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
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
causes of haemoptysis
- Chronic lung disease: TB, bronchiectasis, cystic fibrosis, COPD
- Bleeding disorders
- Pulmonary embolism
- Malignancy -LUNG CANCER
- Heart failure
- Pulmonary renal syndrome
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)
management of cardiac arrest
- ABC + CPR
- pulse/rhythm check
VF/VT
- defibrillate
- amiodarone if refractory
- epinephrine (adrenaline)
Asystole (pulseless)
- epinephrine (adrenaline)
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
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
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)
hearing loss
+ smelly ear discharge
+ vertigo/ facial nerve palsy (with local invasion)
cholesteatoma
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
difficulty walking
+ resting tremors (pill-rolling)
+ rigidity
+ akinesia (bradykinesia)
+postural instability (falls)
+ small handwriting / shuffling gait
+ hypomimic face
Parkinson’s
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
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
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)
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)
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
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
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
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
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
