Signs/symptoms/management of common conditions Flashcards
Gastro-oesophageal reflux disease:
- symptoms? 6
- extra-oesophageal symptoms? 3
- heart burn (dyspepsia) esp after meals, relieved by antacids
- belching/burping
- food/acid regurg
- increased salivation (water brash)
- painful swallowing odynophagia
- fullness feeling
- nocturnal asthma
- chronic cough
- laryngitis/sinusitis
Gastro-oesophageal reflux disease:
- risk factors?
- triggers?
- causes?
- caucasian
- obese
- pregnant
- smoking
- some drugs (eg Ca channel blockers)
- alcohol
- coffee
- fizzy drinks
- chocolate
- fatty foods
- spicy foods
- hiatus hernia
- loss of sphincter tone
- abdominal pressure
Gastro-oesophageal reflux disease:
- non-pharm treatments? 7
- pharm treatments? 3
- further investigations? 3
- reduce triggers
- loose weight
- stop smoking
- take off drugs that relax muscles (Ca channel blockers, nitrites, anti-cholinergics)
- take off drugs that irritate stomach (NSAIDs, bisphosphonates)
- raise head off bed (not extra pillows)
- small meals, don’t eat 3 hours before bed
- antacids
- alginates (gaviscon)
- PPIs (better than H2-blockers)
nb antacids and alginates only relieve symptoms, don’t stop progression
- try giving pharm treatments and see if symptoms subside
- endoscopy (if symptoms >4wks on treatment or cancer red flags)
- if endoscopy negative, 24hr oesophageal ph monitoring
nb only do barium swallow if suspect hiatus hernia
Gastro-oesophageal reflux disease:
- differentials? 5
oesophagial:
- oesophagitis from corrosives/candida/etc
- hiatus hernia
Gastric:
- gastritis (eg nsaids, h pylori)
- gastric or duodenal ulcer
Other systems:
- cardiac (or pulm) disease
peptic ulcers
- two types? (which most common)
- most common causes? 2
- other risk factors? 3
- difference in symptoms between two types of ulcer?
- duodenal (90%) and gastric (10%)
- H pylori (85%)
- drug-induced (NSAIDs, SSRIs, steroids)
- smoking
- increased age
- poor gastric emptying/increased acid secretion
duodenal ulcer = pain before meals or at night (relieved by eating!) (50% asymptomatic)
gastric ulcer = pain after/during meals (also more likely to be asymptomatic)
peptic ulcer disease:
- investigations? 2
- non-pharm treatments? 5
- C13 breath test (most accurate, non-invasive h pylori test)
- if over 55 or ALARMS signs: endoscopy
nb there are other, less used, tests
- stop NSAIDs
- reduce stress
- reduce alcohol consumption
- stop smoking
- eat less trigger food
peptic ulcer disease:
- pharm treatments? 2
if h.pylori:
- triple therapy (2 Abx + PPI)
if drug-induced:
- stop drugs
- PPI (or H2-antagonist)
nb two Abx are norm clarithromycin plus amoxicillin or metronidazole
red flags for peptic ulcer disease? 7 (6 are in an acronym)
- over 55years
ALARMS
- A = anaemia
- L = loss of weight
- A = anorexia
- R = recent onset/progressive symptoms
- M = melaena/haematemesis
- S = swallowing difficulty
peptic ulcer disease:
- differentials? 7
- functional (non-ulcer) dyspepsia
- gastritis or duodenitis
- GORD/oesophagitis
- hiatus hernia
- gastric malignancy
- pancreatic cancer
- gallstones
(- duodenal crohns)
(- TB)
(- lymphoma)
also think of possible resp or cardiac conditions
IBS:
- risk factors? 2
- triggers? 4
- age + gender affected?
- FH
- mental health conditions
- stress/anxiety
- mensturation
- gastroenteritis
- certain foods/drinks
- onset norm in 20s
- 2x more women
nb there is no demonstrable abnormalities in GI tract
IBS:
- most common symptoms? 6
- crampy abdo pain (relieved by defecation/passing wind)
- diarrhoea +/or constipation
- feeling of incomplete evacuation
- passing mucus
- abdo bloating + distention
- excessive wind
nb symptoms often worse after food
nb symptoms are chronic (>6 months)
IBS:
- less common symptoms? 5
- signs on examination? 2
- lethargy
- nausea
- back ache
- urinary urgency/frequency +/- incontinence
- dyspareunia (pain during sex)
examination is normal, bar:
- general abdo tenderness
- abdo distension
IBS:
- investigations?
- differential diagnosis? 7
investigations are focused on excluding other conditions:
- crohn’s disease (blood tests + endoscopy)
- UC
- food intolerances (eg lactose, good history)
- coeliac disease (serology)
- colorectal cancer (risk factors, onset)
- ovarian cancer (risk factors, onset)
- endometriosis (symptoms)
IBS:
- non-pharm treatments? 4
- pharm treatments? 3
depends on prevailing symptoms (eg avoid sorbitol sweeteners if diarrhoea, cut dietary fibre if constipation)
- alter diet
- avoid triggers
- CBT (second line)
- probiotics
- analgesics (norm avoid NSAIDs)
- smooth muscle relaxants (eg mebeverine)
- low dose amitryptyline or citalopram (second line)
focus of treatment is symptom control
Gallstones:
- who does it affect? 4
- other risk factors? 7
- female
- fat
- fourty
- fertile
- diabetes mellitus
- crohns disease
- oral contraceptive
- HRT
- pregnancy
- smoking
- recent weight loss
nb gallstones are common!
gallstones:
- 4 different presentations?
incl signs/symptoms
biliary colic (most common):
- pain in RUQ (often severe)
- pain lasts >30 mins (<8 hrs)
- pain may radiate to back
- may have nausea + vomitting
- no fever or abdo tenderness
acute cholecystitis (2nd most common):
- same as biliary collic
- PLUS fever + tenderness in RUQ (+ve murphy’s sign)
cholangitis (rare):
- same as cholecystitis
- PLUS jaundice
(- rigors)
gallstone pancreatitis (rare):
- severe pain, radiating to back
- nausea/vomitting common
gallstones:
- bloods? 2
- other investigations? 1
- FBC (looking for ^WCC in cholecystitis)
- LFTs (obstructive jaundice)
- ultrasound is first line + most accurate imaging
nb even if imaging + bloods are normal, gallstones are not rulled out
nb can use MRCP or ERCP as follow up
nb xray very rarely helpful!
gallstones:
- non-pharm treatment? 1
- pharm treatment? 2
- surgical treatment? 1
- avoid fatty foods/drinks that trigger symptoms
- analgesia
- Abx (if clinical signs of infection)
- cholecystectomy
nb if gallstones are in gallbladder and asymptomatic then leave alone
- only if symptomatic or visualised in bile duct then treat with surgery
differential diagnosis for gallstones:
- liver? 2
- bile duct? 2
- pancreas? 2
- stomach? 3
- other GI? 2
- liver cancer
- acute hepatitis
- chorangiocarcinoma
- bile duct strictures
- pancreatitis
- pancreatic cancer
- PUD
- gastritis
- GORD
- IBS
- IBD
differential diagnoses for acute appendicitis:
- GI? 8
- urological? 3
- gynaecological? 6
- other? 2
- perforated ulcer
- acute cholecystitis
- pancreatitis
- gastroenteritis
- diverticulitis
- intestinal obstruction
- meckel’s diverticulum
- crohns disease
- cystitis
- pyelonephritis
- right uteric colic
- ectopic pregnancy
- torted ovary
- ovarian cyst
- endometriosis
- dysmenorrhoea
- Pelvic inflammatory disease/salpingitis
- mesenteric adenitis
- diabetic ketoacidosis
fibrocystic breast disease:
- cause?
- risk factors? 2
aka fibrocystic breast condition (FBC)
not fully understood, could be dt hormone levels as condition becomes rarer post-menopause
- age (30-50 highest risk)
- HRT may increase risk (contraceptive pills may decrease risk)
fibrocystic breast disease:
- clinical presentation?
- mobile/tethered?
- where on breast?
breast lump(s)
can cause discomfort (in a cyclical menstural pattern)
- intermittent/persistent breast aching or tenderness
- breast skin/nipples may be tender/itchy
- smooth (norm mobile) lumps w defined edges
- most often in upper, outer section of breast
fibrocystic breast disease:
- investigation? 1
- non-pharm treatment? 2
- pharm treatment? 1
possibly mammogram or MRI if really suspicious
- well-fitting, supportive bra (to reduce pain)
- hot or cold compress
- OTC pain killers
nb most don’t require invasive treatment
breast carcinoma
- risk factors? 13
- % of breast cancers that are found in men?
nb most related to increased unopposed oestrogen
- nulliparity (or 1st preg >30years old)
- NOT breastfeeding
- early menarche
- late menopause
- oestrogen containing contraceptives
- HRT
- increased age
- high BMI
- high alcohol intake
- lots of chest radiation
- FH
- BRCA 1 + 2 genes
- PMH of breast cancer
1% of breast cancers are found in men
nb 1 in 9 women will get breast cancer in their life
- a quarter are picked up by mammography screening
breast carcinoma:
- symptoms/signs? 4
- lump in breast (often tethered + poorly demarcated)
nb malignant lumps are often painless
- nipple changes (shape, nipple bleeding)
- skin changes (tethering, peau d’orange)
- enlarged axillary lymph nodes
breast carcinoma:
- investigations? 4
triple assessment (for all breast lumps!)
- clinical examination
- radiology (US if <35, mammography + US if >35)
- histology/cytology (norm from US guided core biopsy)
if found to be malignant, sentinel node biopsy
breast carcinoma:
- specific pharm treatment? 3
- surgical treatment?
- chemo/radiation treatment?
- tamoxifen (for oestrogen receptor +ve tumours)
- herceptin (for Her +ve tumours)
- aromatase inhibitors (eg anastrozole) reduce peripheral oestrogen synthesis, only used in post-menopausal women
depending on stage:
- wide local excision
- total mastectomy +/- breast reconstruction
- axillary node clearance (if sentinel node +ve)
adjunct chemo used in all but those with best prognosis
radiotherapy used in many
- can also radiate axilla if don’t want surgical clearance
nb tamoxifen increases risk of uterine cancer, warn patients!
MI/ACS:
- most common cause?
- non-modifiable risk factors? 3
- modifiable risk factors? 8
rupture/erosion of the fibrous cap of atheromatous plaque in coronary artery -> platelet-rich clot + vasoconstriction produced by platelet release of serotonin + thromboxane
nb can rarely be dt vasospasms or vasculitis
- older age
- male
- FH (1st degree relative had IHD <50)
- hyperlipidaemia
- hypertension
- metabolic conditions (diabetes)
- poor diet
- lack of exercise
- stress/depression
- smoking
- cocaine use
MI/ACS:
- symptoms? 8
- what is a silent MI?
- who is most likely to get a silent MI? 2
- acute central chest pain (>20 mins)
- pain in L arm, jaw or back
- anxiety (impending doom)
- fatigue
- nausea
- sweatiness
- palpatations
- SOB
MI presents without chest pain
- elderly
- diabetics
MI/ACS:
- signs? 3
nb history often more important!
- pale/grey
- sweaty (can’t fake!)
- high pulse
nb may be signs of heart failure (^JVP, , 3rd heart sound, basal crepitus)
nb may also hear pericardial rub
MI/ACS:
- bloods? 5
- other investigations? 1
- troponin
nb creatinine Kinase -MB rarely used now - FBC
- U+Es
- glucose
- lipids
- ECG (ST elevation or new LBBB)
nb in 20% of ACS, ECG is normal initially!
can do CXR to exclude differentials but don’t delay treatment to do!
MI/ACS:
- initial pharm treatment? 7 (acronym)
- treatment for STEMI? 2
BROMANCE
- beta-blockers
- reassurance
- oxygen
- morphine (IV)
- aspirin
- nitrates (GTN)
- clopidogrel
- antiEmetics (eg metoclopramide)
(nb sometimes give a NOAC as well for VTE prophylaxis)
nb don’t give B blockers if:
- bradycardiac
- hypotensive
- heart failure
- asthmatic
- fibrinolytics (rTPA)
- PCI surgery
MI/ACS
- long-term pharm treatments? 5
- long-term non-pharm treatments? 4
- aspirin
- clopidogrel
- statin
- B blocker (norm metoprolol)
- ACE inhibitor
- more exercise
- control diabetes (if relevant)
- better diet
- stop smoking
differential diagnosies for MI/ACS:
- cardiovascular? 5
- resp? 2
- GI? 3
- other? 1
angina
- pericarditis
- myocarditis
- aortic dissection
- PE
- pneumonia
- pneumothorax
- oesophageal spasm
- GORD
- acute pancreatitis
- MSK pain
Angina pectoris:
- three types?
- pathophysiology?
- stable angina
- unstable angina
- prinzmetal (variant) angina
normally atheroma -> reduced O2 supply to heart muscle -> pain
(other rarer causes)
variant angina = spasms in coronary artery
Angina pectoris:
- modifiable risk factors? 4
- unmodifiable risk factors? 6
- high fat diet
- smoking
- lack of exercise
- psychological stress
- age
- male
- FH (IHD <50yrs)
- diabetes
- hypertension
- elevated CRP
Angina pectoris:
- three features of stable angina (according to NICE)?
- triggers for stable angina, bar physical exertion? 3
- associated symptoms? 4
- constricting discomfort in:
- – front of chest
- – neck
- – shoulders
- – jaw
- – arms
- precipitated by physical exertion
- relieved by rest or GTN within about 5 mins
- emotion
- cold weather
- heavy meals
- dyspnoea
- nausea
- sweating
- light-headedness
Angina pectoris:
- non-pharm management? 3
- pharm management? 4
- stop smoking
- loose weight
- more exercise
- GTN spray (contraindicated w Viagra)
(- consider long-acting nitrate) - Beta-blocker (or Ca channel blocker)
- Aspirin
- Statin (if high chol)
nb can give K+ channel activator (eg nicorandil) if unresponsive
nb get diabetes and HTN under control too
nb consider surgery if bad
Angina pectoris differentials:
- CVS? 7
- Resp? 3
- GI? 4
- MSK? 4
- psych? 1
CVS
- MI
- unstable angina
- prinzmetal angina
- dissecting thoracic aneurysm
- pericarditis
- acute HF
- arrhythmias
Resp
- PE
- pneumothorax
- pneumonia
GI
- peptic ulcer
- ruptured oesophagus (boerhaves*)
- GORD
- pancreatitis
MSK
- costochondritis
- rib fracture
- arthritis
- pulled muscle
Psych
- anxiety/panic attack
AF
- commonest causes? 4
- other causes?
- what percentage are idiopathic (‘lone AF’)?
common:
- IHD (+/ MI or heart failure)
- HTN
- valvar heart disease
- hyperthyroidism
other:
- congenital heart disease
- caffeine/alcohol/stimulants
- sick sinus syndrome
- wolf-parkinson white
- acute infection (e.g. pneumonia)
- PE
- low K or Mg
10% are idiopathic
AF:
- risk factors? 3
- excessive alcohol + caffeine intake
- obesity
- age
AF:
- symptoms? 4
- signs? 1
- palpitations
- chest pain/dyscomfort
- dyspnoea
- faintness
nb often asymptomatic
- irregularly irregular pulse
nb if caused by valve disease then will hear a murmur (nb often mitral valve disease)
AF:
- bloods? 3
- other test needed? 1
- findings on other test? 2
- U&E
- troponin
- thyroid function test
- ECG
- absent P waves
- irregular QRS complexes
nb consider echo to look for structural abnormalities
AF:
- three TYPES of treatment?
- outline above treatment and which patients each would be suitable for
1) treat underlying cause
- suitable for:
- – acute precipitating event (alcohol toxicity, infection, hyperthyroidism)
2) Rhythm control
- suitable for:
- – younger patients (<65)
- – highly symptomatic
- – concurrent CCF
- – recent onset AF (<48hrs)
- how:
- – echo (TOE) to check for thrombus, treat with lmwh or warfarin prior to cardioversion (4 wks if thrombus found or >48hrs after start of AF)
- – pharmacological or electrical cardioversion
Rate control: - suitable for: --- older patients (>65) --- previous cardio version failure - how: --- Warfarin (or dabigitran) --- Beta blocker (or rate-limiting Ca channel blocker) (--- if fails, add amiodarone or digoxin)
Essential Hypertension:
- systolic/diastolic definition of high BP?
- % prevalence in 45-54 yo?
- % prevalence in over 75s?
- % that is actually secondary to another condition (e.g. conn’s syndrome)
over 140/90mmHg
- 30% of 45-54 yo
- 70% of over 75s
5% is secondary
Essential Hypertension:
- non-modifiable risk factors? 3
- modifiable risk factors? 4
- afrocarribean ethnicity
- increased age
- FH
- diabetes
- obesity
- high salt intake
- high alcohol intake
- smoking
Essential HTN:
- bedside tests/investigations? 3
- blood tests? 3
- BP (incl 24-hr BP monitor)
- fundoscopy (hypertensive retinopathy)
- urine dipstick (protein)
nb can also do an ECG (looking for LVH or myocardial ischaemia) or possibly even an echo
nb on cardio exam may find LV heave or artery bruits
- blood cholesterol
- fasting glucose
- U&E (see kidney damage)
Essential HTN:
- non-pharm management? 6
- pharm control for all? 1
- 1st line drug for <55 yo?
- 1st line drug for >55 yo + black ethnicity of any age?
- weight loss
- exercise
- low fat diet
- reduce salt intake
- reduce alcohol intake
- stop smoking
- statin (also diabetes control if relevant) (which one??)
<55 yo
- ACE inhibitor (or ARB if hate cough) (which ACE inhibitor??***)
> 55 yo or black
- Ca channel blocker (or thiazide diuretic) (Which Ca channel blocker???***)
DVT:
- Risk factors? 10
- increased age
- obesity
- past DVT
- pregnancy
- synthetic oestrogen
- trauma
- surgery (esp pelvic or orthopaedic)
- immobility
- cancer
- thrombophilia
DVT:
- symptoms + signs
- scoring system used?
- blood test?
- imaging?
- red
- painful
- swollen
- hot
must be UNILATERAL
- WELLS
- D-dimer (very sensitive, not specific)
(- nb could do specific bloods if suspect thrombophilia) - ultrasound of leg
DVT:
- treatment?
- prevention? 3
- high dose LMWH
- or high dose LMWH with warfarin then take LMWH off
(nb warfarin is pro-thrombotic for first 48hrs)
- low dose LMWH
- TED stockings
- stay mobile
DVT:
- infectious differential diagnoses? 3
- other DD? 4
- cellulitis
- superficial thrombophlebitis
- insect bite
- ruptured baker’s cyst
- sprain/rupture achilles tendon
- physical trauma (imvl haematoma)
- peripheral (stasis) oedema (or lymphedema)
nb other rarer causes (e.g. compartment syndrome)
Common causes of heart failure:
- Right-sided? 4
- Left-sided? 4
Right-sided
- LVF
- pulmonary stenosis
- Right ventricular MI
- lung disease (cor pulmonate)
Left-sided
- Left-ventricular MI
- hypertension
- aortic stenosis
- mitral or aortic regurg
nb CCF = right AND left failure
nb rare causes include steroids, come chemo, cocaine and other stuff
Signs + symptoms of heart failure:
- Right-sided? 6
- Lef-sided? 10
Right-sided
- peripheral oedema
- ascites
- nausea
- anorexia
- pulsation in neck + face (RHF -> tricuspid regurg)
- murmur (+/or 3rd ‘gallop’ heart sound)
Left-sided
- fatigue
- wheeze (cardiac ‘asthma’)
- SOB
- poor exercise tolerance
- displaced apex beat
- cold peripheries
- nocturnal cough (+/- pink frothy sputum)
- orthopnoea
- paroxysmal nocturnal dyspnoea (PND)
- nocturia
nb think logically about the back-up of fluid when each side of the heart has failed
Heart failure:
- blood tests?
- other investigations? (and what they show)
- BNP
- FBC
- U&E
(- LFT, may cause hepatic-congestion) - ECG (indicate cause)
- CXR (ABCDE)
- – Alveolar oedema (bat wing shadow)
- Kerley B lines (interstitial oedema)
- – Cardiomegaly (heart width >50%)
- – Dilated prominent upper lobe vessels
- – pleural Effusion (blunting of angles)
- Echocardiogram
- – valvular defects, previous MI, ejection fraction, hypertrophy etc
Heart failure differential diagnoses:
- conditions causing dyspnoea? 5
- conditions causing peripheral oedema? 6
dyspnoea DD:
- COPD
- asthma
- PE
- lung cancer
- anxiety
peripheral oedema DD:
- prolonged inactivity
- venous insufficiency
- nephrotic syndrome
- hypoalbuminaemia
- some drugs (some Ca channel blockers, NSAIDs)
- obesity
Diabetes Mellitus type 2:
- pathogenesis?
- norm age of onset?
- non-modifiable risk factors? 6
- modifiable risk factors? 3
- medications that increase risk? 3
- pathogenesis?
decreased insulin secretion +/- insulin resistance
- 40-50 (but can get MODY)
- family history
- PMH of gestational DM
- PMH of polycystic ovary syndrome
- PMH of HTN
- black or asian ethnicity
- low birth weight
nb metabolic syndrome = high blood sugar, high cholesterol, HTN + central obesity
- obesity
- inactivity
- low fibre/high sugar diet
(nb smoking + alcohol also increase risk) - statins
- corticosteroids
- thiazide diuretic + B blocker
type 2 Diabetes Mellitus:
- symptoms? 12
MOST type 2 DM is ASYMPTOMATIC until complications occur!!
- poyluria
- polydipsia
- increased hunger
- fatigue
- unexplained weight loss (or gain?)
- blurred vision
- headaches
- recurrent infections
- poor wound healing
- recurrent vaginal thrush
- acanthosis nigrocans
- numbness/tingling of feet
type 2 Diabetes Mellitus:
- signs on examination? 2
- blood tests? 2 (incl abnormal numbers)
- diagnostic criteria? 2
- other bedside test? 1
- diabetic retinopathy
- diabetic nephropathy
- blood glucose (see below)
- HbA1c >48mmol/L
- symptoms of hyperglycaemia PLUS fasting glucose of >7mmol/L or random glucose of >11mmol/L (or HbA1c >48mmol/L)
- asymptomatic but with two separate positive glucose blood tests
- urine dipstick
type 2 Diabetes Mellitus:
- non-pharmacological treatment? 3
- 3 classes of drug used (bar insulin)? + examples?
- what’s 1st line etc?
- loose weight
- more high fibre/low sugar diet
- exercise more
- metformin
- sulphonylureas (gliclazide)
- thiazolidinediones (pioglitazone)
metformin is first line (titrate up to minimise GI upset + monitor renal function)
gliclazide as mono therapy or w metformin is 2nd line
thiazolidines are third line if metformin +/- gliclazide contraindicated or not adequate (even then you’d norm start on insulin)
nb many other drugs as well…