Misc conditions Flashcards
BENIGN PROSTATIC HYPERPLASIA
i) what is it? how is it characterised histologically? name three risk factors
ii) what type of symptoms are seen? (2)
iii) which examination is done? why? name three other investigations that can be done
iv) will PSA be raised?
i) enlargement of the prostate
* charac by non cancerous hyperplasia of glandular epithelium and stromal tissue in the prostate > inc in size
* RF = age, family history, black/african, obese
ii) see lower UTI symptoms
* voiding symptoms (hesistancy, weak stream, incomplete empty, dribbling
* storage symptoms (inc urine frequency, nocturnia, urge incontinence)
iii) rectal exam to distinguish between BPH and prostatic cancer (firm, smooth and symmetrical)
* urine freq and volume chart, urine dip, post void bladder scan to assess for chronic retention
iv) PSA may be marginally elevated
BPH TREATMENT
i) which drug can be trialled if symptomatic? how does this work?
ii) what should be given if this doesnt work?
iii) name two surgical procedures that can be done and how they work
iv) what is the main complication of BPH? name two others
v) what is TURP syndrome?
i) alpha adrenoreceptor antagonist (alpha blocker eg tamulosin) > relax prostatic smooth muscle via block of alpha adrenoRs
ii) still symptomatic post adreno antag > give 5alpha reductase inhibitors such as finasteride (prevent conversion of testos to DHT > decerase in prostatic volume) - may take 6 months to see benefits of 5a inhibitors
iii) refractory to medical management or develop significant sequale of BPH > surgery
- TURP - trans urethral resection of prostate > endoscopic removal of obstructive prostate tissue using a diathermy loop to increase urethral lumen size
- HoLEP prodecure involves laser to hear and dissect sections of prostate into the bladder > good outcomes and low post op complications
- can also do photoselective vaporisation, transurethral microwave therapy
iv) Main complication is high pressure retention > chronic or acute on chronic urinary retention > post renal kidney injury
- reccurent UTIs
- significant haematuria
v) TURP syndrome > hypo osmolar irrigation is used during procedure which can cause fluid overload and hponatremia (confusion, nausea, agitation, visual change)
MASTITIS/ABSCESS
i) what is mastitis? what is the most common cause? what are two classification by lactational status? which one is tobacco smoking a RF for? why?
ii) name four symptoms? which type commonly present in first three months of breastfeeding or during weening? how may a breast abscess appear? which imaging should be done?
iii) how should masitis be treated? (2) what can be given if there is persistent infection or it affects multiple areas? how should an abscess be treated?
iv) what is a breast abscess? name a complication and how it is managed?
) mastitis = inflammation of breast tissue - acute or chronic
- most common cause is infection - S.aureus but can also be granulomatous
- can be classed by lactation status:
* lactational - seen in 1/3 breastfeeding women
* non lactational - occ in women with duct ectasia > RF is tobacco smoking > damages sub areolar duct walls > pre dis to bacterial infection
ii) tenderness, swellling, induration (hard) and erythema over area of infection
- lactational - presents in furst 3 months of bf or during weaning > cracked nipples and milk stasis
- breast abscess > tender erythematous masses with puncutum (point) > confirm via US
iii) treat masitis with Abx and Simple analgesics
- lactational > continued mulk drainage/feeding is recommended
- persistent infection/multiple areas > consider DA agonist eg cabergoline for cessation of breastfeeding
- abscess > prompt bx nd US guided needle aspiration (adv may req draining under local anaes)
iv) Breast abscess > collection of pus within lind granulation tissue (usually from acute mastitis)
- may form a mammary duct fistula > sx mx with flistulectomy and abx
OLECRANON BURSITIS
i) what is it? why is this area prone to inflam? what can cause it? name three less common causes?
ii) name two symptoms? what can be seen initially? what can this progress to? is range of motion affected? why?
iii) what bloods should be done (3) what is plain film radiograph used for? what gives a definitive diagnosis?
iv) what does treatment depend on? what analgesia should be given? what can be done if swelling is large? what is done if there are systemic symptioms and infection?
v) what can be done for prolonged/untreatable cases? name two complications?
i) inflammatory pathology of the elbow
* prone to inflam due to superficial position and vulnerability to pressure and trauma
* usually dev due to repetitive flexion extension movement > irritates brusa
* less common causes = gout and RA
* less common = bursa can become infection through skin abrasion or puncture (s aureus)
ii) pain and swelling over olecranon
* may be small swelling initially then increase in size/discomfort/erythema
* range of motion usually preserved as joint capsulse not involved (min discomfort in extreme movement) (septic arth causes pain with any movement)
iii) routine bloods - FBC and CRP
* serum urate levels for gout, look for rheum causes
* plain film radiograph wont confirm but can rule out bony injury
* defintive dx = fluid aspiration > send for microscopy and culture (look for infection and presence of crystals) > can also provide symptomatic relief for some patients
iv) dep on whether there is an infection
* swellings without infection > tx with analgesia (NSAID) and rest
* may splint elbow for short period of time
* if swelling is large > high levels of discomfort > washout in theatre
* systemic symp and infection > IV abx and surgical drainage
v) *septic arthritis
* osteomyelitis
GORD
i) what happens? is it more common in M or F? name four risk factors? which classification system is used?
ii) what does the lower oes sphincter normally do? what happens in GORD? how is the oes mucosa damaged
iii) what is the main symptom? when is this the worst? name four other symptoms? name four red flag symptoms - what should be investigated for?
iv) is exam usually remarkable? what % will already have barrets oes?
v) what is the gold standard investigation for diagnosis? what does this comprise of? what score is given? what investigation is done to exclude malignancy - when would this be necessary?
i) gastric acid from stomach leaks up into the oes
- 2:1 M:F
- - Los angeles classification - size of breaks in oes (grade A-D)
- - RF = age, obese, male, alcohol, smoking, caffiene, spicy food
ii) lower oes sphincter controls passage of contents from oes to stomach - - in GORD more sphincter relax therefore gastric contents reflux into the oes
- refluxed acid results in pain and mucosal damage to the oes
iii) main symptom us chest pain (burning retrosternal sensation) worse after meals, lying down, bending over or straining (relieved by antacids)
- excess belching, odynophagia, chronic or nocturnal cough
- red flag symptoms = dysphagia, weght loss, early satiety, malaise, loss of appetite - investigate for malignancy
iv) examination unremarkable - 10% have barrets oes
v) 24hr pH monitoring is gold standard in dx - when medical tx (PPI) has failied and surgery is being considered
- 24hr pH monitor - assess criteria such as amount of time acid is present in oes anc correlation between acid and symptoms > de meester score to determine correlation bet symptoms and reflux
- upper GI endoscopy to exclude malig and investigate for complications - not required in absence of red flag symptoms
GORD TREATMENT
i) what are the first steps in management? what are first line pharma tx? does this work for most patients?
ii) when do symptoms recur? what is done to prevent this?
iii) when is a patient surgically managed? (3) name three things surgical management is good for
iv) what surgical procedure is done? what is the result of this? what are the main SE of the surgery? (3) how long does it usually take for these to settle?
v) name four complications? what is 7yr risk of adenocarcinoma?
i) start with conservative steps > avoid ppts, weight loss and smoking cessation
- PPI are first line and are effective for most patients
ii) symptoms tend to recur after stopping PPIs so most patients stay on them lifelong
iii) sx management if fail to respond to medical, patient preference, patients with complications eg recurrent pneumonia
- sx more effective than medical tx for symp relief, QOL and cost
iv) funodplication > GOJ and hiatus are dissected and the fundus is wrapped around the GOJ to create a new lower oes sphincter
- main SEs are dysphagia, bloating, inability to vomit = usually settle after 6 weeks
v) aspiration pneumonia, barrets oes, oes stricture, oes cancer
- 7yr risk of adenocarcinoma is 0.1% where initial endoscopy is absent of strictures, barrets metaplasia
HIATUS HERNIA
i) what is a hernia? what is a hiatus hernia? what most commonly herniates?
ii) what are the two main stypes? what happens in each? which one is a true hernia?
iii) what is the biggest RF? name three others
iv) do most patients present with symptoms? name the most common symptom? name four other symptoms? what may be heard in the chest? is clinical exam usually remarkable?
v) what is gold standard investigation? what does it show? name another investigation that may be done
i) hernia = protrusion of whole or part of an organ through the wall/cavity that contains it into an abnormal position
- hiatus hernia = protrusion of organ from abdo cavity into thorax through the oes hiatus
- typically stomach herniating (can be small bowel, colon, mesentery)
II) classified into
* sliding hiatus hernia (80%) > gastro oes junction, abdo oesophagus and cardia of stomach move/slide up through the diaphragmatic hiatus into the thorax
* rolling/para oes hernia (20%) - upward movement of gastric fundus > lies alongside a normal positioned gastro oes junction > bubble of stomach insude thorax = true hernia with peritoneal sac
iii) age is the biggest RF, pregnancy, obesity and ascites due to increased intra abdo pressure and superior displac of the viscera
iv) most are asymp
- most common symp > gastro oes reflux symptoms such as burning epigastric pain, worse when laying flat
- vomiting, weight loss, bleeding/anaemia, hiccups or palpitations as it can irritate disphraghm or percardial sac, swallowing difficulties
- clinical exam is usually normal
- - if large then bowel sounds may be auscultated in the chest
HIATUS HERNIA TREATMENT
i) what is first line pharma treatment? what does this do? when should it be taken? name three lifestyle advice that may be given? which two things can inhibit lower oes sphincter function therefore worsen symptoms?
ii) name three indications for surgical management?
iii) what happens in a cruroplasty? what happens in fundoplication?
iv) name three complications? what are rolling HH prone to?
v) name a complication that results in a surgical emergency? what is borchardts triad?
i) first line pharma management is PPI eg omeprazole to reduced acid secretion and control symptoms > take in morning before food
- lifestyle advice eg weight loss, alteration of diet, sleep with head of bed raised
- - smoking cessation and reduce alcohol because both inhibit lower oes sphincter func and worsen symptoms
ii) surgical management when remaining symptomatic after medical therapy, increased risk of strangulation/vlvulus or nutrirtional failure due to gastric outlet obstruc
iii) cruroplasty > hernia is reduced from thorax into the abdomen and hiatus reapprox to right size > mesh to strengthen repair
- fundoplication > gastric fundus is wrapped around lower oes and stitched in place > strengthen LOS to prevent reflux and keep GOJ in place below the diaphragm
iv) recurrence of hernia, bloating due to inability to belch, dysphagia if fundoplication is too tight or crural repair too narrow, fundal necrosis - blood supp via left gastric is disrupted > sx emergency
- rolling hiatus hernia are prone to incarceration and strangulation
v) gastric volvulus (stomach twists on itself 180 > obstruc of gastric passage and tissue necrosis) sx emergency
- volvulus can present with borchardts triad > severe epigastric pain, retching but not vomit, inability to pass an NG tube
HYPOTHYROID - HISTORY AND EXAMINATION
i) what weight change may be seen?
ii) what may they be intolerant to?
iii) give three other symptoms
iv) what heart rate may be seen if prolonged/severe?
v) how may reflexes be affected?
i) weight gain
ii) cold intolerance
iii) tiredness, constipation, menorrhagia
iv) bradycardia
v) slow relaxing reflexes - upstroke of reflex normal but long to relax
HYPOTHYROID - INVESTIGATIONS AND TX
i) what antibody may be investigated for?
ii) what is the treatment? in which two groups of patients would you start on a lower dose?
iii) how long should be waited before repeating thyroid function tests if the patients symptoms are not improving?
i) look for thyroid auto antibody (TPO)
ii) treat with thyroxine (T4) - start on 100u
- if very elderly/ischaemic heart disease - use lower dose (25ug)
iii) wait 6 months before repeating TFTs, even if the patient doesnt feel better (there can be a lag phase before patients feel better
T1DM
i) what is it? what is the genetic concordance in twins? when does it usually present?
ii) name three presenting features? what blood glucose is seen? how may it present acutely? how is it dx? does C peptide and auto ABs confirm dx? when should the patient not be screened
iii) what may be seen on bloods? name three other RF? what should be done if the patient is symptomatic (weight loss)? (3) name three auto antibodies that may be positive?
iv) what treatment should be offered first? what is first line insulin treatment? what is second line? how often should glycaemic control be checked?
i) autoimmune/idiopathic destruction of panc beta islet cells, low genetic concordance in twins
- Usually presents in childhood/puberty
ii) polydipsia, polyuria, weight loss, ketosis,
* Raised venous glucose (>7mmol/L fasting or >11.1mmol/litre random),
* * May present acutely with DKA
* - Dx on clinical grounds - what is the pt presenting with?
* C peptide & diabetes auto Abs (doesn’t confirm dx)
iii) Hyperglycaemia, ketosis, rapid WL, age <50yrs, BMI <25, family history of AI disease
* May be positive for auto Abs (ICA, IAA, GAD, IA-2A)
* * Microalbuminuria, decreased renal function
* * Random venous >11mmol/l
* Fasting plasma glucose >7mmol/L
* * 2 hour post OGTT >11.1mmol
* HbA1c >48mmol/mol
* * dont screen during asymptomatic phase
* IF PT IS SYMPTOMATIC (weight loss
* Random plasma glucose, Fasting plasma glucose, 2 hour plas glucose (2hrs post OGTT) and HbA1c
iv) 1) Offer lifestyle advice - diet/exercise
2) Treat with insulin - basal bolus (first line) or mixed regimen (second)
3) Review glycaemic control annually (HbA1c <48mmol is ideal)
4) Follow up for eye/foot/nerve complications
HAEMORRHOIDS
i) what are they? what are they made of? what are they classified according to? name three risk factors?
ii) what is the most common symptom? name four other symptoms? how may a prolapsed haemmorhoid appear? when may exam not be normal?
iii) what investigation is done to confirm diagnosis? what should be done if there is a complication to exclude other pathology?
i) abnormal swelling or enalargement of anal vascular cushions ( act to assist anal sphincter in maintaining continence)
- three vasc cushions pos at 3,7,11 oclock when looked at patient in lithotomy position
- cushions can become abnormally enalarged > pathological
- classified according to size - 1st degree (remain in rectum) to 4th degree (persistently prolapsed)
- RF - excess straining from chronic constipation, increased age, raised intra abdo pressure (preg, chronic cough, ascites)
ii) painless bright red rectal bleeding - commonly after defacation on paper or in toilet (blood is seen on surface of stool, not mixed in)
- also get itching due to chronic mucus discharge and irritation, anal lump, rectal fullness and soiling due to in incontinence
- large prolapsed haemm can thrombose > painful > purple/blue/oedematous/tense/tender perianal mass
- exam usually normal unless they have prolapsed
iii) proctoscopy (rigid sigmoidoscopy) to confirm dx
- significant bleeding > FBC and clotting screen
- colonoscopy if complication to exclude other anal pathology
HAEMORRHOIDS MX
i) how are most managed? name three lifestyle advice that may be given? anme two drugs that can be given
ii) how can 1st and 2nd degree be treated? how may 2nd or 3rd degree be treated? what is done for 3rd/4th degree?
iii) name three post op complications
i) most are managed conservatively espec if uncomplicated
- lifestyle advice > increase fibre and fluids to decrease constipation
* laxatives and topical analgesia eg lidocaine gell or oral opioids if symptoms worsen
ii) 1st and 2nd degree can be treated with rubber band ligation > draw haemm into suction fun and place rubber band over the next (in clinic or theatre)
Surgical mx
- haemmorhoid artery ligation for 2nd or 3rd degree > identify with doppler then tie it off > infarcts and falls off
- haemmorhoidectomy for 3rd and 4th dergree > excise tissue ensuring internal sphincter muscle reamins
iii) Post op = recurrence, stricturing, faecal incontinence
IRRITABLE BOWEL SYNDROME
i) what is it? what is it associated with? who is it most common in? what criteria is used for diagnosis?
ii) name three things that a 6 month history of can point towards IBS? name three red flag symptoms that should not be missed?
iii) name three lifestyle changes that can be implemented? name three pharma drugs that can be trialled? if patient is refractory to tx - what can be done?
i) * functional bowel disorder > abdo pain and discomfort is assoc with defacation and/or change in bowel habit in absence of organic cause
- more common in women 20-30yrs
- altered GI sensitivity towards stimuli > may be triggered by enviro factors (physiol and psych stress) and foods/bacteria
- - Rome criteria for diagnosis
ii) 6 months hx of: abdo pain/discomfort. bloating, change in bowel habit
Must elicit red flag features
- unintended weight loss
- * rectal mass/bleeding
- * FH bowel or ovarian cancer
- * aged over 60 with >6weeks altered bowel habit
iii) diet change - regular meals and adequate hydration - avoid high fibre, starch, caffiene, carbonated drinks
- Single avoidance diet - low FODMAP
- - pharma therapy - anti spasmodics, laxatives or anti motlility (loperamide), amytriptylin
- * consider psych therapy - CBT, psychotherapy, hypnotherapy if refractory to other tx
UTI
i) what is it? what is the most common type? why does it affect women more? what is the most common causative organism?
ii) name four risk factors? what is uncomplicated/complicated/recurrent/relapsing?
iii) name three symptoms? how is an upper UTI more likely to present? (3)
iv) what investigation should be done? what two things are likely to be seen if a UTI is presennt?
v) what is offered to men? what abx is given? what is offered to women? what is given if complicated/uncomplicated? what should be done if symptoms persist?
vi) which group of people should always be sent for culture with asymptomatic bacteruria
i) infection of urethra, bladder or kidneys
cystitis is the most common
mostly affects women due to shorter urethra length - in men should always warrant clinical suspic
Ecoli most common organism
ii) RF > immunosupression, diabetes, underlying renal tract abnorms
Uncomplicated > normal underlying GU anatomy and physiology
Complicated > underlying anatomy or physiol predisposes to UTI (outflow obstruc)
Recurrent > repeat infection with new organism
Relapsing > repeat infection with the same organism
iii) Dysuria, increased freq or urgency
smelly urine
upper UTI - more likely to px systemically unwell with fever, loin pain, back pain
iv) Urine Dip
Working dx of UTI given typical symptoms and leucocyte esterase/nitrites on urine
v) drink fluids and wipe from front to back
- Men - offer symp relief with paracetamol and treat lower UTI without assoc indewelling catheters with trimethiprim 200mg BD for 7 days
- - Women - symp relief with paracetamol or NSAIDS
if uncomplicated - trimethoprim 200mg BD for 3 days /nitrofurantoin 50mg QDS for 3 days
complicated - consider prolonging abx therapy for 3 days
- if symptoms persist > send for MC&S
vi) all pregnant women with asymp bacteruria should be sent for culture and treated with 7 days of nitro
