Presenting symptoms Flashcards
Amaenia (general)
Def: Haemoglobin conc. <135g/L in men and <115g/L in women. Due to decreased production or increased destruction
Symptoms: Fatigue SOB Faintness Palpatations (plus angina if there is previous IHD) Headaches Anorexia
Signs:
Pallor
Hyperdynamic circulation - tachycardia, flow murmur (ejection-systolic over apex), cardiac enlargement
Types - look at MCV (normally 76-96fL)
Low MCV = microcytic
1) Iron def.
2) Thalasaemia (particularly if MCV is too low for the Hb value and RBC count is raised)
3) Sideroblastic (v.rare)
NB 2&3 will show accumulation of iron (increase serum iron and ferritin and low total iron binding cap TIBC)
Normal MCV = normocytic
1) Acute blood loss
2) Chronic anaemia (or \ MCV)
3) Bone marrow failure
4) Renal failure
5) Hyperthyroidism (or / MCV)
6) Haemolysis (or / MCV)
7) Pregnancy
High MCV = macrocytic
1) B12 or folate deficiency
2) Alcohol excess/liver disease
3) Reticulocytosis (increase in immature RBCs)
4) Cytotoxics (e.g. hydroxycarbamides)
5) Myelodysplastic syndromes
6) Marrow infiltration
7) Hypothyroidism
8) Anti-folate drugs (e.g. phenyltoin)
Others
Haemolytic anaemias - suspect if there is >2% of reticulocytes, mild rmacrocytosis, increased bilirubin
Considerations
Cause
Onset - is it chronic or acute?
If transfusion is indicated (acute, severe or HF)
Give it slowly
With 10-40mg Furosemide
If HF check for signs of overload - JVP, bibasal creps
Chest pain
Causes Cardiovascular Angina Aortic Aneurysm dissection Myocardial infarction Myocarditis Pericarditis
Respiratory Pleurisy Pneumonia Pneumothorax Pulmonary Embolus
Other
Anxiety
Musculoskeletal
Oesophagitis
Cyanosis
Def: Dusky blue skin (peripherally) or mucosae (central), which represents 50g/L of Hb in its reduced form
NB Limitions
it is a clinical description
it is not necessarily indicative of hypoxia (e.g. in anaemia there will be less Hb in reduced form)
Causes: Lung disease - inadequate O2 transfer. E.g. luminal obstruction asthma COPD pneumonia PE pulmonary oedema
Therefore may be corrected by inspiring O2
Congenital Cyanotic Heart Disease
E.g.
Transposition of the great arteries
Right to left shunt
Rare
Methaemoglobinaemia (usually drug induced e.g.sulphonamides, nitrites)
Peripherally it can occur in cold, hypovolaemia, arterial disease
Combination is possible is LHF
Faecal incontinence
Common in the elderly
Often multifactorial
?Passive or urgency-related
Causes:
Sphincter dysfunction - vaginal delivery leading to tear of sphincter or pudendal nerves. Surgical trauma
Impaired sensation - diabetes, Ms, dementia, spinal cord lesions
Faecal impaction - overflow
Idiopathic
Assessment
Per rectum examination
Assess neurological function
Management
Make sure toilet is in easy reach
Pelvic floor rehab
Loperamide 2-4mg
Sepsis
Life-threatening organ dysfunction caused by dysregulated host response to infeciton
UK mortality 37,000/y
Septic shock: when combined with -
1) Lactate >2mM
2) Patient requiring vasopressors to maintain MAP >65mmHg
Assessment - high NEWS score, but be extra conscious for patients with:
1) Communication difficulties
2) Immunosuppressed
3) Recent surgery or pregnant
4) Indwelling lines
In general: Altered mental state RR 21-24 (or greater) SysBP 91-100 HR >90 Urine output - nil for >12h Local signs of infection (4 cardinal signs) Rigors or temp <36 Feeling awful
Consider
ABCDE
6
Give:
Abx - broad spec within one hour
IV Fluids - 500ml boluses of crystalloids (normal saline or Hartman’s) over 15mins, with 1h (NB caution HF)
High-flow Oxygen - to achieve >94% (or 88%-92%). 15L 70% non-re-breathe
Take:
Lactate (serial ABGs) - cellular hypoxia marker, normally 0.5-2.2 venous and 0.5-1.6 arterial
Blood cultures
Urine output hourly
Also
Bloods - FBC, U&E, CRP, LFT, clotting
Imaging - of suspected source
Mirco samples - of sputum, urine and wounds
Liaise with critical care team
Common causes
UTI
Pneumonia
Peritonitis
Change in skin colour
Blue - cyanosis
Yellow - jaundiced (in particular with scleral icterus) or uraemia, pernicious anaemia, carotenaemia
Pallor - (non-specific) aneamia
Hyperpigmentation - Addison’s, haemochromatosis (slate-grey) and amiodarone, gold, silver, minocycline therapy
SOB
Common causes Respiratory Acute Pneumothorax Pulmonary Embolus Psychogenic
Subacute Asthma Bronchiolitis Croup (children) Pneumonia Tuberculosis
Chronic
Pulmonary Fibrosis
COPD
Cardiac
Ischaemic heart disease
Left ventricular failure
Valvular heart disease
Other Anaemia Anaphylaxis Fluid overload (renal failure) Foreign body inhalation Obesity
Other causes Respiratory ARDS Occupational lung disease Pulmonary hypertension Cardiac Congenital heart disease Myocarditis Pericarditis Other Abdominal distension Neuromuscular diseases Myositis
Vomiting
GI
gastroenteritis, peptic ulceration, pyloric stenosis, obstruction, paralytic ileus, acute cholecystitis, acute pancreatitis
CNS Meningitis/encephalitis Migraine Increased intracranial pressure Brainstem lesions Motion sickness Meniere's disease Labyrinthitis
Metabolic/endocrine Uraemia HyperCa HypoNa Pregnancy Diabetic ketoacidosis Addison's
Alcohol and drugs Abx Opiates Cytotoxics Digoxin
Psychiatric
Self-induced
Psychogenic
Bullimia nervosa
Others
MI
Autonomic neuropathy
Sepsis
Headache
Important to ID
1) Subarachnoid
2) Meningitis
1)
Acute
Worse ever headache
Feel like they have been hit over the head
Examine
• be aware of false localising signs
• papilloedema
CT head ASAP • ?normal or not - if not then call neurosurgeon Normal - leave - LP • NB to rule out raised ICP • NB to wait 12h and look for breakdown of blood cells e.g. bilirubin and xanthochroma
2) Signs of infection Try to ID if bacterial or viral ?shake their head ?rashes LP and broad spec Abx
Confusion
AMT, 4AT screening
Past history, NB try to get some corroborative help
• is this different?
?Fall or trauma
• CT for haemorrhage
?Infection e.g. UTI • Examine • Investigate - white cells - CRP - Na - LFTs - blood glucose
?Anaemia, diabetes
DSH/Poisoning
Paracetamol OD:
Charcoal if within 1h Measure blood paracetamol • at least 4h after If above treatment threshold • give NAC
Check INR and creatinine (not LFTs)
Seizure
Recovery position
ABC
If going on a long time consider terminating
• benzodiazepine
Falls/faints/collapse
NB history
• is there a pro-drome
Medications
Postural
Arrhythmias
Coma
Causes: TOMES • Toxins • Organ failures • Metabolic (COATPEGS) - CO2 - O2 - ammonia - temp - ptt - electrolytes - glucose • Endocrine, seizure
Clubbing
Cardiac Cyanosis IE Congenital Atrial mixoma
Respiratory
Lung cancer
Bronchiectasis
(everything but asthma and COPD)
Gastric
Crohns
Cirrhosis
