test - Split (1) Flashcards
abdoPainDDX
can be by region or by organ. GASTRO: i) Gastroduodenal (PUD, gastritis, malignancy, gastric volvulus. ii) Intestinal (appendicitis, obstruction, diverticulitis, gastroentereitis, mesenteric adenitis, strangulated hernia, IBD, inutssusception, volvulus, TB) iii) Hepatobiliary (acute/chronic cholecystitis, cholangitis, hepatitis) iv) Pancreatic (acute/chronic pancreatitis, malignancy) v) Spleen (infarct, spontaneous rupture). URINARY: cystitis, acute urinary retention, acute pyelonephritis, ureteric colic, hydronephrosis, tumour, pyonephrosis, PCK. GYNAE: ruptured ectopic, torsion of ovarian cyst, ruptured ovarian cyst, salpingitis, severe dysmenorrhoea, mittelschmerz, endometriosis, red degeneration of a fibroid. VASCULAR aortic aneurysm, mesenteric embolus, mesenteric angina, mesenteric venous thrombosis, ischaemic colitis, dAA. PERITONEUM secondary peritonitis, primary (rare). ABDO WALL: strangualted hernia, rectus sheath haematoma, cellulitis. RETROPERITONEUM: retroperitoneal haemorrhage (eg anticogaulants). REFERRED PAIN: AMI, pericarditis, test torsion, pleurisy, herpes zoster, lobar pneumonia, thoracic spin disease (eg disc, tumour). MEDICAL (all rare): hypercalcaemia, uraemia, DKA, sickle cell disease, addisons, acute intermittent porphyria, Henoch-Schonlein purpura, tabes dorsalis
acuteAngleClosureGlaucomaEx
hazy, semi-dilated pupil
acuteAngleClosureGlaucomaHx
photophobia, visual disturbances, seeing haloes, painful red eye
acuteAorticDissection(AAA)Epi
elderly males with HTN, or younger pts with CTD (Marfan or Ehlers-Danlos or fam hx)
acuteArterialOcclusionEx
6Ps: pain, pallor, pulseless, paraesthesia, paralysis, perishingly cold
acuteArterialOcclusionHx
sudden, pain, can’t move, feels cold
acuteCoronarySyndrome(ACS)-STEMIEx
clammy, sweaty, sob, pale, alternatively: cardiac arrhytmias, heart failure, severe hypotension w cardiogenic shock, ventricular septal rupture/papillary muscle rupture, systemic embolism or pericarditis
acuteCoronarySyndrome(ACS)-STEMIHx
central, heavy, burning, crushing, tight retrosternal, lasting for several minutes, not relieved by SL GTN, anxiety, SOB, N/V, pain rad to neck/jaw/arms/back occasionally epigastrium (or may present at these sites alone) ** atypical presentations in elderly, diabetics, and females
acuteCoronarySyndrome(ACS)-STEMIIx
ECG: TWI or STEMI in contigious leads. Posterior infarcts = tall R and STDep in V1-4
acuteCoronarySyndrome(ACS)-STEMIRf
cig, htn, age, dm, hyperchol, male, fam hx, previous angina/heart failure
acuteKidneyInjury(AKI)DDX
- Prerenal (low BP, hypovol, renal artery occlusion from mass or emboli), 2. Renal (intrinsic pathology eg GN, vasculitis, drugs), 3. Post renal (outflow obstruction, ureter, bladder, urethra, due to enlarge prostate, single functioning kidney with calculi, pelvic mass/surgery)
acuteKidneyInjury(AKI)Dx
acute rise in baseline urea and cr +/- oliguria
acuteKidneyInjury(AKI)Ex
volume status, BP, HR, JVP, basal creps, gallop rhyth,, oedma, palpable bladder
acuteKidneyInjury(AKI)Hx
previous renal problems, comorbidities, UO, fluid intake, nephrotoxic medication? (eg NSAIDS, gentamicin, IV contrast)
acuteKidneyInjury(AKI)Ix
urine (colour, hourly volume, dipstick, MCS, osmolality and sodium osmolality), Bloods: FBE (hyperK), UEC, LFT, CK, CRP, osmolality, ESR, Clotting. ABG to look for acidosis, ECG, CXR, urinary tract USS
acuteKidneyInjury(AKI)Rx
IDC (to monitor UO), cause dependent (ie IDC, or fluids if shocked, or frusemide and O2 if overloaded, ins/gluc, cagluc, salbutamol if hyperK associated)
ankleInjuryHx
immediate swelling and inability to WB = serious and suspicious for lig tear/fracture
ankleSprain/Dislocation/FractureScore
Ottawa Foot Rule: 98% sensitive: Request foot x-ray if there is PAIN in mid-foot AND one of these: 1) tender over the base of fifth metatarsal, 2) tender over navicular, 3) unable to WB (ie 4 steps) after injury AND in ED. Ottawa Ankle Rule: Request ankle AP and LAT xray if, Malleolar pain (ie bwn medial and lateral malleolus) AND on of these: 1) bone tenderness over the post edge or tip of distal 6cm of medial OR lateral malleolus, 2) inability to WB within 1st hour and in ED.
anorectalPainDDX
ACUTE: fissure-in-ano, perianal haematoma, thrombosed haemorrhoids, perianal abscess, intersphincteric abscess, ischiorectal abscess, trauma, anorectal gonorrhoea, herpes. CHRONIC: fistula-in-ano, malignancy, chronic perianal sepsis (eg crohns disease, TB), proctalgia fugax, solitary rectal ulcer, cauda equina lesions
aorticStenosis(AS)Aetiology
- stenosis 2ndary to rheumatic heart disease, 2. calcification of bicuspid aortic valve. 3. calcification of tricuspid aortic valve in the elderly
aorticStenosis(AS)Complications
arrhytmias, Stokes-Adams attacks (sudden death), MI, LVF. Only years to live, correlates with symptom severity
aorticStenosis(AS)Epi
M>F. old. bicuspid aorta leads to presentation earlier
aorticStenosis(AS)Ex
narrow pulse pressure, slow-rising pulse, thrill in aortic area, forceful sustained thrusting undisplaced apex beat, harsh ESM, rad to carotids and apex, S2 softened, bicuspid valve may produce an ejection click
aorticStenosis(AS)Hx
SAD (syncope/dizzy on exertion, angina, dyspnoea and other signs of heart failure)
aorticStenosis(AS)Ix
ECG: LVH, LBBB, CXR showing post-stenotic enlargement. ECHO. Angio
aorticStenosis(AS)Rx
Surgery (replacement, balloon dilation (valvoplasty), management of LVF medically, ABX prophylaxis against infective endocarditis
ascitesDDX
HEPATIC: cirrhosis, hepatic tumors, MALIGNANCY: carcinomatosis, abdominal/pelvic ca (primary/secondary), pseudomyxoma peritonei, primary mesothelioma. CARDIAC: card failure, constrictive pericarditis, tricuspid incompetence. RENAL: nephrotic syndrome. PERITONITIS: TB, Spont bacterial. VENOUS OBSTRCUTION: Budd-Chiari syndrome, veno-occlusive disease, hepatic portal vein obstruction, inferior vena cava obstruction. GI: pancreatitis, malabsorption, bile ascites.
backPainAetiology
Most pts in primary care (>85%) have nonspecific low back pain, meaning that the patient has back pain in the absence of a specific underlying condition that can be reliably identified
backPainDisp
HOME: Home care in simple lower back pain: Address the factors that contribute (ie bad work practices and lifting techniques, poor posture, being overweight, lack of exercise, pregnancy, stress, smoking). In the first two to three days patient should aim to minimise pain and assist healing. Ice to back wrapped in towel for 20 minutes, every one to two hours when awake. Avoid ‘HARM” – Heat, Alcohol, Re-injury and Massage for the first few days. Avoid activities you do not really need to do. Sit as little as possible until the pain settles. Avoid extended car travel unless absolutely necessary. When resting, lie in a comfortable position, supported by pillows if necessary. Keep moving as much as possible. Take painkillers when necessary. Physiotherapy as soon as possible.
backPainEx
scoliosis, kyphosis, bony tendereness, paraspinal tenderness, reduced range of movement (especailly flexion), pain on straight leg raise, lower limb neurology in motor, sensory, reflexes, expansile abdo mass. PR exam for decreased tone or sensation
backPainHx
trauma/lifiting, location of pain, duration, aggrevating/relieving factors, radiation, pain in joints, pain or tingling in legs, leg weakness, bladder retention or incontinence, faecal incontinence, altered sensation on passing stool, LOW. PMH: previous, neurological problems, osteoporosis, anaemia. DH: steroids, analgesia. FH: joint or back problems. SH: occupation involves lifting or prolonged sitting
backPainScore
RED FLAGS: Age of onset 55 years? First presentation? Ill health or presence of other medical illnesses? Urinary/bowel incontinence? Saddle anaesthesia? Progressive neurological deficits? Disturbed gait? Malignancy? Current or history of? Fevers/night sweats? Unexplained weight loss? History of trauma? IVDU? Immune suppresed? (ie. HIV, Steroids) Symptoms worse at night? YELLOW FLAGS (psychosocial factors shown to be indicative of long term chronicity and disability) i) Negative attitude that back pain is harmful or potentially severely disabling? ii) Fear avoidance behaviour and reduced activity levels? iii) An expectation that passive, rather than active, treatment will be beneficial iv) A tendency to depression, low morale, and social withdrawal v) Social or financial problems
bronchialCarcinomaHx
low, smoking,
bronchiectasisHx
purulent long-standing sputum production
brugadaSyndromeDisp
Cardio for further evaluation and risk stratification
brugadaSyndromeHx
Fam hx of sudden death? Fever? Anti-arrhytmic? (bc ECG pattern sometimes only seen in fever or after taking anti-arrhytmic drugs (particularly 1C - flecainide, propafenone)
brugadaSyndromeIx
ECG: RBBB morphology, coved ST segment elevation in V1-2 with terminal TWI.
budd-ChiariSyndromeIx
LFT for inc transaminases. FBE, UEC, clotting, thrombophillia screen. Doppler US for flow in hepatic vein. Hepatic venogram.
budd-ChiariSyndromePatho
obstruction to hepatic venous outflow (from hypercoagulable state) resulting in abdo pain, ascites, jaundice, encephalopathy, variceal bleeding and hepatosplenomegaly (due to portal hypertension)
cardiacTamponadeEx
tachycardia, hypotension, pulsus paradoxus, raised JVP which rises on inspiration (ie Kussmaul’s sign)
cardiovascularHx
chest pain, palpitations, soboe, PND, orthopnoea, ankle swelling, claudication
caudaEquinaSyndrome(CES)Aetiology
Sun et al. SR found that cauda equina syndrome was caused by prolapse of the intervertebral disc in 22.7 percent of cases, ankylosing spondylitis in 15.9 percent, lumbar puncture in 15.9 percent, trauma in 7.6 percent, malignant tumor in 7.2 percent, benign tumor in 5.7 percent, and infection in 5.3 percent
cellulitisAetiology
beta-haemolytic strep, S.Aureus, MRSA, Gram-Neg aerobic bacilli (minor number of cases)
cellulitisEx
Clinical symptoms: Erythema, oedema, warm, Entry source: toe web intertrigo, injection sites
cellulitisHx
slow onset (days cf erysipelas which is more accute), swelling, warmth, +/- purulent drainage. most often on lower limbs, but may also be eyes, abdo (in morbid obese)
cellulitisPatho
DDX is erysipelas. E involves upper dermis and superficial lymphatics, whilst C involves deeper dermis and subcut fat. Therefore in E, there is a sign (milian sign) behind the ear, as this are does not have any deeper dermis. E in young and old. C in mid-age-group
cellulitisRf
skin disruption, preexisting skin infection, inflammation (eg eczema / radiotheraphy), odema due to venous congestion, lymp obstruction post surgery. Most important entry is perhaps the skin bwn toes (toe web intertrigo)
cellulitisRx
mark the area w a pen, elevation, hydrate the area to avoid cracks, treat the underlying condition if one found (tinea pedis, lymphoedema, chronic venous insufficiency), diuretics, compressive stockings, ANTIBIOTICS: empirical eTG tba
chestPainDDX
Life-threats: ACS, PE, Aortic dissection, TPT. Complete list: CV (angina, AMI, acute aortic dissection, pericarditis) GI (reflux oesophagitis, PUD, oesophageal spasm, oesophageal rupture, hiatus hernia, biliary colic/cholecystitis, subdiaphragmatic irritation), Pulmonary (Pneumonia, Ptx, PE, pneumomediastinum, pleurisy), MSK (fractured ribs, chest wall injuries, herpes zoster, costocohonditis, secondary tumors to rib) Emotional (Depression) Pleuritic chest pain = Ptx, PE, pericarditis, PE, pneumonia, pleurisy, rib #, costochondritis
chestPainDo
IV, cardiac monitor, sats, O2>94%, FBE, UEC, LFT, Troponin, ECG, repeat in 10min if 1st ECG is non-diagnostic. CXR mainly looking for APO, cardiomegaly, atelectasis. Aspirin 150-300mg, gtn SL (0.6mg tab or 0.4mg spray)
chestPainEx
end-of-bed-quick-look-test, vital signs, appearance (marfanoid - predisposing to aortic dissection), HEENT: xanthelasma = hyperchol, thrush associated with oesophageal candidiasis. RESP:
chestPainHx
site, onset, character, radiation, association, time course, exacerbating/relieving factors, severity, pleuritic, hx of heart disease, similar to previous episodes, PMH: card/respiratory problems, DM, GORD. Drugs: cardiac/resp meds. antacids. FamHx: IHD, premature cardiac death. SHx: smoking, exercise tolerance.
chronicBronchitisEx
hyperexpanded chest, decrased inspiratory movement
chronicBronchitisHx
purulent long-standing sputum production
clavicle#Anatomy
Clavicle = 1st bone to ossify. The only bony connection between arm and the trunk. Articulated distally with acromion and prox with sternum by Atypical synovial joints, because (fibrocartilage not hyaline cartilage). “S” shape. The proximal half curves outward (convex) providing space for the neurovascular bundle of the upper limb. The distal half = concave. # at the junction (midshaft) between these two curves, most likely because this area i) lacks ligamentous attachments to adjacent bones and is the bone’s ii) thinnest segment. Displacement = Proximal fragment superiorly (cephalad) by the pull of the SCM. Distal = inferiorly (caudad) by the weight of the arm. Shortening often occurs (because subscapularis and pectoralis muscles, which internally rotate and pull the arm towards the chest). Even though the clavicle is subcutaneous, with only a thin layer of overlying soft tissue, open fractures are uncommon. However, tenting (ie, taught stretching) of the overlying skin is relatively common. If left uncorrected, tenting may lead to necrosis of the overlying skin and conversion to an open fracture. Tenting is therefore an indication for closed reduction or surgical repair.
clavicle#Anticipate
scapula #, rib #, hemothorax, pneumothorax, brachial plexus injury
clavicle#Dx
Fall on shoulder. direct violence, or FOOSH. Fractures bwn middle and outer third in adults. greenstick in kids. c/o pain. Ex: local deformity. tenderness. Look for tenting! as this is a sign of potential evolving necrosis/needing operative mx. AP X-ray shows the #
clavicle#Ex
crepitus, tenderness, neurovascular exam: lung exam:
clavicle#Hx
fall on shoulder, pain, snapping, cracking, swelling
clavicle#Ix
AP Xray. Sometimes need a 45-degree cephalic tilt view to see midshaft clav fracture
clavicle#Note
69% middle 3rd, 28% distal, 3% proximal /// 87% of clav # are from fall on shoulder, 7% direct blow, 6% FOOSH.
clavicle#Rx
SUPPORT: triangular sling, PAIN: analgesia. SWELLING: ice. OPERATIVE: if nerves/vessels compromised. F/U: Refer to next # clinic. Note: NO longer use of figure of 8 bandage as uncomfortbale and ineffective.
clusterHeadachesHx
retro-orbital pain
coffeeGroundVomitingAnticipate
melena
coffeeGroundVomitingDDX
upper GI bleeding
coffeeGroundVomitingPatho
iron exposed to gastric acid –> oxidization
commonFibular/PeronealNerveAnatomy
MOTOR: Innervates the short head of the biceps femoris directly. Also supplies (via branches) the muscles in the lateral and anterior compartments of the leg. SENSORY: Innervates the skin over the upper lateral and lower posterolateral leg. Also supplies (via branches) cutaneous innervation to the skin of the anterolateral leg, and the dorsum of the foot. Clinical EFFECT of damage: Foot drop, Sensory loss to the dorsal surface of the foot and portions of the anterior, lower-lateral leg. NOTE: A common yoga kneeling exercise, the Varjrasana, has been linked to a variant called yoga foot drop.
commonFibular/PeronealNerveRf
damaged by: fibula fracture, too tight cast
conn’sSyndromeHx
few sx. but HTN, may give headache and poor vision. muscle weakness, spasms, tingling sensation, xs urination. Complications with stroke, AMI, kidney fail, arrhytmia
conn’sSyndromePatho
too much aldosterone –> low renin.
conn’sSyndromeSyn
eponym for primary hyperaldosterism.
constipationDDX
i) Obstruction (diverticular disease, colonic carcinoma, extrinsic compression), ii) Painful anus (fissure-in-ano, perianal abscess, strangulated haemorrhoids, post-haemorrhoidectomy), Adynamic bowel (paralytic ileus, spinal cord injury), Endocrine (diabetes, autonomic neuropathy, myxoedema, hyperparathyroid), Drugs (codeine, morph, TCA, atropine, laxative abuse), Other(dietary changes, anxiety, depression, irritable bowel syndrome, generalised disease, starvation) Congential (Hirschsprungs)
constipationHx
what does the pt mean? abdo pain, distension, N/V, haemodynamic status, absent/tinkling bowel sounds, LOW, PR bleeding
costochondritisAetiology
3 I’s. Idio, infection (direct or haem), inflammation (microtrauma, cough, unaccustomed upper limb movement)
costochondritisEpi
common. females >40y.
costochondritisRx
ABx not effective because cartilage has poor blood supply
diabeticKetoAcidosis(DKA)Hx
4 situations equal incidence. 1. precipitant (infection, stress), 2. treatment non-compliance, 3. new diagnosis, 4. no known precipitant event
diabeticKetoAcidosis(DKA)Patho
xs stress hormones antagonises actions of insulin, the pathogenesis requires two events: (i) increased mobilisation of FFA and, (ii) a switch of hepatic lipid metabolism to ketogenesis.
dvtEx
pain, tenderness, swelling, heat, oedema, Homans signs (on dorsiflexion) - to do or not do?
dvtRf
Malignancy, Presence of a central venous catheter, Surgery, especially orthopedic, Trauma, Pregnancy, OCP, HRT, Tamoxifen, Thalidomide, Lenalidomide, Immobilization, Congestive failure, Antiphospholipid antibody syndrome, Myeloproliferative disorders (eg Polycythemia vera, Essential thrombocythemia/thrombocytosis), Paroxysmal nocturnal hemoglobinuria, Inflammatory bowel disease, Nephrotic syndrome, Inherited thrombophilia (ie Factor V Leiden mutation, Prothrombin gene mutation, Protein S or C deficiency, Antithrombin (AT) deficiency, Dysfibrinogenemia)
dyspepsia(Indigestion)Hx
epig pain related to hunger, eating, specific foods, time of day, bloating, fullness, heartburn. alarms symptoms = anaemia (IDA), LOW, anorexia, recent onset of progressive sx, melaena/haematemesis, swallowing difficulty
dysphagiaHx
- difficulties swallowing solids AND liquids from the start (yes = motility, no = stricture benign or malignant) 2. difficult to make the swallowing movement (yes = ?bulbar palsy especially if coughing on swallowing) 3. odynophagia (yes = ca, ulcer, spasm) 4. intermittent or constant and getting worse (intermittent = oesophageal spasm, latter = malignant stricture) 5. does the neck bulge or gurgle on drinking (yes = pharyngeal pouch)
dyspnoea(SOB)DDX
Sudden (ptx, chest trauma, aspiration, anxiety, APO, PE, anaphylaxis) Acute (asthma, resp tract infection, pleural effusion, lung tumours, metabolic acidosis) Chronic (COPD, anaemia, valvular heart disease, cardiac failure, CF, idiopathic pulmonary fibrosis, chest wall deformities, neuromuscular disorders, pulm HT)
dyspnoea(SOB)Ex
cyanosis (peripheral and or central), kyphosis, conscious state, barrel-chest, pursed-lip breathing, accessory muscle use, clubbing, pulse rhythm, JVP, temperature, traceha, expansion, percussion (dull or resonant. note ptx presents initially with ‘relative dullness’ on unaffected side), murmurs, third heart sound, quiet heart sound in COPD, breath sound volume, wheezing, crepitations, fine inspiratory creps (IPF)
dyspnoea(SOB)Hx
onset, precipitants, relieving factors, associated with cough, sputum, blood stained, haemoptysis, wheezing
earpainDDX
Primary (OM, OE, other infections) Secondary (referred, eg neuralgia, neoplasma, odontogenic)
earpainEx
Otoscopy
earpainHx
pain, pruritus, discharge, hearing loss, any known tympanic membrane perforation, previous ear infections, any prior ear surgery, recent ear instrumentation, and water exposure
enoxaparinRx
DVT/PE prophylaxis 20-40mg/24h depending on renal function. DVT/PE treatment: 1.5mg/kg/24h. ACS treatment: 1mg/kg/12h. CONTRAINDICATIONS: bleeding disorders, thrombocytopenia, severe HTN, recent trauma. CAUTION: hyperK, hepatic/renal impairment. SIDE EFFECT: haemorrhage, thrombocytopenia, hyperK. INTERACTIONS: NSAIDS increases bleeding risk. effect increased by GTN
epiduralHaemorrhage(EDH)Anatomy
1) usually from temporal bone fracture, across the groove of the middle meningeal artery. 2) biconvex shape due to intimnate attachement of dura to inner table, which therefore inhibits soread of blood
epiduralHaemorrhage(EDH)Hx
lucid interval bwn trauma and appearance of symptoms
epiduralHaemorrhage(EDH)Ix
CTB: footbal (biconvex)
erysipelasEx
Miian ear sign (because there is now deeper dermis there!), butterfly involvement of the face
essentialHTNDDX
Renal (GN, DMNephropathy, renal art stenosis, chronic pyelo, PCKD, CTD (eg systemic sclerosis)), Endocrine(cushings, conn’s, pcc, acromegaly), Drugs (Oestrogen-OCP, Corticoids (eg corticosteroids, liquorice), MAOIs and thiamine, sympathomimetics ()), CV, Pregnancy (pre-eclampsia)
essentialHTNEpi
> 90% of HTN are essential
fibula#(Isolated)Ex
neurovascular. focus on common peroneal nerve (ie foot drop, lost sensation to dorsum and lateral leg)
fibula#(Isolated)Hx
direct blow to lateral leg, local pain, swelling, walking-difficulties
fibula#(Isolated)Ix
full length AP and lateral X-ray of tib and fib + ankel and knee joints
fibula#(Isolated)Rx
Support: firm crepe bandage with cotton-wool padding OR below-knee walking plaster, Refer: to fracture clinic
fissure-in-anoHx
constipation, pain on defecation, blood on paper.
gaitEx
initiation, festination, hesitancy, stride length, base (narrow or wide)
gastrointestinalHx
Symptoms: top-to-bottom. Appetite, taste, vomiting, dysphagia, reflux, abdo pain, nausea, opening of bowels, change in stool habit, bowel movement frequency, consistency, colour, pain on passing, recurrent urge, blood (bowl or paper), offensive smell, mucus. Allergies: MEDs: NSAIDs, anticoagulants, hepatotoxics drugs, opioids, laxatives. PHx: GI bleeds, gord, varices, gallstones, liver problems, jaundice, IBD, haemorrhoids, polyps. FamHx: IBD, liver disease, cancer. SHX: foreign travel, illicit drug use, IVDU, etoh.
gcsScore
eye (spontaneous, voice, pain, none), verbal (oriented, confused, inappropriate, incomprehensible sounds, none), motor (command-following, localises, withdrawal, decort, decerebrate, none)
goodpasturesSyndromeHx
haemoptysis, haematuria, renal disease
haemoptysisDDX
Resp (bronchial carcinoma, pneumonia, TB, chronic bronchitis, bronchiectasis, pulmonary oedema, Goodpasture’s, Wegners), Vascular (PE, pulmonary HTN (mitral stenosis), hereditary haemorrhagic telangiectasia), Systemic (coagulation disorders)
haemoptysisDx
sob, sudden (PE, resp infection) or chronic (rest of ddx), pink stained = APO, long-standing sputum = bronchiectasis/chronic bronchitis, flecks of blood = TB, lung ca, mitral stenosis, LOW, other sites of bleeding (haematuria = Goodpastures, epistaxis = wegners and HHT), rheumatic fever, co-existing renal disease
haemoptysisEx
clubbing, cachexia, malar flush, small dilated blood vessels on mucus membranes, JVP, hyperexpanded chest, decrased inspiratory movement, supraclavicular lymphadenopathy, calves for dvt
haemoptysisIx
sputum, ecg, fbe, uec, clotting scree, cxr, bronchoscopy. Specifics (mantoux, urin analysis for red cell casts with GN due to goodpastures or wegners), antiglomerualr basement antibodies, c-ANCA, renal biopsy, tissue biopsy of lung, ct PA, tte
headacheAlternatives
Primary (migraine, tension, cluster, miscellaneous benign types) 2. Secondary (head injury, vascular (bleed, thrombous, malformation), non-vasc intracranial (inc CSF pressure, SOL), substance abuse or withdrawal, infection (meningitis, encephalitis), metabolic (hypoxia, hypercapnoea, hypogly, CO poisoning, dialysis), craniofacial disorder (eg referred pain), neuralgias (trigeminal, occipital, other cranial nerves)
headacheDDX
- Acute (trauma, cerebrovascular (SAH, intracranial bleed/infarction), systemic infection, meningitis, acute angle-closure glaucoma). 2. Chronic or recurrent (tension, migraine, cluster, drugs (eg GTN, nifedipine, substance withdrawal (etoh), psych (inc anxiety and depression). raised ICP (from tumour, hydrocephalus, abscess, benign), temporal arteritis, pre-eclampsia, paget’s disease of bone, severe HTN, CO poisoning
headacheDx
associated worrying features? severe and/or first? chronic unresponsive to treatment? Onset over minutes (primary headaches), hours/days (meningitis), days/weeks (raised ICP) sudden/gradual, severity, altered LOC, fever, vomiting, phonophobia, photophobia, recent LP
headacheEx
Vitals, Head for injury/tenderness, Eyes: VA, conjunctival infection (occurs with acute attacks of cluster headaches and angle-closure glaucoma), pupil reactions, eye movements, papilloedema. Sinuses: palpate for infection/tenderness, Ear: haemotympanum, infection. Oral cavity: infection. Skin: rash, purpura, petechial haemorrhages.
headacheIx
temp
hereditaryHaemorrhagicTelangiectasiaEx
small dilated blood vessels on mucus membranes
hereditaryHaemorrhagicTelangiectasiaHx
haemoptysis, epistaxis
herpesZosterDisp
postherpatic neuralgia occurs after the acute episode and is difficult to treat. get expert help
herpesZosterHx
unilateral dermatomal distribution of chest pain for 2-3days, then rash. Rash = redening, maculopapular evolving into vesicular lesions. How long since vesicle eruption
herpesZosterRx
opioids and steroids for pain releif. Aciclovir 800mg PO five times per day for 7days (or famciclovir 250mg PO TDS for 7days if seen within 72 hours of vesivle eruption)
hyperKalaemiaDDX
1) Pseudo (Delay in separating red cells, haemolysis, Severe leucocytosis/thrombocytosis), 2) Excessive intake (Exogenous: IV or oral KCl, massive blood transfusion, Endogenous/Tissue necrosis Burns, Ischaemia, Trauma, rhabdo, Tumour lysis) , 3) Decrease renal excretion (Drugs interferring w excretion (ie K-sparing diuretics (spirnolactone, amiloride), ACEi/ARBs, NSAIDs, Calcineurin inhibitors, trimethoprim, pentamidine), Renal failure, Addison’s, Hyporeninaemic hypoaldosteronism, 4) Compartmental shift (acidosis, insulin deficiency, digoxin OD, Succinylcholine, Fluoride poisoning, Hyperkalaemic periodic paralysis)
hyperKalaemiaDx
Conscious state, chest pain, palpitations, dizzy, abnormal ECG, breathlessness (due to acidosis), paraesthesia, areflexia, wekaness, abdo pain, hypoglycaemia, hyperpigmentation (ie addisons)
hyperKalaemiaEx
haemodynamic unstable, pulse irregular, stigmata of renal failure
hyperKalaemiaIx
Repeat UEC, dig levels (bc dig toxicity will worsen hyperK), ABG for acidosis if renal fail, ECG (Peaked T, prolonged PRI, broad QRS, flat P, VF), FBE for haemolysis, CK for crush, cortisol (which will be down in addisons)
hyperKalaemiaPhys
K is excreted main (95%) by kidney, rest by gut. excretion is slow. hormonal and acid-base systems shifts K into cell.
hyperKalaemiaRx
1) Stop the cause and nephrotoxics, 2) CaGluconate 10% IV 5-10ml or 15g PO (protects), 3) Salb nebulized 10-20mg, Insulin20U with Dextrose 50g, or IV Sodium Bicarb 50-200mmol (move into cells), 4) Frusemide+resonium, refractory or acidosis –> dialysis (inc excretion)
hyperTensionEx
comfortable/distressed/critical, BP bilat, HR? (brady+htn = increased ICP, tachy+htn = catecholamine), Lungs (Crackles = APO) Note: atheroscleosis/obese measured with small cuff may read facticously too high,
hyperTensionHx
- An emergency? (Aortic dissection, chest pain, arrhytmia, SOB (APO, AMI), sudden headache, vomiting, confusion, seizure) 2. MAOI antidepressant (Isocarboxazid (Marplan), Phenelzine (Nardil), Selegiline (Emsam), Tranylcypromine (Parnate)) 3. AntiHTN meds normally taking
hyperTensionRx
O2>94%,
hypoCalcaemiaDDX
1) Major cause is hypoPTH (form surgery, thyroid dis, autoimm, developmental abn of PTH gland.
hypoCalcaemiaDisp
Calcium-vitD tablet, Complications: seizures, arrhytmias, cataracts, bone #
hypoCalcaemiaDx
dec GCS, chest pain, palpitations, dec BP, abn ECG
hypoCalcaemiaEx
hyperreflexia, tetany, Trousseau’s (ie spasm of hand from inflated BP cuff for 3-5min), Chovstek’s (uni and ipsilat twitch of face from tapping the facial nerve 2cm anterior to audiory meatus), dec BP, bradycardia, arrhytmia, concern is tetany –> laryngospasm
hypoCalcaemiaHx
carpopdeal spasm, twitching of muscle, tingling around mouth, distal paraesthesia, fatigue, depression, dry skin, coarse hair,
hypoCalcaemiaIx
UEC, CMP, Albumin, ALP, PTH, VitD, ECG: prolonged QT, ST abn, arrhytmias
hypoCalcaemiaPatho
loss from ECF is greater than replacement from intestines and bones. Concern is laryngospasm!
hypoCalcaemiaPhys
albumin binds 40% of ecf Ca, so need to correct. Levels controlled by vitD and PTH
hypoCalcaemiaRx
if severe tetany: 10ml 10% ca gluc over 10min. correct other elec deficiencies, if mild/asymp - monitor. **Need to correct hypoCa before acidosis if that is present, bc correcting acidosis w bicarb will make the ca fall even further
hypoKalaemiaDDX
Decreased intake (K-free IV fluids, reduced oral intake). Excessive loss from Renal, GI, Endocrine. Renal (diuretics, renal tubular disorders). GI (diarrhoea, vomiting, fistulas, laxatives, villous adenoma). Endocrine (cushing’s syndrome, steroids, hyperaldosteronism, alkalosis)
hypoKalaemiaHx
chest pain, palpitations, muscle weakness, myalgia, constipation, paralytic ileus, cardiac arrhytmia (ranging from ectopics to serious arrhytmias), hypotonia
hypoKalaemiaIx
UEC, BSL for DKA. ABG for metabolic alkalosis. ECG (flattened T, ST dep, U waves, prolonged QT). CMP (look for decrease, as magneisum is required for adequate processing of K+). Plasma aldosterone (raised in Conn’s syndrome). Plasma renin (low in Conn’s). Cortisol (diurnal cariation lost in cushings). Urinary free cortisol (elevated in cushings). ACTH
ketoacidosisAetiology
starvation, alcoholic, diabetic
ketoacidosisHx
starvation, chronic alcoholic has binge then stops dirnking AND eating, GI sx (NV, abdo pain, haematemesis, melaena), magnesium low
ketoacidosisPatho
ketoacidosis = high anion gap metabolic acidosis due to xs keton bodies (ie keto-anions) in the blood. these ketone bodies (acetiacetatem beta-hydroxybutyrate, acetone) are released into blood from liver when hepatic lipid metabolism has changed to increasing ketogenesis. Always either relative or absolute insulin deficiency
leftAnteriorFascicularBlock(LAFB)Dx
LAD, ‘qR complexes’ in leads I and aVL, ‘rS complexes’ in leads II, III, aVF, QRS duration normal or slightly prolonged (80-110 ms), Prolonged R wave peak time in aVL > 45 ms, Increased QRS voltage in the limb leads
legPainDDX
trauma (#, disloacations, crush injuries), inflammatory (RA, Reiter’s, ank spond), Infective (cellulitis, septic arthritis, myositis, osteomyelitis), degenerative (OA, meniscal lesions, baker’s cyst), vascular (intermittent claudication, DVT, acute arterial occlusion), Neurological (sciatica, peripheral neuropathy, neurogenic claudication), Metabolic (Gout), Neoplastic (osteogenic sarcoma, secondary deposits), Other (cramp, PMR, strenous exercise)
legSwellingDDX
- Local swelling. 1a) Acute (trauma, DVT, cellulitis, RA, Allergy) 1b) Chronic. Varicose veins, venous obstruction (eg pregnancy, pelvic tumor, post-phlebitic limb), Dependency, lymphoedema, congential malformation (eg AVfistulae), paralysis (failure of muscle pump) 2. General swelling (CCF, hypoprotein(eg liver fail, nephrotic syndrome, malnutrition), renal failure, fluid overload, myxoedema)
legSwellingDx
pain, trauma, recent pregnancy, abdominal or pelvic malignancy, prev surgery, radiotheraphy to lymph nodes, thyroid disease, failures (heart, liver, renal), malnutrition, poliomyelitis in childhood, nerve lesions
liverFunctionTests(LFTs)DDX
- AST/ALT 2:1, normal ALP, inc GGT, macrocytosis = alcoholic liver disease. 2. AST inc +++, ALT + = acute viral hepatitis 3. AST, ALT LDH increase = ischaemic hepatitis 4. ALP and GGT ++ = cholestasis
maisonneuveFractureAnatomy
This is a combination of spiral fracture of the proximal fibula and ankle injury which could manifest by widening of the ankle joint due to distal tibiofibular syndesmosis and/or deltoid ligament disruption, or fracture of the medial malleolus. It is caused by pronation external-rotation mechanism.
malignancyHx
b-symptoms (night sweats, fevers, LOW), LOA, fatigue, malaise, TBA
meningitisEx
petechial haemorrhages, kernig’s sign (pain on extending knee whilst hips flexed)
meningitisHx
photophobia, neck stiffness
meningitisIx
CT urgent and prior to LP if suspicion of inc ICP
metastaticCancerToBoneNote
The bone is one of the most common sites of metastasis. A history of cancer (excluding nonmelanoma skin cancers) is the strongest risk factor for back pain from bone metastasis. Among solid cancers, metastatic disease from breast, prostate, lung, thyroid, and kidney (BPLTK) cancers account for 80 percent of skeletal metastases
migraineHx
preceeding aura, unilateral, throbbing headache, photophobia, precipitants (cheese, red wine, chocolate), flashing lights, NV,
mitralStenosisEx
malar flush, arrhytmia, mitral area reveals loud first heart sound, mid-diastolic rumbling, accentuated by expiration in left lateral position
mitralStenosisHx
sob
mitralStenosisRf
rheumatic fever
nephroticSyndromeDx
Def: proteinuria (>3g/24h), hypoalb (
nephroticSyndromeEpi
Oedema (periorbital, peripheral, genital). Ascites (Fluid thrill, shofting dullness)
nephroticSyndromeHx
SWELLING face, abdo, limbs, genital. Symptoms of UNDERLYING disease (eg SLE). Symptoms of COMPLICATIONS (renal vein thrombosis, loin pain, haematuria)
nephroticSyndromeRf
fam hx of renal disease / atophy
nephroticSyndromeRx
Oedema (FR 1L/day, Na restriction, diuretics, oral/IV). Cause (minimal change GN = steroids, immunosup). Monitor (BP, UEC, FBalance). VTE prophylaxis (Heparin/Clexane)
nephrotoxicDrugsNote
tba
neuroCNEx
1 - not tested. no subjectively reported anosmia / decreased taste sense, 2-
normalRangeOfMovement(ROM)Note
tba
oesophagealSpasmHx
pain worse with swallowing
opioidConversionRx
tba
OSAHx
day-time sleepy, morning headache, snoring, breath-gasping during night / nocturnal choking, disturbing partner during sleep, silence followed by loud snoring
OSARf
age, male, obese, craniofacial/upper airway soft tissue abnormalities, OTHER (smoking, nasal congestion, menopause, fam hx, comorbs(pregnancy, end-stage renal dis, CHF, chronic lung disease, stroke)
otitisExternaDisp
ENT clinic for formal Aural toilet. Direct ENT referral if severe and painful occlusion.
otitisExternaEpi
Any age group. 10% in lifetime. 5-14years commonest. More likely in summer.
otitisExternaEx
pinna pulling worsens pain, erythema, oedema, debris and drainage in the canal, desquamation. Otosocpe: The tympanic membrane may be erythematous in external otitis and only partially visible due to canal edema.
otitisExternaHx
pain, pruritus, discharge, oedema, hearing loss
otitisExternaIx
clinical dx, consider malignancy only if persistent case or otalgia out of proportion (CT/MR)
otitisExternaPatho
Infectious (commonest), allergic, dermatologic. P. aeruginosa (38 percent), S. epidermidis (9 percent), and S. aureus (8 percent). Swimming RF because excess moisture –> skin maceration and breakdown of the skin-cerumen barrier, changing the microflora of the ear canal to predominantly gram-neg bacteria.
otitisExternaRf
Recent water exposure, Instrumentation of the auditory canal (eg cotton buds), trauma, canal occluding devices (hearing aids, earphones, or diving caps), allergic contact dermatitis, psoriasis, atopic dermatitis, prior radiation therapy (as it may have cause ischaemic ear canal), any known tympanic membrane perforation, previous ear infections, any prior ear surgery.
otitisExternaRx
1) Clean thoroughly (eg remove debris) 2) Treat inflammation and infection (eg abx ear drops, and wick to ensure in the canal, +/- steroids) - fluoroquinolones ofloxacin and ciprofloxacin good cover of both pathogens P.aeruginosa and S.Aureus 3) Analgesia, 4) Avoid promoting factors, 5) Follow-up and culture recalcitrant cases / consider DDX
otitisExternaSyn
Swimmer’s ear / external otitis
otitisMediaEx
Otoscope: Air-fluid level along the tympanic membrane is indicative of a middle ear effusion and underlying otitis media
paget’sDiseaseOfBoneIx
ALP increased
painDx
site, onset, character, radiation, association, time course, exacerbating/relieving factors, severity
palpitationsDDX
Sinus Tachycardia (anxiety, emotional stress, caffeine, nicotine, etoh), Cardiac Arrhytmias (ectopic beats, PVCs or PACs, AF, SVT, VT)
palpitationsEx
ideally done during attack, listen for HR - not just palpate radially, BP, screen for underlying cardiac disease (eg MVP which is assoc w SVT and Afib)
palpitationsHx
what was felt (pounding, galloping or fluttering), frequency, regular or irregular (think ectopics or afib), precipitants, onset and offset (abrupt = SVT. Arrhythmia upon standing up straight after bending over and ending when lying down = AVNRT. Terminating post carotid sinus massage or other vagal maneuvers (eg Valsalva) = SVT, AVNT), tap out the rhythm on table/bed, light-headedness, dizzy, syncope (assoc w serious arrhytmias), chest pain, sweating, sob, age of first onset,
palpitationsIx
Bloods: rule out anemia and hyperthyroidism. ECG: for conduction defects or enlargement or ischaemic changes, ambulant ECG monitoring if high risk
palpitationsNote
DEF: Palpitations are a sensory symptom. They are defined as an unpleasant awareness of the forceful, rapid, or irregular beating of the heart
pancreatitisScore
Ranson: On admission WBV>16, age>55, BGL>10, AST>250, LDH>350 48hours into admission: Hct drop>10% from admission +++
pericarditisAetiology
Assocxiated with AMI, 2-6weeks post AMI = dressler syndrome, viral (coxsackie B virus, HIV), bacterial (pneumonia and/or septicaemia), TB (especially in HIV pts), locally invasive carcinoma, rheumatic fever, uraemia, collagen vascular disease (SLE, polyarteritis nodosa, RA), after cardiac surgery or radiotheraphy, drugs (hydralazine, procainamide, methyldopa, minoxidil)
pericarditisAnticipate
pericarditis and myocarditis goes together often. Determine the cause of the pericarditis
pericarditisDx
chest pain, low grade fever, pericardial friction rub
pericarditisHx
sharp, retrosternal, radiating to the back, worse on inspiration, pain can be worse with swallowing, pain worse on deep inspiration/lying flat/raising both legs (ie inc venous return), releaved by sitting up, but may be transient
pericarditisIx
cardiac monitor, bloods, card enzymes, viral serology, ECG (tachy, concave ST elevation, PRi depression, later: T wave flattens, becomes symmertrical inverted. Decreased voltage = effusion. electrical alternans suggests pericardial effusion), CXR (but need >250mls of effusion to see card enlargment)
pericarditisRx
NSAIDs (colchicine 1mg BD +/- Pred 50mg PO or Dexamethasone4mg PO/IV for pain control)
pneumoniaAetiology
- CAP (s.pneum, h.inf, mycoplasma.pneumonia. remainder = s.aureua, legioneela, moraxella catarrhalis, chlamydia). viruses = 15%. 2. HAP (gram Neg enterobacteria ro s.aureus. Also consider pseudomonas, klebsiella, bacteroides, clostridia) 3. aspiration (stroke, myasthenia, bulbar palsies, dec GCS, oesophageal disease, poor dental hygiene can aspirate oropharyngeal anaerobes 4. immunocompromised pts ( s.pneumo, h.inf, s.aureus, m.catarrhalis, M.pneumo. G Neg bacilli, pneumocystis jiroveci. Others = fungi, viruses, mycobacteria
pneumoniaDx
acute LRTI + fever + chest symptoms + abn CXR
pneumoniaHx
Where and who (as determines pathogen) - cap, hap, aspiration, immunocompromised
pneumoniaScore
SMART-COP (age cutoff at 50 alters scoring slightly): SBP25 in young and >30 in old = 1, HR>125 = 1, acute confusion = 1, oxygen low sats or PaO2 or PaO2/FiO2, 93 or 90% = 2, pH 7mmol/l, RR >30, Low BP (
pneumoThorax(PTx)Disp
advice as per BTS guidelines, which consists of i) Patients should be advised to return to hospital if increasing breathlessness develops, ii) Follow up by respiratory physicians until full resolution, iii) Air travel should be avoided until full resolution or 6weeks, and iv)Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.
porphyriaHx
Acute attacks precipitated by drugs (barbituates, oestrogens, progesterones, etc). Other precipitants = etoh, smoking, sudden dieting, stress, abuse, pregnancy. Abdo pain. Peripheral neuropathy (predominanetly motor). Tachycardia, HTN, Postural hypotension. Hyponatraemia, psychiatric manifestations (eg agitation, depression, mania, hallucinations)
porphyriaIx
hyponatraemia, fresh urine sample protected from light to test for amino laevulinic acid and porphobilinogen concentrations. In acute attack, the urine goes dark red/brown, if exposed to light
porphyriaPatho
haem biosynthesis disorders in which enzyme deficiencues > porphyrin accumulation and their precursors.
porphyriaRx
supportive. CHO intake. careful attention to antiseizure mx as many drugs as CIed in acute attacks
pulmonaryEmbolismEx
inc JVP, tachypnoea,cardia, hypotension, RV heave. pleural rub
pulmonaryEmbolismHx
sob, pleuritic chest pain, haemoptysis, dizzy, leg pain
pulmonaryEmbolismIx
ECG (tachy, RBBB, TWI in V1-4, S1Q3T3). D-dimer Wells=
pulmonaryEmbolismScore
Wells score (DVT signs - ie leg swelling and pain on deep vein palpation = 3, PE most likely dx = 3, HR>100 =1.5, >3d immob/surgery in last 4/52 = 1.5, prev DVT/PE = 1.5, Haemoptysis = 1, malignancy (current rx, palliated) = 1.
pulmonaryOedemaHx
pink sputum, sob recumbent,
radiculopathyDx
Radiculopathy = Sx or impairments related to a spinal nerve root. May be due to degenerative changes in the vertebrae, disc protrusion, and other causes. As the root varies, the sx varies, but >90% are L5 and S1 radiculopathies
raisedIntraCranialPressure(ICP)Aetiology
tumoru, hydrocepahlus, cerebral abscess, benign intracranial HTN
raisedIntraCranialPressure(ICP)Ex
papilloedema (on fundoscope), loss of retinal nerve pulsation
raisedIntraCranialPressure(ICP)Hx
bursting pain, worst in morning, changes with position/cough/sneeze
RBBBIx
M in V1, W in V6
refeedingSyndromePatho
biochemical dysfunction aw the reinstitution of calorific intake in malnourished pts. may present in numerous ways. decreased electrolyes (mg, ca, glucose, thiamine), usually within 4days of startin refeeding. shift from fat to CHO metabolism –> inc insulin secretion. ins leads to cell uptake of phosphate and K cauing the serum levels of these to drop. decreased ATP in the metabolic pathway and decreased 2,3DPG in erythrocytes = tissue hypoxia and impairement of myocardial contractility
refeedingSyndromeRx
prevent, measure K, phos, mg, ca, replace electrolytes, thiamine, multivitamine, calories gradually
refluxOesophagitisDisp
endoscopy for H.Pylori testing
refluxOesophagitisHx
pain worse with swallowing
reitersDiseaseHx
conjunctivits, urethritis
salicylatePoisoningHx
V, tinnitus, deafness, sweating, vasodilation, hyperventilation, dehydration. Severe=coma, convulsions. Rare features=non-card APOD, cerebral oedema, renal failure
salicylatePoisoningIx
hypokalaemia. hyperpyrexia and hypoglycaemia (particularly in children)
salicylatePoisoningPatho
aspirin = 300mg acetylsalicylic acid. 150mg/kg =mild toxicity. 500mg/kg = severe/possible fatal toxicity. Can get poisoning from absorption through the skin
sickleCellCrisisHx
preceeded by hypoxia/ischaemia situations (eg infection, dehydration, etc) or de novo.
sickleCellDiseasePatho
mutation > Hgb abnormality. deoxygenation and acidosis > sickling > increased blood viscosity > sludging > stasis (stasis is again the basis)
socialHxHx
home: who live with, kind of house, any help, own ADLs (eg cooking, dressing, washing), mobility: walking aids, exercise tolerance, climb stairs, lifestyle: occupation, etoh, smoking, rec drugs
spinalEpiduralAbscessHx
Initial symptoms (eg, fever and malaise) are often nonspecific. over time, localized back pain may be followed by radicular pain and, left untreated, neurologic deficits
spinalEpiduralAbscessRf
Risk factors include recent spinal injection or epidural catheter placement, injection drug use, and other infections (eg, contiguous bony or soft tissue infection or bacteremia). Immunocompromised patients may also be at higher risk.
spleenAnatomy
1×3×5×7×9×11 rule. The spleen is 1” by 3” by 5”, weighs approximately 7 oz, and lies between the 9th and 11th ribs on the left hand side
spleenPhys
large lymph node, blood filter, red blood cells (removes old ones and holds reserve), immune system, recycles iron
spleenRuptureEx
tachycardia, hypotension, abdo tenderness, pain referred to Left shoulder/shoulder tip
spleenRuptureHx
rib fractures recently, enlarge spleen recently (eg EBV, malaria, leukaemia) + trauma to the area. Acute rupture versus Delayed (up to 2/52 post trma)
spleenRuptureIx
CXR (for ?fractured ribs ?basal pleural effusion). Abdo US and/or CT. AXR is not helpful. (although if done, may see displaced stomach bubble to the right, and enlarge soft-tissue shadow in splenic area)
spleenRuptureRf
left lower rib injuries following trauma (associated with splenic damage in 20% of cases). Occasionally there can be injury to an already enlarged spleen (ie from glandular fever, malaria, leukaemia, etc)
subarachnoidHaemorrhage(SAH)Hx
neck stiffness
subarachnoidHaemorrhage(SAH)Rf
berry aneurysm
subduralHaemorrhage(SDH)Ix
CTB: most common in parietal region. crescent along the inner table of the skull, effacement of ipsilateral ventricle, midline shift
subduralHaemorrhage(SDH)Rf
elderly (given decreased resilence of bridging veins), cerebral atrophy (ie elderly and alcoholics - given the increased tension on veins)
syncopeDisp
SFSS: (San Francisco Syncope Score) to determine risk of serious adverse outcomes. CHF, Haematocrit
syncopeEx
postural BP
syncopeHx
presyncopal sx (palpitations, )
systemsReviewHx
CVS: CP, palp, SOB, ankle swelling, orthopnoea. RESP: Cough, sputum, wheeze, SOB. ABDO: pain, NV, bowel habits, stool colour and consistency, distension, dysuria, frequency, urgency, haematuria. NEURO: headache, photophobia, neck stiffness, weakness, change in sensation, balance, fits, falls, speech, changes in vision/hearing. SYSTEMIC: appetite, weight loss / gain, fever/night sweats, malaise, stiff/swollen joints, fatigue, rashes/itch, sleep pattern
temporalArteritisEx
tender along course of superficial temporal artery, absent pulsation
temporalArteritisHx
localised pain over artery, jaw claudication, throbbing headache
temporalArteritisIx
ESR raised
tensionHeadacheHx
tight band
transientIschaemicAttack(TIA)Rf
ABCD2 score (admit if 5 or more) to predict risk of stroke in short-term. Age > 65 (1 point) BP >140/90 (1 point) C symptoms = Hemi = 2 points, Dysphasia (2 points) Duration - >1hour (1 point) Diabetes (1 point)
tuberculosisEx
nail clubbing,
tuberculosisHx
LOW, LOA, flecks of blood on sputum, night sweats, cough, fever, chills,
tuberculosisPatho
infection (pulm or extrapulm), usually caused by mycobacterium tuberculosis, latent and active stages
urinaryTractInfection(UTI)Aetiology
75-90% E.Coli. Next is Staphylococcus saprophyticus… klebsiella…proteus mirabilis CLASSIFICATION: Simple (typically young and not pregnant with normal urinary tract) vs complicated (abn anatomy, urinary obstruction or incomplete emptying (eg due to instrumentation/catheter/pregnancy/underlying disease eg diabetes)
urinaryTractInfection(UTI)DDX
CYSTITIS (lower tract) = dysuria, freq, suprapub discomfort, +-/ macro haematuria, no vag discharge. PYELONEPHRITIS: loin pain, fever, chills, urinary symptoms. URETERIC CALCULUS + INFECTION: severe pain++. Be suspiscious as this could lead to sepsis + permanent injury to the kidneys.
urinaryTractInfection(UTI)Epi
Femals: by 32 years of age, 50% of women will report at least one UTI. Males: bacteruria beyond infancy = 0.1%. increases to around 3.5% with prostatic disease. 15% in hospitalised men >70yo. Homosexual at increased risk
urinaryTractInfection(UTI)Hx
dysuria, frequency, haematuria, suprapubic tenderness, discharge. IN ELDERLY:, institutionalised pts, non-specific sx + decline correlates POORLY with UTI despite pyuria and bacteriuria –> find another cause. IN MEN: the most common cause of recurrent lower tract UTI = prostatitis, so look for evidence like chills, dysuria, prostaic tenderness.
urinaryTractInfection(UTI)Ix
for most outpatient women with typical symptomatology, cultures not needed
urinaryTractInfection(UTI)Rf
sexual activity is the most important RF in young women, previous UTIs, cathether, homosexual men
urinaryTractInfection(UTI)Rx
ONLY treat asymptomatic bacteriuria in pregnant women and those about to have significant urological procedures
wegnersGranulomatosisEx
loss of nasal bridge, saddling of nose
wegnersGranulomatosisHx
haemoptysis, epistaxis, renal disease
wegnersGranulomatosisIx
c-ANCA
