Week 4 Flashcards
20 year old female presents with 1/12 hx right flank pain, worsening over last 5 days. 3 day hx of UTI, treated with trimethorpim, no further dysuria but persisting back pain. Pain worse on movement. Exacerbated on inspiration. Nausea, vomiting, some loose stools. Increased thirst but no polyuria. Feel generally unwell and TATT. Takes COCP
a) What further questions must you ask this woman?
O/E: Apyrexial, normal BP, right flank tenderness, no masses palpable
b) Possible causes of pain?
c) Differentiating between causes
d) How would you investigate?
a) LMP, PV bleeding
b) Mechanical (muscle strain, etc.), renal (stones, hydronephrosis, infection), lung bases (pleurisy - examine chest)
c) Stones: colicky pain, haematuria
Pyelonephritis: fever, septic
Mechanical: worse on movement
Pleurisy: worse on inspiration
d) - Pregnancy test
- Urine sent for MSU
- Bloods: glucose/HbA1c (TATT), FBC and ESR (infection), UEs and creatinine (kidneys)
- Renal USS
22 year old male presents with 1 year history of visible lump in throat. Over past few weeks, it has enlarged and he can now feel it. No interference with eating or drinking. No systemic symptoms. No history of tonsillitis. Smokes 10 per day.
- O/E: unilateral enlarged tonsil on right side. No other abnormality. No lymphadenopathy
a) Likely diagnosis
b) Management
a) Benign enlarged tonsil
b) Advise smoking cessation, reassurance. TCI if any changes/systemic symptoms
54 year old male presents with 1 week history of cough, occasionally bringing up green sputum but less now. Previously feverish and sweaty but less now.
- O/E: obs normal. Fine bibasal creps but no focal signs
a) Red flags to ask about
b) Likely cause and management
a) Haemoptysis, weight loss, increasing SOB
b) Viral LRTI - reassurance, fluids, bed rest, given likely prognosis. TCI if worsening
58 year old male presents with a first headache of sudden onset, 3 days ago. Some nausea and vomiting. No red flags
-O/E: BP 155/80, HR 72, Temp 36.7C.
a) What is important to elicit about the onset?
b) What examinations are important?
c) What are the differentials?
d) How would you manage this?
a) Thunderclap, context (what were they doing at the time, e.g. during sex, exertional, head injury)
b) Fundoscopy, neuro
c) Migraine (rare onset at this age, so consider other diagnoses also), related to HTN, GCA, space-occupying lesion, SAH
d) - ESR to exclude GCA
- Continue with co-codamol
- Worsening advice given (progressive, persistent, fever, meningism, vomiting, weakness, seizures, etc.)
- Repeat BP in 4/52
Headache red flags
a) Onset
b) Duration
c) Associated Sx
d) Precipitating / exacerbating factors
e) Comorbidities
a) Thunderclap, new onset severe headache over 50 years old
b) Progressive or persistent new headache, or changing headache
c) - Fever, impaired consciousness, seizure, neck pain/stiffness or photophobia — meningitis /encephalitis.
- Papilloedema — consider space occupying lesions, intracranial hypertension.
- New-onset neurological deficit, change in personality and new-onset cognitive dysfunction — consider CVA/SOL.
- Atypical aura (duration greater than 1 hour, or including motor weakness) or aura occurring for the first time in a patient during use of COCP - consider CVA.
- Dizziness — consider serious causes such as ischaemic or haemorrhagic stroke.
- Visual disturbance — can be associated with migraine but also with serious causes such as acute closure glaucoma and temporal arteritis.
- Vomiting — can associated with migraine but may also be associated with a serious cause of headache such as mass lesion, brain abscess, or carbon monoxide poisoning.
d) - Preceding head trauma (prev 3 months).
- Valsalva manoeuvre (such as coughing, sneezing, bending or exertion [physical or sexual])
- Worsens on standing - consider CSF leak.
- Worsens on lying down — consider SOL
e) Immunosuppression (e.g HIV), malignancy (current or prior), pregnancy (pre-eclampsia)
30 year old male presents with lump on right testicle. Felt on palpation but not noticed otherwise. Recent epididymitis, finished course of ofloxacin and resolved. No further pain. No dysuria or discharge etc. No red flags. Patient anxious
-o/e: very small nodule felt on right testis, mildly tender. No other abnormality.
a) Likely diagnosis
b) Management
a) Epididymal cyst/ thickening post-infection
b) - Reassure that likely due to infection
- However, due to anxiety, referred for USS on non-urgent basis
35 year old female presents with ongoing left flank pain. Intermittent, no radiation, worse on twisting movements, relieved partly by paracetamol. Treated for UTI 4 days ago, finished course with some symptoms improvement. Some shivering and feeling cold. Nausea, no vomiting, bowels loose. Some dysuria, no haematuria.
- O/E: apyrexial, some renal angle tenderness, no palpable masses.
a) What other Qs to ask?
b) Likely diagnosis
c) What tests to do before deciding on management?
d) Management in this case
a) LMP, pregnancy (important for abx choice)
b) UTI ongoing symptoms (in spite of likely resolved infection)
c) Urine dip! (+ pregnancy test if relevant)
d) - Urine dip showed only leukocytes +1, so likely resolved infection.
- Reassure, advise fluids and given worsening advice (fevers, unwell, etc.)
- Send MSU (no abx unless bug found and persisting infection)
28 year old female presents with history of migraines. Typical visual aura followed by vomiting, bilateral headaches lasting 3-7 days. Disabling, only relieved by sleep. Takes sumatriptan as soon as headache comes on, no relief. Also on max doses 2 hourly alternating ibuprofen/paracetamol but no relief. Stressed, occasional low mood, anxiety. No known triggers. Third migraine episode in last month.
a) Red flags to ask about
b) Management
c) Important things to check before prescribing medications
a) Meningitis (fever, neck stiffness), SOL (worse in morning, progressive, weakness, seizures, etc.)
b) - Start propanolol low dose for prevention
- Worsening advice given
- Keep headache diary, including foods
c) HR and BP (beta-blockers), allergies, comorbid disease (e.g. asthma - BBs contraindicated)
23 week old baby presents with 2/7 pulling at right ear. Teething at the moment. No history of severe illness or ear infection
- O/E: Normal TM, apyrexial, chest clear
a) Important Qs to ask re: baby health
b) Likely diagnosis
c) Management
a) Eating and drinking (and what are they feeding on), wet and dirty nappies, fevers, floppiness, drowsiness, irritable, inconsolable, rashes.
b) Referred pain due to teething. No signs of ear infection
c) Reassure. TCI if worsening
50 year old male presents with 3 year history of low mood related to tinnitus.
a) What must be established with the tinnitus?
b) What can be done for tinnitus?
c) Management of the low mood
d) In patients with low mood/other psychiatric illness, what questions must you ask?
a) Unilateral (MRI head) or bilateral
b) - No cure
- Refer to ENT/audiology
- Sound therapies for distraction
- Antidepressants may help
- British Tinnitus Association:
https: //www.tinnitus.org.uk/sound-therapy
c) - Antidepressant +/- talking therapy
- Review in 2 weeks
d) Substance misuse (alcohol, drugs), thoughts or acts of harm to self or others
31 year old comes in for CHC pill. Smoker, no history of VTE, normal BMI, two children (3 and 9).
a) What advice should you give her?
b) What guidelines are useful to guide risk of various forms of contraception?
c) Give some contraindications to COCP
d) The risk of VTE on CHC must be balanced with the risk of VTE in…?
a) Stop smoking (above age 35 and smoker = contraindication to COCP)
b) UK MEC: file:///C:/Users/hackguest/Downloads/fsrh-ukmec-summary-pages-2017.pdf
c) - <6 weeks postpartum
- VTE
- HTN, IHD, CVA, valvular disease
- Migraine with aura
- Smoker > age 35
d) Pregnancy! (> CHC risk)
54 year old male. Persisting lump on back of neck. Seen one month ago, no changes but patient concerned. No other lumps, no systemic symptoms.
- O/E: 2cm mobile soft solid lump on right posterior subcutaneous area of neck. Non-tender. No lymphadenopathy. No skin changes.
a) Why is it unlikely to be: i) lymph node, ii) malignant, iii) cystic
b) Likely diagnosis
c) Management
Patient also had incidental BP of 146/82
d) Explain this finding
e) Management
a) i) Site, ii) Mobile, soft, no other symptoms, no rapid growth, no lymphadenopathy, iii) not fluctuant
b) Lipoma
c) - Reassure
- USS
d) Anxiety about lump
e) Advise lifestyle changes
Review in 4 weeks with HCA
69 year old male presents with 3/7 pain in left lateral leg. Came on suddenly while reading the paper. No known precipitant. There constantly, not worse on exertion nor relieved by rest. Had angioplasty in same leg 2014 for intermittent claudication, asymptomatic since. Also has peripheral nerve disease in both feet causing numbness and stabbing pains. On gabapentin 500mg TDS.
a) What is important to comment on the examination?
b) Which bit did I miss? (good assessment of vascular supply)
c) Likely cause and management
d) Why IC is unlikely?
a) - Inspection - colour, skin changes, swelling.
- Palpation - CRT, temperature (hot - infection, DVT; cold - ischaemia), pitting oedema, tenderness, pulses
b) Cap refill time
c) Muscle cramp/strain; reassure, stretch, ice, analgesia. Watch and wait - TCI if worsening, go to ED if severe
d) Not related to exertion, no other features of ischaemia, short history.
40 year old female presents with a 12 day history of left ankle pain that came on suddenly while walking. Toothache like that radiates up the left leg to the lower back. Not worse on exertion. Interfering with sleep. Not relieved by 2 ibuprofen per day or Anadin.
- O/E: high arches, 4/5 dorsiflexion left foot, normal sensation. SLR 20 degrees on left, 70 on right. Increased pain on dorsiflexion of left foot.
a) What important hx details are omitted ?
b) Likely diagnosis. Differential?
c) Management
d) Why is Anadin not recommended?
e) Important to tell patient when starting amitryptilline
f) How to establish whether there has been a fracture/sprain?
g) Ottawa ankle rules for XR foot/ankle
h) What other causes of foot pain are common in athletes?
a) Red flags for CES - bladder, bowel, perineal sensation, leg weakness
b) Sciatica - referred pain to ankle.
DDx: nerve entrapment in ankle (due to bone deformity)
c) - Start amitryptilline (help more with sleep compared with gabapentin/ pregabalin)
- Advise keep active and stretching
- TCI if worsening (red flag advice given) and consider physio at this point
d) Contains 300mg aspirin, which might irritate stomach in combination with ibuprofen; also, only 200mg paracetamol so less than half normal dose. And … $$$
e) Drowsiness - may be at risk if driving morning after; should subside after a few days
f) Tenderness, swelling, limited ROM
g) In context of pain in midfoot/ankle related to trauma, XR indicated if any of the following are present:
- Bone tenderness at medial/lateral malleolus, navicular or base of 5th MT
- Inability to weight bear both immediately after injury AND in ED (unable to take 4 steps)
h) Plantar fasciitis.
Less common - tarsal tunnel syndrome
25 male, 4/7 pain in right knee. Occasional locking and clicking. 2/7 pain in right hip also. Hurts when walking. No other joints affected. Systemically well.
-o/e: apyrexial, right knee painful and limited ROM, tender, no swelling or erythema. Ligaments all stable.
a) Differentials
b) Management?
a) Cartilage damage, foreign body (locking, clicking, etc.)
b) XR knee. If NAD - refer to MSK
c)
