Rahul's Differentials Flashcards
What are the ‘non-sinister’ differentials of a headache?
- Tension-type headache (stress related)
- Migraine (really common actually)
- Sinusitis
- Medication overuse headache - for those on migraine meds and/or analgesia
- Temporomandibular joint dysfunciton syndrome
- Trigeminal neuralgia
- Cluster headache
What are the signs of Horner’s?
Partial ptosis
Miosis
Anhydrosis
Enophthalmos
What are the differentials for a large pupil?
Cranial nerve 3 palsy
Holmes-Adie Syndrome
Trauma
Drugs (tropicamide, atropine, cocaine, ecstasy)
What are the differentials for a small pupil?
Horner's syndrome Argyll-Robertson syndrome Age-related miosis Drugs (opiates) Anisocoria (different sized pupils)
List the causes of Horner’s syndrome
CENTRAL: Stroke Syringomyelia Multiple sclerosis Tumour Infection
PREGANGLIONIC LESION: Pancoast tumour Thyroidectomy Trauma Cervical Rib
POSTGANGLIONIC LESION: Carotid artery dissection Carotid aneurysm Cavernous sinus thrombosis Cluster headache
State where the lesion is for MONOCULAR BLINDNESS
Before the nerve
Ipsilateral optic nerve lesion
State where the lesion is for HOMONYMOUS HEMIANOPIA
Contralateral optic radiation
Contralateral occipital lobe
State where the lesion is for BITEMPORAL HEMIANOPIA
Optic chiasm
State where the lesion is for LEFT/RIGHT SUPERIOR QUADRANTANOPIA?
Contralateral temporal optic radiation
State where the lesion is for LEFT/RIGHT INFERIOR QUADRANTANOPIA?
Contralateral parietal optic radiation
State where is the lesion for HOMONYMOUS HEMIANOPIA WITH MACULAR SPARING
Contralateral occipital lobe infarct due to posterior cerebral artery infarct
The middle cerebral artery supplies the occipital pole
State what is responsible for Arcuate Scotoma?
Glaucoma
State what is responsible for Central Scotoma?
Macular Degeneration
Macular oedema
What are the differentials for HAEMATEMESIS
Oesophagitis/Gastritis/Duodenitis Bleeding peptic ulcer (gastric or duodenal) Oesophageal varices Mallory-Weiss tear Oesophageal cancer Gastric cancer Arteriovenous malformations Bleeding diathesis Trauma to oesophagus or stomach Scleroderma Hereditary heamorrhagic telangiectasis Aorto-enteric fistula (related to an aortic graft)
What does HAEMATEMESIS indicate?
It is an upper GI bleed
First ix for Haematemesis?
OGD
Follow by possible erect Chest X-ray: check if the peptic ulcer has perforated resulting in pleural effusion
What is Boerhaave’s syndrome?
A tear of the distal postero-lateral part of the oesophagus
What are the two types of blood produced during HAEMATEMESIS
Fresh blood suggestive of an upper GI bleed
Coffee Ground blood seen due to partial digestion by stomach acids
What are the two types of blood found in stool?
Tarry black stool - Malaena which is due to an upper GI hemorrhage
Haematochezia - Fresh blood in the stool suggestive of a lower GI haemorrhage (however, it could also be from an upper GI bleed)
What is a Mallory-Weiss tear?
It is a laceration of the mucosa at the junction between the stomach and the esophagus
What are EASY BRUISING, DISTENDED ABDOMEN, PUFFY ANKLES and LETHARGY suggestive of?
Liver failure
What does episodic dyspepsia suggest (indigestion)
GORD - Gastro-oesophageal reflux disease
Note: Jaundice is itchy so the patient may have scratch marks
Note: More than 4 spider naevi indicates liver disease.
What is macrocytic anemia and what is it suggestive of?
A high MCV but low hemoglobin
Seen in those who consume ALCOHOL, or have VITAMIN B12 or FOLATE DEFICIENCIES
List causes of low albumin
Liver failure
Malnutrition (just not getting enough protein in the diet)
Renal nephrotic syndrome
What causes raised ALT, AST
Damage to hepatocytes seen in alcohol abuse and liver cirrhosis
What does raised urea in the presence of a normal creatinine suggest?
Pre-renal uraemia - Increased urea due to increased protein ingestion due to blood in the GI tract
What is the treatment for a bleeding oesophageal varix?
- Endoscopic band ligation
- Endoscopic sclerotherapy
- Balloon tamponade
What does a PPI do for a bleeding peptic ulcer?
Reduce chances of rebleeding
Treatment for H. pylori?
Triple therapy -
PPI and a combination of two antibiotics
Doxasosin
Anti emetic
Difficulty swallowing could mean?
DYSPHAGIA - true difficulty swallowing could be HIGH DYSPHAGIA or LOW DYSPHAGIA which is felt a few seconds after swallowing
ODYNOPHAGIA - Painful swallowing due to malignancy or infection e.g Candidiasis
GLOBUS - Lump in the throat
Ways to divide DYSPHAGIA
High Dysphagia
Low Dysphagia
DDx of High Dysphagia
Stroke Parkinson's disease Myasthenia Gravis Multiple sclerosis Myotonic dystrophy MND Cancer Pharyngeal pouch
DDx of Low Dysphagia
ACHALSIA
Foreign body
Cancer
Stricture
What is ACHALISA
The lower oesophageal sphincter does not open leading to the backing up of food
What questions would you ask to a patient who presented with difficulty swallowing?
- How long have these symptoms being going on for - a stuck food bolus will present immediately, a cancer over days - weeks, a motility issue - months to years
- Does the painful swallowing come and go? - Persistent/progressive: CANCER
INTERMITTENT: STRICTURE - Can you swallow solids…fluids…or both…what about saliva?
Difficulty with solids then fluids –> STRICTURE
Difficulty with fluids > solids –> MOTILITY ISSUE
Absolute dysphagia likely due to poorly chewed food bolus
What would someone with CREST syndrome suffer with?
CALCINOSIS
RAYNAUD’s
ESOPHAGEAL DYSMOTILITY
Sclerodactyly - Build up of fibrous tissue in the fingers which causes them to bend
What is the most common type of oesophageal cancer?
Adenocarcinoma (the less common type is SQUAMOUS CELL)
Velvety epithelium in the esophagus can suggest?
Barrett’s oesophagus
What are the RF for Oesophageal cancer
Adenocarcinoma:
BARRETT’S OESOPHAGUS
Squamous cell carcinoma: Alcohol Smoking Dietary nitrosamines Aflatoxins Achalsia Plummer-Visons syndrome Hereditary tylosis Coeliac disease
DIAGNOSE: Dysphagia, Hoarseness, Bovine cough
Damage to recurrent laryngeal nerve
1. Infiltration of the nerve by primary malignancy of the oesophagus or a mediastinal malignancy that then compresses the oesophagus causing dysphagia
- ORTNER’s syndrome - Compression of recurrent laryngeal nerve by left atrium
MS –> Hypertrophy of left atrium
What questions do you need to ask in a cough history?
- How long has this been going on for (Acute or chronic)
- Is the cough CONSTANTLY THERE or DOES IT COME AND GO?
- Are you coughing anything up?
- Any blood while you’re coughing
- What time does the cough usually come? When is it worst?
- Can you describe the cough to me? Wheezy, bovine/breathy, dry, gurgling/wet?
What environmental factors would you ask about for someone with a cough?
Smoking
Occupation
Pets
Change of house/office
NOTE: TB is often linked with foreign travel to South Asia, Central Asia or sub-Saharan Africa. IF YOU SUSPECT TB YOU MUST ASK ABOUT CLOSE CONTACTS WHO ARE ALSO COUGHING
Note: Neutrophillia is associated with bacterial infection
Urea is an indicator of severity in pneumonia
What are the features of a pneumothorax on examination?
- Decreased chest expansion UNILATERALLY
- Increased resonance over area of pathology
- Decreased breath sounds
- Decreased vocal fremitus
What does blood-streaked sputum suggest?
INFECTION OR BRONCHIECTASIS
What does pink and frothy sputum suggest?
PULMONARY OEDEMA
What does frank haemoptysis suggest?
TB
Lung Cancer
PE
Bronchiectasis (also blood streaked sputum)
Cough worse at night and better in the mornings is indicative of?
Asthma
Cough worse at night especially lying down is indicative of?
GORD or Pulmonary Oedema
List the likely causes of the following coughs: Wheezy cough Bovine/Breathy cough Dry cough Gurgling/wet cough Whooping cough
COPD or Asthma Vocal cord paralysis Bronchitis, Interstitial lung disease Bronchiectasis Pertussis
List the DDx of DRY AND ACUTE COUGH
Asthma Rhinitis/Sinusitis with post-nasal drip Upper respiratory tract infection Drug induced e.g. ACE inhibitors Smoke/toxin inhalation Inhaled foreign body Lung cancer Pulmonary oedema
List the DDx of PRODUCTIVE AND ACUTE COUGH
Lower Respiratory Tract Infection
COPD
TB
List the DDx of DRY AND CHRONIC COUGH
Asthma GORD Post-nasal drip Smoking Lung cancer Drug induced COPD
List the DDx of PRODUCTIVE AND CHRONIC COUGH
Bronchiectasis
TB
Lung cancer
Recurrent aspiration
What does Cough + Tender cervical lymphadenopathy suggest?
Upper Respiratory Tract infection
What happens to vocal fremitus when there is consolidation and when there is effusion
It increases in CONSOLIDATION
In decraeses in effusion
List the signs of right heart failure
Peripheral oedema Raised JVP Parasternal heave Loud or palpable heart sound Tricuspid regurgitation
What are the two complications of pneumonia?
- Spread of infection resulting in PLEURAL EFFUSION, EMPYSEMA, ABSCESS, SEPTICAEMIA
- Damage to local structures in BRONCHIECTASIS, PNEUMOTHORAX
List two obstructive airway diseases
Asthma
COPD
What does FEV1 stand for
Forced Expiratory Volume in 1 second
Volume of air that can be forcibly blown out after a full inspiration
What does FVC stand for
Forced Vital Capacity
Volume of air that can be blown out after full inspiration
What features suggest asthma
Wheeze Breathlessness Chest tightness Cough worse at night/early morning Cough triggered by exercise, allergen, exposure, cold air on or after taking aspirin or beta-blocker History of atopic disorder Family history of asthma and/or atopy Wheeze on auscultation Low FEV1, PEF, or serum eosinophilia
What are the 3 things that haemoptysis can be confused with?
- Haematemesis
- Epistaxis (especially after a posterior nosebleed)
- Bleeding gums
List the DDx of Haemoptysis
V - PE, Left Ventricular Failure, Bleeding Diathesis I - TB, Pneumonia, Lung abscess T - Iatrogenic, rib fracture, stab A - N/A M - N/A I - Granulomatosis with polyangiitis, SLE, Goodpasture's syndrome, N - Primary/Metastatic Lung cancer C - N/A D - Bronciectasis E - N/A F - N/A
Drugs: Warfarin, Crack Cocaine
What is a Bleeding Diathesis?
Bleeding tendency e.g coagulopathy, severe thrombocytopenia
What does a mass lesion/nodules on an X-ray indicate?
Carcinoma, TB, Abscess,
What does Hilar Lymphadenopathy on an X-ray indicate?
Sarcoidosis, Infection (TB), Malignancy (Hodgkin’s Lymphona, Carconoma)
How do you confirm lung cancer in a patient?
A pathological sample is required for confirmation
CT-guided percutaneous fine needle biopsy is required if peripheral or BRONCOSCOPY
Where are you most likely to find TB (Mycobacterium Tuberculosis) in the lungs?
The upper lobes becauses Mycobacterium tuberculosis is highly aerobic and the apices are the most oxygenated parts of the lungs.
What are the two types of Pleural effusions and what is the difference?
Transudate - <25 g/L of protein in the fluid
Exudate - >35 g/L of protein in the fluid
Causes of Transudative pleural effusions and Exudative pleural effusions
Transudate: Heart failure, fluid overload, constrictive pericarditis, liver failure (decrease protein production), malabsorption, nephrotic syndrome
Exudative: Pathogens, Inflammatory cells, Malignant cells in the pleural space.
What are the different types of Malignant Primary lung neoplasms?
1. Non-small cell lung cancer (80%): ADENOCARCINOMA (30-40%) SQUAMOUS CELL (20-30%) - most common to cause haemoptysis and secrete PTHrP LARGE CELL CARCINOMA (10%) Other (5%)
- Small cell lung cancer (20%) can secrete ADH (causing HYPONATRAEMIA) or ACTH
What are the common primary tumours that lead to lung cancer mets?
- Colorectal
- Breast.
- Renal
- Cervix, Ovary
List the extra-pulmonary manifestations of lung cancer
- Bone mets –> Bony pains
- Hypertrophic pulmonary osteroarthropathy (HPOA)
- Ectopic ACTH –> Cushingoid syndrome (muscle weakness, oedema, skin hyperpigmentation)
- Hypercalcaemia - confusion, polyuria, polydipsia, hypotonoia, hyporeflexia, muscle weakness
- Eaton-Lambert syndrome
DDx of a coin lesion
Parenchymal tymor - benign, primary lung cancer, secondary lung cancer Lymph node: Lymphoma Granuloma: TB, Sarcoid Abscess Hamartoma Foreign object
List the DDx of Chest Pain
Musculoskeletal pain Acute Coronary Syndrome (MI or unstable angina) Pulmonary Embolism Stable Angina Pneumothorax Pleurisy (2ndary to infection) Oesophagitis Cocaine induced coronary spasm Anxiety Peptic ulcer disease or gastritis Myopericarditis Cholecysititis Acute pancreatitis Thoracic aortic dissection Thoracic aortic aneurysm Coronary vasospasm Oesophageal spasm Boerhaave's perforation of the oesophagus
What other conditions could cause a raised Troponin
Any condition which causes cardiac damage
Coronary artery spasm
Aortic dissection
Myopericarditis
Severe heart failure
Cardiac trauma from surgery or road traffic accident
PE
Troponin may also be misleading in someone with renal failure.
What are the Ix for Chest Pain
ECG Bloods: Troponin Serum cholesterol FBC U&Es - Potassium could hint at arrhythmias Inflammatory markers - WCC and CRP Capillary glucose Amylase
Imaging: CXR
What is the interesting relationship between diabetics and MIs?
Diabetics are more likely to suffer from ‘silent MI’s’ those without chest pain
What would an aortic aneurysm or dissection show on a CXR?
A widened mediastinum
Note: Remember in the end diagnosis of MI depends on elevated troponin or rapidly rising troponin.
Chest pain is not always a feature in the elderly or long-standing diabetics. ECG readings are also non-diagnostic.
What are the drugs used to treat Acute Coronary Syndrome (think of the acronym)?
MONABASH
Morphine/Metoclopramide (anti-emetic)
Oxygen (to keep saturation above 94%)
Nitrates (GTN, isosorbide mononitrate infusion)
Antiplatelets (aspirin, clopidogrel, prsugrel)
Beta-blockers (not for those with heart block, asthma, acute heart failure)
ACE-inhibitors
Statins
Heparin
What are the secondary things to do for patients with ischaemic heart disease?
Lifestyle changes - Smoking cessation, low-salt diet, exercise, weight loss, cardiac rehabilitation programmes
Risk factor control with medication -
BP control: ACEi < 55 and white
CCB or Thiazide diuretics if >55 and Afro-Carribean
Cholesterol reduction: Statins otherwise fibrates
Diabetic control
Low-dose aspirin for life and ADP receptor inhibitor
What are the common complications of MI? (DARTH VADER)
Death Arrhythmia Rupture (septum or the outer walls) Tamponade Heart Failure Valve disease Aneurysm Dressler's syndrome (autoimmune pericarditis is 2-10 weeks after MI; simple pericarditis is 2-4 days) Embolism Reinfarction
NOTE: ACS typically respond to GTN spray
NOTE: Pericarditis will show ST elevation in almost all leads as well as slight PR segment depression.
What pathology can Marfan’s predispose you to?
Dissected thoracic aorta
Dissected aortic aneurysm
Pneumothorax (because they are often tall and thin)
What would you hear on auscultation if a patient had pulmonary oedema?
Bi-basal crackles
Why do some patients with MI get nause and vomitting and other do not?
Due to the BEZOLD-JARISCH REFLEX
An inferior MI will irritate the diaphragm and a result cause vomitting.
How would a posterior MI look like on an ECG?
ST depression in V1, V2, V3 with tall R waves
Look for dominant R waves in V1
Inferior lead ST elevation in infarction
Name the first investigation for a patient with query new onset angina
Exercise tolerance test
What would you expect to see in an ECG of a patient who had a previous MI?
Abnormal Q waves - > 2mm deep
What are the changes seen over 7 days in a patient who has a STEMI?
- Tented t waves
- ST elevation in the affected leads, with ST depression in the reciprocal leads 24-48 hours after
- T wave inversion, 1-2 days after MI and persisting for weeks or months unless MI is treated
- Abnormal Q waves.
What does LOW WELLS SCORE + LOW D-Dimer indicate?
Low chance of a PE
What are the 3P’s of Pleuritic chest pain
PE
Pneumonia
Pneumothorax
How would you describe Pleuritic chest pain
A sharp, stabbing, burning chest pain which is worse on inhaling or laughing
What are carotid bruits a sign of?
Peripheral vascular disease
List the causes of SOB
SOB can be due either to not enough oxygen getting around the body or increased respiratory drive.
- Insufficient oxygen getting into the lungs
- Obstructed airways
- Dcreased lung volume
- Decrease volume of functional lung
- Inability to inflate the lungs - Insufficient oxygen into the blood
- Damage to alveoli
- Fluid between the alveoli and capillary
- Disrupted blood supply - Insufficeint O2 around the body
- Reduced cardiac output
- Anaemia
- Shock (blood pressure <90/60 mmHg) - Increased respiratory drive
- Hysterical hyperventilation
- Acidaemia
What kind of cough would you expect with asthma?
A dry cough
What kind of cough would you expect with pneumonia
A persistent, productive cough
What are the DDx of SOB with onset of seconds-minutes
Bronchospasm (due to acute asthma or COPD) Anaphylaxis Laryngeal oedema PE Pneumothorax Flash pulmonary oedema Hysterical hyperventilation Inhaled foreign body Tension pneumothorax Acute epiglottitis/supraglottitis
What are the DDx of SOB with onset hours to days?
Pneumonia Heart Failure Pleural effusion Post-op atelectassis Chronic pulmonary emboli Altitude sickness Guillian-Barre syndrome Myasthenia Gravis Acute Respiratory Distress Syndrome Lung Collapse
What are the DDx of SOB with onset weeks to months?
COPD Chronic asthma Heart failure Pulmonary fibrosis Anaemia Bronchiectasis Physical deconditioning Obesity Pulmonary hypertension Mesothelioma Pulmonary tuberculosis Kyphoscoliosis Ankylosing spondylitis Motor neuron disease
In a CXR what 3 things do you want to ensure? Other than patient’s details and PA
Good penetration - not too white not too dark
Adequte inspiration - So things don’t look too hazy
Not rotated - Spinous processes equidistant to medial ends of the clavicle
List the features of RHF
Raised JVP
Peripheral oedema
List the features of LHF
Bibasal cracles - suggestive of pulmonary oedema
Displaced apex beat
CXR showing bilateral pulmonary oedema
List the post-operative causes of breathlessness
Atelectasis (alveolar collapse): Pneumonia Pulmonary oedema PE (classically DVTs occur 10 days after) Anaemia Pneumothorax
What is the treatment for Atelectasis?
Physiotherapy
Oxygen
Analgesia
Questions to ask in family history of suspected asthma patient?
Family history of Eczema Hayfever Nasal Polyps Allergies
What are the three pillars of asthma management?
- Avoid the triggers - smoke, allergens, exercise in cold air
- Bronchodilate (open those airways!) - b2 agonists/phosphodiesterase inhibitors/antimuscarinics
- Reduce immune response in lungs - inhaled/oral corticosteroids
What pneumonia is common in immunosuppresed patients?
Pneumonia caused by the opportunistic organism: Pneumocystis jiroveci common in those with AIDS
Diagnosed by performing microscopy + silver staining and culture on sputum and bronchoalveolar lavage samples.
What kind of inhaler is the blue inhaler?
Salbutamol
What kind of inhaler is the green-white?
Ipratropium
Antagonises muscarinic receptors preventing PNS smooth muscle contraction
The common side effects of ACEi?
Cough
Issues related to kidney damage
What are the DDx of Breast Lump
Carcinoma Benign cystic change Fibroadenoma Cyst Breast abscess Fat necrosis Periductal mastitis Galactocele Phyllodes tumour Sarcoma Duct papilloma Lipoma Sebaceous cyst Prominent costal cartillage/rib
How does age affect the DDx of Breast Lump
<30: Physiologically normal, benign cystic change, fibroadenoma, Abscess, Galactocele
30-45: Benign cystic change, cyst, abscess, carcinoma
45-60: Cyst, abscess, carcinoma
> 60: Carcinoma
What antibiotic could be used in cellulitis?
Flucloxacillin
What are the RF for breast cancer?
Previous history of breast cancer Family history of breast cancer History of ovarian, endometrial or bowel cancer Radiation to the chest wall Menarche before 13 Menopause after 51 No kids (nulliparity) Having a first child after the age of 30 Not breast-feeding HRT Use of the oral contraceptive pill Obesity
What are the follow discharges from the nipples indicative of? Blood Serous Green, brown, yellow discharge Milky discharge
Blood - Carcinoma
Serous - Intraductal papilloma
Green, brown, yellow - Periductal mastitis
Milky - Galactocele
NOTE: Breast cancer does not often come with the constitutional symptoms/FLAWS symptoms. However, it may present with mets in the form of…?
Back pain
What are the key features to look for in a breast examination?
Asymmetry
Contours
Skin changes
Nipple discharge or changes
What is the approach for investigating solid lumps in the breast clinic?
Breast lumps should undergo triple assessment:
- Clinical examination
- Radiological examinatio
a) USS if <35 years old
b) Mammogram w or w/out USS if >35 years old - FNA or core biopsy
FNA - type of cells (dysplastic or not)
Core biopsy - invasion of local structures
Where is breast cancer likely to metastasize to and how should imagine be done accordinlty?
Liver - CT abdomen, MRI abdomen, contrast-enhanced USS
Bone - Axial skeleton via bone scintigraphy or CT or MRI
Long bone imaging via bone scintigraphy or plain radiographs
Chest - CT
Brain - CT
Some hospitals recommend CT with/out PET
What does HYPERECHOIC on an USS mean?
The structure appears BRIGHTER
Seen in solid masses
What does HYPOECHOIC on an USS mean?
The structure appears DARKER
Seen in fluid-filled cysts
How does breast cancer present in a man?
Unilateral, non-tender, irregular surface, indistinct margins and hard consistency
What are the causes of Gyanaecomastia?
Liver disease Drugs (cimetidine, spironolactone, phenothiazines, finasteride, anabolic steroids) Primary testicular failure Acquired testicular failure Secondary testicular failure Endocrine tumours Non-endocrine tumours
What determines prognosis of breast cancer?
Tumour stage Tumour grade Hormone receptor status Tumour type Patient age Treatment type
What are the risks of lymph node clearance?
Lymphoedema
Long thoracic nerve injury
Axillary vein thrombosis
What is PRCB score
P - Physical examination
R - Radiological examination
C - Cytology (FNA)
B - Biopsy (core biopsy)
Score: 1 - Normal for P/R; Inadequate for C 2 - Benign 3 - Probably benign 4 - Probably malignant 5 - Malignant
What are the DDx of ACUTE Epigastric pain
Acute pancreatitis Perforated peptic ulcer Gastritis/Duodenitis Peptic ulcer disease (gastri or duodenal) Biliary colic Acute cholecystitis Ascending cholangitis Myocardial infarction Ruptured Abdominal Aneurysm Mesenteric ischaemia Basal pneumonia Oesophagitis (due to GORD) Non-ulcer dyspepsia Chronic pancreatitis Incomplete bowel obstruction Boerhaave's perforation Gastric Cancer Pancreatitc cancer Acute hepatitis
Make a SOCRATES cheat list for the presentation of acute pancreatitis
Site: Epigastrium (could be elsewhere) Onset: 10-20 minutes Character: Deep/boring pain Radiation: To the back Attenuating factors: Sitting forwards Severity: Very severe
Note: Sitting forward is better for those with pancreatitis and Neutrophilia is a strong indicator of pancreatitis
Pain that starts in epigastrium –> rest of abdomen
Peritonitis
Perforated gastric ulcer
Pain that starts in epigastrium and moves up to chest
Likely cardiac in origin
Pain that stays in the epigastric region?
Likely biliary in origin
DDx sudden onset epigastric pain?
Perforation
MI
DDx of epigastric pain that takes 10-20 minutes to come on?
Acute pancreatitis
Biliary colic
DDx of a epigastric pain that takes hours to come on?
Inflammation that is either acute cholecystitis or pneumonia
DDx of epigastric pain that is crushing/tightnes?
Cardiac
DDx of sharp/burning epigastric pain?
Peptic ulcer
Gastritis
Duodenitis
DDx of deep/boring epigastric pain?
Pancreatitis
DDx of epigastric pain that radiates to the back?
Pancreatitis
Leaking AAA
Possibly peptic ulcer
DDx of epigastric pain that goes to the shoulder?
Basal pneumonia
Subphrenic abscess
DDx of epigastric pain that radiates to the jaw, neck or shoulder?
Cardiac
DDx of retrosternal chest pain?
Oesophagitis
MI
What makes acute pancreatitis better?
Sitting forward
What is the surgical dogma on what makes peptic ulcers/duodenal ulcers better or worse?
Peptic ulcers are WORSE on eating
Duodenal ulcers are BETTER on eating
DDx of constant epigastric pain?
Biliary colic
DDx of pleuritic chest pain?
PE
Pneumothorax
Pneumonia
List 4 conditions you want to know in a PMH if a patient has epigastric pain?
Biliary disease - Have you ever had gallstones before?Peptic ulcer disease - Have you ever had a peptic ulcer?
GORD - recurrs
Which drugs predispose to Peptic Ulcer disease?
NSAIDs
Steroids
Bisphosphonates
Salicylates (aspirin)
Which drugs predispose to acute pancreatitis?
Sodium valproate
Steroids
Thiazides
Azathioprine
What are the DDx of Epigastric pain?
Acute pancreatitis Perforated peptic ulcer Gastritis/Duodentitis Peptic ulcer disease (gastric or duodenal) Biliary colic Acute cholecystitis - inflammation of the gall bladder Ascending cholagnitis - Inflammation of the bile duct Myocardial infarction Ruptural abdominal aortic aneurysm Mesenteric ischaemia Basal pneumonia Oesophagitis (due to GORD) Non-ulcer dyspepsia Chronic pancreatitis Imcomplete bowel obstruction
Causes of Jaundice
Ascending cholangitis
Gallstone-induced acute pancreatitis
Acute hepatitis
List the Ix for an acute epigastric presentation
History Examination FBC CRP Amylase or lipase Liver enzymes Albumin U&Es Calcium Glucose ABG Troponin USS ECG CXR
What does a raised AST and ALT indicate?
Damage within the liver to hepatocytes
What does a raised ALP, GGT, Bilirubin indicate?
Damage within the biliary tree or compression of the biliary tree for ex. due to oedema of the pancreas
What does a raised ALP alone indicate?
Problems with bone or placenta
What does a raised GGT indicate?
Excessive alcohol intake
What are the causes of acute pancreatitis?
I - Idiopathic G- Gallstones E - Ethanol T - Trauma S - Steriods M - Mumps/HIV/Coxsackie infection A - Autoimmune S - Scorpion bites H - Hyperlipidaemia/Hypercalcaemia/hypothermia E - ERCP D - Drugs (sodium valproate, steroids, thiazides, azathioprines)
Treatment for a patient with pancreatitis
I would begin with an ABCDE approach
Airway
Breathing
Circulation
I would then treat the underlying cause e.g Gallstones through laparascopic cholecystectomy
as well as give him IV fluids, Oxygen, Analgesia, Antiemetics, DVT prophylaxis, Low fat diet
Treatment for patient with severe pancreatitis
ERCP within 72 hours of onset of pain along with sphincterotomy and then cholecystectomy.
How do you prevent reoccurent in a patient who has alcoholic pancreatitis?
Focus on cessation of drinking.
List the RF for peptic ulcer disease
Smoking
Alcohol
Management of dyspepsia
Lifestyle advice - reduce/eliminate alcohol, caffeine, chocolate, fatty food and smoking, lose weight
Full-dose PPI
Test and treat H.pylori
- C-urea breath test
- Anti-Helicobacter blood serology
- H.pylori positive endoscopic biopsy
How do you treat H. pylori?
Triple therapy
PPI + 2 antibiotics
7 day TD PPI with
Metronidazole 400 mg + Clarithromycin 250 mg
Amoxicillin 1 g + Clarithromycin 500 mg
DDx of raised amylase
Acute pancreatitis (if >1000 U/L) Pancreatitic trauma Pancreatic carcinoma Perforated peptic ulcer Acute Appendicitis Acute Cholecystitis Ectopic pregnancy Pelvic inflammatory disease Mesenteric ischaemia Leaking AAA Bowel obstruction Mesenteric ischaemia Mumps Pancreatic carcinoma Opiate medications
What is the triad of peritonitis?
Motionless patient
Tenderness and guarding on abdominal palpation
Absent bowel sounds
Top DDx for pain around the face
Trigeminal neuralgia
Giant cell arteritis
What are the ‘red flags’ that would lead to a endoscopy?
- Persistent vomitting
- Chronic GI bleed
- Weight Loss
- Progressive dysphagia
- Iron deficiency anaemia
- Epigastric mass
- Suspicious barium meal
- Age >= 55 with unexplained and persistent recent-onset dyspepsia
List the 5 complications of peptic ulcer?
- Haemorrhage - Bleeding esp in those on blood thinners
- Perforation - manifests as haematemesis/melaena and leads to peritonitis
- Penetration - Not to peritoneum but to organ parts of GI tract, food no longer makes it worse, diarrhoea, weight loss
- Scarring - Satiety, bloating, vomitting
- Malignancy
What are the local complciations of pancreatitis
- Necorsis of the pancreas - The pancreas is being autodigested and eventually it dies.
- Abscess formation
- Pseudocysts
- Paralytic ileus - lack of movement of bowl
- Duodenal stress ulceration
- Fistula formation to colon
- Obstructive jaundice due to choledocholithiasis or pancreatic oedema
What is Choledocholithiasis
Gallstones in the common bile duct
What are the systemic complications of pancreatitis?
Sepsis Shock Acute renal failure (due to hypoperfusion) Respiratory compromise Disseminated intravascular coagulation Hypocalcaemia Hyperglycaemia Pancreatic encepholopathy
DDx of low faecal elastase?
Pancreatitis
Crohn’s
Coeliac’s
Short gut syndrome
What is the difference between Cushing’s ulcers and Curling’s ulcers
They are both peptic ulcers
Cushing’s ulcers are due to brain injury
Curling’s ulcers are due to burns
DDx of decreased amylase clearance
Renal failure
Macroamylasaemia
Diabetic ketoacidosis
Head injury
Which 4 systems can influence the vomitting center in the medulla?
- CNS
- Vestibular system
- Chemoreceptor trigger zone
- CN IX and CN X
List the DDx of nausea and vomitting due to pathology of the vestibular system
Benign paroxysmal positional vertigo
Labyrinthitis
Motion sickness
Meniere’s disease
List the DDx of nausea and vomitting due to pathology of the chemoreceptor trigger zone
Hormones Electrolytes Medications Alcohol Toxins
List the DDx of nause and vomitting due to pathology of the CNS
Pain Anxiety Raised ICP Meningitis Encephalitis
List the DDx of nausea and vomitting due to pathology of the Abdominal/Cardiac systems affecting CN IX or CN X
GI obstruction
GI infection
Inflammation of diaphragm (as in inferior MI’s)
Inflammation of liver, pancreas, gallbladder, peritoneum
What are the worrying signs of peritonitis?
Motionless patient
Tender, rigid abdomen
Absent bowel sounds
What are the worrying signs of bowel obstruction?
Bilious (green) or faeculent (foul like) vomit
Distended abdomen
Absolute constipation
Abdominal pain
What are the worrying signs of raised ICP
Early morning vomitting
Headache worse when lying down
Nerve VI palsy
What are the worrying signs of meningitis?
Stiff neck
Photophobia
Headache
What are the worrying signs of meningitis?
Stiff neck
Photophobia
Headache
Reduced consciousness
What are the worrying DDx of haematemesis
Bleeding peptic ulcer
Oesophageal varices
What does guarding and rigidity on palpation suggest?
Peritonitis
What do absent bowel sounds and tinkling/high pitched tinkling sounds indicate?
Absent bowel sounds: Bowel obstruction - ileus (functional)
Tinkling/high pitched: Bowel obstruction - mechanical
What Ix do you need to do in a patient with nausea and vomitting
FBC, CRP - infection, inflammation
U&Es - vomiting can cause electrolyte imbalances, need baseline in case of surgery
Venous Blood Gas - pH and lactate give idea of how sick patient is; metabolic acidosis+raised lactate = ill
Liver enzymes -
GGT + ALP = cholestatic picture
AST + ALT = hepatitis
Amylase - confirm/exclude pancreatitis
G&S
Supine abdominal radiograph - bowel obstruction, foreign body, toxic megacolon
Erect chest radiograph - Air under diaphragm to indicate perforation
Pregnancy test
Tox screen
Contrast studies
Abdominal CT
Head CT
In a patient awaiting surgery for small bowel obstruction what is the management plan?
- Manage patient with an A to E approach
- Nil by mouth - reduces the risk of aspiration on induction by anaethesia
- Drip and suck: IV fluids + aspiration of gastric contents
- Analgesia
- Antiemetics
LEARNING POINT: Avoid NSAIDs in dehydrated patient or those with AKIs
They are nephrotoxic!
LEARNING POINT: Morning sickness is most common in the first trimester
When is surgery indicated in a patient with small bowel obstruction?
There are signs of strangulation or peritonism
After 48 hours the obstruction has not resolved
There is no history of abdominal surgery, so sinister causes are more likely
What is the difference between D&V caused by toxins and that caused by infection?
A toxin from ‘food-poisoning’ rarely persists more than 24 hours
What does ketonuria suggest?
That the patient is in metabolic starvation
What is Kussmaul breathing?
Breath has sweet smell to it due to ketones
The breathing is deep labored and gasping
At first in acidosis - the breathing is swallow and rapid
What is the management of DKA
IV fluids to rehydrate
IV insulin as an infusion to suppress ketosis
Monitor fluid balance, cap glucose, ketones, serum potassium
Potassium therapy
What is the management of a patient with a perforated appendix which leads to PERITONITIS?
Note that peritonities is high risk as the patient is at risk of deteriorating into septic shock from gut contents getting into the peritoneal cavity
- A to E approach
- Resuscitation with IV fluid bolus
- Broad spectrum antibiotics
- Analgesia
- Antiemetics
- Nil by mouth
What would you give a dehydrated patient that can tolerate oral fluids?
Oral rehydration solution with sodium, glucose, water
Ask them to have a little and often
What are the causes of nause and vomitting in a patient with cancer?
Metabolic: Hypercalcaemia, uraemia
Intracranial: Raised ICP due to brain mets
GI: constipation, bowel obstruction, ileus, hepatomegaly
Psychogenic: anxiety
Chemotherapy or opiate analgesia
What are porthole scars?
Laparascopic surgery
Which two patients with vomiting would you not prescribe metoclopramide?
Patient with bowel obstruction
Patient with Parkinson’s
List some complications of vomitting
Dehydration Renal impairment Electrolyte imbalance - hyponatraemia, hypocholaraemia Aspiration Aspiration pneumonia Mallory-Weiss tear in mucose of oesophagus Boerhaave's perforation Loss of tooth enamel
What is the cause of Jaundice?
Excessive collection of bilirubin in tissues
Extravascular breakdown of RBCs results in what abnormal cells?
Spherocytes
Intravascular breakdown of RBCs results in which abnormal cells?
Schistocytes (it’s shit if they’re breaking down in your blood)
What are the 6 pathways that can lead to jaundice?
- Intravascular haemolysis
- Extravascular haemolysis
- Reduced hepatocyte uptake
- Enzyme defects in conjugation
- Hepatocyte damage
- Bile flow obstruction
What does pre-hepatic jaundice mean?
Excess production of bilirubin likely due to too much haemolysis
What does hepatic jaundice mean?
Problem with hepatocytes - hepatitis
What is PSC?
Primary sclerosing cholangitis
What does post-hepatic jaundice mean?
Problem with the outflow of bile perhaps outside the liver - common bile duct obstruction or inside the liver (PSC)
What is a sign of obstructive jaundice?
Pale stool and dark urine and steatorrhoea (foul smelling +foul)
NOTE: All pre-hepatic jaundice is uncojugated
NOTE: Hepatic jaundice can be conjugated or unconjugated
What are the DDx causes of Jaundice?
Intravascular haemolysis - congenital or acquired
CONGENITAL: G6PD deficiency, pyruvate kinase def, sickle cell, thalassaemia
ACQUIRED: artifical heart valves, blood group mismatch, DIC< malaria, HELLP syndrome in pregnant women
Extravascular haemolysis
CONGENITAL: Hereditary
ACQUIRED: Autoimmune
Reduced hepatocyte uptake: portosystemic shunts
Congenital enzymatic problems: Gilbert’s syndrome, Crigler-jannar syndrome
Decreased excretion of bilirubin
What is HELLP syndrome?
It is a variant of pre-eclampsia, seen in later stages of pregnancy or child birth
H- Haemolysis
EL - Elevated Liver enzymes
LP - Low Platelet count
What is an indication of extravascular haemolysis
Spherocytes
Splenomegaly
What are the causes of decreased bilirubin excretion?
Dubin-Johnson syndrome
V: Budd-Chiari syndrome (hepatic vein thrombosis)
I: Viral/bacterial hepatitis (leptospirosis or Weil’s disease)
T: Gallstones, stricture (After ERCP)
A
M: Wilson’s disease, haemochromatosis
I: Primary biliary cirrhossi, Primary sclerosing cholangitis
N: Metastatic liver cancer, hepatocellular carcinoma, pancreatic cancer, cholangiocarcinoma
E: intrahepatic cholestatis of pregnancy
What is haemochromatosis?
Absorption of too much iron Bronzed skin Polyrura Weight loss Infections
Diagnosis age 50 for men, 10-20 years after menopause
Hemosiderosis - deposition of iron in liver, pancreas,
Tx: Blood letting, medication
List the signs of dehydration
Tachycardia, narrow pulse pressure, hypotension
What do green rings around the iris/Kayser-Fleischer rings suggest?
Wilson’s disease
What does splenomegaly suggest?
Extravascular haemolysis
What ix in someone who is jaundiced and what do you look for?
FBC –> Anaemia –> Blood flim
Serum bilirubin levels –> Raised unconj –> Blood film
Liver enzymes (ALT + AST) –> Raised –> Viral serology/ASMA, ANA, AMA, Alcohol
Biliary enzymes (ALP + GGT) –> AMA, Alcohol, USS biliary tree
Urine bilirubin –> positive –> USS biliary tree
Serum amylase –> USS biliary tree
DDx of microcytosis
Thalassaemia
iron-deficiency
What is bilirubin in the urine indicative of?
Post-hepatic obsturction
What makes up a haemolysis screen?
Haptoglobins (it will be depleted)
LDH (released by haemolysed RBCs)
Direct antiglobulin test (DATs or Coombs)
Blood film
What is Antismooth muscle antibodies positive in?
Type 1 autoimmune hepatitis
What is antimitochondrial antibodies elevated in?
Primary Billiary Cirrhosis
LEARNING POINT: An USS will be good at picking up mechanical obstruction of the bile duct
IF a mechanical obstruction cannot be identified other caused such as Primary Billiary Cirrhosis or Primary Sclerosing Cholangitis should be thought of.
NOTE: Prothrombin time is an indicator of compromised liver function
What are the outcomes for Hep B
Full recovery
Carriers
Chronic symptomatic Hep B –> cirrhosis or hepatocellular carcinoma
Fulminant hepatitis
Managment of someone with Hep B
Practice safe sex Minimise alcohol consumption Avoid sharing toothbrushes or razors Trace contacts Vaccinate current sexual partners and childre n
What is the management of primary biliary cholangitis?
Raised Anti-mitochondrial antibodies (AMA) are indicative of PBC
MX: Refer to hepatologist
Confirm diagnosis via MRCP and liver biopsy
Immunosuppresion (because PBC is autoimmune mediated destruction of bile ducts)
Bile salt replacement - ursodeoxycholic acid
Fat soluble vitamin replacement - supplement A, D, E, K
Pruritis itch management - anti histamines, cholestyramine
Liver transplant
Patient with jaundice and UC, what do you immediately think of?
Primary sclerosing cholangitis
Elevated perinucear antineutrophil cytoplasmic autoantibodies PANCA
List the DDx of RUQ pain
Biliary colic Cholecystitis Duodenal ulcer Pancreatitis Basal pneumonia Ascending cholangitis Gastric ulcer Small bowel obstruction Appendicitis Hepatitis (VADA) Pyelonephritis Cancer Aortic dissection AAA Inferior MI Fitz-Hugh-Curtis syndrome (Adhesions around the liver capsule due to gonorrhoeae or Chlamydia)
DDx of midline, dull epigastric pain that moves to RUQ and back as well as right scapula (Boas’s sign)
Cholecystitis
