
GU causes
Testic torsion Rupt ovarian cyst PID Endometriosis Ectopic preg
Pain onset
Sudd severe, rap prog, becomes gen and const- hollow visus perf, rupt AAA, or mesent infarc.
Preceding constipat- CR CA or divertic as cause of perf.
Prior dyspepsia- rupt ulcer cause of perf.
COexist PVD, HTN, HF, AF- AAA or mesent isch cause.
Circ fail following pain- sepsis or bleed. Eg AAA, ecoptic preg.
Ovarian or testic torsion- sudd sev pai and naus.
Volvulus- sudd pain and assoc acute obstruc.
Pain char
Acute- inflamm and obstruc.
Inflamm- const pain, worse on move or cough. Can persis hours.
Colicky pain- bowel obstruc, uterus contrac. Secs to mins. Moving or knees up can help.
Bil and renal colic- rap peaking pain, pesists sev hrs, then grad goes. Us relieved by analgesia.
Dull, vague and poorly loc us inflamm or low grade infec eg append, salpingitis, divertic.
Peptic ulcer
Epig, grad onset, gnawing, into back. Remiss for weeks ot months. Worse nocturnal and when hungry. 30 mins to hrs durat. Exacerbated by spicy, alc, NSAID. Relieved by food, antacid, vom. Mild to mod sev.
biliary colic
Epig and R hypochondrium, rapidly incr, constant, below R scap. Can count attacks Unpredictable 4-24hr Cant eat during pain Severe
Acute pancreatitis
Epig and L hypochondrium, sudd onset, const, into back. Can count attacks Heavy drinking worse Over 24hr Cant eat during pain Eased by sit up Severe
Renal colic
Loin, rapid incr, const, into genitalia and inner thigh. Us a discrete episode Worse after dehyd 4-24hr Severe.
Radiating pain
Right hypoch to shoulder or interscap- diaph irrit eg cholecystitis.
Loin to groin and genit- renal colic.
Central abdo to back, relieved by sit forw- acute pancreatitis.
Central, later RIF- acute appendicitis
Sev back and abdo pain- rupt or dissec aorta
Ing canal- ureteric pain
Other abdo symps
Anorexia NV Sev painless vom- gastric outlet or SI obstruc. Faeculent- late LI obstruc. In peritonitis vom with retching and can cause MW tear or boerhaave. Change bowel habit. Ask about urinary symps Wind and flatulence Dysphagia Distension Bleeding Jaundice Reflux
Timing
Can be delay after perf before peritonitis
In SI obstruc colic change to persis pain can sugg isch
Non GI causes of abdo pain
MI
Dissecting aneur- tearing interscap pai, hypot, asymm fem pulses.
Verteb collapse
Cord comp
Pleurisy- lat pain on cough, pleural rub.
Herpes zoster- hyperaesthesia, vesicles.
DKA- cramps, vom, air hungerm tachy, breath sweet
Salpingitis or ectopic- suprapubic and IF, NV, fever.
Gonad torsion- low abdo pain, NV.
Pain severity
V sev and not relieved by opiates- isch vasc event eg bowel infarc or rupt AAA.
Sev but responds to analgesia- pancreatitis or peritonitis.
Swallow
Globus and early satiety is not related
Neurologic dysphagia worse for liq- choke, nose regurg.
Neuromusc dysphagia or oes dysmotil- worse for solid.
Achalsia- LOS fail relax. Can cause aspirat. And CP.
mech dysphagia- CA if wl, no refluc. Stricture if no wl and heartburn.
Dysphagia causes- tonsillitis, bulbar palsy, CVA, achalasia, pharyng pouch, MG, dysmotil, CA, ext comp, benign stricture, oesophagitis.
Symps to ask- pain, progressive, time, HB, solid or liq, level that food sticks, regurg.
NV
Often assoc pallor, sweating, hyperventil.
Dyspepsia naud but no vom.
Gastric outlet obstruc- projectile, not bile stained.
Obstruc distal to pylorus bile stain.
Comm causes- gastroeneteritis, cholecystitis, pancreatitis, hepatitis, sev pain.
Non alimentary- RICP, migraine, meniere, drugs, DKA, renal fail, preg, ED.
Symps to ask- warning, pain, time of day, bile/blood/faeculent.
Distension
Ascites- Accum fluid in perit cav.
Functional bloating- flucs dur day, resolves at night. Us IBS.
Constipat rarely causes distension.
Painless in wom- ovarian pathol or preg.
Fat, flatus, faeces, fluid (ascites and bladder), fetus, functional (IBS).
Ascites
Exudate-inflamm or malig.
Transudate- hepatic cirrhosis with portal HTN, acute hepatic V occlus, hypoproteinaemia eg nephotic synd.
Constrictive pericarditis and RHF. Check JVP and ausc for rub.
TB peritonitis- low gluc
Pancreatitis- high amylase.
diarrhoea
Freq loose stool.
High vol over 1L per day.
Secretory- due to int inflamm eg infec, IBD. Contins if dont eat.
Osmotic- malabs, drug AE, motility prob. Osmotic stops if dont eat.
Steattorhoea.
Low vol eg IBS.
Bloody- IBD, colonic isch, infective gastroenteritis.
Acute causes- infec gastroenteritis eg C diff, drugs eg AB.
Chronic over 4 wk- IBS, IBD, parasite, CR CA, autonomic neuropathy eg DM, laxative abuse, hyperthyroid, overflow from faecal impaction, SI or right colon resection, malabs.
Symps to ask- time, urgency, tenesmus, contin, stool consis and vol, freq, blood/mucous/pus, sleep, travel, sex hx, alc, drugs, surg, IBD, fam hx, other symps.
IBS
Bloating, dyspepsia. Rome III criteria- recurr abdo pain at least 6 mnth, assoc with 2 or more of- Impr with defecation Onset assoc with chnage in stool freq Onset assoc with change in stool form
Constipation
Reduc colon mobil, reduc rectal sensat, anorectal dysfunc.
Anismus- impaired evac process.
Tenesmus- rectal inflamm or tum.
Obstruc- absol ocnstip, vom, distens.
Causes- diet, IBS, obstruc, CA, drugs, hypothyr, hyperCa, immboil eg stroke and parkinsons.
Symps to ask- time, freq, how long straining, pain, bleed, stool shape, meds.
Coffee ground vom
Pepsin degradation of blood.
Malaena
Tarry shiny black, specif smell.
Diff from black stool seen in iron or bismut therap.
UGI bleed causes- ulcer, MW tear, oesophagitis, gastritis, varices, CA, vasc malformat.
Symps to ask fro haematemesis and malaena- GI hx, alc, NSAID, CS, type blood, retching, blood in first vomit.
jaund
Skin, sclerae, mucous mems.
Seen when over 50umol/L.
Causes- haemolysis, gilberts, hepatitis, cirrhosis, drugs, gallst, panc CA, cholangiocarcinoma.
Qs- appet, wl, abdo pain, bowel habit, bleed, dark urine, fever, drugs, alc, pmh, prev jaund or hep, blood transfus, fam hx, sex hx, tattoo, pruritis.
Charcots triad fever, pain, jaund- asc cholangitis.
Painless- CA.
rectal bleed
Haemorrhoid Fissure CR polyp or CA IBD Isch colitis Diverticular dis Vasc malformat
GI affects of drugs
Oral CS- weight gain NSAID- dyspepsia, UGI bleed SSRI- naus ABs, PPI- diarr Opioids- constipat Paracetamol and TB drugs- jaund, hep Fluclox and co amox- jaund, cholestatic Methorexate- liver fibrosis
GI alarm feats
Persis vom Dysphagia Fever Wl Bleed Anaemia Painless, watery, high vol diarr Nocturnal symps
Viral hep RFs
IV drugs Tattoo Travel Transfus Sex RFs
Hands
Clubbing
Koilonychia spoon
Leukonychia liver dis
Palmar eryth liver dis
Mouth
Angular chellitis iron defic
Atrophic glossitis iron defic
Aphthous ulcer gluten enteropathy and IBD
LNs
Troisiers sign- L supraclavic LN enlargem due to gastric or panc CA.
Widesp LNs with hepatosplenomegaly- lymphoma.
Chronic liver dis signs
Jaund Spider naevi due to excess oestrogen due to reduced hepatic breakd. Plamar eryth due to excess oestrogen Ascites Gynaecomastia Testic atrophy Leukonychia hypoalb Clubbing cirrhosis, IBD, malabs. Asterixis hepat enceph Fetor hepaticus breath portosys shunt Dupuytrens alc, fam hx, DM, smok, chol, HIV
liver fail signs
Fetor hepaticus
Flapping tremor
Variable mental state
Lat neuro- spasticity and limb ext, extensor plantar resp.
Caput medusa
Recanal of umb V along faliform lig
Prods distended Vs drainign away from umb.
distension
Obese- sunken umb Ascites- umn flat or everted. Scars Asymm Masses Gen or loc
Pain
Pain in sev areas on light palp- peritonitis, or anx
Vol gurading- vol abdo musc contrac due to pain
Invol- reflex contrac when parietal inflamm
Thoracic breathign with rigid abdo- gen perotnitis
RIF pain- append or corhns ileitis
Rebound tend not necess peritonitis- pain after deep palp
Bowel sounds
Visible peristalsis
Palpat
Epig mass- panc or gastric CA, AAA
Hepatomeg
Gen distens- Fs
RIF mass- caecal CA, crihns, append
LUQ mass- spleen cant get above, kidn can get above
LIF mass- sigm CA, constipat, divert mass.
murphys sign
Breathe in
Palp RUQ mid clavic
As liver descends inflamed gb hits finger- pain and sudd arrest of inspiration
Acute cholecystitis if RUQ pain too
gb
If jaund and palpab gb- extrahepat obstruc eg panc CA or gallst (courvoisier)
hepatomegaly causes
ALD Steatosis AI hep Viral hep Prim bil cirhosis HCC Mets CA RHF Lymphoma, leuk Amyloidosis, sarcoidosis
splenomegaly causes
Has to triple to be palp
Us ribs 9-11 mid ax
Lymphoma, leuk Myeloprolif disorders Haemolytic anaemia Glandular fever Malaria Bact endocarditis TB Rheum arth SLE Sarcoidosis, amyloidosis
ascites causes
Shifting dulln
Malig Chronic liver dis Sev HF Nephrotic synd Hypoprot
Hepatosplenomegaly causes
Lymphoma Myeloprolif dis Cirrhosis with portal HTN Amyloidosis Sarcoidosis Glycogen storage dis
Ascites px
Weight gain
Incr girth
Shifting dullness
Ausculatation
R of umb, 2 mins
Above umb for aorta and bruits
2-3cm lat to umb for renal bruit
Liver bruits
Absence- paralytic ileus or peritonitis
Incr freq and vol, high pitch tinkling- obstruc
Bruits- atheroma or aneur or SMA sten
Friction rub- peri hepatitis or splenitis
Splash over 4hr after eat- delayed gastric emp eg pyloric sten
Hernias
External- abn protrusion bowel or omentum from abdo cav.
Internal- through mesent defects or into retroperit sp, not visible.
Cough impulse.
Ing hernia
Ing canal- pubic tubercle to ASIS.
Ing hernias are above and medial to pubic tubercle.
Femoral hernia
Fem canal- below ing lig and lat to pubic tubercle.
groin swell causes
Ing or fem hernia LN Lipoma, cyst Hydrocoele Undesc testis Psoas abcess Femoral aneur
Groin hernia px
Dull dragging discomfort Exacerbated by straining Groin swelling or lump Symps us worse at end day and after activ Might be reducible
Strangulated hernia
Tense Tender No cough impulse Bowel obstruc Later sepsis and shock Surgical emerg- risk infarc and peritonitis.
indications for DRE
Susp append, pelvic ancess, peritonitis, low abdo pain. Diarr, constip, tenesmus, anorectal pain. Rectal bleed, iron defic anaem. Unexpl wl. Lower abdo mass. Prostate symps. Dysuria, freq, haematuria. Abdo, spinal or pelvic trauma.
DRE
Prostate ant, 2 lobes and median groove.
In fem vagina and cervic ant. Puborectalis musc is upper end anal canal.
If susp fissure then give LA suppository 10 mins bef to reduce ext sphinct spasm.
Haemorrhoids only palpab if thromosed.
Rectal CA.
Lateralised tenderness suggs pelvic peritonitis.
Gynae malig can cause frozen pelvis.
BPH- symm enlargem.
Prostate CA- hard, irreg, asymm, no median groove.
Prostatitis or abcess- change in consis and tenderness.
Hypogonadism- small prostate.
Abn stool appearance
Pale- biliary obstruc
Pale and greasy- steatorrhoea
Black tarry- UGI bleed malaena
Grey/black- oral iron or bismuth therap
Silvery- steat plus UGI bleed eg pancreatic CA
Fresh blood in or on stool- LI, rectal or anal bleed
Stool mixed with pus- infective colitis or IBD
Ricewater- cholera.
proctoscopy
Do DRE first Flex siggy instead if examining mucosa. Haemorrhoid Fissure Rectal prolapse
