presentations Flashcards
what syndromes can cause a patient to appear confused
delirium
dementia
mental impairment
psychosis
receptive dysphasia
expressive dysphasia
questions to ask all confused patiented
abbreviated mental test score
- orientation in time, space, person
- long/short term memory
three step command
name three common objects
- tests for receptive/expressive dysphasia
other symptoms
- pain
- SoB
- cough
- urinary symptoms
collateral history for confused patients
normal state
time course
drug history
infectious causes of delirium
chest
urinary
encephalitis
brai abscess
sepsis
neoplastic causes of delirium
brain tumour
vascular causes of delirium
stroke
MI causing hypoperfusion
immunological causes of delirium
neuropsychiatric lupus
Hashimoto’s encephalopathy
traumatic causes of delirium
subdural haematoma
extradural haematoma
endocrine causes of delirium
hypothyroidism
hyperthyroidism
DKA
drug related causes of delirium
intoxication/withdrawal of alcohol, opiates, psychiatric medications
diuretics
digoxin
thyroid medication
metabolic causes of delirium
hypoxia
hypercapnia
hypoglycaemia
hypercalcaemia
sodium/electrolyte imbalances
thiamine, folate, B12 deficiencies
degenerative conditions and delirium
chronic
do not cause delirium
predispose patients to delirium
key vital signs of confused patient
pulse and RR
BP
- hypoperfusion
- Cushing’s response indicative of raised ICP
O2 saturation
temperature
- hypothermia can cause confusion
blood glucose
- capillary sufficient, abnormal results require follow up with venous sample
- T1DM hyperglycaemia -> DKA
- T2DM hyperglycaemia -> hyperosmolar hyperglycaemia syndrome
important signs to look for in a confused patient
consciousness - GCS
septic focus
- chest
- urine
- cellulitis
- meningitis
pupils
focal neurological signs
needle track marks
asterixis (metabolic flap)
breath (for alcohol)
bitten tongue and/or posterior shoulder dislocation
bitten tongue and/or posterior shoulder dislocation in a confused patient
suggests convulsive seizure
screening in confused patients
septic screen
- FBC
- CRP
- blood culture
- urine analysis
- urine MC & S
- chest radiograph
metabolic screen
- ABG
- U&Es
- TFT
- liver enzymes
- thiamine, folate, B12 levels
toxicology screen
ECG - to exclude ixchaemia or arrhythmia
conservative measures for confused patients
do not leave unattended
quiet side room
glasses/hearing aids
discontinue nonessential medication
promote good sleep hygiene
consider fluids + nutrition
sedation if patient becomes aggressive and is a risk
post operative confusion may be caused by
hypoxia
opiates
electrolytes
infection
sleep loss
what functions are tested in the MMSE
orientation in space and time
short and long term memory
attention
language (comprehension and expression)
calculation
visuospatial ability
define “acute confusional state”
observable state of relatively suffer impaired:
- attention
- awareness
- cognition
that tends to fluctuate during course of day
interchangeable with “delirium”
diabetic ketoacidosis and clinical signs
seen in type 1 diabetics
polyuria, polydipsia, decreased mental state
- due to hyperglycaemia
nausea, vomiting, abdo pain, fatigue, SoB, Kussmaul breathing
- due to acidosis
hypotension and tachycardia
- due to dehydration
confusion and Kussmaul breathing in diabetic patients
late signs of DKA
take seriously
how to distinguish opiate overdose from TCA or cocaine overdose
opiates:
- pinpoint pupils
- respiratory depression
cocaine: sympathetic effects
- dilated pupils
- sinus tachycardia
- hypotension
- pyrexia
- resp depression and urinary retention
TCAs: sympathetic and parasympathetic effects
- dilated pupils
- sinus tachycardia
- brisk reflexes
- urinary retention
- dry mouth
- drowsiness
- upping plantar reflexes
treatment for confused patient with Hx/suspicion of alcohol abuse
immediate thiamine fro prophylaxis of Wernicke’s encephalopathy
ddx for lateral neck lump
artery
- carotid artery aneurysm
- subclavian artery aneurysm
- carotid body tumour
nerves
- neurofibroma
- schwannoma
lymphatics
- lymphatic malformation
lymph nodes
- infective
- neoplastic
- granulomatous
salivary glands
- infective autoimmune
- neoplastic
larynx
- layngocele
pharynx
- pharyngeal pouch
branchial arch remnant
- branchial cyst
- sinus
- fistula
skin/superficial subcutaneous
- lipoma
- epidermal cyst
- abscess
- dermoid cyst
muscle/cartilage/bone
- sarcoma
- cervical rib
- torticollis
lateral neck lump in children
75% are benign
congenital and inflammatory lumps most common
- branchial cleft cysts
- lymphatic malformations
- lymphadenitis
malignancies are usually a lymphoma or sarcoma
- sometimes papillary thyroid carcinoma
lateral neck lump in adults (> 40yrs)
up to 75% are malignant
- 80% of malignancies are metastases
- 20% are lymphomas
if infectious signs are absent
- lymphadenopathy due to metastatic carcinoma
causes of green coloured stool
- bile pigment hasn’t broken down properly could be due to diarrhoea
- antibiotics - change gut microbiota
- Graft-versus host disease (diarrhoea + green stool)
- bacterial infection (salmonella, norovirus)
- foods: green dye/ vegetables
causes of light/white coloured stool
- lack of bile in stool = bile duct obstruction
- anti-diarrheal medications (bismuth subsalicylate)
causes of yellow/foul smelling stool
- excess fat due to malabsorption (coeliac disease)
- small intestine infection
causes of bright red stool
- red food, dyes, drinks
- haemorrhoids
- anal fissures
- lower GI tract bleeding (diverticulitis, IBD, cancer)
causes of black/ dark brown stool
- iron supplements
- anti-diarrhoeal drugs (bismuth subsalicylate)
- upper GIT (stomach) bleeding
causes of reddish/ maroon stool
- red food, dyes, drinks
- bleeding from somewhere in GIT (IBD, diverticular disease, cancer)
Investigations for abnormal stool colour
- ask about diet/ medication
- stool microscopy, culture and sensitivity - check for infection
- fecal calprotectin - inflammatory marker
*
questions to ask about a neck lump
how long has it been there? has the lump changed in size? is the lump painful? are there any other lumps?
associated symptoms of neck lump to ask about
symptoms suggestive of infection - malaise - fever - rigors - acute history symptoms suggestive of head/neck cancer - dysphonia - stridor - stertor - breathing difficulty - dysphagia - odynophagia - globus - cough - haemoptysis - otalgia - unilateral hearing loss - nasal discharge - epistaxis
aspects of history of infective or malignant cause of neck lump
infection: - recent infection/URTI - contact history - recent trauma/insect bite - scratches/;bites - recent history of foreign travel malignancy: - known current/previous cancer - FHx of head/neck cancer - radiotherapy to neck - smoker - high alcohol intake
importance of social history in context of neck lump
smoking and high alcohol consumption are strong independent risk factors for development of head and neck cancer
superficial neck lumps
lipoma abscess epidermal cyst dermoid cyst
neck lump in anterior triangle
branchial cyst/sinus/fistula carotid body tumour carotid artery aneurysm salivary gland laryngocele
neck lump in posterior triangle
cystic hygroma cervical rib pharyngeal pouch subclavian aneurysm
tender and/or warm neck lump suggests
infective or inflammatory nature *exception: tuberculous adenitis
hard neck lump
malignant lymph nodes
rubbery neck lump
rubbery - chronic inflammatory lymph nodes
lymphomatous nodes
soft neck lump
acute inflammatory lymph nodes
fluctuant neck lumps
branchial cysts
cystic hygromas
pharyngeal pouches
laryngoceles
cold abscesses
epidermal cysts
dermoid cysts
lipomas
pulsatile neck lump
subclavian/carotid artery aneurysm
carotid body tumours often pulsatile
immobile neck lump
majority of lymph nodes are relatively mobile
malignant lymph nodes may be attached to adjacent structures
tuberculous nodes may appear matted together
lymphadenopathy and parotid masses in a case of neck lump require
further assessment after systematic neck examination
patient presents with neck lump, what should you do if infectious lymphadenopathy is suspected?
examine throat, pay particular attention to tonsils
systematically inspect all lymph nodes of head and neck
patient presents with neck lump, what should you do if malignant lymphadenopathy is suspected?
- examine scalp, face, ears, mouth, and nose - potential squamous cell carcinoma/melanoma
- examine all lymph nodes of head and neck
- examine breasts (in women) and lungs
- palpate for hepatosplenomegaly - if suspected lymphoma/chronic lymphocytic leukaemia
- full abdo exam - if Virchow’s node palpable
- examine nasal cavity, nasopharynx, oropharynx, and hypopharyns with fibreoptic endoscope
neck lump and parotid swelling
examine integrity of facial nerve
- palsy may result from invasive malignant tumour
examine oral cavity for soft palate displacement
- by tumour involving deep lobe of parotid
red flag sign for a malignant lymph node
tethering to surrounding structures
define gynecomastia
overdevelopment of breast tissue in boys/men
causes of gynecomastis (CODES)
- Cirrhosis
- Obesity
- Digoxin
- estrogen agonists
- Spiranolactone
- newborn boys (oestrogen passes through mothers placenta)
- puberty
- older men => less testosterone/XS fat
- testes lump/infection (MUMPS, TESTICULAR FAILURE)
- PPIs
- illegal drugs (anabolic steroids, marijuna, heroin)
- Endocrine disorders (testicular/ adrenal/ pituitary tumour- prolactinoma)
what genetic disorder has gynecomastia?
Kleinfelters syndrome
Investigations for gynaecomastia
- Blood hormone levels (prolactin, LH, FSH, TSH, LFTs and HCG)
- Breast US
- mammogram
- Testicular exam
Treatment for gynecomastia
- surgery to remove XS breast tissue
- Medication to adjust hormone imbalance
- Or stop medication after GP review
(neck lump) initial investigations for suspected squamous cell carcinoma that has metastasised to lymph nodes
US - shape, size, echogenicity, vascularity
fine needle aspiration - cytological diagnosis, can be US guided
*If FNA suggests lymphoma, core biopsy required to confirm subtype
ddx for midline neck lump
thyroid
- physiological goitre
- multi nodular goitre
- grave’s
- thyroiditis
- thyroglossal cyst
- thyroid cyst
- solitary adenoma
- carcinoma
non-thyroid
- lipoma
- dermoid cyst
- epidermal cyst
- abscess
- lymphoma
questions to ask about midline lump
duration?
any changes in shape and size?
painful?
any other lumps?
midline lump - associated symptoms to ask about
symptoms suggestive of:
- hypo/hyperthyroidism
- compression/invasion
- stridor
- dyspnoea
- dysphagia
- vocal changes
- infection
- malaise
- fever
- rigors
midline neck lump PMHx and FHx questions
PMHx
- autoimmune disorders
- risk factors for thyroid malignancy
FHx
- autoimmune disease
- hereditary forms of thyroid carcinoma
midline neck lump which is superficial suggests?
lipoma
epidermal cyst
dermoid cyst
abscess
midline neck lump which is deep suggests issue with
thyroid gland
midline lump that moves on swallowing suggests which structure is involved
thyroid gland
midline neck lump which moves on tongue protrusion suggests
thyroglossal cyst
midline neck lump tethered to neighbouring muscle or skin suggests
malignancy
riedels thyroiditis
midline neck lump - solid, solitary nodule
malignancy is more likely
midline neck lump - solitary cystic nodule
thyroglossal/epidermal/dermoid/thyroid cyst
simple investigations for thyroid status
TSH
- if low → request T3 and T4
- if high → request thyroid peroxidase antibodies
serum calcitonin
- IF significant FHx of thyroid cancer/MEN-2
further investigations for nodule found on thyroid
FNA
US guided
little indication for radionuclide scanning, CT, or MRI
FNA of thyroid nodule outcomes
Thy1 = insufficient aspirate to make dx
Thy2 = benign
Thy3 = follicular lesion/suspected follicular neoplasm
Thy4 = suspicious of malignancy
Thy5 = diagnostic of malignancy
can FNA distinguish between benign follicular adenoma and malignant follicular carcinoma?
No
management of thyroid cancer
- surgery
- T3 replacement
- radio-iodine ablation
- T4 suppression
- follow up
surgical management of thyroid cancer
low risk = thyroid lobectomy
high risk = total/near total thyroidectomy
T3 replacement after surgical management of thyroid cancer
replacement of thyroid hormone because less/no thyroid gland tissue remaining
TSH levels must be high for radio-iodine ablation
- stop administration of exogenous thyroid hormone
- T3 has shorter half life and can be stopped nearer to the time of therapy
radio-iodine ablation in thyroid cancer
eliminate malignant cells left behind after surgical intervention
patients given recombinant TSH to stimulate radio-iodine uptake
T3 suppression stopped 2 weeks before treatment
T4 suppression in thyroid cancer
- suppress TSH secretion completely
- if TG levels then rise in presence of T4 suppression = return of malignant thyroid cells
follow up of thyroid cancer
annual clinical examination
serum TSH and TG
prognosis of thyroid cancer
overall 10 yr survival rate = 80-90%
good
intermittent painful swelling of parotid gland on one side of face
question to ask about precipitants of the swelling?
whether painful swelling is related to eating
HPC suggestive of salivary gland calculi which may cause outflow obstruction
- increased salivary production causes increased backpressure into gland resulting in painful distention
characteristic features of MEN syndromes
autosomal dominant
MEN-1
- parathyroid: hyperplasia/adenoma
- pituitary: prolactinoma/GH secreting tumour
- pancreas: insulinoma/gastrinoma/non-functional
MEN-2A
- thyroid: MTC
- adrenal: phaeochromocytoma
- parathyroid: hyperplasia/adenoma
MEN-2B
- thyroid: MTC
- adrenal: phaeochromocytoma
- mucocutaneous neuromas
Turner’s is associated with which neck lump
cystic hygromas
sjogre’s is a risk factor for which neck lump
non-hodgkin’s lymphoma
histological types of thyroid neoplasia
papillary
follicular
medullary
lymphoma
anaplastic/metastase (rare)
indications for prophylactic thyroidectomy
children with FHx of MEN-2A, MEN-2B, or familial MTC
*familial MTC more likely to be bilateral and metastasise early
MEN-2A: < 5yrs
MEN-2B: < 1 yr
FMTC: > 10 yrs
potential complications of thyroidectomy
- injury to recurrent laryngeal nerve
- unilateral damage = weak, hoarse voice
- bilateral damage → may require tracheostomy
- injury to superior laryngeal nerve
- results in difficulty shouting or singing
- transient voice changes in absence of nerve injury (3-6 months)
- transient hypocalcaemia (due to parathyroid bruising)
- hypoparathyroidism (parathyroid damage)
- hyperthyroid storm
- very rare
- if not adequately medicated prior to surgery → large amounts released during surgery
- postoperative haemorrhage and airway compromise
- general complications of surgery
tachycardia in hyperthyroidism
associated with AF particularly in older patients
persists during sleep
What 4 pathways that affect vomiting centre
- vestibular system
- CNS
- CN IX, X
- chemoreceptors
broad causes of nausea
- vestibular (BPPV, motion sickness, menier’s disease)
- CNS (menengitis, encephalitis, raised ICP)
- CN IX, X (GI obstruction, GI inflammation, liver problems)
- chemoreceptors (alcohol, toxins, medications)
other - renal failure, anxiety, hyperthyroid, cyclic vomiting syndrome
questions to ask with nausea
- contents
- partially/ undigested
- fecal/ bile -
- blood
- timing + duration
- straight after eating- peptic ulcer
- early morning - morning sickness, raised ICP
- acute- bowel obstruction, infection
- changes to bowel habits- constipation/ diarrhoea
- pregnant?
- Foreign travel/ food/ close contacts
- Previous surgery - adhesions => bowel obstruction
- medication- ABs, chemo, opiates, anti-convulsants /alcohol/ drugs
acute nausea (<1 month) + headaches
menegitis
raised ICP (hydrocephelus- space occupying lesion)
migraines
nausea + head spinning/vertigo
- BPPV
- menieres
- motional sickness
- labrynth disease
- vestibular schwanomma
nausea + diarrhoea + fever (worrying)
infectious gastroenteritis
nausea + abdominal pain + fever
- gastroenteritis
- food poisoning
- appendicitis
- pancreatitis
- cholecystitis
- mesenteric adenitis
nausea + abdominal pain + no fever
- small/large bowel obstruction
- DKA
- toxins (lead)
- drug overdose/ side effects
- mesenteric ischaemia
- MI
- due to pain (testicular torsion, kidney stones, period cramps)
nausea + constipation
- bowel obstruction due to ileus (lack of muscle contraction of bowel)
nausea + straight after eating
peptic ulcer
gastic outlet obstruction
chronic nausea (>1 month) + weight loss
- coeliac disease
- upper GI obstruction
- mechanical- oesophageal cancer
- functional- motor neuron disease
chronic nausea + no weight loss
- oesophagitis
- pharyngeal pouch
nausea + rigid, motionless patient + absent bowel sounds (worrying)
peritonitis
nausea + reduced consiousness (worrying)
Diabetic ketoacidosis
nausea + haematemesis (worrying)
bleeding peptic ulcer
oesophageal varices
investigations for nausea
Bloods
- FBC- Hb,WCC, CRP
- U&Es- abnormal electrolytes/ CT contrast for surgery
- LFT- raised ALP=biliary disease, raised ALT/AST= hepatitis
- amylase = exclude pancreatitis
- group and save - for surgery
Imaging:
- AXR- look for bowel obstruction
- CXR- air under diaphragm (bowel perforation)
Other
- pregnancy test
- toxicology screen
- CT contrast studies
- CT abdo
life threatening causes of chest pain
- acute MI
- angina/ACS
- aortic dissection
- tension PTX
- PE
- oesophageal rupture
features of chest pain that suggest cardiac causes
- dull pain
- radiates to jaw, arm or epigastrium
- associated with exericse
Cardiac causes of chest pain
- angina (pain on exercise, better on rest/GTN spray)
- MI (sudden + central tight pain, nausea, sweating)
- aortic dissection (sudden tearing pain => radiates to back aortic regurg)
- IHD (CVD risk factors)
- pericarditis (pleuritic chest pain, flu-like)
- coronary artery spasm (cocaine use)
Respiratory causes of chest pain
- pneumothorax (sudden, sharp+ pleuritic pain, breathless)
- pneumonia (fever, sputum, cough)
- pulmonary embolism (sudden pleuritc pain, flights/surgery)- diagnosis of exclusion
GI causes of chest pain
- oesophagitis - chest pain + dysphagia
- oesophageal tear (Borrhaeve’s- vomiting => pain) RARE
- oesophageal spasm- pain worse after meals
- GORD/heartburn- epigastric pain + reflux symptoms
- peptic ulceration/ gastritis- epigastric pain + nausea/vomiting
- pancreatitis
- cholecystitis- pain worse after meals, gallstone Hx (XS alcohol)
Musculoskeletal causes of chest pain
- muscle strain
- rib fractures
- bony metastases
- costochondritis (inflammation of cartilage that connects ribs to sternum- triggered by exercise/coughing/straining)
other causes of chest pain
- pleurisy
- empyema
- herpes zoster
- cervical spondylosis
- sickle cell crisis
key investigations for chest pain
Bedside:
- ECG (FIRST LINE) - MI (ST elevation)
Bloods:
- FBC (anaemia make IHD worse)
- U&Es
- troponin (high in MI)
- consider D dimer only if low probability of venous thromboembolism (Well’s score)
Imaging
- CXR - round opacity (PE), hyper-inflated lungs (pneumothorax), opacity (pneumonia)
- Echocardiography - check heart valves
- Coronary angiography (coronary artery disease)
causes of pleuritic chest pain (pain on inspiration +/- radiate to shoulder)
- pericarditis (fever)
- pneumothorax (sharp pain, breathless)
- pneumonia + TB (fever, sputum, cough)
- pulmonary embolism (breathless, haemoptysis)
- lung cancer
- autoimmune (rhematoid arthritis/ lupus)
- COVID-19
describe metabolism of bilirubin
- production of unconjugated bilirubin from RBC breakdown by macrophages in spleen => Hb => Fe + unconjugated bilirubin
- conjugation of unconjugated bilirubin which travels to liver bound to albumin => glucuronate (water soluble)
- excretion
Differentials for acute diarrhoea in younger patients
- infective diarrhoea
- IBS
- Coeliac disease
- Crohn’s disease
- Ulcerative colitis
- medications (antibiotics, laxatives)
differentials for acute diarrhoea in elderly patients
- neoplasm (pancreatic cancer/ colonic adenocarcinom)
- diverticular disease
- ischaemic colitis
- bacterial overgrowth (in diabetics)
How to assess acute diarrhoea immediately
- ABC
- Check dehydration status - high HR, low BP, dry mucous membranes
- Check electrolyte/ pH imbalance - ABG
Questions to ask about diarrhoea
- travel abroad?
- eaten anything unusual?
- low fibre diet? (IBS)
- know people with similar symptoms
- stress? (IBS)
- ABs/ PPIs => diarrhoea side effect
- FHx of bowel disease?
associated Examination findings with diarrhoea + differentials
- clubbing- IBD/ hyperthyroidism
- uveitis
- mouth ulcers- crohn’s
- virchows node- GI malignancy
- erythema nodosum- IBD
- dermatitis herpetiformis- coeliac
- pyoderma gangrenosum- IBD
Investigations for acute diarrhoea
Bedside - glucose (exclude diabetes
Bloods
- FBC- Hb/Fe/B12 - malabsorption IBD
- CRP/ESR- inflammatory markers
- anti-TTG- coeliac
- TFTs- exclude hyperthyroidism
- LFTs- albumen low in malabsorption
- U&Es- check dehydration
Faecal occult blood test- UC
Faeces MC&S- exclude infectious causes
C. diff toxin test
=> X-ray/ CT
=> Colonoscopy
causes of abdominal distension (4Fs)
- fluid (ASCITES)
- flatus (Obstruction)
- fat- obesity
- faeces
- foetus
- f’ing big tumour
Hx for adominal distension
obstruction
- nausea/vomiting
- not opened bowels (constipation)
- previous surgery (SBO)
- previous hernias (SBO)
pregnant
Cancer => FLAWs
Clinical signs for abdominal distension
Fluid (ASCITES)
- shifting dullness
- abdominal thrills
Flatus (OBSTRUCTION)
- tinkling bowel sounds
Tumour
- palpable mass (gastric cancer)
Causes of Ascites
(C,C,N,M,B,I)
- liver disease (cirrhosis, alcoholic hepatitis)
- heart disease (congestive heart failure, constrictive pericarditis)
- Hypoalbuminanaemia (nephrotic syndrome, malnutrition, protein-losing enteropathy)
- Malignnacy (liver, ovarian, pancreatic, peritoneal metastasis)
- Hepatic vein obstruction (Budd-Chiari syndrome)
- Chronic Infection/inflammation(HEPATITIS C, pancreatitis, appendicitis, infective peritonitis, )
Questions to ask a patient with ascites (fluid)
- Social Hx: alcohol intake
- Hx of cirrhosis/ HF
- Check for malignancy (FeverLethargyAnaemiaWeightlossS, FHx)
- check for hepatitis C (IV drug user, tattoos/ piercings, HIV)
- PMHx- Autoimmune (autoimmune hepatitis)
- Associated symptoms (breathlessness, orthopnea, swelling => Heart failure)
Investigations for a patient with ascites
- US abdomen
- Blood tests (FBC, U&E, LFTs)
- Paracentesis -analyse ascitic fluid using needle + syringe
=> fluid appearance (clear = liver cirrhosis, cloudy= pancreatits/ perforated bowel, bloody= malignancy, milk= lymphoma, TB, malignancy)
- protein
- Glucose (< serum= TB/malignancy)
- Amylase (>serum = pancreatitis)
- Serum ascitic albumin gradient (serum albumin- ascitic fluid albumin)
=> high SAAG =cirrhosis, hepatic failure, Budd-chiari, alcoholic hepatitis, kwashiokor malnutrition)
=> low SAAG = malignancy, infection, pancreatitis, nephrotic syndrome
Presenting symptoms of ascites
- abdominal distension
- abdominal discomfort
- shortness of breath
- weight gain
- reduced appetite
Clinical signs of ascites
- shifting dullness
- abdominal thrills
Associated signs:
- raised JVP => congestive heart failure
- liver disease signs (jaundice, palmar erythema, dupuytrens contracture, spider naevi)
- peripheral oedema => nephrotic syndrome
Management of ascites
- diuretics (spiranolactone +/- fureosemide with peripheral oedema)
- fluid restrict + dietary Na+ restrict
- monitor vitals
- therapeutic parecentesis (+ IV human albumin)
- treat cause of ascites
If encephaopthaic: lactulose (laxative + reduce ammonia synthesis), phosphate enema, AVOID SEDATION(diazepams), treat infection/bleeding
*diuretics= reduce Na+ reabsorption =>increase water removal
what is jaundice
yellowing of skin, sclerae, and mucosae due to high levels of bilirubin
pre-hepatic causes of jaundice (unconjugated hyperbilirubinaemia)
- overproduction - haemolysis
- impaired hepatic uptake - drugs
- impaired conjugation - syndromes
- physiological neonatal jaundice - combination of above
- Gilbert syndrome (50% are carriers => asymptomatic jaundice)
hepatic causes of jaundice (conjugated hyperbilirubinaemia)
- hepatitis (alcoholic/ viral/ autoimmune)
- viral: CMV, EBV => infectious mononeucleosis
- drugs and alcohol
- septicaemia
- alpha-1 antitrypsin deficiency
- haemochromatosis
- right heart failure
- cirrhosis
- liver metastases/abscess
Hx taking for jaundice, ask about
- blood transfusions (Hep C)
- alcohol use (alcoholic hepatitis, cirrhosis)
- IV drug use (Hep C)
- piercings/tattoos (Hep C)
- sexual activity
- travel
- FHx
- previous medications
signs in examination of jaundiced patient
hepatic:
- dark urine
post-hepatic:
- itching (bile salts/acids leaking into bloodstream)
- palpable gallbladder (pancreatic cancer/ unlikely to be gallstones as would shrink gallbladder)
- dark urine and pale stool (cholestatic jaundice)
portal hypertension
- ascites
- splenomegaly
- visible veins
chronic liver disease:
- palmar erythema
- dupuytren’s contracture
- spider naevi
- gynaecomastia
- leuconychia/ Terry’s nails
- clubbing
- xanthalasma
Liver failure (SEVERE)
- liver flap (XS ammonia)
- hepatic encephalopathy (XS ammonia)
- lymphadenopathy
tests for jaundiced patient
Bloods
- FBC - check for haemolysis/ sickle cell
- clotting screen- PT marker of liver function
- LFT- high AST/ALT (hepatitis), high alkaline phosphotase (post-hepatic), high bilirubin= jaundice
- CRP
- U&Es
- blood film
- total protein
- albumin
- MC&S
- hepatic serology- check for hepatits
Imaging:
- Abdominal US- enlarged gallbladder/ spleen
- CT/MRI abdo - enlarged spleen
Other:
- liver biopsy
management of jaundice
- hydration
- broad spec abx if obstructive
- monitor for ascites/encephalopathy (treat with latulose, phosphate enemas, avoid sedation)
- liver failure => liver transplant
post-hepatic causes of jaundice (obstructive)
- gallstones (common bile duct stones)
- pancreatic cancer
- primary biliary cholangitis (associated with UC)
- primary sclerosing cholangitis
- compression of bile duct
- cholangiocarcinoma
- drugs
post-hepatic causes of jaundice (obstructive)
- gallstones (common bile duct stones)
- pancreatic cancer
- primary biliary cholangitis (associated with UC)
- primary sclerosing cholangitis
- compression of bile duct
- cholangiocarcinoma
- drugs
management of jaundice
- hydration
- broad spec abx if obstructive
- monitor for ascites/encephalopathy (treat with latulose, phosphate enemas, avoid sedation)
- liver failure => liver transplant
tests for jaundiced patient
Bloods
- FBC - check for haemolysis/ sickle cell
- clotting screen- PT marker of liver function
- LFT- high AST/ALT (hepatitis), high alkaline phosphotase (post-hepatic), high bilirubin= jaundice
- CRP
- U&Es
- blood film
- total protein
- albumin
- MC&S
- hepatic serology- check for hepatits
Imaging:
- Abdominal US- enlarged gallbladder/ spleen
- CT/MRI abdo - enlarged spleen
Other:
- liver biopsy
signs in examination of jaundiced patient
hepatic:
- dark urine
post-hepatic:
- itching (bile salts/acids leaking into bloodstream)
- palpable gallbladder (pancreatic cancer/ unlikely to be gallstones as would shrink gallbladder)
- dark urine and pale stool (cholestatic jaundice)
portal hypertension
- ascites
- splenomegaly
- visible veins
chronic liver disease:
- palmar erythema
- dupuytren’s contracture
- spider naevi
- gynaecomastia
- leuconychia/ Terry’s nails
- clubbing
- xanthalasma
Liver failure (SEVERE)
- liver flap (XS ammonia)
- hepatic encephalopathy (XS ammonia)
- lymphadenopathy
Hx taking for jaundice, ask about
- blood transfusions (Hep C)
- alcohol use (alcoholic hepatitis, cirrhosis)
- IV drug use (Hep C)
- piercings/tattoos (Hep C)
- sexual activity
- travel
- FHx
- previous medications
hepatic causes of jaundice (conjugated hyperbilirubinaemia)
- hepatitis (alcoholic/ viral/ autoimmune)
- viral: CMV, EBV => infectious mononeucleosis
- drugs and alcohol
- septicaemia
- alpha-1 antitrypsin deficiency
- haemochromatosis
- right heart failure
- cirrhosis
- liver metastases/abscess
pre-hepatic causes of jaundice (unconjugated hyperbilirubinaemia)
- overproduction - haemolysis
- impaired hepatic uptake - drugs
- impaired conjugation - syndromes
- physiological neonatal jaundice - combination of above
- Gilbert syndrome (50% are carriers => asymptomatic jaundice)
what is jaundice
yellowing of skin, sclerae, and mucosae due to high levels of bilirubin
causes of acute epigastric abdominal pain
- Stomach- GORD, peptic ulcer, gastritis, Malignancy
- Pancreas - acute pancreatitis
- (above)- MI
- (below)- ruptured aortic aneurysm
- (right) - hepatits, cholecysitits
Hx for epigastric acute abdominal pain
- nausea => appendicitis, pancreatitis
- FLAWs => malignancy
- pain relieved by antacids => GORD
- Pain relieved by sitting forward => pancreatitis
- pain worse after eating => pancreatitis, GORD, cholecystitis
- crushing pain radiates to arm/jaw => MI
- pain radiates to RUQ => pancreatitis
- pain radiates to RLQ =>appendicits
- low bp + pain radiates to back => AAA
- Hx of gallstones => pancreatitis
- NSAID use => peptic ulcer
- Alcohol => gastritis, pancreatitis, alcoholic hepatitis,
causes of RUQ acute abdominal pain
- Liver- hepatitis, abscess
- Gallbladder - cholecystitis, cholangitis, gallstones
- (left) - pancreatitis, pyelonephritis, peptic ulcer
- (below) -retrocecal appendicitis
- (above)- lobar pneumonia
*
Hx for acute RUQ pain
- Charcot’s triad (fever/RUQ pain/jaundice) => cholangitis
- resp symptoms (cough/sputum/fever)=> pneumonia
- urinary symptoms (dysuria,dark urine) => pyelonephritis
- pain radiating to shoulder => cholecystits/ biliary colic
- SEVERE pain after fatty meals => biliary colic
- alcohol use => alcoholic hepatitis, peptic ulcer
- IV drug user/ blood transfusion/ transplant/ tattoos=> Hep C
Causes of acute LUQ abdominal pain
- spleen (splenic rupture)
- GI - ischaemic colitis, biliary colic, renal colic
Causes of acute RIF abdominal pain
- GI- Appendicits, IBD, mesenteric adenitis (children), malignancy, inguinal hernia, meckel’s diverticulum
- Gynae- ovarian/testicular torsion, ovarian cysts, ovarian rupture, ectopic preganancy, STIs
- Renal - UTIs, renal colic
Causes of acute LIF abdominal pain
- GI - diverticulitis, IBD, colorectal cancer, volvulus
- Gynae- ovarian/testicular torsion, ovarian cysts, ovarian rupture, ectopic pregnancy, STIs
- Renal - renal colic, UTI
Hx for acute R/L illiac fossa pain
- Age: younger => mesenteric adenitis, older => diverticulitis
- FLAWs => malignancy
- diarrhoea + PR bleeding => IBD
- urinary symptoms (dysuria) + unprotected sex=> UTI
- loin=> groin pain => renal colic
- epigastric => RIF pain => Appendicitis
- pregnant? last period? => ectopic pregnancy
- sexual history (unprotected sex) => STIs
Causes of diffuse abdominal pain
- obstruction- small/large bowel
- infection- peritonitis, gastroenteritis
- inflammation - IBD
- ischaemia- mesenteric ischaemia
- medical conditions: DKA, Addison’s, hypercalcemia, lead poisoning, porphyria
*
Hx for diffuse abdominal pain
HPC
- constipation + vomiting => obstruction
- fever + sudden diarrhoea + vomiting
- nausea/vomiting + tan => addison’s
- osmotic symptoms (polyuria, polydypsia, nocturia) + ketone breath => DKA
PMHx
- diabetes => DKA
- addison’s => addison crisis
SHx
- travel Hx => gastroenteritis
define cough
reflex to irritation of the airways triggered by airway cough receptors to get rid of toxins
Hx taking for cough
HPC:
- onset (acute/ chronic)
- duration (how long have you had the cough)
- character of cough (dry, productive)
- sputum produced (colour, amount)
- triggers: cold, pollen, dust, exercise, lying flat
- night-time symptoms: (orthopnea, wake up at night, day-time fatigue)
- associated symptoms: wheeze, SOB, chest pain, palpitations, fever, sore throat
- RED FLAGs: haemoptysis, hoarse voice, dysphagia, weight loss, lethargy, anorexia, vomiting
PMHx:
- any heart/lung problems (COPD, asthma, CF)
- previous respiratory infections
DHx:
- medication (ACE-inhibitors => cough)
FHx:
- asthma
SHx:
- smoker- COPD, smokers cough
- XS alcohol
- travel Hx (TB)
- sleep disruption
- home life- kids at home (pneumonia)
- occupation - asbestos (builder)
causes of acute cough
- upper respiratory tract infection (cold/ flu-infleunza)
- whooping cough
- COVID-19
- acute bronchitis
- sinusitis
- acute exacerbation of asthma/ COPD
- PE
- pneumothorax
chronic causes of cough (>8 weeks)
- COPD
- asthma
- GORD
- ACE-inhibitors
- post nasal drip
- Cough hypersensitivity syndrome (environmental triggers)- irritant (dust, pollen, chemicals, cigarette smoke, foreign boodies)
Uncommon:
- CF
- lung cancer
- Pulmonar fibrosis
- bronchiectasis
- sarcoidosis
- infections (pneumonia, TB, whooping cough)
Investigations for cough
Bedside:
- pulse oximeter
Bloods:
- pertussis serology (whopping cough)
- C-reactive protein (pneumonia)
Imaging
- CXR (pneumonia, PE)
- CT (bronchiectasis)
Other:
- peak expiratory flow volume (if asthma suspected)
- spirometry (if COPD)
Management of cough
Assess severity (Cyanosis, Hypotension SBP <90, Exhaustion, Silent chest, Tachycardia)=> urgent hospital referral
Treat cause
- Upper respiratory tract infection - analgesia, herbal remedies, stop smoking (no antibiotics)
- airway obstruction (COPD/asthma) - bronchodilators + ICS
define palpitations
- a more noticeable heart beat
- pounding chest
- irregular heart beat
History taking for palpitations
HPC:
- onset (how, when)
- triggers (exercise, position, alcohol, caffeine, stress/anxiety, poor sleep)
- rate/rythm (how fast are they, have you measured HR, can you tap out the pattern of heartbeat)
- duration (how long does it last)
- frequncy (how often does it happen)
- can you stop the palpitations by holding breath/straining
- ADVERSE symptoms (chest pain, syncope, dizziness, SOB, sweating, extreme fatigue)
- associated symptoms (fever, productive cough, weight loss, low mood, heat intolerance, vomiting/diarrhoea, tremor)
PMHx:
- any problems with your heart (CHF, CHD, heart valve problems, cardiomyopathy)=> increases risk of arrhythmias
- any mental health problems (anxiety, depression)
- any previous surgeries/ been to hospital before
DHx:
- CVD related(beta blockers, beta agonists, QT prolonging medication)
- herbal remedies (with caffeine)
FHx:
- any family have heart problems
- has anyone in your family died of a sudden heart problem (<40 years)
SHx:
- smoking, alcohol
- recreational drugs (cocaine/ecstacy/amphetamines=> activates SNS, opiates=> activate PNS, cannabis both)
- diet/ exercise
- safety (occupation -heavy machinery/ driving => advise to take time off work till they are fully investigated)
Common causes of palpitations
- anxiety/stress (panic attack)
- hyperthyroidism
- drugs (cocaine/ecstacy/amphetamines)
- caffeine
- arrythmias=> VT, SVT (AF, sinus tachycardia, atrial flutter) ectopic heartbeat
- heart disease/heart failure/ MI/ structural heart disease= heart valve problems
- palpitations
- chest pain (central, crushing) => radiates to left jaw/arm
- sweating
Myocardial infarction
- palpitations/tachycardia
- weight loss
- heat intolerance
- nausea/diarrhoea
- sweating
- low mood
- tremor
hyperthyroidism
- palpitations
- productive cough (green)
- fever
pneumonia
- palpitations
- low mood
- tremor
- sweating
- history of anxiety
- anxiety
- palpitations
- fatigue
- alcohol misuse
- sleep deprivation
- palpitations
- can be stopped by holding breath/straining
- paroxysmal supraventricular tachycardia
Investigations for palpitations
Bedside:
- ECG (check for arrythmias)
Bloods
- FBC- WCC (infection), Hb (anaemia)
- TFTs- exclude hyperthyroidism
- U&Es
- drug screen
Imaging:
- ECHO - check for structural heart disease (if murmur present)
- Continuous Ambulatory monitoring
What’s the diagnosis?
Ventricular tachycardia
When to arrange for emergency admission for someone with palpitations?
- Ventricular tachycardia
- Persistant SVT
- breathlessness, syncope, chest pain
- hypotension
define pallor
lighter skin complexion than normal due to reduced concentration of oxyhaemoglobin
- reduced oxygen
- reduced blood flow
- reduced number of red blood cells
common causes of pallor
- anaemia (reduced RBC production)- acute: bleeding from trauma/surgery/intestinal, chronic: CKD, low B12/iron/folate, sickle cell, thalassemia
- shock
- blockage of artery in limb (ischaemia) => acute limb ischaemia
- illness
- drug use
- lack of sun exposure
- cold/ frostbite
Symptoms associated with anaemia (acute onset)
- chest pain
- breathlessness
- tachycardia
- low bp
- loss of consciousness
Symptoms associated with chronic anaemia
- heavy menstrual bleeding
- fatigue
- sensitivity to cold
- paleness
- painful, pulseless, perishingly cold, parasthesis, paralysis LIMBS
acute limb ischaemia
RED flag symptoms associated with paleness => emergency admission
- fainting
- abdominal pain
- vomiting blood
- rectal bleeding
- fever
Investigations for pallor
- stool culture - check for intestinal bleeding
- pregnancy test- (cause anaemia)
Bloods:
- FBC- low Hb (anaemia)
- U&Es (creatinine => check for AKI/CKD)
- TFTs (hypothyroidism => anaemia)
- serum iron
- serum B12/ folate
- LFTs
Imaging:
- Abdo X-ray
- Abdo US
- Arteriography
management of pallor
treat cause:
- shock => CPR, fluids, oxygen
- iron/b12/folate supplements
- balanced diet
- surgery for arterial blockage
define hypotension
SBP <90
DBP <60
types of hypotension
- orthostatic hypotension (low bp on standing)
- post-prandial hypotension (low bp after eating)
- neurally mediated hypotension (low bp after standing for long periods)
risk factors for hypotension
- older age
- medications -diuretics (furosemide), alpha blockers (tamulosin) /beta blockers, levodopa, anti-depressants, viagra
- comorbidities (diabetes, Parkinson’s, heart conditions)
Causes of shock + hypotension (EMERGENCY)
- Early pregnancy
- Cardiogenic shock (heart disease)
- ruptured aortic aneurysm
- Addison crisis
- Severe hypothyroidism (myxoedema coma)
- Septic shock (recent infection)
- Chronic liver disease (GI haemorrhage)
- thrombosis risk (PE)
- Anaphylactic shock
- rapid/severe bleeding (caused by trauma)
- dehydration (caused by vomiting, diarrhoea, exercise)
causes of chronic/recurring hypotension
- chronic liver disease
- Addison’s
- hypopituitarism
- severe hypothyroidism
- secondary amyloidosis
- diabetic neuropathy
Young
- pregnancy
- vasovagal syncope
Older
- parkinson’s
- vitamin B12 deficiency
History taking for hypotension (not in shock)
HPC:
- fever/chills (sepsis)
- chest pain (MI, PE)
- dyspnoea (heart failure, PE)
- haemoptysis (PE, HF, pneumonia)
- abdo pain (peptic ulcer => GI bleeding, AAA)
- haematemsis (upper GI bleed)
- vomiting/diarrhoea (gastroenteritis)
PMHx:
- Heart disease
- Diabetes
- Previous PE/DVT
- peptic ulcer disease
- chronic liver disease
- dialysis induced hypotension
DHx:
- anti-hypertensives (alpha blockers)
- anti-depressants
- OCP => increase PE
SHx:
- smoking (peptic ulcer diseae, PE, MI)
- alcohol (peptic ulcer disease, chronic liver disease)
- cocaine (ACS)
- hypotension
- inspection: jaundice, spider naevi, gynaecomastia, dupuytren’s contracture, palmar erythema
- palpation: hepatomegaly
chronic liver disease
- hypotension
- associated symptoms: cough, SOB, tired, palpitations,dizziness
- inspection: cyanosis, peripheral oedema
- palpation: raised JVP
- auscultation: crackles at lung base
heart failure
- hypotension
- palpation: expansile, pulsatile mass
AAA
- hypotension
- hyperpigmentation
- collapse
- hypoglycaemia
- fatigue
- Bloods: hyperkalemia (arrythmias/cardiac arrest), hyponatremia
Addison’s crisis
assessment for hypotension
- check for shock (tachycardia, reduced consciousness, altered cognition, increased RR, oligouria, XS sweating)
Bedside:
- ECG
- pregnancy test
Bloods:
- FBC- Hb (anaemia)
- U&Es (low Na+ = addison’s)
- LFTs (chronic liver disease)
- TFTs (hypothyroidism)
- troponin (MI)
- d-dimer
- clotting screen
- serum B12
Management of hypotension
In shock:
- CPR
- fluids
- oxygen
- treat cause
Not in shock
- identify cause
acute causes of breathlessness (sudden onset)
*seconds-mins
- Pulmonary embolism
- Pneumothorax
- Foreign body obstructing airway
- anaphylaxis
- anxiety attacks
subacute causes of breathlessness (mins-hrs)
- airway inflammation/obstruction (COPD/ asthma exacerbation)
- pus (chest infection - pneumonia, TB)
- fluid (acute HF)
chronic causes of breathlessness (days-months)
- unresolved airway inflammation/obstruction (COPD, asthma)
- unresolved chest infection
- unresolved HF
- malignancy
- large pleural effusion
- interstitial lung disease
- obesity
- thyrotoxicosis (goitre)
- anaemia
- neuromuscular
History taking for breathlessness
HPC:
- onset (acute/subacute/ chronic)
- duration
- triggers- cold/exercise/ lying flat
- night time symptoms (orthopnea, wheeze, day-time fatigue)
- exercise tolerance (how far up stairs before breathless/stop) MRC breathless scale
- associated symptoms: cough, wheeze, fever, chest pain, sputum, palpitations
- RED FLAGS: haemoptysis, weight loss, lethargy, anorexia
PMHx:
- lung conditions (COPD, asthma, CF)
- Heart problems
- previous childhood infection (bronchiectasis)
- previous surgeries (stasis- PE)
DHx:
- inhalers for asthma (colour, dose, proper technique and taking it regularly)
FHx
- asthma
- heart problems
SHx
- smoker - COPD, lung cancer
- alcoholic - COPD
- home life - increased kid contact (pneumonia)
- occupation - asbestos (builders)
- travel - TB
- immobility (long flights) - PE
investigations for breathlessness
Bedside:
- ECG (RBBB in PE, check for MI, LVH)
- Baseline obs
Bloods:
- FBC - high WCC (infection)
- D-dimer (PE)
- sputum cultures (pneumonia, bronchiectasis)
- blood glucose
- U&Es
- toxicology screen
- ABG if sats < 94%
Imaging
- CXR (pneumothorax, pneumonia, pleural effusion)
- CT chest (bronchiectasis)
Other:
- Spirometry -FEV1:FVC (COPD/asthma)
- Peak expiratory flow volume (asthma)
breathlessness + wheezing may suggest
asthma
COPD
heart failure
anaphylaxis
breathlessness + stridor (upper airway obstruction) may suggest
foreign body/tumour
acute epiglottis (younger patients)
anaphylaxis
trauma (eg. laryngeal fracture)
breathlessness + crepitations may suggest
heart failure
pneumonia
bronchiectasis
fibrosis
Management of breathlessness
- Oxygen (>98% unless COPD 88-92%)
Treat cause
- infection (pneumonia/TB)- antibiotics
- airway obstruction/inflammation (COPD/asthma)- bronchodilators + steroids
- clots - thrombolysis (severe)/ LMWH
- Pneumothorax => aspirate/ chest drain
- chest physio/ pulmonary rehab (bronchiectasis, CF)
breathlessness + clear chest may suggest
PE
hyperventilation
metabolic acidosis (eg. DKA)
anaemia
drugs (eg. salicylates)
shock
pneumocystis jirovecii pneumonia
CNS causes
- breathlessness
- pain
- palpation: tracheal deviation if tension PTX
- percussion: increased resonance
pneumothorax
- breathlessness
- percussion: stony dullness
pleural effusion
Hx taking for sore throat
HPC:
- onset
- associated symptoms: throat pain, inflammed tonsils, difficulty swallowing/ breathing, hoarse voice, earache, rash
- infection=> fever, runny nose, cough, headache
Risk factors:
- allergies
- exposure to tobacco smoke / chemicals
- immunocompromised
- work with children/ in close quarters
RED FLAGs for sore throat (emergency referral)
- difficulty breathing / swallowing
- neck lump
- blood in saliva
- sore throat > 1 week
Causes of sore throat
Viral (pharyngitis/ tonsilitis)
- cold
- influenza (flu)
- measles
- Mononucelosis
- chickenpox
- croup (harsh barking cough - childhood infection)
- covid-19
Bacterial
- Strep throat (Streptococcus A pyogenes)
Other
- allergies (fur, dust, pollen)
- irritants (tobacco smoke, pollution, alcohol, spicy foods)
- dryness (breathing through mouth - chronic nasal congestion)
- muscle strain (talking/yelling/screaming for too long)
- GORD
- HIV (recurrent = fungal oral thrush/ cytomegalovirus)
- tumours
Investigations for sore throat
Bedside:
- throat swab (+ve = strep throat/ bacterial infection)
Bloods:
- FBC
- CRP
*viral infections usually resolve on their own/ bacterial infections need antibiotics
How to prevent sore throat?
Good hygiene
- wash hands
- don’t share food/drink/toothbrushes
- disinfect surfaces
- avoid close contact
- avoid touching face
Causes of wheeze (BREATHE)
- Bacterial pneumonia/endocarditis
- Reactive airway disease (asthma, COPD, anaphylaxis)
- Embolism (PE)
- ACS
- Tension pneumothorax/ tamponade
- Heart failure
- Excitation (arrythmias)
+
- sleep apnoea
- bronchitis/ bronchiolitis
- emphysema
- lung cancer
- cystic fibrosis
Hx taking for wheeze
HPC:
- onset
- wheeze at night
- wheeze when you breathe in/out or both
- triggers (exercise + exercise tolerance/ food)
- relieving factors
- associated symptoms: SOB, productive cough, chest pain
- allergies
SHx:
- smoker (COPD)
- occupation (asbestos=> pulmonary fibrosis)
Investigations for wheeze
Bedside:
- sputum culture - pneumonia
- ECG- arrythmias/ ACS
- reduced peakflow expiration (obstructive- asthma/COPD)
Bloods:
- FBC - WCC (infection)
- CRP
Imaging: CXR
- consolidation (pneumonia)
- darker +/- lung collapse (Tension Ptx)
- hyper-inflated lungs + barrell chest (COPD)
Other:
- lung funtion tests (flow-volume loop)
causes of haemoptysis
- Chronic lung disease: TB, bronchiectasis, cystic fibrosis, COPD
- Bleeding disorders
- Pulmonary embolism
- Malignancy -LUNG CANCER
- Heart failure
- Pulmonary renal syndrome
Hx taking for haemoptysis
HPC:
- colour of blood (bright red with frothy sputum)
- how much blood (>150ml/hour or >600ml/day = massive)
- associated symptoms: fever, sputum, night sweats, chest pain, shortness of breath, leg swelling, bloody nasal discharge
- RED flag symptoms
- Risk Factors for PE (immobilisation/ long flights/ pregnancy)
PMHx:
- previous surgery
- bleeding disorders (haemophillia)
- recurrent nose bleeds (bleeding disorder)
DHx:
- anticoagulants (heparin, warfarin)
- OCP (PE risk)
FHx:
- FHx of VTE (PE risk)
SHx:
- smoker (COPD/lung cancer)
- travel history (TB)
Red flag symptoms with haemoptysis
- lethargy (cancer)
- anorexia/loss of appetite (cancer)
- weight loss (cancer)
- back pain
- reduced/ absent breathing
- malaise
Examination findings for haemoptysis
Resp
- I: cachexia (cancer), ecchymoses (bleeding disorder)
- P: lymphadenopathy (infection)
- P: dullness (consolidation)
- A: wheeze, stridor, crepitations
Cardio:
- raised JVP, peripheral oedema, new heart murmurs (HF)
Investigations for haemoptysis
Bedside:
- urine dip (check for glomerulonephritis)
Bloods:
- FBC
- coagulation screen
Imaging:
- CXR (consolidation/ tumour)
causes of epistaxis (INDian FANTA)
- INfections (rhinitis, sinusitis, lupus)
- Deviated septum/ Drugs (corticosteroids/anticoagulants) / Diptheria/ Danlos
- Foreign body
- Atmospheric
- Neoplasms (SCC)
- Trauma/surgery
- Allergy
- Bleeding disorders (haemophillia)
Assessment of epistaxis
- acute epistaxis usually harmless and self-limiting
- investigations - FBC, coagulation screen (bleeding disorders)
Management
- sit forward + mouth open, pinch nose 15 mins
- transfer to hospital if haemodynamically ustable/ posterior bleed (profuse bleeding from both nostrils, bleeding site not identified)
define cardiac arrest / cardiorespiratory arrest
- heart suddenly stops working (electrical problem)
- sudden collapse
cardiac causes of cardiac arrest
- arrythmias (conduction abnormalities)- VF
- ACS
- valve disease (structural heart disease)
- cardiomyopathy
Reversible causes of cardiac arrest (4H&6Ts)
- Hypokalemia/ hyperkalemia
- hypoxia
- hypovolaemic shock
- hypothermia
- tamponade
- thrombosis (PE)
- toxins
- tension pneumothorax
- trauma
- thromboembolism
management of cardiac arrest
- ABC + CPR
- pulse/rhythm check
VF/VT
- defibrillate
- amiodarone if refractory
- epinephrine (adrenaline)
Asystole (pulseless)
- epinephrine (adrenaline)
pathophysiology of peripheral oedema
- poor lympatic drainage (lymphoedema)
- increased microvascular filtration
causes of peripheral oedema
- Heart failure
- cor pulmonale (RSHF)
- DVT
- pregnancy
- cirrhosis (long term liver damage)
- nephrotic syndrome (XS protein in urine)
- chronic venous insufficiency
RED flags with peripheral oedema
- DVT risk factors (long haul flights, surgery, OCP, FHx of thromboembolism)
- dyspnoea, orthopnea, nocturnal dyspnoea => HF
Hx taking for peripheral oedema
HPC:
- onset - DVT (sudden)
- unilateral (DVT)/ bilateral - HF, nephrotic, cirrhosis
- redness/ swelling/ tenderness - DVT
- changes in urination -nephrotic
- dyspnoea, orthopnea, nocturnal dyspnoea- CHF
- triggers: worse on standing - chronic venous insufficiency
PMHx:
- recent surgery/ immobility- DVT
- Wilson’s, Haemochromatosis, viral Hep, fatty liver disease - Cirrhosis
- Varicose veins/ previous VTE- chronic venous insufficiency
DHx:
- OCP- DVT
SHx:
- alcohol - cirrhosis (chronic use)
- IV drug user - viral hepatitis => cirrhosis
- recent long haul travel - DVT
unilateral peripheral oedema
+ red tender swollen leg
+ dilated superficial veins
+ long haul flight/ surgery / OCP
DVT
bilateral oedema
+ I: raised JVP
+ P: hepatomegaly
+ P: ascites (shifting dullness)
+A: S3 gallop
Heart failure
bilateral oedema
+ Hx of COPD, Pulmonary embolism, OSA => pulmonary hypertension
+ I: raised JVP
+P: hepatomegaly
+P:
+A: wheeze, rales
cor pulmonale
bilateral oedema
PMHx: fatty liver disease, Wilson’s, Haemochromtosis, autoimmune, viral hepatitis
SHx of chronic alcohol use
EXAM: I: jaundice, spider naevi, caput medusa , P:shrunken/nodular liver, P: ascites (shifting dullness), A:
Cirrhosis
bilateral oedema
+ frothy urine / changes in urine colour
+ swelling in peri-orbial region
Nephrotic syndrome
investigations for peripheral oedema
Bedside
- pregnancy test
- ECG- HF
- urinalysis - nephrotic syndrome (proteinuria)
Bloods:
- LFTs - cirrhosis (high bilirubin + low albumin)
- coagulation studies - Cirrhosis (low PT)
- D-dimer - DVT
- U&Es- nephrotic syndrome (low albumin + high creatinine => renal dysfunction)
Imaging
- echocardiogram- cor pulmonale
- duplex USS- DVT
bilateral oedema
+ chronic swelling, weakness, heaviness in legs
+ worse on standing
+ Hx of varicose veins, obesity, previous VTE
Chronic venous insufficiency
Hx taking for acute rash
HPC:
- onset
- duration
- redness/ itchiness/ swelling/ painful
- radiation
- associated symptoms: fevers, dry skin
- has it changed over time
- anything make it worse/ better (tried anti-histamine/steroid creams)
- any new medication (antibiotics)
- bites/stings
- in contact with anyone with similar rash
- had anything like this before
PMHx:
- allergies/ atopy
- autoimmune
- diabetes/ IBD => skin lesions
FHx:
- any skin problems in the family
SHx:
Systems review:
- dyspnoea/ wheeze=> anaphylaxis
- abdo pain/diarrhoea => Crohn’s
- fever => cellulitis
- peripheral oedema
Causes of acute rash
- allergy
- contact dermatitis (skin reaction when it touches something)
- bites/stings
- new medication (antibiotics)
- autoimmune conditions (lupus - butterfly rash)
- infections (bacteria, viral, fungal candidasis )
- cellulitis
types of perianal symptoms
- pain
- discharge (mucus/ blood)
- swelling
- fissures (tears in lining of anus)
Hx taking for perianal symptoms
HPC:
- pain- SOCRATES
- itchiness/ redness around bottom area
- any discharge (mucus/pus/sticky stool)
- bleeding => colour, on wiping/mixed with stool, how often,how much
- RED FLAG symptoms: change in bowel habit, weight loss, fevers, feeling more tired now than a year ago
- Any constipation, diarrhoea, nausea
PMHx/DHx:
- bowel problems (IBD)
FHx:
- any bowel problems in the family (colorectal carcinomas)
SHx:
- diet (high fibre content)
Causes of anal pain
- anal fissures (tears in anus lining)- due to constipation
- haemorroids (swollen vessels in anal canal)- due to constipation/straining
- constipation
- anal abscess/ fistula
- Crohn’s/ IBD
- infection (STI/ fungal infection)
- levator ani syndrome (aching pain around anus)
- proctalgia fugax
- prostatits (prostate inflammation)
- rectal carcinoma (rare)
sharp burning anal pain when going to poo
+ blood on wiping
anal fissures
anal pain
+ bleeding after poo
+ redness/soreness/itchiness around bottom
+ feels like a lump around anus
haemorrhoids
anal pain when sitting
+ redness/irritation of bottom
+ fever
+pus/blood when you poop
anal fistula/ abscess
Investigations for anal pain
- PR exam - feel for anal fissures, haemorrhoids, prostatitis, check for blood on glove => CANCER
- Stool culture test - MC&S
- faecal calprotectin (bowel inflammation)
- Blood tests - FBC, LFTs (metastasis), U&Es
causes of subjective tinitus
- Ear wax
- Related to hearing loss - ageing, otosclerosis, Meniere’s
- Infection (otitis media)
- Neurological - acoustic neuroma, MS
- Ototoxic drugs - valproate, ACE-inhibitors, anti-malarial, aspirin
- Metabolic - hypothyroidism, diabetes
- Loud noise exposure (shooting/motorbike)
Hx taking for tinitus
HPC:
- site (uni/bilateral)
- onset
- duration
- hearing loss?
- ear pain?
- discharge?
- pulsatile?
- episodic/ continuous?
- associated symptoms: fever, vertigo, dizziness, sensitivity to loud noises, facial weakness, jaw claudication
- subjective (only person hears) objective (other ppl hear)
- triggers- loud noises, sleep position, stress, lack of sleep
PMHx:
- hearing/ear problems
- ear surgery
- head trauma
- CVD, metabolic disease
FHx:
- hearing problems
- ear problems
DHx:
- ototoxic drugs
SHx:
- any exposure to loud noises (concerts)
objective causes of tinitus (RARE)
Vascular
- arteriovenouos malformations
- aortic stenosis /mitral regurgitation
- carotid/vertebral artery stenosis
- vascular tumours
Anaemia
Symptoms associated with tinitus that need urgent referral
- vestibular symptoms-vertigo
- SUDDEN neurological symptoms- facial weakness
- suspected stroke
- high suicide risk
Examination for tinitus
Otoscopy
- wax
- otitis media
- otitis externa
- cholesteatoma
- perforation of tympanic membrane
Weber/ Rine- conductive or sensorineural hearing loss
Neuro exam (check for cranial nerve problems)
If pulsatile/objective tinitus - check bp, heart murmurs, bruits
types of hearing loss
- conductive- bone conduction> air conduction (external/middle ear affected)
- sensorineural- air conduction > bone conduction (inner ear affected)
- mixed
causes of hearing loss
- wax
- foreign object
- tumour
- infection (otitis media/ otitis externa/ labrynthitis= inner ear infectio)
- cholesteatoma (cyst on tympanic membrane => invades to middle ear)
- trauma/noise related
- presbycusis (ageing)
- drug side effects (aspirin, NSAIDs, antibiotics)
RED FLAG conditions with hearing loss
- stroke - FAST
- temporal fracture - blood behind ear
Hx taking for hearing loss
HPC:
- onset
- unilateral/bilateral (ageing)
- associated symptoms: ear pain, fluid, tinitus, vertigo, facial palsy, nausea, headache, fever
- any recent trauma
- any recent infections (otitis media)
Causes:
- wear hearing aids/ clean ears with cotton buds (wax)
- saw child put anything inside their ear (foreign object)
- swimming/ surfing in cold water (exostosis)
- trauma/ scuba diving (tympanic membrane perforation)
- loud noise exposure (power tools/ shooting/ motorbikes)
- recent plane travel (middle ear effusion)
hearing loss
+ smelly ear discharge
+ vertigo/ facial nerve palsy (with local invasion)
cholesteatoma
sudden hearing loss
+ vertigo
+ nausea
labrynthitis
hearing loss
+ ear pain
+ fever
+swelling behind ear
+ previous upper respiratory tract infection
acute otitis media
Examination findings for hearing loss
Otoscopy
- swollen ear canal, yellow discharge => otitis externa
- ruptured tympanic membrane
- bulging tympanic membrane => acute otitis media
- fluid behind tympanic membrane => middle ear effusion
- blood behind tympanic membrane => temporal bone fracture
- nectrotic debris/ drainage => cholesteatoma
Rinne’s test
- conductive hearing loss (louder on bone >air)
- normal/sensorineural hearing loss (louder on air >bone)
Weber’s test
- louder in one ear (conductive hearing loss on affected side/ sensorineural hearing loss on unaffected side)
Cranial nerve palsies => (temporal bone fracture, cholesteatoma, stroke, acoustic neuroma)
Investigations for hearing loss
if not diagnosed clinically
- Pure tone audiometry - assess type + degree of hearing loss
- CT temporal bone
causes of seizures
- Vascular- strokes/ TIA/ embolisms
- Infection- meningitis, encephalitis, cerebral malaria
- Trauma
- AV malformation
- Metabolic - hyponatremia, hypoxia, hypoglycaemia
- Idiopathic
- Neoplasms
- pSychiatric => Drug overdose, sleep problems, stress
types of seizures
- tonic- increased tone
- myoclonic- rhythmic jerking
- atonic - loss of muscle tone
differentials for seizures
- TIA
- syncope
- sleep disorders (narcolepsy)
- Parosyxmal Movement disoders
- migraine
- drop attack
Causes of leg pain
- Vascular - DVT, PAD (intermittent claudication, acute limb ischaemia), varicose veins
- Infection (nerves)
- trauma - muscle/ligament/tendon injury, fractures
- Metabolic - T2DM/ hypothyroidism, low Vit B12/B6
- Idiopathic
- Neoplasms
- Spine related
- herniated disc
- radiculopathy (cervical, thoracic, sciatica)
- spondilolisthesis (slipped vertebrae)
- degenerative disc disease
Main investigations for leg pain
Bloods:
- D-dimer -DVT
- HbA1c - diabetes
Bedside:
- ABPI- PAD
Imaging
- X-ray (fractures, new bone growths)
- MRIs - spinal chord pathology
- CT angiography - PAD
Hx taking for leg pain
HPC:
- site, onset, character, radiation
- Associated symptoms: numbness/ tingling, weakness, back pain, urinary/bowel incontinence, fever
- Recent travel
- recent trauma
- worse on movement
PMHx:
- Diabetes
- thyroid issues
SHx:
- Mood lately
Unilateral Leg pain
+ worse on coughing/ sneezing
+ numbness/ tingling
+ weakness
Lumbar radiculopathy (sciatica)
bilateral leg pain (one worse than other)
Pale, pulseless, paralysis, parasthesia, cold
+ no hair on legs
+ leg ulcers which heal slowly
+ skin colour changes- blue
Acute limb ischaemia
Bilateral leg pain (one worse than other)
+ pain comes on walking and relived by rest
+ numbness/tingling
+weakness
+ cramping
Intermittent Claudication
causes of swollen leg (unilateral)
Acute:
- DVT (risk factors: long haul flights/stasis, OCP, obesity) symptoms= painful hot leg
- cellulitis (swelling gets bigger, previous wound)
- ruptured baker’s cyst (swelling in popliteal fossa => calf)
- TRAUMA
- septic arthritis (pevious wound -infected, SEVERE leg pain on movement, swelling over joints)
- compartment syndrome (swelling in calf, reduced pulses/sensation, moving ankle/toes => pain in calf)
- allergic reaction to insect bite
Chronic:
- lymphoedema (risk factors: previous radiotherapy/surgery=> poor lymph drainage) symptoms= lymphadenopathy
- venous insufficiency/ venous obstruction
causes of swollen leg (bilateral)
Acute:
- acute HF (mainly RHF)
Chronic
- chronic right sided heart failure
- pregnancy
- drugs (beta blockers)
- hypoalbuminuria (low albumin)
- lymphoedema
- venous insufficency/ venous obstruction
History for swollen leg
- location of swelling (joint-septic arthritis, popliteal fossa= ruptured bakers cyst)
- changes to size of swelling - cellulitis gets bigger
- wounds/cuts/bites - allergic reaction/ infected wound => septic arthritis/cellulitis
- painful on movement (septic arthritis = SEVERE, move toes/feet(passive movement) => calf pain =compartment syndrome)
- FLAWs => pelvic tumour
- PMHx - previous surgery/ radiotherapy (lymphoedema)
- DHx-OCP=>increases VT risk
- stasis/ long haul flights =>DVT risk
Investigations for swollen leg
Blood tests:
- FBC
- D-dimer (DVT risk)
- clotting screen
Imaging
- Doppler utrasound of calf (DVT)
causes of limb weakness (sudden onset)
- Neuro- stroke, parkinson’s, Lou-gherig’s (nerve damage => muscle twitching/weakness)
- NM- myasthenia gravis (weakness of skeletal muscles)
- Autoimmune - MS, Guillan-Barre
- Spinal pathology - slipped disc, sciatica, tumour
- Toxins - alcohol neuropathy
- Peripheral neuropathy (diabetes, hypothyroidism)
- EMERGENCY: cauda equina
Neuromuscular causes of limb weakness (intermittent)
- Lambert–Eaton myasthenic syndrome
- Myasthenia gravis
- Acute or chronic inflammatory demyelinating polyradiculopathy
- Dermatomyositis/polymyositis and Sjögren’s syndrome
- Spinal muscular atrophy
Hx taking for limb weakness
HPC:
- uni/bilateral
- sudden onset
- associated symptoms:
- leg/back pain
- redness/swelling
- numbness/tingling
- incontinence
- grip strength/ fine movements
- chewing/difficulty swallowing
- dry mouth/postural hypotension- autonomic nerve involvement
- FLAWs- neoplasm signs
PMHx:
- autoimmune conditions
- diabetes/ hypothyoroidism (peripheral neuropathy)
sudden limb weakness (arm)
+facial weakness (droopy face)
+slurred speech
+ confusion
stroke
sudden limb weakness
+ optic neuritis (blurred vision)
+ vertigo
+ diplopia
+ incontinence
+ parasthesia (loss of sensation)
+ tremors
+ difficulty walking
MS
sudden limb weakness
+ limb pain worse on movement/ sneezing/ coughing
sciatica
sudden limb weakness (hands/legs/feet)
+ droopy eye lids
+ difficulty speaking/swallowing
Myasthenia gravis
difficulty walking
+ resting tremors (pill-rolling)
+ rigidity
+ akinesia (bradykinesia)
+postural instability (falls)
+ small handwriting / shuffling gait
+ hypomimic face
Parkinson’s
sudden limb weakness
+ pain worse on standing/sitting
+ numbness/tingling
slipped disc
Investigations for limb weakness
Bloods:
- serum creatine kinase activity (marker of muscle disease)
Antibodies: (neurophysiological studies)
- anti-acetylcholine receptor antibodies
- anti-voltage gated calcium channel antibodies
Imaging:
- chest X-ray
- CT scan of chest
types of tremors
- resting tremor - hands on lap (with gravity)
- postural tremor- fixed body part against gravity
- action tremor - on voluntary movement
- physiological - fine tremor in normal people + usually normal neuro exam
- intention tremor (action) - tremor on voluntary movement and worse when moving towards a target.
- essential tremor - tremor usually in hands, difficulty doing tasks like writing/ drinking tea, head/neck/ voice shaking involved
- Resting tremor - Parkinsonian (pill-rolling), MS
causes of resting tremors
- Parkinson’s (pill-rolling Tremor, Rigidity, bradykinesia, postural instability, shufling gait)
- Parkinsonism
- MS (*LOVDIP)
- extrapyrimidal diseases (usually caused by anti-psychotic drugs)
- essentilal tremor
- hyperthyroidism
*LOVDIP= Limb weakness/L’hermitte’s, Optic neuritis, Vertigo, Diplopia, Incontinence, Parasthesia
causes of postural tremors
- physiological- normal ppl + trigger (illness, fever, hyperthyroidism, ANXIETY)
- alcohol
- drugs
- Wilson’s disease (rare genetic disorder -XS Cu in brain/liver)
- essential tremor - + head tremor, FHx, improves with alcohol
- neurological disorders (dystonia- involuntary muscle contraction, parkinsonism, MS)
- heavy metal poisoning
Causes of physiological tremors
- alcohol withdrawal
- metabolic disturbances (hypoglycaemia, hyperthyroidism)
- drugs - amiodarone (antiarrythmic), antidepressants, beta receptor agonists, caffeine
- stress/ anxiety
causes of action/intention tremor
- cerebellar disease (other DANISH symptoms)
- MS
- tumours
- spinocerebellar degenerations
- vascular disease
*D-dysdiadokinesia,Ataxia, Nystagmus, Intention tremor, Slurred speech, Heel-shin test
Examination of tremors
Neuro exam - Tone, power, reflexes, sensation, coordination
Inspection
- mask-like (parkinsonian)
- hands outstretched palms up (intention tremor => cerebellar disorder)
- type of tremor (pill-rolling => parkinsonian)
Power
- rigidity + bradykinesia => parkinsonian
Coordination
- dysdiadokinesia (cerebellar disease)
- finger -nose pointing (cerebellar disease)
Cranial nerve exam (look for neurological disease)
- visual problems- loss/double vision (MS)
Investigations for tremors
*usually don’t need investigation
- trial stopping medication
Bloods:
- FBC
- U&Es- check for electroyte disturbance (Ca2+/Na+/K+)
- LFTs
- TFTs- check for hyperthyroidism
- blood/urinary copper levels - check for Wilson’s disease
Imaging
- CT/MRI head - check for neurological disease
Tremor worse when drinking tea
+ difficulty writing
+ head/neck/voice shaking
+ bettter with alcohol
Essential tremor
differentials for lower back pain
- cauda equina
- spinal stenosis
- fracture (trauma/ osteoarthritis)
- malignancy
- infection (osteomyelitis/ discitis)
- inflammatory back pain
serious conditions that can cause lower back pain (4)
- cauda equina syndrome
- spinal fracture
- cancer
- infection (discitis, vertebral osteomyelitis, spinal epidural abscess)
red flags of cauda equina syndrome (presenting with lower back pain)
- saddle anaesthesia
- bilateral neurological deficit of legs (motor weakness)
- recent fecal incontinence
- recent urinary retention/ incontinence
red flags of spinal fracture (presenting with lower back pain)
- sudden severe central spinal pain relieved by lying down
- history of major trauma
- structural deformity of spine
- tenderness over vertebral body
red flags of cancer (presenting with lower back pain)
- >50
- gradual onset of symptoms
- severe unremitting pain when upright, aching night pain, pain worsened by straining
- unexplained weight loss
- Hx of cancer
red flags of infection (presenting with lower back pain)
- fever
- TB/ UTI infection
- Diabetes
- IV Drug user
- HIV /immuncompromised
Questions to ask for back pain?
- SOCRATES (night pain?)
- sleep position
RED FLAGS (TUNAFISH)
- trauma
- unexplained weight loss
- neurological (incontinence)
- age
- fever
- inflammatory/ IV drugs
- Steroids
- Hx of cancer
- Examine gait, posture, skin changes, bruising, deformity, neck swelling
low back pain
+ night pain not relieved when supine
+ morning stiffness relieved by exercise
+ gradual symptoms
ankylosing spondylitis
low back pain
+non-specifc/ localised tenderness
+ risk factors: female, older, smoker, uses coricosteroids
osteoporosis
low back pain
+ unilateral pain
+ rash in distribution of dermatome
- Shingles (herpes zoster)
low back pain
+ unilateral leg pain (down to toes)
+ numbness/tingling, muscle weakness in a dermatome (nerve root compression)
sciatica
investigations for lower back pain
- generally just manage symptoms but if there is suspicion of specific pathology (compression fracture due to osteoporosis) do a spinal X-ray
management for back pain
- anti-inflammatory painkillers (ibuprofen, naproxen)
- hot/cold compression packs
- physiotherapy
- stretching/yoga to keep active
acute joint pain/swelling causes
single joint
- gout/ pseudogout
- traumatic synovitis (inflammation of joint lining)
- injury => haemoarthrosis (bleeding into joint space)
- osteomyelitis
- bursitis (inflammed bursa- shoulder,elbow,hip,knee, heel)
multiple joints:
- Rheumatoid arthritis
- Psoriatic arthitis (psoriasis + arthritis)
- reactive arthritis/ reiter’s (eye + urethra +joint inflammation)- triggered by infeciton
- viral infections => arthritis (viral hepatitis, rubella)
- connective tissue disorders (Lupus, scleroderma)
RARE but severe
- septic arthritis
sudden joint pain/swelling (usually big toe)
+ redness, tender (inflammation)
+ limited range of motion
PMHx: diabetes, kidney disease, obesity
FHx
SHx: high uric acid diet (red meat, sweet drinks), XS alcohol,
Gout
+ SEVERE joint pain
+ swollen, red, warm joint
+ fever
+ limping child
septic arthritis
swollen, tender joints (smaller joints affected first- fingers/toes)
+ warm joints
+ joint stiffness in morning/inactive periods
+ fatigue
+ fever
+ loss of appetite
PMHx: obesity
FHx:
SHx: smoking
Rheumatoid arthritis
causes of knee joint pain/swelling
traumatic
- ACL tear
- PCL tear
- MCL tear
- LCL tear
- patella dislocation
- traumatic meniscus
- unhappy triad - AC/MCL tear + cartillage damage
non-traumatic
- patello-femoral pain syndrome (PFPS)
- gout/pseudogout flare up
- patella tendinopathy
- osteoarthritis
+sudden knee pain
+ after sports injury (change in direction/ sudden deacceration)
+ swelling +instability
traumatic knee injury - ACL tear
+ acute kneecap pain
+ global swelling
+ clicking knee
+ after twisting of leg/ goalkeeper kick
+ RF: hypermobile, previous dislocation
patella dislocation
+ acute knee pain
+ delayed swelling
+ locked in knee
traumatic meniscus
Investigations for knee pain
- MRI (ligament tears, fractures)
causes of chronic joint pain/stiffness
- ageing
- osteoarthritis - wear + tear of cartillage
- Rheumatoid arthritis (inflammation of synovial membrane)
- ankylosing spondylitis (chronic back pain + early morning stiffness)
- lupus - autoimmune (malar rask, joint pain/stiffness/swelling)
- polymylagia rheumatica
chronic joint pain
+ early morning stiffness
+ reduced movement
+ tenderness, swollen joint
PMHx: obesity, diabetes, haematochromatosis, joint injuries
Osteoarthritis
joint pain/ stiffness/ swelling
+ malar rash
+ fatigue
+ fever
+ SOB/ chest pain
+ skin lesions worse on sun exposure
+fingers/toes turn blue when exposed to cold
Lupus
joint pain/stiffness. swelling (finger, toes, foot, lower back pain)
PMHx: psoriasis
psoriatic arthritis
+ pain/ stiffness in lower back or hips
+ worse in morning/ periods of inactivity
+ HLA-B27 gene
Ankylosing spondylitits
joint pain/stiffness (knees, ankles, feet)
+eye inflammation (conjuctivitis)
+ urinary problems (increased frequency)
+ rashes on soles/palms, mouth sores
+ swollen sausage fingers/toes
reactive arthritis
+ non-traumatic knee pain
+ gradual onset
+ started new intense gym routine
patello-femoral pain syndrome (PFPS)
Types of headaches
- Tension - tight band around head
- Migraines - throbbing pain + light sensitivity/aura
- Cluster - unilateral pain around eye
- Sinus - face/nose/ cheek pain + fever, runny nose
- drug side effects (nitrates, CCBs)
less common
- exercise induced (pulsing headache as blood flow increases to brain and swells)
- thunderclap
- rebound - medication overuse
- post traumatic
- carbon monoxide poisoning/anoxia
red flag symptoms for headaches
- thunderclalp headache (subarachnoid haemorrhage)
- red eyes and halos around lights (glaucoma)
- neurological symptoms
- fever, photophobia, neck stiffness (meningitis)
- >50
- FLAWs (malignancy)
- scalp tenderness in over 50s (gaint cell arteritis)
severe pain around eyes
+ 2-3 times a day
+ red/watery eyes, drooping and swelling of 1 eyelid, runny nostril, flushed face
+ restlessness
cluster headache
central tightness around head (dull aching)
+/- neck pain/ eye pain
+ triggers: stress, dehydration, squinting, missing meals, bright sunlight
tension headache
cheek, eye, face pain
+ fever, runny/blocked nose
sinus headache
severe throbbing unilateral headache
+ nausea
+ light sensitivity (headache better in dark rooms)
+ positive aura (flashing lights/zig-zags, numbness, dizziness)
migraine
headaches worse on lying down
+ early morning nausea
+ headache initiated by coughing/ straining/ exertion
+/- black spots in eyes (enlarged blind spots)
+/- cranial nerve VI palsy (no abduction)
raised ICP (could be due to primary tumour/ metastasis spread/ space-occupying lesion)
Investigation => fundoscopy (papilloedoma/optic disc swelling=> suggests raised ICP)
frontal + temple headache
+ scalp tenderness
+ eating causes jaw claudication
+ associated polymalgia rheumatica
temporal arteritis
sudden SEVERE occipital headache (thunderclap)
+ nausea
+/- mild photophobia
Subarachnoid haemorrhage
investigations for headache
- bloods + urinalysis - identify/eliminate underlying cause of headache, eg. thyroid, infection
- cranial nerve test - neurological signs
- fundoscopy - papilloedema/ optic disc swelling (raised ICP)
- Imaging: CT head, Brain MRI
Other:
- eye pressure test - glaucoma
- EEG - not standard, performed if suspected seizures
- spinal tap - infection of brain/spinal cord
causes of abdominal mass
- Cyst -ovarian (most common)
- Benign tumour (Fibroma/Lipoma)
- Cancer (gastric, liver, colon, kidney)
- inflamed lymph node
- Pancreatic abscess
- Hepatomegaly
- Splenomegaly
- Crohn’s
- AAA
- hydronephrosis (swollen kidneys due to blockage)
- Hernia (due to chronic straining)
lower abdominal mass
+ female
+ tender
+ mobile
Cysts (ovarian)
abdominal mass
+ FLAWs (fever, lethargy, appetitie loss, weight loss)
+ FIRM, hard, painless lump
cancer
UQ abdominal mass
+ fever
+ pain
pancreatic abscess
umbilical abdominal mass
+sharp pain radiating to back/behind belly button
AAA
abdominal mass
+ pain in flanks
+ fever
+ nausea
hydronephrosis
abdominal mass
+ persistant diarhoea
+ rectal bleeding
+ weight loss
+ fatigue
+ crampy abdominal pain (after eating)
Crohn’s
types of hernias + locations
- epigastric
- umbilical
- incisional (where a previous incision was made)
- spigelian (hernia through tissue that separates rectus and lateral obliques)
- femoral (medial + inferior to pubic symphysis)
- inguinal (lateral + superior to pubic symphysis)
Investigations for abdominal mas
Bloods:
- hormone levels (ovarian cyst)
Imaging:
- US (ovarian cyst)
- colonoscopy (Crohn’s)
- Angiogram (AAA)
differentials for RIF mass
- Crohn’s disease
- Appendix mass or abscess
- Caecal carcinoma,
- Ovarian or renal mass,
- TB, Actinomycosis or amoebic abscess
causes of fatigue
Physiological:
- pregnancy
- XS exercise
- breast feeding
- lack of sleep
Physical:
- anaemia
- diabetes mellitus
- malignancy
- hypothyroidism
- chronic illness (COPD, HF, liver failure)
- glandular fever
- Vitamin D/B12 + folate deficiency
- Obstructuve sleep apnoea/ obesity
- Chronic fatigue syndrome (doesn’t improve with rest)
Psychological:
- depression
- stress/ anxiety
- loss
Hx for fatigue
HPC:
- onset (sudden= infection/toxins, gradual = chronic illness, anaemia, metabolic)
- severity
- triggers (worse in morning = depression)
- urinary symptoms-polydypsia, nocturia, polyuria (DM)
- weight loss (malignancy, DM, addison’s)
- FLAWs (malignancy)
- joint pain/stiffness (RA)
FHx:
- diabetes
- cancers
DHx:
- medication
SHx:
- smoking, alcohol, recreational drugs
- mood (depression)
- sleep (quantity, pattern)
- occupation (shift workers => tired)
- exercise
investigations for fatigue
Bedside:
- Obs/BP, blood glucose, pregnancy test
Bloods:
- FBC (anaemia/ blood cancer)
- ferritin (anaemia)
- HbA1c (diabetes)
- ESR/CRP - inflammation
- U&Es (renal disease)
- LFTs (liver disease)
- Vit D/ vitamin B12 + folate
Management of fatigue
- improve sleep hygiene (avoid screens)
Treat underlying cause
- diabetes mangement (weight loss, diet, metformin)
- iron supplements
- levothyroxine
causes of polydypsia (thirst)
- Diabetes mellitus
- Diabetes insipidus
- drugs (corticosteroids/ diuretics)
- psychogenic polydypsia (XS thirst => polyuria/nocturia)
- schizophrenia
- mood disorders (depression)
- anorexia
Hx for polydypsia
HPC:
- onset
- associated symptoms: nocturia, polyuria, fatigue, weight loss/gain, vision changes, frequent slow healing sores
- any recent head trauma
PMHx:
- mental illness (depression, schizophrenia)
- diabetes
DHx:
- diuretics / corticosteroids => increase thirst
FHx:
- diabetes
SHx:
- diet (high salt)
- exercise
- smoking, alcohol
Investigations for polydypsia
Bedside:
- OBS: bp
- blood glucose
- water deprivation test (check for DI + add desmopressin to differentiate between cranial and nephrogenic)
Bloods:
- HbA1c
- FBC
- U&Es (check for renal dysfunction)
Hx for rectal prolapse
HPC:
- when? how long?
- what triggers it to prolapse? going to toilet/ sneezing, coughing/ movement
- has it changed?
- had it before?
- Other symptoms? pain, fecal incontinence, rectal bleeding, mucus discharge
- any bleeding? colour? on wiping/ mixed in with stool?
- RED FLAGS: change in bowel habit, appetite, weight loss, night sweats, lethargy, fever
Define rectal prolapse and it’s risk factors
protrusion of rectal mucosa +/- whole rectum wall
Risk factors:
- elderly females
- raised abdominal pressure (chronic constipation/ straining, diarrhoea, pregnancy)
- previous surgery
- pelvic floor dysfunction
- neurological disorders
- children: CF, Hirshprung’s
Examination + Investigations for rectal prolpase
Exam:
- DRE - concentric rectal mucosa +/- decreased anal tone
Investigations:
- stool MC&S - exclude infection
- barium enema/ colonosocpy - look for other lesions
causes of red eye
- conjuctivitis
- episcleritis/ scleritis
- acute glaucoma
- anterior uveitis
- corneal ulcer
- trauma
- chemicals
Hx taking for red eye
HPC:
- site- one/both eyes
- pain
- itching
- discharge (watery/ pus-like)
- photophobia (cornea affected)
- vision loss
- foreign body sensation
- recent trauma
- associated symptoms: headache, nausea
- wear contact lenses?
red eye
+ painful
+ uncontrolled hypertension/ trauma/ idiopathic
subconjuctival haemorrhage
red eye
episcleritis
*scleritis = more redness + more pain
PAINFUL red eye
+ photophobia
+ halos around light
acute glaucoma
painful red eye
+ irregular pupil size
+ photophobia
+ cloudy vision
uveitis
red eye
+ itching
+ pus-like discharge/watery discharge
- bacterial conjuctivtis = redness, dryness, pus-like discharge
- viral conjuctivitis = redness, itching, watery discharge
- allergic conjuctivitis = redness, itching, swelling of eyelid + conjuctiva
common causes of dizziness
- Inner issues causing vertigo (BPPV, meniere’s, infection, migraine)
- orthostatic hypotension
- poor circulation (cardiac arrythmias, TIA, heart attacks, cardiomyopathies)
- neurological (multiple sclerosis, Parkinson’s)
- medications (anti-seizure drugs, antidepressants, sedatives and tranquilizers, antihypertensives)
- anxiety
- anaemia
- overheating/ dehydration
Types of dizziness
- vertigo = spinning sensation
- lightheaded
- unbalanced
- woozy sensation
History taking for dizziness
HPC:
- onset (sudden)
- duration
- timing (episodic/ continuous)
- triggers (head position)
- auditory symptoms (hearing loss, tinitus, aural pressure)
- visual changes (blurry vision, double vision)
PMHx: (could also cause dizziness)
- diabetes (hypoglycaemic episodes)
- MS
- migraines
- connective tissue disorders
- SLE
- previous head trauma/ surgery
DHx:
- aminoglycoside antibiotics => ototoxicity
- recreational drugs
- alcohol
- anaesthetics
- anti-arrythmic drugs
FHx:
- migraines
SHx:
- CVD risk factors (smoking, alcohol, hypertesion=> high salt/cholesterol diet)
Assessment of dizziness
Bedside: BP
Bloods:
- FBC
- blood glucose
HINTS
- Head impulse test (turn head quickly and keep eyes fixed on object)=> +ve (catchup-saccade = peripheral vestibular lesion
- Check for Nystagmus => vestibular neuritis/central causes (spontaneous horizontal nystagmus/away from lesion)
- Skew (cover eye, if misaligned and eye moves after uncovering = +ve test)-
Ear
- otoscopy- crust in upper middle ear = cholesteatoma
- Weber’s (512Hz fork on forehead and which ear sound is louder) -hear in affected ear (conductive-middle ear), in unaffected (sensorineural-inner ear)
- Rinne’s (fork on mastoid, then by ear)- louder on mastoid = conductive, louder in air (normal/sensorineural)
- pure tone audiogram (check for hearing loss)
Eye
- eye movements (opthalmoplegia with CN palsy =MS, diplopia/Horner’s => central lesion
- Fundoscopy - papilloedema (intracranial hypetension)
- Visual acuity test
Balance
- dix-hallpike maneouver (patient lies flat, rotates head 45 right, then head on right ear - checks for nystagmus)- BPPV
Neuro exam
- Facial nerve palsy => tumours, cholesteatoma, granulomatosis with polyangitis
- Dysarthria (posterior circulation stroke/ vertebral artery dissection)
- Facial numbness = posterior circulation stroke
Cardio exam
- irregular pulse = arythmias
- postural hypotension
- ECG
Imaging:
- CT brain/ temporal bones
- MRI of internal auditory meatus and brain
dizziness triggered by standing up too quickly
- orthostatic hypotension
- pre-syncope
- dizziness
- altered gait, weakness, nystagmus, opathalmoplegia
Multiple sclerosis
Management of dizziness
Acutely
- Sit/ lie down immediately in a darkened room
- treat cause
Long term advice:
- Avoid driving a car or operating heavy machinery
- Avoid using caffeine, alcohol, salt and tobacco
common causes of vertigo (spinning sensation)
Peripheral:(more common)
- BPPV (otolith in semicircular canals)
- Menieres disease (disorder of inner ear)
- ear infection
- vestibular neuritis (inflammation of vestibular nerve)
- labrynthitis (inflammation of inner ear +/- CN VIII)
- acoustic neuroma
Central:
- stroke
- TIA
- cerebellar tumour
- Multiple sclerosis
RED flags for vertigo (5D’s)- suggest central cause
- prolonged, severe vertigo
- new-onset headache or recent trauma
- focal neurological signs and symptoms
- central-type nystagmus
- an abnormal response to the Dix-Hallpike manoeuvre
- inability to stand up or walk even with the eyes open
- diplopia (double vision)
- dysmetria (can’t do smooth coordinated movements as can’t judge distance)
- dysphonia (hoarse voice)
- dysphagia
- Dysarthria (difficulty speaking)
- episodic vertigo
- triggered by head movement (bending down, turning head)
- relieved on head rest
- lasts seconds
BPPV
- episodic vertigo
- hearing loss
- tinitus
- aural fullness
- lasts minutes/hours
Meniere’s disease
episodic vertigo
+URTI
+ no tinitus/ hearing loss
vestibular neuritis
- continuous vertigo lasting hours-days
- hearing loss, tinitus
- caused by upper respiratory tract infection (fever)
- triggered by head movement but also present at rest
- associated with otitis media (ear pain, ear disharge)
labrynthitis
Hx taking for vertigo
HPC:
- spinning sensation
- onset
- duration
- triggers- on head movements, when standing, at rest
associated symptoms:
- changes to hearing, tinitus, fullness, discharge
- fevers
- changes to vision (diplopia, blurry vision)
- headaches
- nausea
RED FLAGS
PMHx:
DHx: ototoxic drugs (NSAIDs, chemo, antibiotics, loop diuretics)
FHx: strokes
Examination for vertigo
- facial asymmetry
- ear exam - inspect external ear, test hearing, rinnes + weber, otoscope (wax, foreign body, redness, bulging TM, cone of light, fluid)
- testing of cranial nerves and cerebellar function
- eye exam
- checking for signs of peripheral neuropathy
- abnormal gait
Special tests:
- Romberg’s test
- Dix-Hallpike manoeuvre
- the head impulse test
- Unterberger’s test
- alternate cover test
causes of lower GI bleeding
- vascular- angiodysplasia
- inflammation- IBD
- infection- infectious colitis
- cancer- colorectal, anal
- rectum- anal fissures, haemorrhoids
- bowel - diverticular disease, colonic polyps, Meckel’s diverticulum
Hx taking for lower GI bleeding
HPC:
- onset, colour, on wiping/mixed with stool
- recent fevers - infection
- recent travel - infectious colitis
- FLAWS- cancer
- changes in bowel habit- cancer, IBD
- constipation, low fibre diet, straining => anal fissure, haemorrhoids
PMHx: colitis, colonic polyps
DHx: anticoagulants (increased bleeding)
FHx: bowel cancers
Investigations for lower GI bleeding
Stool MC&S
- infectious colitis
- faecal calprotectin - IBD
Bloods:
- FBC, iron studies (check for iron deficiency anaemia)
- ESR- infectious colitis
- CRP- inflammation
qFIT test - check for cancer
Imaging:
- colonoscopy/ sigmoidoscopy - IBD, diverticular disease
Red flag symptoms associated with lower GI bleeding => 2WW referral
- unintentional weight loss
- iron deficiency anaemia
- change in bowel habit (increased diarrhoea)
- abdominal/rectal mass
- fever, lethargy, loss of appetite, night sweats (FLAwS)
- positive/raised qFIT
Causes of upper dysphagia
Structural:
- pharyngeal pouch
Neurological:
- Parkinson’s
- MS
- myasthenia gravis
- Stroke
- motor neuron disease
causes of lower dysphagia (swallowing problems)
Obstructive:
- oesophageal/gastric carcinoma
- GORD + peptic strictures
- oesophagitis
- foreign body
- Shatzki rings
Neurologcal:
- achalasia
- oesophageal spasm
investigations for dysphagia
Bloods:
- FBC
- LFTs
- ESR/CRP
Imaging:
- OGD
- CT with oral contrast (check for perforation)
- Barium swallow
complications of dysphagia
- malnutrition
- aspiration pneumonia
- oesophageal perforation (iatrogenic)
progressive difficulty swallowing solids => liquids
+ weight loss, loss of appetite, night sweats, lethargy
oseophageal/ gastric carcinoma
difficulty swallowing solids, but normal swallowing fluids
+/- Hx of GORD
peptic stricture
dysphagia
+ difficulty swallowing solids = liquids
- achalasia
- neurological disorders
- very narrow lumen
dysphagia
+ neck bulges/ gurgles on drinking
pharyngeal pouch
causes of odynophagia
- ingestion
- pill-induced esophagitis
- radiation injury
- infectious esophagitis (Candida, herpesvirus, and cytomegalovirus)
Hx taking for falls
Before:
- onset? happened before?
- triggers
- recent head trauma/ infections
- new medication
- associated symptoms
- CARDIO- SOB, palpitations, chest pain, exercise induced
- NEURO- headaches, vertigo, nausea, photophobia
- EAR - tinitus, hearing problems
During:
- witnesses?
- loss of consciousness (blackout)
- duration?
- epilepsy symptoms (tongue biting, jerking, incontinence)
After;
- recovery time?
- tired/confused atfter (epilepsy)
- injury to hips/neck/spine (fractures) =>CT
- support at home/ ADLs
- PMHx-
- FHx- sudden cardiac death
- DHx- antihypertensives
Causes of falls
- weak muscles (polymylagia rheumatica, arthritis)
- poor balance (stroke, parkinson’s)
- dizziness/lightheaded (dehydration, postural hypotension, inner ear problems- labrynthitis, menieres, BPPV)
- blackouts/faints
- medication side effects (antihypertensives, antiepileptics, antidepressants)
- ageing related vision/hearing problems (cataracts,glaucoma)
- dementia / confusion
- INFECTION
- CONSTIPATION
- DEHYDRATION
Classification of blackouts
- syncope (true loss of conscioussness) - caused by hypoperfusion
- non-syncope
causes of syncope (loss of consciousness)
reflex (activation of primitive reflex when faced with danger)
- HR slows,BP drops, reduced cerebral perfusion
- vasovagal syncope
- carotid sinus hypersensitivity
- situational syncope
cardiac (reduction in cardiac output)
- arrhythmias
- structural cardiac pathology + outflow obstruction
orthostatic hypotension
- drugs (anti-HTNs, anti-sympathetics)
- dehydration
- autonomic instability
- baroreceptor dysfunction
cerebrovascular (non cardiac causes of reduced cerebral perfusion)
- vertebrobasilar insufficiency
- subclavian steal
- aortic dissection
causes of non-syncope falls
- intoxication
- head trauma
- metabolic
- psychogenic/epileptic seizure
- epilepsy
Hx for blackouts
before:
- Onset? Happened before?
- Recent infections
- Recent head trauma
- Risk factors for fragility (osteoporosis, elderly)
- Triggers (head movement)/ relieving factors
Associated symptoms:
- vertigo, dizziness
- SOB, palpitations, chest pain, triggered by exercise (Cardio)
- Headaches, nausea, photophobia (Neuro)
- Hearing affected, tinnitus, aural fullness
during:
- Any witness?
- duration?
- Loss of consciousness?
- Memory loss
- Nausea, SOB, palpitations
- Tongue biting, incontinence, head turning, prodrome (SEIZURE)
after:
- how long to recover?
- tired after(neuro-post seizure)
- Bruising, lucid interval
- Any head/neck/hip injuries => go for CT scans
PMHx:
- has it happened before?
- diabetes?
- cardiac illness?
- PVD?
- epilepsy?
- anaemia?
- psychiatric illness?
FHx:
- congenital heart problems
- sudden cardiac death <40
DHx:
- New medication
- insulin/oral hypoglycaemics
- anti-HTN
- vasodilators
- anti-arrhythmics
- antidepressants
- anticoagulants
examination findings for blackouts
- Basic obs + postural bp
- Cardio exam- slow/irregular pulse, heart murmur, carotid bruits
- Neuro exam- bitten tongue, focal neurological signs
investigations for patient presenting with loss of consciousness
bloods
- capillary blood glucose
- FBC
- U&Es
Other
- ECG-arrythmias
- echocardiogram
- carotid sinus massage
- CT brain
*EEG not NICE recommended because of low specificity and risk of false positive
features of a blackout due to vasovagal syncope
- short lived
- posture - prolonged standing
- prodrome- sweating, feeling hot, pale
- provoking factors - pain/medical procedure
- most common cause of blackouts in young adults
features of a blackout due to cardiac cause
- SOB, chest pain, palpitations before blackout
- without warning, during exercise
- FHx: of sudden cardiac death <40
- quick recovery
- common cause of blackouts in >55s (secondary to IHD)
features of a blackout caused by epilepsy/seizure
- tongue biting, incontinence, jerking, deja vu
- after blackout feels very tired/ confused
features of blackouts that indicate severe central neurological cause
- prolonged/severe vertigo
- new onset headache
- focal neurological signs: numbness, weakness, vision changes, nerve palsies
- personality/behaviour change
- DANISH (dysdiadokinesia,ataxia, NYSTAGMUS, intention tremor,slurred speech, hypotonia)- cerebellar stroke/tumour
features of blackouts caused by orthostatic hypotension
- common in >80s
- SBP difference >20 on standing
- lightheaded/ dizzy on standing up quickly
- new medication
- diuretics
- anti-hypertensives (ACE inhibitors, BB, CCBs, alpha blockers)
*significant morbidity
- fractures
- loss of confidence
- loss of independence
*mortality
- head injuries
- venous thromboembolic disease/infection due to prolonged bed rest after a fall
stokes-adams attacks
AKA cardiogenic syncope
sudden transient loss of consciousness
induced by slow/absent pulse and subsequent loss of cardiac output
underlying cause:
- third degree heart block
- sinoatrial disease
not associated with change in posture or trigger
typically last seconds
twitching may occur if > 15-20s
- due to cerebral anoxia
types of urinary symptoms
- haematuria
- oliguria
- incontinence
- polyuria
- nocturia
- proteinuria (severe => frothy urine)
causes of polyuria
- diabetes mellitus
- diabetes insipidus
- pregnancy
- kidney/liver failure
- anxiety
- alcohol, caffeine
- Cushing’s syndrome (XS cortisol)
- medications
- diuretics
- CCBs
- SSRIs
- tetracyclines
- lithium => nephrogenic DI
causes of nocturia
- increased fluids before bed - alcohol, caffeine
- medication before bed (diuretics, CCBs, lithium)
- diabetes
- bladder problems (obstruction, cystitis)
- prostate problems (BPH, tumour)
- sleep problems (sleep apnoea, insomnia)
- restless leg syndrome
- pregnancy / childbirth
- menopause
causes of proteinuria
Common:
- Diabetes
- Dehydration
- Inflammation
- Low blood pressure
- Fever
- Intense activity
- High stress
- Kidney stones
- Taking aspirin every day
- Very low temperatures
Serious:
- Immune disorders such as lupus
- Kidney inflammation (glomerulonephritis)
- A blood cancer called multiple myeloma
- Preeclampsia, which affects pregnant women
- A buildup of protein in your organs (amyloidosis)
- Cardiovascular disease
- Intravascular hemolysis, a condition in which red blood cells are destroyed
- Kidney cancer
- Heart failure
Investigations for urinary symptoms
- Urinalysis + MC&S- blood, infection
- Bloods: FBC (anaemia), HbA1c (diabetes), U&Es, LFTs, cholesterol
- Bladder scan
- Cytoscopy
causes of haematuria
urological (upper + lower tract)
- infection: pyelonephritis, prostatitis, cystitis
- malignancy: prostate, bladder, kidney
- urinary stone disease
- trauma + recent surgery
- parasite - schistosomiasis
non-urological (medical, pseudohaematuria)
investigations for haematuria
- urinalysis (nitrates, PSA, leukocytes)
- urine culture (checks for infection)
- flexible cytoscopy (looks inside bladder/urethra)
- urine cytology (check for abnormal cells)
- CT urogram scan
types of haematuria
- visible
- non-visible (blood is present only on urinalysis)
=> symptomatic (suprapubic pain/ renal colic)
=> asymptomatic
total haematuria
damage to bladder/ ureter/ kidneys
terminal haematuria
severe bladder irritation
pink visible haematuria + not painful
+ industrial carcinogen exposure/ smoking history
bladder cancer
RED FLAG
foreign travel + haematuria
schistosomiasis
nitrates +/- leukocytes on urinalysis + haematuria
infection
visible/ microscopic haematuria
+ difficulty urinating
+ frequency
+ urgency
+ nocturia
+ dysuria (pain)
+ incontinence
+positive PSA test
- prostate involvement (BPH, prostatitis)
high albumin: creatinine ratio + haematuria
renal failure
visible haematuria
+ dysuria (painful to pee)
+ burning sensatin
+ cloudy, smelly pee
+ frequent urination
+ urgency (urge to pee after peeing)
UTI
gross haematuria (30%)
+ fever
+ costovertebral angle pain
+ nausea/vomiting
acute pyelonephritis
define oligouria
- reduced urine output
- <400ml/day in adults, <0.5ml/kg/hr in kids
causes of oligouria
- dehydration (burns, blood loss, vomiting/diarrhoea)
- medications (NSAIDs, antibiotics, chemotherapy, )
- obstruction (stones, tumour, scar tissue, enlarged prostate)
- INFECTION/ SHOCK
- AKI
investigations for oligouria
- urine dip (haematuria-obstruction, proteinuria-AKI)
- urine culture MC&S (infection)
Bloods:
- FBC (infection)
- U&Es
Imaging:
- US/CT of kidneys (CKD/ stones)
types of urinary incontinence
- stress incotinence- pressure on bladder (exercise, coughing, sneezing)
- urge incontinence- increased need to go (infection, diabetes, neurological disease)
- overflow- dribbling as bladder doesn’t empty fully
- functional incotinence- physical/mental impairment => can’t get to toilet quickly enough e.g. arthritis- unbutton
- mixed (stress + urge)
causes of incontinence
Overflow
- obstruction- stones
- BPH/prostate cancer
Stress
- pregnancy/ childbirth
- hysterectomy surgery damage nerves/bladder
- coughing, sneezing, constipation, straining
- OBESITY
- eldery
Urge
- infection (UTI)
- cystitis
- alcohol/caffeine
- Neurological
- MS
- Parkinson’s
- stroke
- brain/spinal injury (cauda equina syndrome)
OTHER:
- medication (ACE-inhibitors, diuretics, antidepressants, sedatives, HRT)
Investigations for urinary incontinence
- urinalysis (check for UTI)
- bladder diary
- post-voidal residual volume (check for overflow incontinence)
If considering surgery:
- Urodynamic testing
- pelvic US
causes of weight loss
- MALIGNANCY (FLAWS)- leukaemia, lymphoma, myeloma, sarcoma, carcinoma
- psychological
- DEPRESSION/stress/anxiety
- anorexia
- endocrine
- hyperthyroidism
- T1DM
- addison’s
- reduced appetite- dysphagia (achalasia), medication
- parasitic infections
- malabsorption
- Coeliac
- Crohn’s
- chronic pancreatitis
4.
Investigations for weight loss
Bloods:
- FBC - anaemia/infection/malignancy/malabsorption
- ESR/CRP- inflammation
- TFTs - hyperthyroidism
- U&Es- CKD, addison’s (low Na+/high K+)
- LFTs/ clotting screen- liver metastasis
- anti-TTG - coeliac disease
Imaging
- CXR - malignancy/ TB
progressive weight loss
+ heat intolerance
+ oligoamenorrhoea
+tremors, sweating, palpitations
+ proptosis
hyperthyroidism (Graves)
1yr progressive weight loss
+ BMI <17.5
+ distorted perception of body image
Anorexia
3 month weight loss
+ loss of appetite
+ hepatomegaly + jaundice
+ heavy alcohol drinker
IX: high alfa-fetoprotein, liver US
- hepatocellular carcinoma
- liver metastasis
progressive weight loss
+ pain in shoulder
+ Horners (ptosis, myois, anhydrosis)
+ hoarse voice (compressed recurrent laryngeal nerve)
+ CXR - consolidation in apices
Pancoast tumour (lung carcinoma)
progressive weight loss
+ 1yr progressive dysphagia (solids + liquids)
+ reccurent infections
+ CXR - dilated oeosphagus, lower lobe consolidation (aspiration)
achalsia
causes of bruising
- non-accidental (abuse)
- accidental trauma
Easy bruising
- vascular disorders (senile purpura/ simple purpura)
- clotting disorders (haemophillia, Von willebrand disorder, vitamin K deficiency)
- platelet disorders (leukaemia, ITP, liver disease, Henoch-Schlonlein purpura/systemic vasculitis)
- drugs
- corticosteroids
- anticoagulants- heparin, warfarin, apixaban/rivaroxiban
- anti-platelets- aspirin, clopidogrel
- low platelets -alcohol
Other:
- Endocrine - hypothyroidism (weight gain, delayed wound healing), Cushings (obesity, striae, moon face, muscle weakness)
assessment for bruising
Hx:
- easily bruise?
- associated heavy periods, nose bleeds, gum bleeds (clotting disorder)
- recent trauma
- PMHx, DHx
- FHx of clotting problems, connective tissue disorders,
- alcohol Hx
- malnutrition
Ix
- FBC- leukaemia, ITP
- blood film
- clotting screen
- LFTs - liver disease
- U&Es- renal disease
- TFTs -hyperthyroidism
Red flags for brusing
- abuse (v. large, in children who aren’t mobile yet, multiple clusters, hand print)
- FLAWS- cancer
+delayed bruising
+ prolonged bleeding
+ swelling/ painful joints (haemarthrosis)
+ FHx
haemophillia
+ increased brusing
+ jaundice
+ ascites, caput medusa, spider nevi
chronic liver disease
easy bruising
+ stretchy/transparent skin
+ FHx
Ehrler’s Danos
increased bruising
+ fatigue (anaemia)
+ recurrent infections (neutropenia)
leukaemia
myeloma (bone pain)
easy bruising
+menorrhagia
+ sudden onset petechiae
+ nose bleeds
ITP
groin lump may represent …
psoas sheath
femoral nerve neuroma
femoral artery aneurysm
femoral vein/long saphenous vein dilation
lymphadenopathy
inguinal/femoral hernia
testicular: ectopic testis, undescended testis, hydrocele of cord
lipoma
abscess
sebaceous cyst
questions to ask about a groin lump
how long has it been there?
is it always there?
is it reducible?
has it changed in size?
is it painful?
are there any other lumps?
femoral pseudoaneurysm may develop after …
angioplasty
heavy lifting may lead to…
inguinal hernia
define saphena varix
saphenous vein dilation due to incompetence at sapheno-femoral junction
what can cause a saphena varix to change in size
increase: standing for long periods of time
decrease: lying down
rapid change in size of groin lump suggests…
infective process
- psoas abscess
- lymphadenopathy
painful groin lump suggests…
strangulated hernia
groin abscess
femoral pseudoaneurysm
can inguinal hernias be bilateral?
yes
questions to ask if you suspect a hernia
- abdominal pain?
- risk of bowel obstruction and strangulation - things that increase intra-abdominal pressure?
- straining at stool
- chronic cough
- heavy lifting - prior surgery in groin?
- can predispose to incisional hernias
questions if you suspect infection/malignancy
- trauma or infection in LL/groin?
- anal/scrotal/skin symtpoms?
- fever?
- weight loss, night sweats, pruritus?
lymphoma: fever, pruritus
palpation of groin lump
- site - anatomical region, tissue layer, extension beyond scrotum
- size?
- tender and/or warm?
- solid or fluctuant?
- pulsatile?
- cough impulse?
- reducible? direction of reducibility?
site of saphena varix
over sapheno-femoral joint
sites of hernias
neck of swelling
superomedial to pubic tubercle = inguinal
inferolateral to pubic tubercle = femoral
lump extending into scrotum suggests
indirect inguinal hernia
Causes of breast pain
- Normal period pain (cyclic - dull aching pain with period radiates to arm)
- infection (mastitis)
- hormonal changes
- trauma
- previous breast surgery
- Fibrocystic breast disease (common - painful lumps in breast)
- large breasts (non-cyclic tight, burning pain => back/shoulder/neck pain)
- poorly fitted bra
- breast cysts (fibro
- extramammory - costochondritis-pain from ribs spreads to breast
Hx taking for breast pain
HPC:
- Site
- onset
- radiation
- associated symptoms - tenderness, discharge, skin changes, lumps, fevers
- breast feeding ?
- when was last period/ is pain related to menstrual cycle
- recent trauma
- menopause
DHx:
- any new HRT
FHx:
- Breast problems
- breast/ ovarian cancer
differentials for a breast lump
common
- fibroadenoma
- cyst
- invasive breast cancer
- DCIS (ductal carcinoma in situ)
- papilloma
- fact necrosis
- breast abscess
uncommon
- phyllodes tumour
- adenoma
Hx taking for breast lump
HPC:
- site
- onset
- associated symptoms: skin changes (peau d’orange), pain, nipple discharge, nipple inversion
- changing in size
- when was last period/ irregular or regular
- have any children? breastfeeding? for how long? (protective 2yrs)
PMHx:
- ovarian cancer
FHx:
- breast/ovarian cancer (BRACA genes)
Assessment of breast lump
Examination
- inspect breasts (assymetry/ skin changes (peau d’orange/dimpling) / nipple inversion/discharge)
- check if lump is mobile (hands on hips, bend down)
- check lump site/size/shape/smoothness (clockface)
- check lymph nodes (in armpit, in neck)
US/ mammogram (>35)
Biopsy - confirm diagnosis
+ smooth, rubbery lump
+ mobile
+ <40
+ US: solid, oval lump/ mammogram: oval lump with calcifications
fibroadenoma
+ rubbery, well-defined lump
+ mobile
+ breast pain/ fluctuates with period
+ US: sharp borders, no echoes
fibrocystic breast
+ hard, fixed mass
+ nipple inversion/ discharge
+ skin changes: peau d’orange, skin dimpling
+ lymphadenopathy
+ FHx of breast cancer
+ mammogram: irregular shape, calcifications
+ biopsy: hyperchromatic nuclei cells invading stroma
invasive breast cancer
+ breast lump may/may not be present
+ usually asymptomatic
+/- nipple discharge, cracking skin (Paget’s disease)
+ mammogram: microcalcifications
DCIS
+ large well-defined breast mass
+ 40-60yrs
+ recent/rapid breast enlargement
Phyllodes tumour
+ small lump
+ bloody nipple discharge
intraductal papilloma
types of nipple discharge
- clear
- yellow- infection
- milky - pregnancy/ galactorrhea
- bloody- intraductal papilloma
causes of nipple discharge
- breastfeeding/pregnancy
- blocked/enlarged milk duct
- breast infection (mastitis)
- side effect of medication - OCP
- small-non cancerous lump of breast
- breast cancer (DCIS, papilloma, invasive carcinoma)
unilateral, spontaneous discharge
+ mass
+ skin changes
breast cancer (most common = intraductal papilloma)
