Minor Illnesses + Acute Presentations Flashcards
Define cough
Reflex response due to airway irritation
Acute = less than 3 weeks
Sub-acute = 3-8 weeks
Chronic = more than 8 weeks
Causes of acute cough
URTI
Acute bronchitis
Pneumonia
Acute exacerbations of asthma or COPD
Causes of sub-acute cough
Airway hyper-responsiveness following specific infections - Mycoplasma pneumoniae
Post-infectious cough - pertussis
Ongoing infections
Causes of chronic cough
Cigarette smoke exposure ACE-i Post-nasal drip syndrome Asthma GORD
Define common cold
Mild, self-limiting URTI characterized by nasal stuffiness and discharge, sneezing, sore throat and cough
Complications of URTI
Sinusitis
LRTI
Acute otitis media
Risk factors for complications of URTI
Comorbidities - asthma - COPD - DM - cystic fibrosis Older age and young children Immunocompromised Smoking
Clinical features of URTI
Sore/irritated throat Nasal irritation, congestion, discharge and sneezing Cough Hoarse voice General malaise Rapid onset over 1-2 days
Differential diagnosis of URTI
Meningitis Upper airway obstruction Nasal foreign body Influenza Streptococcal pharyngitis Allergic rhinitis Glandular fever Whooping cough (pertussis)
Management of URTI
Reassure self-limiting and complications are rare
Antibiotics and antihistamines are ineffective and may cause adverse effects
Adequate fluid
Healthy food
Adequate rest
Define urinary tract infection
Infection of any part of urinary tract usually by bacteria
- also fungi, viruses or parasites
Define lower UTI
Infection of bladder
Define cystitis
Inflammation of the bladder
Define upper UTI
Pyelitis, pyelonephritis
Define uncomplicated UTI
Infection by a usual pathogen in a person with normal urinary tract and normal kidney function
Define complicated UTI
One or more risk factors are present that predispose to persistent infection, recurrent infection or treatment failure
Define recurrent UTI
Repeated UTI which may be due to relapse or reinfection
3 or more UTIs in last 12 months
Causative organisms of UTIs
Escherichia coli - 80%
Staphylococcus saphrophyticus
Klebsiella pneumoniae
Proteus mirabilis
Routes of entry by bacteria into urinary tract
Direct - insertion of catheter into bladder, instrumentation or surgery
Via blood stream - immunocompromised
Retrograde - ascending through urethra into bladder
Risk factors for UTI in males
Over 50 BPH Catheterisation Previous urinary tract instrumentation or surgery Previous UTI
Anal sex Immunosuppression DM Recent hospitalisation Uncircumcised men Vaginal sex
Complications of UTI in males
Renal function impairment Prostatitis Pyelonephritis Sepsis Urinary stones
Clinical features of UTI in men
Temperature 1.5 degrees higher than normal New frequency or urgency New incontinence New or worsening delirium/debility New suprapubic pain Visible haematuria
Urine sample collection methods
Mid-stream (MSU) - routine recommended method
- first part of voided urine discarded and without interrupting flow 10ml collected
Clean-catch (CCU)
- whole specimen collected
Catheter urine sample (CSU)
Features of urine dipstick that suggests UTI
Positive for nitrite and leukocyte esterase
Management of UTI in men
Start empirical antibiotic
- trimethoprim or nitrofurantoin - 7 days
Risk factors for UTI in children
Age below 1 year Female sex White Previous UTI Voiding dysfunction Vesicoureteral reflux Sexual activity No history of breastfeeding Immunosuppression
Complications of UTI in children
Renal scarring/damage
Hypertension
Bacteriuria and hypertension during pregnancy
Renal insufficiency and failure
Complications of UTI in women
Ascending infection - pyelonephritis, renal and peri-renal abscess
Pre-term delivery and low birth weight if pregnant
Risk factors of complications of UTI in women
Pregnancy Older age Healthcare associated Presence of symptoms for more than a week before presentation Urologic instrumentation Pre-existing urological conditions Comorbidities
Management of UTI in women
Not recurrent
- advise on self-care methods
- simple analgesia
- avoid dehydration
- assess need for antibiotic
- nitrofurantoin for 3 days
- trimethoprim for 3 days
Recurrent
- personal hygiene
- avoid douching and occlusive underwear
- wipe front to back
- adequate hydration
- avoid delay of habitual and post-coital urination
- antibiotic prophylaxis
- trimethoprim or nitrofurantoin
- amoxicillinDefine acute bronchitis
Lower respiratory tract infection which causes inflammation of the bronchial airways
- cough resulting from acute inflammation of trachea and large airways without evidence of pneumonia
Define pneumonia
Infection of lung tissue in which the air sacs in the lungs become filled with microorganisms, fluid, inflammatory cells
- affects function of lungs
Organisms causing acute bronchitis
Viral infection
- rhinovirus
- enterovirus
- influenza A and B
- parainfluenza
- coronavirus
- adenovirus
Causative organisms of community-acquired pneumonia
Bacterial infection
- streptococcus pneumoniae
- haemophilus influenzae
- staphylococcus aureus
- group A streptococci
- moraxella catarrhalis
Complications of acute bornchitis
Usually mild and self-limiting
Cough lasts 2-3 weeks
Pneumonia may occur as a complications
Complications of pneumonia
Pleural effusion Empyema Lung abscess Acute respiratory distress syndrome Septic shock Disseminated infection
Parts of the CURB-65 scoring
1 point for each feature
- confusion - new disortietnation
- raised RR - 30 bpm or more
- low BP - 60 diastolic or 90 systolic
- over 65
Management of acute bronchitis
Conservative - adequate fluid intake - paracetamol or ibuprofen - stop smoking Offer antibiotics if systemically unwell or back up for those at higher risk - doxycycline - not for pregnant women - amoxicillin
Risk factors for complications of acute bronchitis
Pre-existing comorbid condition Older than 65 with 2 or older than 80 with one of the following - hospital admission in previous year - DM - history of congestive heart failure - current oral corticosteroids
Management of CAP
Conservative - rest - adequate fluid intake - simple analgesia Antibiotics - amoxicillin
Define blepharitis
Common chronic inflammatory condition affecting the margin of the eye
Usually bilateral
Categorises fo blepharitis
Anterior - inflammation of the base of the eyelashes
- bacterial - staphylococci
- seborrhoeic dermatitis
Posterior - inflammation of the meibomian glands
- meibomian glands run along posterior eye margin - produce lipid secretion which provides the lipid layer of the tear film
Complications of blepharitis
Meibomian cyst External stye Changes to eyelashes - loss, misdirection and depigmentation Eyelid thickening, ulceration and scarring Contact lens intolerance Dry eye syndrome Conjunctivitis Corneal inflammation
Clinical features of blepharitis
Burning, itching and crusting of eyelids Symptoms worse in morning Both eyes affected Recurrent hordeolum Contact lens intolerance
Management of blepharitis
Symptoms controlled with self-care
- eyelid hygiene - cleaned twice daily
- warm compress
Define a hordeola
Stye
Acute localised infection or inflammation of the eyelid margin
- bacterial infection of cilium and adjacent gland with local abscess formation
- usually staphylococcal`
Types of hordeola
External stye
- appears on eyelid margin
- caused by infection of eyelash follicle and associated sebaceous or apocrine gland
Internal stye
- occurs on the conjunctival surface of the eyelid
- caused by infection of Meibomian gland
Complications of hordeola
Infective conjunctivitis
Periorbital or orbital cellulitis
Meibomian cyst
Clinical features of hordeola
Acute-onset painful localised swelling near eyelid margin that develops over several days
Usually unilateral
External
- located at eyelid margin around eyelash follicle
- points anteriorly through the skin - small, yellow, pus-filled spot may be visible
Internal
- swelling tender and localised on internal eyelid
Management of stye
Self-care advice
- self limiting and rarely causes serious complications
- warm compress to closed eyelid for 5-10 mins 2-4 times daily
- do not attempt to puncture stye
- avoid contact lenses or eye makeup until area has healed
Define uveitis
Inflammation of uveal tract - iris, ciliary body and choroid
Causes of uveitis
Systemic autoimmune disorders - sarcoidosis - psoriatic arthropathy - MS Infection - herpes simplex - herpes zoster virus - CMV Trauma Neoplasia
Complications of uveitis
Vision loss
Visual impairment
Paediatric uveitis
Clinical features of uveitis
Pain or dull ache Red eye Diminished or blurred vision Watering of eye Photophobia Flashes and floaters Unreactive of distorted pupil
Management of uveitis
Refer to ophthalmologist Non-infectious - corticosteriods - cycloplegic-mydriatic drug Infectious - antimicrobial drug - corticosteriods - cycloplegics
Define conjunctivitis
Inflammation of conjunctiva
- conjunctiva is thin, transparent mucous membrane lining anterior part of sclera
Causes of conjuctivitis
Viral - adenovirus - herpes simplex - varicella zoster Bacteria - streptococcus pneumonia - staphylococcus aureus - haemophilus influenzae
Clinical features of conjuctivitis
Acute onset conjunctival erythema Discomfort - grittiness, burning Watering and discharge Bacterial - purulent or mucopurulent discharge Viral - mild to moderate erythema of conjunctiva and pruritis
Differential diagnosis of conjuctivitis
Acute glaucoma Scleritis Episcleritis Keratitis Uveitis Iritis Corneal ulcer Atopic of allergic conjunctivitis Nasolacrimal duct obstruction Subconjunctival haematoma Dry eye Blepharitis Thyroid eye disease
Features for referral for conjunctivitis
Suspected gonococcal or chlamydia conjunctivitis
Possible herpes infection
Suspected periorbital or orbital cellulitis
Recent intraocular surgery
Corneal involvement
Management of viral conjunctivitis
Reassure most cases self-limiting and do not require antimicrobials
Advise self-care
- bathing eyelids with cotton wool soaked in sterile saline to remove discharge
- cool compress
- lubricating drops or artificial tears
Avoid antibiotics
Inform infective so should prevent spread
- wash hands with soap and water
- separate towels and flannels
Management of bacterial conjunctivitis
Advise most cases resolve within 5-7 days
Treat with topical antibiotics if severe
- chloramphenicol 0.5% drops
- fusidic acid
Causes of lumbar back pain
Non-specific low back pain Sciatica Vertebral fracture Intra-abdominal pathologies Ankylosing spondylitis Cancer Infection
Risk factors for lumbar back pain
Obesity
Physical inactivity
Occupational factors - heavy lifting
Depression and other psychological factors
Red flags symptoms for cauda equina syndrome with back pain
Severe or progressive bilateral neurological deficit of the legs - major motor weakness with knee extension , ankle eversion or foot dorsiflexion
Recent-onset urinary retention or urinary incontinence
Recent-onset faecal incontinence
Perianal or perineal sensory loss
Unexpected laxity of anal sphincter
Red flags symptoms for spinal fracture with back pain
Sudden onset of severe central spinal pain which is relieved by lying down
History of major trauma
Structural deformity
Point tenderness over vertebral body
Red flag symptoms of cancer with back pain
Over 50
Gradual onset of symptoms
Severe unremitting pain that remains when person is supine, aching night pain that prevents of disturbs sleep
Localised spinal tenderness
No symptomatic improvement after 4-6 weeks conservative therapy
Unexplained weight loss
Past history of cancer
Red flag symptoms of infection with back pain
Fever Tuberculosis or recent UTI Diabetes History of IV drug use HIV infection Immunosuppressants
Management of non-specific back pain
Reassure Analgesia to manage pain - NSAID - do not offer paracetamol - benzodiazepine if has muscle spasms Physiotherapy for manual therapy Encourage to stay active, resume normal activities and return to work asap
Define dyspepsia
Complex of upper gastrointestinal tract symptoms which are typically present for four or more weeks including
- upper abdominal pain
- heartburn
- acid reflux
- N+V
Define GORD
Gastro-Oesophageal Reflux Disease
Reflux of gastric contents back into oesophagus
- causing predominantly heartburn and acid regurgitation
Risk factors for GORD
Stress and anxiety Smoking and alcohol Trigger foods - coffee, chocolate OBesity Drugs that increase LOS pressure - alpha-blockers, anticholinergics, benzodiazepines, beta-blockers Pregnancy Hiatus hernia FH
Risk factors for Barrett’s oesophagus
Male gender
Long duration or increased frequency of GORD
Previous oesophagitis or hiatus hernia
Previous oesophageal stricture or ulcers
Complications of GORD
Oesophageal ulcers Oesophageal haemorrhage Anaemia - chronic blood loss Oesophageal stricture Aspiration pneumonia Barrett's oesphagus
Management of GORD
Lifestyle measures - weight loss - avoid trigger foods - eat smaller meals - stop smoking - reduce alcohol consumption Sleep with head of bed raised Assess for stress and anxiety Review medication Ask about over the counter medication - antacids, alginates PPI for 4 weeks
Classification of headaches
Primary - migraine - tension - cluster Secondary - trauma - intracerebral haemorrhage - giant cell arteritis - malignancy - meningitis Cranial neuropathies - trigeminal neuralgia - optic neuritis
Features that indicate serious cause of headache
New severe
- intracranial haemorrhage
- venous sinus thrombosis
Progressive/persistent
- mass lesion
- subdural haematoma
Fever, impaired consciousness, neck pain or photophobia - meningitis or encephalitis
Papilloedema - SOL
Dizziness - ischaemia or haemorrhagic stroke
Visual disturbance - migraine, acute closure glaucoma, temporal arteritis
Vomiting - migraine, mass lesion, brain abscess or CO poisoning
Diagnostic criteria for migraine without aura
At least 5 attacks with following criteria - headache attacks lasting 4-72hrs Headache has at least 2 criteria - unilateral location - pulsating quality - moderate or severe pain intensity - aggravation by or causing avoidance of routine physical activity During headache at least 1 - nausea - vomiting - photophobia - phonophobial
Diagnostic criteria for migraine with aura
At least 2 attacks
One or more following reversible aura symptoms
- visual - zigzag lines or scotoma
- sensory - pins and needles
- speech and language - aphasia
- motor weakness
- brainstem - vertigo, diplopia
- retinal - monocular scintillations or scotoma
At least 2 of the following
- aura symptom spreads gradually over at least 5 mins
- each individual symptom lasts 5-60 mins
- unilateral
- aura accompanied or followed within 60mins by headache
Diagnostic criteria for tension-type headache
Recurrent episodes of headache lasting from 30mins to 7 days
- not associated with N/V
Headache consists of
- bilateral location
- pressing or tightening quality
- mild or moderate intensity
- not aggrevated by routine physical activity
Diagnostic criteria of cluster headache
5 severe or very severe attacks of unilateral orbital, supraorbital or temporal pain lasting 15-180mins
Associated with at least one
- ipsilateral conjunctival injection or lacrimation
- nasal congestion / rhinorrhoea
- eyelid oedema
- forehead and facial sweating
- forehead and facial flushing
- sensation of fullness in ear
- sense of restlessness or agitation
Attacks occur between every other day and 8 per day for more than half the time
Diagnostic criteria for medication overuse headache
Occurs on at least 15 days per month and pre-existing headache disorder
Regularly overused drugs for more than 3 months
- ergotamines
- triptans
- simple analgesics`
- opioids
Management of cluster headache
Refer to neurologist or GP with special interest
Subcut or nasal triptan
Do not offer paracetamol, NSAIDs, opioids, ergots or oral triptans
Short burst oxygen therapy
Advise on avoidance of triggers
Advise on risk of medication overuse headache
Management of medication overuse headache
Explain diagnosis
Withdrawal of overused drug is mainstay of treatment
- drugs such as triptans and simple analgesics can be stopped abruptly
- headache may continue for 1 month
Management of tension type headache
Simple analgesics
- do not offer opioids
If chronic offer
- up to 10 sessions of acupuncture over 5-8 weeks
- pharmacological prophylaxis with low dose amitriptyline
Complications of migraine
Reduced functional ability and QoL Medication overuse headache Progression to chronic migraine Status migrainosus Migraine aura-triggered seizure Increased risk of stroke
Management of migraine
Explain diagnosis and provide information
Advise
- keep headache diary can help identify triggers
- avoid known triggers and lifestyle management
- stress management
- good sleep hygiene
- adequate hydration
- regular meals
- exercise
- maintenance of healthy weight
Advise on medication overuse headache
For women who have migraine with aura hormonal contraception is contraindicated
Simple analgesics
Triptan
Anti-emetics - metoclopramide
Define sprain
Stretch and/or tear of ligament
Classification of sprains
Grade 1 - mild stretching without joint instability
Grade 2 - partial rupture of ligament without joint instability
Grade 3 - complete rupture of ligament complex with joint instability
Define strain
Stretch and/or tear of muscle fibres and/or tendon
Classification of strain
1st degree - few muscle fibres, normal strength
2nd degree - several injured fibres, mild swelling, loss of strength, visible bruise
3rd degree - muscle tears all way through, pop sensation, total loss of muscle function, severe pain and swelling, difficulty bearing weight
Causes of sprain
Abnormal or excessive forces applied to a joint
Causes of a strain
Muscle stretched beyond its limits
Forced to contract too strongly
Risk factors of sprains and strains
Frequent participation in sports - contact sports and those that feature quick starts - reduced strength and flexibility - poor exercise technique - wearing inappropriate footwear - inadequate warm up and cool down - muscle fatigue Sudden trauma Anatomical variations Overweight/obese Previous sprain/strain
Complications of severe sprains
Chronic instability
Loss of function
Pain
Secondary degenerative changes
Complications of severe strains
Muscle atrophy
Muscle fibrosis
Heterotrophic ossification
Compartment syndrome
Clinical features of sprain
Pain around affected joint Tenderness Swelling Bruising Functional loss Mechanical instability
Clinical features of strain
Muscle pain Spasm Weakness Inflammation Cramping Large haematomas Swelling
Management of sprains and strains
Analgesia for pain relief - paracetamol - topical NSAID gel - codeine added onto paracetamol PRICE measures - protection - support - rest - 48-72 hrs - ice - compression - elevation Avoid HARM in 72hrs - heat - alcohol - running - massage
Cardiac causes of chest pain
Acute coronary syndrome - unstable angina and myocardial infarction Stable angina Dissecting thoracic aneurysm Pericarditis/cardiac tamponade Acute congestive cardiac failure Arrhythmias
Clinical features of dissecting thoracic aneurysm
Sudden tearing chest pain radiating to back and inter-scapular region Signs - high BP - blood pressure differentials - inequality in pulses - new diastolic murmur
Clinical features of pericarditis/cardiac tamponade
Symptoms
- sharp constant chest pain relieved by sitting forward
- may radiate down left shoulder
- worse on inspiration, swallowing and coughing
- fever, cough and arthralgia
- breathlessness, dysphagia, cough and hoarseness
Signs
- pericardial friction rub
- hypotension
- muffled heart rate
- juglar venous distention
Clinical features of acute congestive heart failure
Symptoms - ankle swelling - tiredness - severe breathlessness - orthopnea - coughing Signs - elevated jugular venous pressure - gallop rhythm - inspiratory crackles at lung bases - wheeze
Diagnosis of acute coronary syndrome
12-lead ECG - pathological Q waves - LBBB - ST segment and T-wave abnormalities - normal ECG does not exclude High-sensitivity blood test for serum troponin - detectable level
Pulmonary causes of chest pain
PE Pneumothorax/tension pneumothorax CAP Asthma Lung/lobar collapse Lung cancer Pleural effusion
Clinical features of PE
Symptoms - acute-onset breathlessness - pleuritic chest pain - worse on inspiration - cough - haemoptysis - syncope Signs - tachypnoea - 20bpm - tachycardia - mild pyrexia - signs of DVT
Clinical features of pneumothorax
Symptoms - sudden-onset pleuritic pain and breathlessness - with or without pallor and tachycardia Signs - reduced chest wall movements - reduced breath sounds - reduced vocal fremitus - increased resonance of percussion on affected side
Clinical features of CAP
Symptoms - cough - sputum - wheeze - dyspnoea - pleuritic chest pain Signs - dull percussion note - bronchial breathing - coarse crackles - increased vocal resonance - fever, sweating and malaise
Clinical features of asthma
Symptoms - wheeze - breathlessness - cough - often worse at night, first thing in the morning and upon exercise/exposure to allergens Signs - increased RR and wheeze during acute exacerbations - none when feeling well
Clinical features of lung/lobar collapse
Symptoms - localised chest pain - breathlessness - cough Signs - reduced chest wall movement on affected side - dull percussion note with bronchial breathing - reduced or diminished breath sounds
Clinical features of lung cancer
Symptoms - chest or shoulder pain - haemoptysis - dyspnoea - weight loss - appetite loss - hoarseness - cough Signs - finger clubbing - cervical or supraclavicular lymphadenopathy
Clinical features of pleural effusion
Symptoms - localised chest pain - progressive breathlessness Signs - reduced chest wall movements on affected side - stony dull percussion note - diminished or absent breath sounds - signs of fluid overload - heart or renal failure
Other causes of chest pain
GI - acute pancreatitis - oesophageal rupture - peptic ulcer disease/GORD -acute cholecystitis MSK - rib fracture - costochondritis - spinal disorders - disc prolapse, cervical spondylosis Psychogenic Herpes zoster
Emergency treatment of ACS
Glyceryl trinitrate O2 if sats less than 94% Aspirin Resting 12-lead ECG Ambulance admitt
Emergency treatment of acute pulmonary oedema
IV diuretic - furosemide
IV opioid - diamorphine
IV anti-emetic - metoclopramide
Nitrate - GTN spray
Define angina
Pain/constricting discomfort in chest, neck, shoulders, jaw or arms caused by insufficient blood supply to the myocardium
- stable = occurs predictably with physical exertion or emotional stress
- unstable = occurs at rest - requires urgent admission to hospital
Complications of angina
Coronary Artery Disease - stroke - MI - unstable angina - sudden cardiac death Other - anxiety and depression - reduced QoL
Features of stable angina
Precipitated by physical exertion Constricting discomfort in front of chest, neck, shoulders, jaw or arms Relieved by rest or GTN in about 5 mins Atypically - GI discomfort - breathlessness - nausea
Risk factors for angina
Smoking High blood pressure Overweight High cholesterol Inactivity Poor diet High alcohol intake
Management of stable angina
Sublingual glyceryl trinitrate (GTN) Beta-blocker or calcium channel blocker Secondary prevention - low-dose aspirin - ACE-i
Define dyspnoea
Breathlessness
Subjective distressing sensation or awareness of difficulty with breathing
Cardiac causes of breathlessness
Silent MI Cardiac arrhythmia Acute pulmonary oedema Cardiac tamponade Chronic heart failiure
Pulmonary causes of breathlessness
Asthma Chronic obstructive pulmonary disease Pneumonia PE Pneumothorax Pleural effusion Lung/lobar collapse Bronchiectasis Interstitial lung disease Lung or pleural cancer
Other causes of breathlessness
Anaemia
Diaphragmatic splinting - ascites, obesity or pregnancy
Anxiety-related
Managment of angio-oedema without anaphylaxis
Slow IV or IM chlophenamine and hydrocortisone
Arrange emergency admission
Review after discharge
Causes of acute red eye
Conjunctivitis Subconjunctival haemorrhage Subtarsal or conjuctival foreign body Corenal abrasion Episcleritis Dry eye Blepharitis Ectropion - outward rotation of eyelid margin Entropion - inward rotation of eyelid margin Childmaltreatment Acute glaucoma Anterior uveitis Scleritis Trauma
Presentation of episcleritis
Redness and pain in one or both eyes
Segmental redness
Normal vision, pupil reactions and no corneal staining
Define acute glaucoma
Blockage of usual drainage of aqueous humour into anterior chamber
Presentation of acute glaucoma
Pain in eye - unilateral
Headache
Blurring of vision with lights surronded by halos
N+V
Tender hard eye
Fixed and mid-dilated pupil which is unresponsive to bright light
Presentations of corneal ulcer/contact lens related red eye
Foreign body sensation Photophobia Blurred vision Discharge Pain
Red eye causes that need same-day ophthalmologist assessment
Acute glaucoma Corneal ulcer Anterior uveitis Scleritis Trauma Chemical injuries Neonatal conjunctivitis
Define acute abdomen
Sudden onset severe abdominal pain
Differentials of an RUQ pain
Cholecystitis Pyelonephritis Ureteric colic Hepatitis Pneumonia
Differentials of LUQ pain
Gastric ulcer
Pyelonephritis
Ureteric colic
Pneumonia
Differentials of pain of LLQ
Diverticulitis Ureteric colic Inguinal hernia IBD UTI Gynecological Testicular torsion
Differentials of pain in RLQ
Appendicitis Ureteric colic Inguinal hernia IBD UTI Gynecological Testicular torsion
Differentials of pain in epigastric region
Peptic ulcer disease
Cholecystitis
Pancreatitis
MI
Differentials of pain in umbilical region
Small/large bowel obstruction
Appendicitis
AAA
Causes of acutely unwell child
Meningitis/sepsis
Pneumonia
Choking
DKA
Causes of tiredness
Chronic heart failure Diabetes mellitus Hypothyroidism Hyperthyroidism Iron-deficiency anaemia Insomnia Anxiety Depression
History for diabetes mellitus
Polyuria Polydipsia Weight loss Polyphagia N+V Reduced vision Altered consciousness
Examination findings for diabetes mellitus
Volume depletion - dry mucus membranes, decreased skin tugor
Confusion
Retinopathy
Neuropathy
Investigations for diabetes mellitus
Fasting blood glucose level - > 6.9 mmol/L HbA1c - > 4.8 mmol/mol Oral glucose tolerance test - > 11 mmol/L
History of chronic heart failure
Decreased exercise tolerance Dyspnoea on exertion Orthopnea PND Previous MI
Examination findings of chronic heart failure
Oedema
Displaced apex beat
JV disstension
Investigations for chronic heart failure
BNP - increased
CXR - cardiomegaly, pulmonary oedema, pleural effusion
ECG - anterior Q waves, BBB, left axis deviation
History of iron deficieny anaemia
Asthenia Hair loss Dyspnoea Menorrhagia Dysphagia
Examination findings of iron deficiency anaemia
Pallor
Tachycardia
Systolic ejection murmur
Blue sclera
Investigations for iron deficiey anaemia
FBC - reduced Hb and Hct, reduced MCV and MCH
Ferritin - reduced
History of insommnia
Difficulty initiating sleep
Waking frequently
Poor concentration
Depressed mood
Examination findings for insomnia
Reduced alertness
Red and puffy eyes
Abscence of sings suggesting orgainc illnees
History for depression
Reduced mood
Loss of interest
Feeling hopless
Suicidal ideation
Clinical examination findings for depression
Psychomotor slowing
Agitiation
Investigations for depression
PHQ2 or PHQ9 screening tool
History of hyperthyroidism
Weight loss
Increased appetitie
Oligomenorrhoea
Heat intolerance
Clinical examination findings for hyperthyroidism
Weight loss Hyper-reflexia Tachycardia AF Fine tremor
Investigations for hyperthyroidism
TSH - decreased
T4/3 - increased
Increased uptake on radioiodine scan
History for hypothyroidism
Weakness Cold Hair/eyebrow loss Weight gain Constipation Peri-orbital swelling
Clinical examination findings for hypothyroidism
Bradycardia Hypothermia Slow movement Delayed reflexes Goitre Enlargement of tongue
Investigations for hypothryoidism
T4 - reduced
TSH - increased
History of menstural headache
Episodic headache - associated cyclical occurance
History of tension headache
Emotional stressors
Depression
Insomnia
Tight band like or vice-like bilateral steady aching non-pulsatile constricting pain
Hisotry of migraine headache
POUNDing
- Pulsatile
- 4-72 hOurs
- Unilateral
- Nausea/vomiting
- Disabling intensity
Causes of headache
Migraine Acute sinusitis Otitis media Temporomandibular joint syndrome Medication overuse Medication withdrawal Menstrual headache
Hisstory of acute sinusitis
Frontal headache Nasal congestion Mucopurulent nasal discharge Fever Coughing Sneezing
Clnical findings of acute sinusitus
Sinus tenderness
Reproducible pain on percussion of frontal/maxillary sinuses = bacterial
History of otitis media
Common in children Otalgia Irritability Anorexia Vomiting Fever
Clinical examination of otitis media
Bulging opacified tympanic membrane with reduced mobility
White, pink, red or yellow membrane
Investigations for otitis media
Otoscopy
- bulging, opacified tympanic membrane
History of TMJ syndrome
TMJ pain on mastication
Noise in the joint
Limited mandibular movement with jaw locking
History of medication overuse headache
Headache occuring more than 15 days per month Pre-existing headache disorder Regular medication - paracetamol - NSAIDs - triptans - opiods
History of medication withdrawal headache
Recent medication changes
- hypertension
- antihistamines
- caffeine
- pseudoephedrine
- opiates
- corticosteriods
Causes of dyspepsia
Cholecystitis Functional dyspepsia Helicobacter pylori infection GORD/oesophagitis Peptic ulcer disease Lactose intolerance
Hisotry o fcholecysititis
Epigastric or RUQ pain radiating to the right scapula
Nausea and pain lasting 3-6 hours
Clincial examination findings for cholecystitis
Positive murphys sign
Tender RUQ/epigastrium
Jaundice
Fever
Investigations for cholecystitis
Abdominal USS
History of functional dyspepsia
Heartburn
Nausea
Upper abdominal pain
Investigations for functional dyspepsia
Haemoglobin - normal
Urea breath test - negative
History of H.pylori infection
History or FH of previous peptic ulcer disease
Early years spent outside North America/Western Europe
Investigations for H.pylori infection
Urea breath test - positive
Stool antigen test - positive
History of GORD
FH of GORD Hiatal hernia Heartburn Acid regurgitation Dysphagia
Clinical findings of GORD
Bloating
Laryngitis
Enamal erosion
Halitosis
Investigations for GORD
PPI trial - symptoms should improve
Oesophagogastroduodenoscopy
History of peptic ulcer disease
History of NSAID use
Past ulcers
Smoking
Ingestion of food improves pain
Investigations for peptic ulcer disease
H.pylori breath test/stool antigen
Upper gastrointestinal endoscopy
History of lactose intolerance
Bloating
Abdominal distress
Loose stool after ingestion of lactose
Investigations for lactose intolerance
Dietary change
Lactose breath test - positive
Causative organism of thrush
Candida albicans
Clinical features of thrush
Thick, white vaginal discharge - usually non-malodorous Vulva itching Vulval soreness/irritation Superfical dysparenunia Dysuria
Management of thrush
Conservative - wear loose, cotton underwear - controlled diabetes - change of contraceptive Medical - intravaginal antifungal cream of pessary - clotrimazole - oral antifungal - fluconazole
Complicated candida infection
Recurrent infections - 4 or more in 1 year
Severe infection
Infection with other yeasts
Infection during pregnancy
Infection in women with uncontrolled diabetes or are immunocompromised
Risk factors for vulvovaginal candidiasis
Oestrogen exposure Immunocompromised state Poorly controlled diabetes mellitus Treatment with broad spectrum antibiotics Local irritants Sexual behaviours Contraception - spermacide gels - COCP HRT
Define bacterial vaginosis
Overgrowth of predominately anaerobic organisms
Vagina loses normal acidity and pH increases to greater than 4.5
Clinical features of bacterial vaginosis
50% asymptomatic
Fishy-smelling, thin, grey/white homogeneous discharge - not associated with itching or soreness
Management of bacterial vaginosis
Aysymptomic - no treatment usually required
Symptomatic
- reduce vaginal douching, antiseptics, bubble bath
- oral metronidazole
Define diarrhoea
Passage of three or more loose/liquid stools per day
Acute - less than 14 days
Causes of acute diarrhoea
Viral infection - norovirus Bacterial cause - salmonella species - campylobacter jejuni - shigella species - escherichia coli Parasitic causes - cryptosporidium - giardia Drugs - laxatives - ARBs - antibiotics - chemotherapy - metformin - NSAIDs - PPIs - SSRIs Anxiety Food allergy Acute appendicitis Intestinal ischamia
Causes of blood diarrhoea
Bacterial - campylobacter jejuni - salmonella - escherichia coli - shigella - clostridium difficile Viral - cytomegalovirus Parasites - entamoeba histolytica - schistosomiasis
Causes of chronic diarrhoea
IBS Diet - FODMAP malabsorption - artificial sweeteners - caffeine - excess alcohol IBD Microscopic colitis Coeliac disease Malabsorption - lactose intolerance - pancreatic insufficiency Colorectal cancer Bile acid diarrhoea Constipation and faecal impaction
Red flag symptoms with diarrhoea
Blood in stool Recent hospital or antibiotic treatment Weight loss Evidence of dehydration Nocturnal symptoms
Causative organism of glandular fever
Epstein-Barr virus
Clinical features of glandular fever
Fever Pharyngitis Cervical or generalised lymphadenopathy Malaise Splenomegaly
Risk factors for EBV
Kissing
Sexual contact
Differentials for glandular fever
Group A Strep pharyngitis Hep A Acute HIV infection Adenovirus Human herpes virus 6 Cytomegalovirus infectoin Herpes simplex virus 1 Influenza infection
Management of glandular fever
Supportive care - paracetamol/ibuprofen - good hydration - avoid stenuous physical activity and contact sports for 3-4 weeks - risk of splenic rupture Corticosteriod - prednisolone - reduce upper airway obstruction and haemolytic anaemia IV immunoglobulin - thrombocytopenia
Complications of glandular fever
Severe upper airway obstruction Splenic rupture Fulminant hepatitis Encephalitis Severe thrombocytopenia Haemolytic anaemia
Investigations for glandular fever
FBC - lymphocytosis Heterophile antibodies - monospot - positive EBV-specific antibodies - positive LFTs elevated
