Triads Flashcards
Vertigo,
Tinnitus,
Hearing Loss
Menieres Disease
Pale child
Severe colic
Vomiting
Acute intussusception
Features:
Sausage shaped mass in RUQ
Bowel sounds alternating high pitched to absent
Emptiness in RIF (signe de dance)
PR exam +/- PR blood - red currant jelly stool
Check for hernias
Ix: USS Abdo
Mment: barium enema, hydrostatic reduction, surgical referral
Intense pain
Pale and shocked
Back pain
Ruptured AAA
Normal diameter 3cm
Significant diameter 5cm
Dangerous >6cm
Mment: Oxygen, Ambulance, Iv fluids (large bore ivc), Urgent surgical referral.
Localised RIF pain
Anorexia,
Nausea + vomiting
Guarding
Acute Appendicitis
Esp 20-30yo
Pain oft central then progressing to RIF over 6 hours Tenderness - McBurney’s
Rovsing sign - RIF tenderness while palpating LIF.
Psoas sign - pain on right hip resisted flexion or passive leg elevation
Obturator sign - pain on right hip and knee flexion with internal hip rotation.
Mment:
Investigations are generally not helpful
Urgent surgical referral
If perforation: Start Iv fluids, Ceftriaxone + Metronidazole
Colicky central pain
1min duration every 3-10 mins
Vomiting
Distension
Nil flatus
Small Bowel Obstruction
Signs: Tinkling bowel sounds, Dehydration/hypovolemia, PR: empty rectum.
Check all hernial orifices
Ix: Abdo X-ray >4 air fluid levels in step ladder
CT scan
Urgent surgical referral
IV Fluids
Colicky pain (non central)
Distension
+/- Vomiting
Large bowel obstruction
Exam: Abdominal distension, Rigidity, Increased bowel sounds.
PR exam: empty rectum
Ix: Abdo X-ray - separation of haustra, coffee bean sign (sigmoid volvulus)
Mment:
Ng tube drip and suck
Surgical referral
Severe pain
Sudden onset
Anxious, grey, sweaty,
Deceptive improvement 2-6 hrs post onset.
Perforated Peptic Ulcer
Ix: BP, PR CXR (erect), CT abdomen.
Mment: Pain relief
NG tube - drip and suction
IV Fluids
Broad spectrum Abs
Hospital
Intense pain
Radiates to the groin
Restlessness
Microscopic haematuria.
Ureteric colic
Ix: Urine dipstick, Urine MCS, UEC, LFT, CMP,
Abdo-pelvic X-ray, USS KUB, CT Non - contrast KUB is most diagnostic (Sn 97%, Sp 96%), IVP if recurrent.
Mment: ketoralac 10 - 30mg im
Morphine 5-10mg im/Iv And metoclopramide,
10mg Iv Diclofenac 50mg TDS 7 days
Stone for analysis
Dietary advice: 2L water daily, avoid caffeinated foods and beverages, rhubarb, beer, red wine, processed/organ meats (high oxalates), increase citrate in diet, eat high fibre.
Referral for intervention if:
Stone > 5mm, High grade obstruction, Gross hydronephrosis,
Fever/UTI, Unremitting pain, Stone fails to progress, T2DM, Staghorn calculus, Solitary kidney.
Severe pain esp post prandial
Vomiting
Pain radiating esp right shoulder
Murphy’s sign (RUQ tenderness)
Biliary colic
Ix: USS abdo, LFTs, Helical CT,
If prev. Cholecystectomy then Iv colangiography
Complications: cholecystitis, perforation, obstructive jaundice, acute pancreatitis.
Anxiety
Prostration
Intense central pain
Profuse vomiting
+/- bloody diarrhoea
Mesenteric artery occlusion
Watery diarrhoea initially
Progress to confusion
Absent bowel sounds, Tachycardia or AF
Ix: CRP, ALP, X-ray shows thumb printing (bowel wall thickening) - also seen in other types of colitis. CT abdo
Surgical referral.
Severe Pain
Nausea and vomiting
Lack of Abdo signs
+/- Fever
Acute pancreatitis
Ix: WCC -leeukocytosis
Serum lipase elevated
CRP, BSL elevated
Hypocalcaemia
Blood gas PaO2
LFTs
Plain X-ray
Acute Abdo pain (LIF)
Left sided radiation
Fever
+/- tenderness, guarding, rigidity in LIF.
Acute diverticulitis
Ix: FBC (leukocytosis), ESR elevated, Faecal m/c/s Pus in stools,
CT Abdo - If ct not available erect CXR for perforation (air under diaphragm) and erect + supine Abdo X-ray
Mment: Admit to hospital, Rest gut, Ng tube - suction, Analgesia, Broad spectrum Abs, (Mild: amoxycillin + clavulanate 500mg TDS for 7 days Severe: Ceftriaxone 1gm daily + Metronidazole 500mg TDS)
Surgery if complications
Screening colonoscopy when settles.
Diarrhoea
Abdominal pain
Weight loss
Joint pain (migratory)
Whipple’s disease
Also: malabsorption ( inc steatorrhoea and hypoalbuminaemia), Abdominal lymphadenopathy, Skin changes (darkening, Nodules, Uveitis, Endocarditis, Dementia, Memory loss, Confusion, Weakness, Ataxia, Ocular myorhythmia (eye twitches)
Dx by duodenal biopsy Very rare 1:1,000,000
Due to a genetic failure in immunofunction and subsequent internal colonisation of T. whipplei
Malaise
URTI symptoms (rhinitis, sinusitis, etc)
LRTI symptoms (wheeze, cough)
+/- Febrile illness
Wegner’s granulomatosis
75% of patients develop glomerulonephritis
Malaise
Cough
Fever
+/- erythema nodosum
Sarcoidosis
Multi system involvement
Lungs: granulomas, fibrosis, perihilar lymphadenopathy
Skin: EN, plaques, maculopapular eruptions
Cardiac: conduction abnormalities inc complete HB and ventricular arrhythmias, pericarditis.
Eyes: uveitis, facial nerve palsy/ptosis Hyperprolactinemia, hypercalcaemia
Diagnosis is by exclusion
Treatment: NSAIDs, prednisolone 15mg daily for 4 weeks, methotrexate 5-10mg Po, weekly + folic acid 5mg weekly on an alternate day.
Less than 16 YO
Limping or Reduced physical activity
Morning joint pain and stiffness
Joint swelling
Lethargy
Poor appetite
Juvenile Idiopathic Arthritis
Mangement: Referral to Paediatric Rheumatologist
Child, esp < 5 YO
Joint pain or stifness esp morning.
High remittent fever
Coppery red (Salmon Pink) rash
lymphadenopathy
Systemic Onset Juvenile Idiopathic Arthritis (Still Syndrome)
Adult version is Adult-onset Still disease.
Referral to Specialist
Young esp 5 - 15 YO
Acute onset fever
Joint pains
Malaise
Migratory (flitting) arthritis
+/- History of sore throat
Rheumatic Fever
Diagnosis requires either
2 + major criteria, or 1 major & 2 + minor criteria
Major criteria: Polyarthritis, carditis, chorea, subcutaneous nodules, Erythema marginatum
Minor criteria: Fever + 38 degC, previous RF or RHD, arthralgia, Raised ESR > 30 or CRP > 30, prolonged PR interval on ECG.
Ix: FBC, ESR/CRP, throat swab streptococcal ASOT, Streptococcal anti-DNase B, ECG (Echocardiogram if inc. PR interval), chest xray.
Tx: Bed rest, 900mg Benzathine penicillin IM (450mg if < 20Kg)
Paracetamol 15mg/kg QID
If carditis ACEI + Corticosteroid
Note: if diagnosed with acute rheumatic fever or rheumatic heart disease, then will need 4 weekly IMI of Benzathine Penicillin.
Advancing age
Joint pain worse at end of day
Pain relieved by rest and non weight bearing.
Joint deformity (Bouchard’s nodes at PIP and Heberden’s nodes at DIP)
No systemic manifestations
Osteoarthritis
Arthritis
Conjuctivitis
+/- iritis
Following urethritis or gastroenteritis
Reactive arthritis
Oedema,
Increased urine albumin,
Dereased serum albumin,
Hyperlipidemia
Nephrotic syndrome
Causes: Nonproliferative:
Focalsegmental glomerulosclerosis
Membranous glomerulonephritis
Minimal Change disease
Thin basement membrane disease
Hypertension,
Haematuria,
Oligouria
Nephritic Syndrome (Glomerulonephritis)
Types:
(Proliferative)
IgA Nephropathy (Most common cause)
Post infectious
Membranoproliferative
Rapidly progressive
Dx: Proteinuria 1 - 3gm/day, Red cell casts,
Tiredness,
Husky voice,
Cold intollerance
Myxoedema (Hypothyroidism)
Also: Constipation, Mental slowing, Depression, Puffiness, Pallor, Hair loss, Weight gain.
Anxiety,
Weight loss,
Weakness,
Thyrotoxicosis.
Also: Heat intollerance, Tremor, Goitre, Proximal myopathy, Hyper reflexia, AF, Lid lag, Lid retraction, Exopthalmos, Opthalmaplegia.
Ix: TSH, T3, T4, Radioisotope thyroid scan, Antithyroid peroxidase
Uniform uptake on scan = Graves
Irregular uptake = toxic multinodual goitre
Tx: Radioactive iodine, Antithyroid drugs (eg carbimazole), Surgery, Adjuncts (propanalol 40mg TDS)
Refer to specialist.
Reduced libido,
Subfertility,
Amenorrhoea,
Erectile dysfunction
Galactorrhoea
Hyperprolactinemia
Causes: Pituitary adenoma, Pituitary stalk damage, Drugs (MJ, Opiates), Metoclopramide, Oestrogens, Pregnancy, Breast feeding.
Acute vertigo,
Nausea,
Vomiting
Acute Vestibular Neuronitis
Tx
Bed rest
Gaze in direction that reduces symptoms
Antiemetic: Prochlorperazine 12.5mg IM
Diazepam 5 - 10mg IM then 5mg TDS PO for 2-3 days
Prednisolone 25mg daily PO, taper over 9 days
Vertigo,
Nausea,
Vomiting,
Hearing loss,
+/- Tinnitus
Acute Labarynthitis
Tx:
Bed rest
Gaze in direction that reduces symptoms
Antiemetic: Prochlorperazine 12.5mg IM
Diazepam 5 - 10mg IM then 5mg TDS PO for 2-3 days
Prednisolone 25mg daily PO, taper over 9 days
Malaise
Weight Loss
Cough
Lung Ca
Haematuria
Loin Pain
Palpable Kidney Mass
Renal Cell Carcinoma
Child esp 2 - 3 YO
Palpable abdominal mass
Haematuria
Malaise
Wilm’s Tumour
Female esp > 40 yo
Abdominal Discomfort
Anorexia
Abdominal bloating/Distension
Ovarian Ca
Ix: Pelvic USS, CA-125,
50 YO is average age of diagnosis
Anemia +/- Haematochezia
Abdominal Discomfort
Change in Bowel habit
Colon Cancer
Jaundice
Anorexia
Abdominal Pain or Discomfort
Pancreatic Cancer (usual ductal adenocarcinoma)
(Until proven otherwise)
Pain presentation depends on location:
Head: Painless
Body or Tail: Epigastric, radiating to back, relived by leaning forward.
Malaise
Pallor
Bone Pain and or Joint pain
esp Age < 45
Acute lymphatic leukemia
Malaise
Pallor
Oral Problems (eg Gingival hypertrophy)
esp Age > 45
Acute Myeloid Leukaemia
Symptoms / Haemotology change has rapid onset
Ix: Bone marrow : Blasts > 20%
If anemia, hypercellular marrow and blasts:
BM blasts 10 - 19 % then RAEB 2
BM blasts 5 - 9% then RAEB 1
RAEB = Refractory anemia with excess blasts
Malaise
Fever or Night Sweats
Pruritis
Painless rubbery lymphadenopathy
+/- splenomegally
Hodgkin Lymphoma
Dx on lymph node biopsy
Ann Arbor system for staging
Fatigue
Fever or Night sweats
Abdominal fullness (Splenomegaly)
esp 40 - 60 yo
Chronic Myeloid Leukaemia
Associated with Philadelphia chromosome
Features
Leukocytosis with left shift
Normocytic anemia
Thrombocytosis (50%)
Eosinophilia
Basophilia
Fatigue
Weight loss
Fever or Night sweats
Lymphadenopathy
Esp > 55 YO
Chronic Lympocytic Leukaemia
Lymph adenopathy 80% (neck, axilla, groin)
Can also have splenomegally (50%)
Mild anemia
Lymphocytosis usually > 15 x 109. Some times greater than 100 x 109
Malaise
Fever or Night sweats
Painless Lymphadenopathy
Older age.
Non Hodgkin Lymphoma
Pruritis is rare
Weakness
Back pain
Recurrent Infection
Multiple myeloma
Ix: Serum protein electrophoresis = paraproteins
Urine Bence Jones Proteins
Bone scan = lytic lesions
Advanced Age
Fatigue
Headache
Epistaxis
Pruritis after hot shower
Polycythemia vera
Malignant prolifeartion of red cells
Also: Splenomegaly, thrombosis
Ix: Increased haematocrit and Hb
Bone marrow biopsy to confirm.
Angina
Dyspnoea
Blackouts or Fainting
Aortic Stenosis
Findings: Low BP, Displaced Apex, ES Murmur (Aortic)
Ix: ECG shows Left ventriclar hypertrophy
S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm
Increased R wave peak time > 50 ms in leads V5 or V6
ST depression and T wave inversion in the left-sided leads (V5,V6, I, AVL
Perineal Pain
Ejaculatory discomfort
Prostatitis
Epigastric pain
Sudden onset
Constant
Radiates to back
Relieved by leaning forward
Acute pancreatitis
Infant
Abdominal distension
Constipation
Occaisional vomiting
Irritable
Anorexia
Hirschsprung Disease
Disorder of innervation of the bowel
Young child
Unilateral Nasal discharge
Often smelly
Inhaled foreign body
Returned traveller
Headache
Fever
Malaise
Malaria
Foreigner
Cough
Fatigue
Tuberculosis
Anaemia, weight loss, dysphagia and older age
Gastric Cancer
Refer for endoscopy
